Different Effects on Fluid Distribution between Tolvaptan and Furosemide in a Liver Cirrhosis Patient with Chronic Kidney Disease

Abstract

A 73-year-old man with liver cirrhosis and advanced chronic kidney disease was admitted to our hospital due to bilateral lower leg edema and appetite loss. Furosemide to treat fluid retention markedly decreased extracellular water compared with intracellular water, but the addition of tolvaptan equally decreased both with a greater diuretic response than furosemide alone. Furthermore, tolvaptan administration increased the plasma colloid osmotic pressure, which might facilitate the shift of fluid from the extravascular space to the intravascular space. This is the first case showing different effects on the fluid distribution between furosemide and additional tolvaptan in the same patient.

Keywords: bioimpedance analysis; extracellular water; furosemide; intracellular water; liver cirrhosis; tolvaptan.

Figure 1.

The clinical course and serial changes in the urine volume, blood urea nitrogen (BUN), serum creatinine (sCr), body weight (BW) and intracellular water (ICW) and extracellular water (ECW). BIA: bioelectric impedance analyses, BCAAs: branched-chain amino acids

Figure 2.

Changes in the extracellular water (ECW), intracellular water (ICW) and total body water (TBW) after admission. The ECW, ICW and TBW were clearly decreased after the initiation of tolvaptan (TLV). Day 0: the day of admission

Figure 3.

Furosemide predominantly decreased the extracellular water (ECW), but tolvaptan decreased the intracellular water (ICW) and ECW similarly for 7 days from the baseline of each treatment (A). Furosemide decreased the ratio of the ECW to the total body water (TBW) (ECW/TBW) and colloid osmotic pressure, whereas tolvaptan increased both parameters (B and C).