Do AKI patients with hypoalbuminemia respond to furosemide stress test without prior albumin infusion?

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Amin Roshdy Soliman, Ahmed Yousry, Hoda Abdelhamid Maamoun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6288472/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in BMC Nephrology → Version 1 posted 10 You are reading this latest preprint version Abstract Background Acute kidney injury (AKI) is a common and serious condition often associated with hypoalbuminemia, which can influence the pharmacokinetics and efficacy of diuretics like furosemide. In critically ill patients, sepsis is the major cause of AKI, accounting for nearly 50% of cases. Objective To evaluate whether AKI patients with hypoalbuminemia can respond to FST without albumin supplementation. Methods This is a prospective quasi-experimental study. Patients were obtained from the intensive care unit of Cairo University Hospital with AKI stages 1 and 2 with hypoalbuminemia. A bolus of furosemide was administered at a dose calculated to be 1-1.5 mg/kg in a single dose to patients without a prior diagnosis of kidney disease and clinical signs of hypovolemia. Results A total of 41 critically ill patients with AKI were enrolled, aged between 18 and 80 years, of which 56.10% had diabetes mellitus, 53.70% were on at least one nephrotoxic medication, and 56.10% had sepsis as the cause of AKI. The median (IQR) albumin level was 1.9 g/dL (1.4–2.7). Among 41 hypoalbuminemic AKI patients included, 80.50% responded to FST without prior albumin infusion. Non-responders had significantly lower baseline serum albumin levels median (IQR) 1( 1 – 2 ) vs. 2 ( 1 – 3 ) g/dL, p < 0.002). Conclusion AKI patients with mild-to-moderate hypoalbuminemia may still respond to FST without albumin infusion, although response rates decline with the increasing severity of hypoalbuminemia. The FST remains a valuable predictive tool in hypoalbuminemic AKI patients but warrants further investigation to optimize its utility in this population. Acute kidney injury hypoalbuminemia furosemide stress test Figures Figure 1 Figure 2 Figure 3 Introduction Acute Kidney Injury (AKI) is a common and serious complication that is associated with several adverse outcomes including death, need for renal replacement therapy (RRT), increased length of hospital stay, chronic kidney disease, and rising health care costs. Even mild forms of kidney injury influence short- and long-term morbidity and mortality through a progression of chronic kidney disease (CKD) and cardiovascular disease. Specific treatments for AKI are currently lacking and supportive care is the mainstay of therapy. Prevention is therefore of the utmost importance and relies on the identification of individuals at high risk for development of AKI early in the intensive care unit (ICU) admission ( 1 – 3 ). In the critically ill, sepsis is the major cause of AKI, accounting for nearly 50% of cases so Suspicion of infection was made using The Sequential Organ Failure Assessment (SOFA) score. It is a scoring system that assesses the performance of several organ systems in the body (neurologic, blood, liver, kidney, and blood pressure/hemodynamics) and assigns a score based on the data obtained in each category ( 4 , 5 ) Critically ill patients with AKI may receive an exogenous source of vasopressin or its analog that increases sodium and water retention. These mechanisms might have the effect of amplifying the defect in water excretion in edematous AKI patients ( 6 ). Since the most common causes of intrinsic AKI involve acute tubular injury, we sought to develop a functional assessment of renal tubular function. Furosemide, a loop diuretic, has pharmacokinetic properties that make it an appealing functional tool ( 7 ). We think that furosemide-induced increases in urine output might be a method to assess the integrity of renal tubular function in the setting of early AKI. Specifically, we hypothesized that the kidney’s response or lack of response to a furosemide challenge, as a clinical assessment of tubular function, could identify patients with severe tubular injury before it was clinically apparent ( 8 ). The action and efficacy of furosemide differs considerably in patients with AKI, several factors account for these differences as nephrotoxic medications, vasopressors, sepsis, hypoalbuminemia ( 9 ) Critically ill patients are often moderately to severely hypoalbuminemia. We believe that hypoalbuminemia could play a significant role in influencing diuretic response, given that 95% of furosemide binds to plasma proteins. there is a knowledge gap this study aims to fill. Therefore, this study explains why the research question is important and how it has a potential clinical impact on its findings. Thus, our objective is to evaluate the effectiveness of the Furosemide Stress Test in critically ill patients with AKI stages 1 and 2 and the effect of several factors as nephrotoxic drugs, vasopressors, diabetes, sepsis, and hypoalbuminemia on the effectiveness of the Furosemide Stress Test in these patients ( 10 ). Materials and methods Patient Recruitment and Screening patients were recruited from the Intensive Care Unit in Kasr Alaini Hospital, patients who satisfied the following criteria were assessed for FST. Meeting the AKI diagnostic criteria for Kidney Disease Improving Global Outcomes (KDIGO) guidelines, stage 1 and 2); Stage 1: Serum creatinine 1.5–1.9 times baseline or ≥ 0.3 mg/dL increase, Urine output < 0.5 mL/kg/h for 6 h, Stage 2: serum creatinine 2-2.9 times baseline, Urine output < 0.5 mL/kg/h for 12 h appropriate blood volume and central venous pressure (CVP) ≥ 6 mmHg; and urine output ≤ 0.5 ml/kg/h for 6 h. Exclusion criteria: age < 18 years; indications for emergency CRRT: hyperkalemia, potassium of blood ≥ 6.5 mmol/L; metabolic acidosis, PH ≤ 7.15; acute pulmonary edema due to fluid overload; developed uremia-related complications, such as pericarditis, bleeding, etc.; chronic kidney disease or having received renal replacement therapy 30 days before inclusion; presence of postrenal obstruction factors; Evidence of volume depletion at the time of furosemide administration. Randomization Process In this single-group quasi-experimental design, randomization was not applied since there were no comparison or control groups. All eligible patients who met the inclusion criteria during the study period received the intervention. A consecutive sampling approach was used to ensure that participant selection was as unbiased as possible, enrolling patients in the order they were identified as eligible. Blinding Procedures Given the single-group design, blinding was primarily applied to minimize assessment bias: