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Azotemia Medication

  • Author: Moro O Salifu, MD, MPH, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
Updated: Feb 12, 2016

Medication Summary

The goals of therapy are to increase renal perfusion and to maintain urine output. Drugs used in the management of patients with azotemia include diuretics, adrenergic agents, plasma volume expanders, and corticosteroids. Specific therapies for various systemic conditions affecting the kidney are discussed in other articles.


Diuretics, Other

Class Summary

Diuretics are used to induce urine output in acute tubular necrosis (ATN) and to treat edema and hypertension. They increase urine excretion by inhibiting sodium and chloride reabsorption at different sites in the nephron.

Furosemide (Lasix)


Furosemide is the drug of choice as a diuretic. It inhibits sodium chloride reabsorption in the thick ascending limb of the loop of Henle.

Hydrochlorothiazide (Microzide)


Hydrochlorothiazide (HCTZ) acts on the distal nephron to impair sodium reabsorption, enhancing sodium excretion. It has been in use for more than 40 years and is generally an important agent for the treatment of essential hypertension.

Chlorothiazide (Diuril)


Chlorothiazide inhibits the reabsorption of sodium in distal tubules, causing increased excretion of sodium and water, as well as of potassium and hydrogen ions.

Metolazone (Zaroxolyn)


Metolazone is given as an adjunct to furosemide in severe edematous states or when furosemide alone does not achieve adequate diuresis. It increases excretion of sodium, water, potassium, and hydrogen ions by inhibiting reabsorption of sodium in distal tubules. Metolazone may be more effective in the setting of impaired renal function.


Volume Expanders

Class Summary

Plasma volume expanders increase plasma oncotic pressure and mobilize fluid from the interstitial space into the intravascular space in hypoalbuminemic patients. They enhance delivery of furosemide to distal tubule.

Albumin (Albuminar, Plasbumin, Albutein)


Albumin is supplied as a 5% solution in 250 mL or a 25% solution in 50 mL. The choice between the 2 formulations is based on whether patient requires additional fluid replacement. Albumin is not used for nutritional supplementation; thus, attempts should be made to improve patient's nutrition.



Class Summary

Corticosteroids are potent anti-inflammatory agents and immunosuppressants. They suppress humoral and cellular response to tissue injury, thereby reducing inflammation.



Prednisone is commonly used for many forms of glomerulonephritis and interstitial nephritis. Once the diagnosis is confirmed, a trial of oral prednisone (starting at 1 mg/kg/day and tapering over 6 weeks) may be considered.

Prednisolone (Orapred, Pediapred, Millipred)


Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body. Once the diagnosis is confirmed, a trial of oral prednisolone (starting at 1 mg/kg/day and tapering over 6 weeks) may be considered.

Methylprednisolone (Medrol, Solu-Medrol, Depo-Medrol)


Methylprednisolone decreases inflammation by suppressing the migration of PMNs and reversing increased capillary permeability. In severe cases, a trial of intravenous pulse methylprednisolone (1 g for 3 days) may be considered once the diagnosis is confirmed.


Alpha/Beta Adrenergic Agonists

Class Summary

Adrenergic agents stimulate vasodilation of the renal vasculature and enhance perfusion.



Above a critical dose (renal dose), dopamine becomes a potent vasoconstrictor. Renal-dose dopamine is used widely, but a clear benefit has not been established.

Contributor Information and Disclosures

Moro O Salifu, MD, MPH, FACP Associate Professor, Department of Internal Medicine, Chief, Division of Nephrology, Director of Nephrology Fellowship Program and Transplant Nephrology, State University of New York Downstate Medical Center

Moro O Salifu, MD, MPH, FACP is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Society of Transplantation, American Society of Diagnostic and Interventional Nephrology, American Medical Association, American Society for Artificial Internal Organs, American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.


Onyekachi Ifudu, MD, MBBS Director of Inpatient Dialysis Services, Associate Professor, Department of Internal Medicine, State University of New York Health Science Center at Brooklyn

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.


George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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Graph shows relation of glomerular filtration rate (GFR) to steady-state serum creatinine and blood urea nitrogen (BUN) levels. In early renal disease, substantial decline in GFR may lead to only slight elevation in serum creatinine. Elevation in serum creatinine is apparent only when GFR falls to about 70 mL/min.
Diagnostic indices in azotemia. Although such indices are helpful, it is not necessary to perform all these tests on every patient. Comparison should always be made with patients' baseline values to identify trends consistent with increase or decrease in effective circulating volume. Use of some of these indices may be limited in certain clinical conditions, such as anemia (hematocrit), hypocalcemia (serum calcium), decreased muscle mass (serum creatinine), liver disease (blood urea nitrogen [BUN], total protein, and albumin), poor nutritional state (BUN, total protein, and albumin), and use of diuretics (urine sodium). Fractional excretion of urea and fractional excretion of trace lithium appear to be superior for assessing prerenal status in patients on diuretics.
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