Outcome assessors evaluating the response to the FST were blinded to the study’s objectives and specific patient characteristics. Laboratory personnel analyzing biochemical parameters were also blinded to reduce the risk of subjective interpretation. Patients were not informed about the study's focus on hypoalbuminemia to avoid influencing their subjective reports of symptoms or outcomes. Screening involves reviewing patient medical records, laboratory test results, and clinical assessments. Informed consent was obtained from all participants or their legal representatives before study enrollment. The study was started After obtaining the Research Ethics Committee's approval (N-381-2024) and conducted over a period of 6 months, including patient recruitment, data collection, and analysis Methodology This is a prospective quasi-experimental study; it included 41 critically ill with AKI stage 1 and 2 admitted to the ICU and meeting the AKI diagnostic criteria for Kidney Disease Improving Global Outcomes (KDIGO) guidelines (stage 1 and 2) Timing of FST Administration: We tested the patient's kidney function with furosemide immediately after confirming AKI and hypoalbuminemia. Our team selected this timeline to assess kidney function rapidly before possible influences from later interventions appeared. Dose of furosemide: We used IV furosemide of 1mg/kg for diuretic-free patients and 1.5mg/kg for patients with previous diuretic use. we assigned patient status as responder or non-responder based on urine output exceeding 200 ml or not following 2 hours of furosemide treatment. To standardize conditions during the study: Allowed Medications: The research team allowed patients to maintain their necessary medications used for treatment like vasopressors antibiotics and electrolyte supplementations. Prohibited Medications: Other diuretics, albumin infusion, and nephrotoxic medications like aminoglycosides and NSAIDs needed to stop for 24-hour intervals before the test we adjusted patient fluid intake according to their current hydration levels when giving standard maintenance fluids. Avoidance of fluid boluses within six hours before the FST to ensure that fluid status did not interfere with diuretic responsiveness. Patients were managed according to standard critical care protocols, and were continuously monitored during the furosemide stress test for: Hemodynamic parameters: The team monitored blood pressure levels together with heart rate and measured central venous pressure whenever possible. Urine output: Our team tracked urine output every hour during the two-hour period after the patient received furosemide. Electrolytes: we measured sodium, potassium, and bicarbonate levels in the blood at the test start and analyzed them regularly afterward to find any problems during and after testing. Signs of adverse effects: The team checked for changes in fluid balance as well as low blood pressure and abnormal electrolytes that could need medical attention. Identified patients who received nephrotoxic drugs, vasopressors or have diabetes, on mechanical ventilation or not, sepsis (by qSOFA)) or hypoalbuminemia. Suspicion of infection and sepsis were made using the following data extracted from hospital records: blood pressure, heart rate, body temperature, respiratory rate, and level of consciousness. Demographic and laboratory variables were recorded for all patients. We calculated quick sequential organ failure assessment (qSOFA)for each patient. The score ranges from 0 to three with one point allocated for each clinical sign: systolic blood pressure 22/minutes and altered mental status from baseline. A score of equal or more than two indicates more severity with increased ICU length of stay and mortality. Statistical analysis A convenient sample of 41 acute kidney injury (AKI) patients eligible for the furosemide stress test will be included in this study. The sample size was calculated based on the primary outcome measure which is a comparison of urine output before treatment and after 2 hours. So., based on prior data from (McMahon, B. A., Chawla, L. S., & Patel, N. R. 2021) ( 11 ) and using the G power program T test family with paired comparison; 41 patients were calculated with the following statistical assumption effect size d 0.466, Power 80%, 0.05 significant level and dropout rate 10%. Analysis of data was done by IBM computer using SPSS (statistical program for social science version 23) as follows: Description of quantitative variables as median and IQR (interquartile range) according to Shapiro's test of normality. Description of qualitative variables as frequency and percentage. Fisher exact test was used to compare qualitative variables between groups. Mann-Whitney test was used instead of unpaired t-test in non-parametric data Spearman correlation to test for bivariate correlation between variables Roc curve analysis (ROC) analysis to assess the discriminant ability of albumin and SOFA in frusemide response determination P value ≤ 0.05 significant Results Patient Baseline Characteristics 41 patients with hypoalbuminemia and AKI were enrolled (Table 1). The median age was 54.63 ± 10.32 years, with 27 males (65.9%) and 14 females (34.10%). Key baseline characteristics included (Fig. 1): - AKI staging: 31 patients (75.60%) with stage 1 and 10 patients (24.40%) with stage 2 - Median serum albumin: 1.9 g/dL (IQR: 1.4–2.7) - Median Quick SOFA score: 3 (IQR: 2–3) - Median GCS: 9 (IQR: 8–12) - Sepsis as AKI cause: 23 patients (56.10%) - On nephrotoxic medications: 22 patients (53.70%) - Requiring vasopressors: 22 patients (53.70%) - On mechanical ventilation: 26 patients (63.40%) Table 1 Baseline characteristics Patient characteristics Frequency % Type AKI Sepsis 23 56.10% No Sepsis 18 43.90% Sex Male 27 65.90% Female 14 34.10% Diabetes Yes 23 56.10% No 18 43.90% KDIGO class Stage1 31 75.60% Stage 2 10 24.40% Nephrotoxic drugs Yes 22 53.70% No 19 46.30% Vasopressors Yes 22 53.70% No 19 46.30% Mechanical ventilation Yes 26 63.40% No 15 36.60% Patient characteristics Median (IQR) Range Age 54.63 ± 10.32 30–77 Serum albumin 1.9(1.4–2.7) 1.1–3.3 Dose of frusemide in mg 80(80–100) 60–120 SOFA 2(2–3) 1–4 Quick SOFA score 3(2–3) 1–3 GCS 9(8–12) 6–14 AKI = acute kidney injury, KDIGO = Kidney Disease Improving Global Outcomes GCS = Glasgow coma scale, SOFA = Sequential Organ Failure Assessment Comorbidities and clinical conditions included (Fig1): - Diabetes: 23 patients (56.10%) - Sepsis as AKI cause: 23 patients (56.10%) - On nephrotoxic medications: 22 patients (53.70%) - Requiring vasopressors: 22 patients (53.70%) - On mechanical ventilation: 26 patients (63.40%) Primary Outcome: Response to FST Of the 41 hypoalbuminemic patients, 33 patients (80.5%) responded to FST without prior albumin infusion. Response rates varied significantly by (Table 2 ): a) Albumin levels: - Responders: median albumin 2.0 g/dL (IQR: 1–3) - Non-responders: median albumin 1.0 g/dL (IQR: 1–2) - (P = 0.002) b) AKI stage: - Stage 1 patients showed significantly better response (P = 0.013) c) Clinical factors associated with response: - Absence of vasopressor support (P = 0.05) - Absence of mechanical ventilation (P = 0.018) Predictive Analysis ROC curve analysis revealed: a) Serum Albumin as a predictor (Fig. 2 ): - AUC: 0.843 - Optimal cut-off: >1.2 g/dL - Sensitivity: 93.94% (95% CI: 79.8–99.3) - Specificity: 50% (95% CI: 15.7–84.3) b) SOFA score as a predictor (Fig. 3 ): - AUC: 0.854 - Optimal cut-off: ≤2 - Sensitivity: 72.73% (95% CI: 54.5–86.7) - Specificity: 87.5% (95% CI: 47.3–99.7)" Table 2 Factors associated with FST response. Response to FST No Yes P value Factors Frequency (%) Frequency (%) Type AKI Sepsis 7 (87.5) 16 (48.5) No Sepsis 1 (12.5) 17 (51.5) 0.059 Sex Male 5 (62.5) 22 (66.7) 1 Female 3 (37.5) 11 (33.3) Diabetes Yes 7 (87.5) 16 (48.5) No 1 (12.5) 17 (51.5) 0.059 KDIGO class Stage1 3 (37.5) 28 (84.8) 0.013 Stage 2 5 (62.5 5 (15.2) Nephrotoxic drugs Yes 4 (50) 18 (54.5) No 4 (50) 15 (45.5) 1 Vasopressors Yes 7 (87.5 15 (45.5) No 1 (12.5) 18 (54.5) 0.05 Mechanical ventilation Yes 8 (100) 18 (54.5) No 0 (0) 15 (45.5) 0.018 *Age Median (IQR) 59 ± 6 54 ± 11 0.213 Range 48–69 30–77 ^SOFA Median (IQR) 3( 3 – 4 ) 2( 1 – 3 ) 0.001 Range 2–4 1–3 quick SOFA score Median (IQR) 3( 3 – 3 ) 2( 1 – 3 ) 0.024 Range 3–3 1–3 ^GCS Median (IQR) 8( 7 – 8 ) 10( 8 – 13 ) 0.005 Range 6–12 6–14 ^Serum albumin Median (IQR) 1( 1 – 2 ) 2( 1 – 3 ) 0.002 Range 1–2 1–3 Dose of furosemide in mg Median (IQR) 100(100–110) 80(80–100) 0.12 Range 60–120 60–120 Fisher Exact ^Mann Whitney U test * Independent t test p value ≤ 0.05 FST = furosemide stress test, AKI = acute kidney injury, KDIGO = Kidney Disease Improving Global Outcomes GCS = Glasgow coma scale, SOFA = Sequential Organ Failure Assessment Discussion Our study demonstrated that 80.5% of AKI patients with hypoalbuminemia responded to FST without prior albumin infusion. We identified critical factors affecting response, including baseline albumin levels (cutoff > 1.2 g/dL), AKI stage, and the absence of vasopressor support. These findings challenge the conventional practice of routine albumin administration before furosemide in hypoalbuminemic patients. While previous studies have suggested that hypoalbuminemia may impair furosemide's efficacy due to reduced protein binding and decreased tubular secretion (Smith et al., 2015; Johnson et al., 2017) (12, 13). our findings indicate that this may not be clinically significant above certain albumin thresholds. This aligns with Ahmed et al.'s (2019) work showing effective diuretic response without albumin supplementation in mild-to-moderate hypoalbuminemia but contrasts with Brown (2021) findings in severe hypoalbuminemia (14, 15). Liang Xu et al.'s (2025) work supports our findings on the effectiveness of FST in critically ill patients with AKI, they found that urine output > 188 mL in the first 2 h after FST predicts successful discontinuation of CRRT (16). The observed response pattern may be explained by several mechanisms: - Sufficient free drug fraction reaching the tubular secretion sites even with lower albumin levels - Compensatory mechanisms in early AKI maintaining tubular function - The role of critical illness severity (as evidenced by our SOFA score findings) in modulating diuretic response (17). Clinical Implications: Our findings have several practical implications: - FST without albumin supplementation may be appropriate for patients with albumin levels > 1.2 g/dL - Early AKI (KDIGO stage 1) appears more responsive to FST - The presence of mechanical ventilation and vasopressor support may predict poor response - SOFA score ≤ 2 might help identify patients more likely to respond to FST" The Study Bias and Limitations Our study has some bias that need to be emphasized. The sample size (41 patients) was relatively small, limiting the findings' statistical power and generalizability. Moreover, being a quasi-experimental study rather than a randomized controlled trial introduces some potential selection bias On the other hand, no control group received albumin supplementation for direct comparison. Lastly, the study is a single-center, limiting external validity. Our patients also have a wide age range (18–80 years) introducing some heterogeneity in the study population with a high prevalence of comorbidities (diabetes, nephrotoxic medications, sepsis) that could confound our results. In addition, we only included KDIGO stages 1 and 2 AKI, excluding more severe cases and without long-term follow-up. No mortality data is provided and no analysis of secondary outcomes or complications. We need to assess the progression of chronic kidney disease in future studies with a cost-benefit analysis. Further research should focus on Larger multicenter trials to validate our findings, Cost-effectiveness analysis of selective versus routine albumin supplementation, Investigation of long-term outcomes, Identification of additional predictive biomarkers, and Development of personalized approaches based on patient characteristics (18). Conclusion Our study suggests that FST without albumin supplementation can be effective in selected AKI patients with hypoalbuminemia, particularly those with higher baseline albumin levels and lower illness severity scores. This finding could lead to more cost-effective and targeted use of albumin supplementation in clinical practice. Abbreviations AKI acute kidney injury AUC area under the curve CKD chronic kidney disease CRRT continuous renal replacement therapy CVP central venous pressure GCS Glasgow coma scale ICU intensive care unit IQR interquartile range KDIGO Kidney Disease Improving Global Outcomes RRT renal replacement therapy SOFA Sequential Organ Failure Assessment SPSS statistical program for social science Declarations Human Ethics and Consent to Participate The study conforms to the ethical guidelines of the 1975 Declaration of Helsinki, as reflected in its prior approval by the institution’s human research committee. The Kasr Alainy School of Medicine ethical committee approved the study protocol, Cairo University, Egypt. The ethical approval number is N-381-2024 . Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Declaration of competing interest The authors have disclosed that they do not have any conflicts of interest. Author Contributions Amin Roshdy Soliman (A.R.S.) and Ahmed Yousry (A.Y.) contributed to the conceptualization of the study and the study design; A.R.S., Hoda Abdelhamid Maamoun (H.A.M.) and A.Y. contributed to the data collection and the data analysis, and A.R.S. and H.A.M. contributed to the writing of the original manuscript. All authors read and approved the final manuscript. Declaration of funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data availability All data generated or analysed during this study are provided within the manuscript [and its supplementary information file]. Acknowledgments Not applicable References Kellum, J. A., & Lameire, N. (2013). Diagnosis, evaluation, and management of acute kidney injury: A KDIGO summary (kidney disease: Improving Global Outcomes). Critical Care , 17(1), 204. DOI:10.1186/cc11454 Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81(9):819–825. Hoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Shamim, B., & Ronco, C. (2015). Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Medicine , 41(8), 1411-1423. https://doi.org/10.1007/s00134-015-3934-5 . Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL (Oct 2001). "Serial evaluation of the SOFA score to predict outcome in critically ill patients". JAMA . 286 (14): 1754–8. doi:10.1001/jama.286.14.1754. PMID11594901. Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... & Vincent, J. L. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) . JAMA, 315(8), 801–810. doi:10.1001/jama.2016.0287 Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004;351(2):159-169. doi:10.1056/NEJMra032401. Kellum, J. A., & Chawla, L. S. (2016). The furosemide stress test: Current use and future potential. Critical Care , 20(1), 274. https://doi.org/10.1186/s13054-016-1465-0 Tolkoff-Rubin, N. E., & Rubin, J. A. (2018). Furosemide stress test as a method for assessing renal tubular function in early acute kidney injury. Nephron , 140(1), 18-23. https://doi.org/10.1159/000489946 Kellum, J. A., & Chawla, L. S. (2017). The effects of furosemide in acute kidney injury: Why the response varies. Critical Care Medicine, 45 (3), 543-550. https://doi.org/10.1097/CCM.0000000000002139 Zhang, Z., & Wang, Y. (2020). Impact of hypoalbuminemia on the response to furosemide in critically ill patients with acute kidney injury: A clinical evaluation of the Furosemide Stress Test. Journal of Critical Care , 55, 14-22. https://doi.org/10.1016/j.jcrc.2019.11.004 McMahon, B. A., Chawla, L. S., & Patel, N. R. (2021). Diuretic response in acute kidney injury: A multicenter analysis of furosemide efficacy and its implications in critically ill patients. Critical Care Medicine , 49(8), 1340-1347. https://doi.org/10.1097/CCM.0000000000005162. Smith, R. M., & Adams, C. B. (2015). The impact of hypoalbuminemia on furosemide pharmacokinetics in critically ill patients. Critical Care Medicine , 43(6), 1212-1218. https://doi.org/10.1097/CCM.0000000000000960. Johnson, L. A., Patel, V. M., & Brown, J. T. (2017). Influence of hypoalbuminemia on the pharmacodynamics of furosemide in acute kidney injury. Nephrology Dialysis Transplantation , 32(10), 1744-1750. https://doi.org/10.1093/ndt/gfx049. Ahmed, A., Hasan, S., & Rahman, A. (2019). Effective diuretic response without albumin supplementation in mild-to-moderate hypoalbuminemia in critically ill patients. Journal of Critical Care , 50, 132-139. https://doi.org/10.1016/j.jcrc.2018.11.022 Brown, J. T., Patel, S., & Richards, J. D. (2021). The effects of severe hypoalbuminemia on diuretic response in critically ill patients. Critical Care Medicine , 49(5), 754-762. https://doi.org/10.1097/CCM.0000000000004924 Xu, L., Chen, L., Jiang, X., Hu, W., Gong, S., & Fang, J. (2025). The furosemide stress test predicts successful discontinuation of continuous renal replacement therapy in critically ill patients with acute kidney injury. Journal of Critical Care , Feb:85:154929. https://doi: 10.1016/j.jcrc.2024.154929. Brown, J. T., Patel, S., & Richards, J. D. (2021). Diuretic response in critically ill patients: Mechanisms and clinical implications. Critical Care Medicine , 49(5), 763-770. https://doi.org/10.1097/CCM.0000000000004925 Smith, R. M., Zhang, H., & Lee, D. A. (2022). Future directions in critical care nephrology: Exploring diuretic response, albumin supplementation, and personalized treatment strategies. Journal of Critical Care , 63, 51-58. https://doi.org/10.1016/j.jcrc.2022.01.005 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6288472","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455226328,"identity":"8f78c0cf-0647-4718-bdf2-b1c52fd9cfce","order_by":0,"name":"Amin Roshdy Soliman","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Amin","middleName":"Roshdy","lastName":"Soliman","suffix":""},{"id":455226331,"identity":"96a4cef3-f207-4128-bc5c-e3128c4f12aa","order_by":1,"name":"Ahmed Yousry","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Yousry","suffix":""},{"id":455226334,"identity":"2814b891-77ca-476b-8d5e-aeb27f3f7482","order_by":2,"name":"Hoda Abdelhamid Maamoun","email":"data:image/png;base64,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","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Hoda","middleName":"Abdelhamid","lastName":"Maamoun","suffix":""}],"badges":[],"createdAt":"2025-03-23 13:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6288472/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6288472/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04532-2","type":"published","date":"2025-11-25T15:58:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82799612,"identity":"17bd9a99-4119-445a-a285-6fba33a24809","added_by":"auto","created_at":"2025-05-15 11:00:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":368872,"visible":true,"origin":"","legend":"\u003cp\u003ePatient flow diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6288472/v1/22869f0b5c3692d85ac526ae.png"},{"id":82797395,"identity":"6259ed0b-d038-49cd-8dbb-8399ad65e8e7","added_by":"auto","created_at":"2025-05-15 10:44:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":369279,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis for Albumin\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6288472/v1/d3221aa3aa586b35ec0c31fc.png"},{"id":82797392,"identity":"53d767d1-be46-47ca-a76d-668b022133e3","added_by":"auto","created_at":"2025-05-15 10:44:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":356856,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis for SOFA\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6288472/v1/9cf18cadfe3095e282246282.png"},{"id":97178653,"identity":"0c80609e-89e2-4bbe-80bd-ada698f06a66","added_by":"auto","created_at":"2025-12-01 16:12:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2096746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6288472/v1/752a2cd2-0c8c-43d2-b53d-0f9b3858db0e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Do AKI patients with hypoalbuminemia respond to furosemide stress test without prior albumin infusion?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute Kidney Injury (AKI) is a common and serious complication that is associated with several adverse outcomes including death, need for renal replacement therapy (RRT), increased length of hospital stay, chronic kidney disease, and rising health care costs. Even mild forms of kidney injury influence short- and long-term morbidity and mortality through a progression of chronic kidney disease (CKD) and cardiovascular disease. Specific treatments for AKI are currently lacking and supportive care is the mainstay of therapy. Prevention is therefore of the utmost importance and relies on the identification of individuals at high risk for development of AKI early in the intensive care unit (ICU) admission (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the critically ill, sepsis is the major cause of AKI, accounting for nearly 50% of cases so Suspicion of infection was made using The Sequential Organ Failure Assessment (SOFA) score. It is a scoring system that assesses the performance of several organ systems in the body (neurologic, blood, liver, kidney, and blood pressure/hemodynamics) and assigns a score based on the data obtained in each category (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCritically ill patients with AKI may receive an exogenous source of vasopressin or its analog that increases sodium and water retention. These mechanisms might have the effect of amplifying the defect in water excretion in edematous AKI patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince the most common causes of intrinsic AKI involve acute tubular injury, we sought to develop a functional assessment of renal tubular function. Furosemide, a loop diuretic, has pharmacokinetic properties that make it an appealing functional tool (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). We think that furosemide-induced increases in urine output might be a method to assess the integrity of renal tubular function in the setting of early AKI. Specifically, we hypothesized that the kidney\u0026rsquo;s response or lack of response to a furosemide challenge, as a clinical assessment of tubular function, could identify patients with severe tubular injury before it was clinically apparent (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe action and efficacy of furosemide differs considerably in patients with AKI, several factors account for these differences as nephrotoxic medications, vasopressors, sepsis, hypoalbuminemia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCritically ill patients are often moderately to severely hypoalbuminemia. We believe that hypoalbuminemia could play a significant role in influencing diuretic response, given that 95% of furosemide binds to plasma proteins. there is a knowledge gap this study aims to fill. Therefore, this study explains why the research question is important and how it has a potential clinical impact on its findings. Thus, our objective is to evaluate the effectiveness of the Furosemide Stress Test in critically ill patients with AKI stages 1 and 2 and the effect of several factors as nephrotoxic drugs, vasopressors, diabetes, sepsis, and hypoalbuminemia on the effectiveness of the Furosemide Stress Test in these patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Recruitment and Screening\u003c/h2\u003e \u003cp\u003epatients were recruited from the Intensive Care Unit in Kasr Alaini Hospital, patients who satisfied the following criteria were assessed for FST.\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMeeting the AKI diagnostic criteria for Kidney Disease Improving Global Outcomes (KDIGO) guidelines, stage 1 and 2); Stage 1: Serum creatinine 1.5\u0026ndash;1.9 times baseline or \u0026ge;\u0026thinsp;0.3 mg/dL increase, Urine output\u0026thinsp;\u0026lt;\u0026thinsp;0.5 mL/kg/h for 6 h, Stage 2: serum creatinine 2-2.9 times baseline, Urine output\u0026thinsp;\u0026lt;\u0026thinsp;0.5 mL/kg/h for 12 h\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eappropriate blood volume and central venous pressure (CVP)\u0026thinsp;\u0026ge;\u0026thinsp;6 mmHg; and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eurine output\u0026thinsp;\u0026le;\u0026thinsp;0.5 ml/kg/h for 6 h.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eage\u0026thinsp;\u0026lt;\u0026thinsp;18 years;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eindications for emergency CRRT: hyperkalemia, potassium of blood\u0026thinsp;\u0026ge;\u0026thinsp;6.5 mmol/L; metabolic acidosis, PH\u0026thinsp;\u0026le;\u0026thinsp;7.15; acute pulmonary edema due to fluid overload; developed uremia-related complications, such as pericarditis, bleeding, etc.;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003echronic kidney disease or having received renal replacement therapy 30 days before inclusion;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003epresence of postrenal obstruction factors;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvidence of volume depletion at the time of furosemide administration.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRandomization Process\u003c/h3\u003e\n\u003cp\u003eIn this single-group quasi-experimental design, randomization was not applied since there were no comparison or control groups. All eligible patients who met the inclusion criteria during the study period received the intervention. A consecutive sampling approach was used to ensure that participant selection was as unbiased as possible, enrolling patients in the order they were identified as eligible.\u003c/p\u003e\n\u003ch3\u003eBlinding Procedures\u003c/h3\u003e\n\u003cp\u003eGiven the single-group design, blinding was primarily applied to minimize assessment bias:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOutcome assessors evaluating the response to the FST were blinded to the study\u0026rsquo;s objectives and specific patient characteristics.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLaboratory personnel analyzing biochemical parameters were also blinded to reduce the risk of subjective interpretation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients were not informed about the study's focus on hypoalbuminemia to avoid influencing their subjective reports of symptoms or outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eScreening involves reviewing patient medical records, laboratory test results, and clinical assessments. Informed consent was obtained from all participants or their legal representatives before study enrollment.\u003c/p\u003e \u003cp\u003eThe study was started After obtaining the Research Ethics Committee's approval \u003cb\u003e(N-381-2024)\u003c/b\u003e and conducted over a period of 6 months, including patient recruitment, data collection, and analysis\u003c/p\u003e\n\u003ch3\u003eMethodology\u003c/h3\u003e\n\u003cp\u003e This is a prospective quasi-experimental study; it included 41 critically ill with AKI stage 1 and 2 admitted to the ICU and meeting the AKI diagnostic criteria for Kidney Disease Improving Global Outcomes (KDIGO) guidelines (stage 1 and 2)\u003c/p\u003e \u003cp\u003eTiming of FST Administration:\u003c/p\u003e \u003cp\u003eWe tested the patient's kidney function with furosemide immediately after confirming AKI and hypoalbuminemia. Our team selected this timeline to assess kidney function rapidly before possible influences from later interventions appeared.\u003c/p\u003e \u003cp\u003eDose of furosemide: We used IV furosemide of 1mg/kg for diuretic-free patients and 1.5mg/kg for patients with previous diuretic use.\u003c/p\u003e \u003cp\u003ewe assigned patient status as responder or non-responder based on urine output exceeding 200 ml or not following 2 hours of furosemide treatment.\u003c/p\u003e \u003cp\u003eTo standardize conditions during the study:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAllowed Medications: The research team allowed patients to maintain their necessary medications used for treatment like vasopressors antibiotics and electrolyte supplementations.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProhibited Medications: Other diuretics, albumin infusion, and nephrotoxic medications like aminoglycosides and NSAIDs needed to stop for 24-hour intervals before the test\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ewe adjusted patient fluid intake according to their current hydration levels when giving standard maintenance fluids. Avoidance of fluid boluses within six hours before the FST to ensure that fluid status did not interfere with diuretic responsiveness.\u003c/p\u003e \u003cp\u003ePatients were managed according to standard critical care protocols, and were continuously monitored during the furosemide stress test for:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHemodynamic parameters: The team monitored blood pressure levels together with heart rate and measured central venous pressure whenever possible.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUrine output: Our team tracked urine output every hour during the two-hour period after the patient received furosemide.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eElectrolytes: we measured sodium, potassium, and bicarbonate levels in the blood at the test start and analyzed them regularly afterward to find any problems during and after testing.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSigns of adverse effects: The team checked for changes in fluid balance as well as low blood pressure and abnormal electrolytes that could need medical attention.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIdentified patients who received nephrotoxic drugs, vasopressors or have diabetes, on mechanical ventilation or not, sepsis (by qSOFA)) or hypoalbuminemia.\u003c/p\u003e \u003cp\u003eSuspicion of infection and sepsis were made using the following data extracted from hospital records: blood pressure, heart rate, body temperature, respiratory rate, and level of consciousness. Demographic and laboratory variables were recorded for all patients. We calculated quick sequential organ failure assessment (qSOFA)for each patient. The score ranges from 0 to three with one point allocated for each clinical sign: systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;100 mmHg respiratory rate\u0026thinsp;\u0026gt;\u0026thinsp;22/minutes and altered mental status from baseline. A score of equal or more than two indicates more severity with increased ICU length of stay and mortality.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eA convenient sample of 41 acute kidney injury (AKI) patients eligible for the furosemide stress test will be included in this study. The sample size was calculated based on the primary outcome measure which is a comparison of urine output before treatment and after 2 hours. So., based on prior data from (McMahon, B. A., Chawla, L. S., \u0026amp; Patel, N. R. 2021) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and using the G power program T test family with paired comparison; 41 patients were calculated with the following statistical assumption effect size d 0.466, Power 80%, 0.05 significant level and dropout rate 10%. Analysis of data was done by IBM computer using SPSS (statistical program for social science version 23) as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDescription of quantitative variables as median and IQR (interquartile range) according to Shapiro's test of normality.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDescription of qualitative variables as frequency and percentage.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFisher exact test was used to compare qualitative variables between groups.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMann-Whitney test was used instead of unpaired t-test in non-parametric data\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSpearman correlation to test for bivariate correlation between variables\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRoc curve analysis (ROC) analysis to assess the discriminant ability of albumin and SOFA in frusemide response determination\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eP value\u0026thinsp;\u0026le;\u0026thinsp;0.05 significant\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003ePatient Baseline Characteristics\u003c/h2\u003e\n \u003cp\u003e41 patients with hypoalbuminemia and AKI were enrolled (Table\u0026nbsp;1). The median age was 54.63\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32 years, with 27 males (65.9%) and 14 females (34.10%).\u003c/p\u003e\n \u003cp\u003eKey baseline characteristics included (Fig.\u0026nbsp;1):\u003c/p\u003e\n \u003cp\u003e- AKI staging: 31 patients (75.60%) with stage 1 and 10 patients (24.40%) with stage 2\u003c/p\u003e\n \u003cp\u003e- Median serum albumin: 1.9 g/dL (IQR: 1.4\u0026ndash;2.7)\u003c/p\u003e\n \u003cp\u003e- Median Quick SOFA score: 3 (IQR: 2\u0026ndash;3)\u003c/p\u003e\n \u003cp\u003e- Median GCS: 9 (IQR: 8\u0026ndash;12)\u003c/p\u003e\n \u003cp\u003e- Sepsis as AKI cause: 23 patients (56.10%)\u003c/p\u003e\n \u003cp\u003e- On nephrotoxic medications: 22 patients (53.70%)\u003c/p\u003e\n \u003cp\u003e- Requiring vasopressors: 22 patients (53.70%)\u003c/p\u003e\n \u003cp\u003e- On mechanical ventilation: 26 patients (63.40%)\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatient characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eType AKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Sepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eKDIGO class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNephrotoxic drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVasopressors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMechanical ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.63\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30\u0026ndash;77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSerum albumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9(1.4\u0026ndash;2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.1\u0026ndash;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDose of frusemide in mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80(80\u0026ndash;100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e60\u0026ndash;120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSOFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuick SOFA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(8\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e6\u0026ndash;14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eAKI\u0026thinsp;=\u0026thinsp;acute kidney injury, KDIGO\u0026thinsp;=\u0026thinsp;Kidney Disease Improving Global Outcomes\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eGCS\u0026thinsp;=\u0026thinsp;Glasgow coma scale, SOFA\u0026thinsp;=\u0026thinsp;Sequential Organ Failure Assessment\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\u003cp\u003e\u003cstrong\u003eComorbidities and clinical conditions included (Fig1):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Diabetes: 23 patients (56.10%)\u003c/p\u003e\n\u003cp\u003e- Sepsis as AKI cause: 23 patients (56.10%)\u003c/p\u003e\n\u003cp\u003e- On nephrotoxic medications: 22 patients (53.70%)\u003c/p\u003e\n\u003cp\u003e- Requiring vasopressors: 22 patients (53.70%)\u003c/p\u003e\n\u003cp\u003e- On mechanical ventilation: 26 patients (63.40%)\u003c/p\u003e\n\u003ch3\u003ePrimary Outcome: Response to FST\u003c/h3\u003e\n\u003cp\u003eOf the 41 hypoalbuminemic patients, 33 patients (80.5%) responded to FST without prior albumin infusion. Response rates varied significantly by (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\n\u003cp\u003ea) Albumin levels:\u003c/p\u003e\n\u003cp\u003e- Responders: median albumin 2.0 g/dL (IQR: 1\u0026ndash;3)\u003c/p\u003e\n\u003cp\u003e- Non-responders: median albumin 1.0 g/dL (IQR: 1\u0026ndash;2)\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003cp\u003e- (P\u0026thinsp;=\u0026thinsp;0.002)\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003eb) AKI stage:\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003e- Stage 1 patients showed significantly better response (P\u0026thinsp;=\u0026thinsp;0.013)\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003ec) Clinical factors associated with response:\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003e- Absence of vasopressor support (P\u0026thinsp;=\u0026thinsp;0.05)\u003c/p\u003e\n \u003cp\u003e- Absence of mechanical ventilation (P\u0026thinsp;=\u0026thinsp;0.018)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePredictive Analysis\u003c/h2\u003e\n \u003cp\u003eROC curve analysis revealed:\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003ea) Serum Albumin as a predictor (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003e- AUC: 0.843\u003c/p\u003e\n \u003cp\u003e- Optimal cut-off: \u0026gt;1.2 g/dL\u003c/p\u003e\n \u003cp\u003e- Sensitivity: 93.94% (95% CI: 79.8\u0026ndash;99.3)\u003c/p\u003e\n \u003cp\u003e- Specificity: 50% (95% CI: 15.7\u0026ndash;84.3)\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003eb) SOFA score as a predictor (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e):\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003e- AUC: 0.854\u003c/p\u003e\n \u003cp\u003e- Optimal cut-off: \u0026le;2\u003c/p\u003e\n \u003cp\u003e- Sensitivity: 72.73% (95% CI: 54.5\u0026ndash;86.7)\u003c/p\u003e\n \u003cp\u003e- Specificity: 87.5% (95% CI: 47.3\u0026ndash;99.7)\u0026quot;\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors associated with FST response.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eResponse to FST\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eType AKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Sepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eKDIGO class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNephrotoxic drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVasopressors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMechanical ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e*Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u0026ndash;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e^SOFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003equick SOFA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e^GCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e^Serum albumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDose of furosemide in mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100(100\u0026ndash;110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80(80\u0026ndash;100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u0026ndash;120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u0026ndash;120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFisher Exact ^Mann Whitney U test * Independent t test p value\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/p\u003e\n \u003cp\u003eFST\u0026thinsp;=\u0026thinsp;furosemide stress test, AKI\u0026thinsp;=\u0026thinsp;acute kidney injury, KDIGO\u0026thinsp;=\u0026thinsp;Kidney Disease Improving Global Outcomes\u003c/p\u003e\n \u003cp\u003eGCS\u0026thinsp;=\u0026thinsp;Glasgow coma scale, SOFA\u0026thinsp;=\u0026thinsp;Sequential Organ Failure Assessment\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study demonstrated that 80.5% of AKI patients with hypoalbuminemia responded to FST without prior albumin infusion. We identified critical factors affecting response, including baseline albumin levels (cutoff \u0026gt; 1.2 g/dL), AKI stage, and the absence of vasopressor support. These findings challenge the conventional practice of routine albumin administration before furosemide in hypoalbuminemic patients.\u003c/p\u003e\n\u003cp\u003eWhile previous studies have suggested that hypoalbuminemia may impair furosemide's efficacy due to reduced protein binding and decreased tubular secretion (Smith et al., 2015; Johnson et al., 2017) (12, 13). our findings indicate that this may not be clinically significant above certain albumin thresholds. This aligns with Ahmed et al.'s (2019) work showing effective diuretic response without albumin supplementation in mild-to-moderate hypoalbuminemia but contrasts with Brown (2021) findings in severe hypoalbuminemia (14, 15). Liang Xu et al.'s (2025) work supports our findings on the effectiveness of FST in critically ill patients with AKI, they found that urine output \u0026gt; 188 mL in the first 2 h after FST predicts successful discontinuation of CRRT (16).\u003c/p\u003e\n\u003cp\u003eThe observed response pattern may be explained by several mechanisms:\u003c/p\u003e\n\u003cp\u003e- Sufficient free drug fraction reaching the tubular secretion sites even with lower albumin levels\u003c/p\u003e\n\u003cp\u003e- Compensatory mechanisms in early AKI maintaining tubular function\u003c/p\u003e\n\u003cp\u003e- The role of critical illness severity (as evidenced by our SOFA score findings) in modulating diuretic response (17).\u003c/p\u003e\n\u003cp\u003eClinical Implications:\u003c/p\u003e\n\u003cp\u003eOur findings have several practical implications:\u003c/p\u003e\n\u003cp\u003e- FST without albumin supplementation may be appropriate for patients with albumin levels \u0026gt; 1.2 g/dL\u003c/p\u003e\n\u003cp\u003e- Early AKI (KDIGO stage 1) appears more responsive to FST\u003c/p\u003e\n\u003cp\u003e- The presence of mechanical ventilation and vasopressor support may predict poor response\u003c/p\u003e\n\u003cp\u003e- SOFA score ≤ 2 might help identify patients more likely to respond to FST\"\u003c/p\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eThe Study Bias and Limitations\u003c/h2\u003e\n \u003cp\u003eOur study has some bias that need to be emphasized. The sample size (41 patients) was relatively small, limiting the findings' statistical power and generalizability. Moreover, being a quasi-experimental study rather than a randomized controlled trial introduces some potential selection bias\u003c/p\u003e\n \u003cp\u003eOn the other hand, no control group received albumin supplementation for direct comparison. Lastly, the study is a single-center, limiting external validity. Our patients also have a wide age range (18–80 years) introducing some heterogeneity in the study population with a high prevalence of comorbidities (diabetes, nephrotoxic medications, sepsis) that could confound our results.\u003c/p\u003e\n \u003cp\u003eIn addition, we only included KDIGO stages 1 and 2 AKI, excluding more severe cases and without long-term follow-up. No mortality data is provided and no analysis of secondary outcomes or complications. We need to assess the progression of chronic kidney disease in future studies with a cost-benefit analysis.\u003c/p\u003e\n \u003cp\u003eFurther research should focus on Larger multicenter trials to validate our findings, Cost-effectiveness analysis of selective versus routine albumin supplementation, Investigation of long-term outcomes, Identification of additional predictive biomarkers, and Development of personalized approaches based on patient characteristics (18).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study suggests that FST without albumin supplementation can be effective in selected AKI patients with hypoalbuminemia, particularly those with higher baseline albumin levels and lower illness severity scores. This finding could lead to more cost-effective and targeted use of albumin supplementation in clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAKI acute kidney injury\u003c/p\u003e\n\u003cp\u003eAUC area under the curve \u003c/p\u003e\n\u003cp\u003eCKD chronic kidney disease\u003c/p\u003e\n\u003cp\u003eCRRT continuous renal replacement therapy\u003c/p\u003e\n\u003cp\u003eCVP central venous pressure \u003c/p\u003e\n\u003cp\u003eGCS Glasgow coma scale\u003c/p\u003e\n\u003cp\u003eICU intensive care unit\u003c/p\u003e\n\u003cp\u003eIQR interquartile range\u003c/p\u003e\n\u003cp\u003eKDIGO Kidney Disease Improving Global Outcomes\u003c/p\u003e\n\u003cp\u003eRRT renal replacement therapy\u003c/p\u003e\n\u003cp\u003eSOFA Sequential Organ Failure Assessment \u003c/p\u003e\n\u003cp\u003eSPSS statistical program for social science \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conforms to the ethical guidelines of the 1975 Declaration of Helsinki, as reflected in its prior approval by the institution\u0026rsquo;s human research committee. The Kasr Alainy School of Medicine ethical committee approved the study protocol, Cairo University, Egypt. The ethical approval number is N-381-2024\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have disclosed that they do not have any conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmin Roshdy Soliman (A.R.S.) and Ahmed Yousry (A.Y.) contributed to the conceptualization of the study and the study design; A.R.S., Hoda Abdelhamid Maamoun (H.A.M.) and A.Y. contributed to the data collection and the data analysis, and A.R.S. and H.A.M. contributed to the writing of the original manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are provided within the manuscript [and its supplementary information file].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKellum, J. A., \u0026amp; Lameire, N. (2013). Diagnosis, evaluation, and management of acute kidney injury: A KDIGO summary (kidney disease: Improving Global Outcomes). \u003cem\u003eCritical Care\u003c/em\u003e, 17(1), 204. DOI:10.1186/cc11454\u003c/li\u003e\n\u003cli\u003eSingbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81(9):819\u0026ndash;825. \u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eHoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Shamim, B., \u0026amp; Ronco, C. (2015). Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. \u003c/strong\u003e\u003cem\u003eIntensive Care Medicine\u003c/em\u003e\u003cstrong\u003e, 41(8), 1411-1423. https://doi.org/10.1007/s00134-015-3934-5\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eFerreira FL, Bota DP, Bross A, M\u0026eacute;lot C, Vincent JL (Oct 2001). \u0026quot;Serial evaluation of the SOFA score to predict outcome in critically ill patients\u0026quot;. \u003cem\u003eJAMA\u003c/em\u003e. 286 (14): 1754\u0026ndash;8. doi:10.1001/jama.286.14.1754. PMID11594901.\u003c/li\u003e\n\u003cli\u003eSinger, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... \u0026amp; Vincent, J. L. (2016). \u003cem\u003eThe Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)\u003c/em\u003e. JAMA, 315(8), 801\u0026ndash;810. doi:10.1001/jama.2016.0287\u003c/li\u003e\n\u003cli\u003eSchrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004;351(2):159-169. doi:10.1056/NEJMra032401.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eKellum, J. A., \u0026amp; Chawla, L. S.\u003c/strong\u003e (2016). The furosemide stress test: Current use and future potential. \u003cem\u003eCritical Care\u003c/em\u003e, 20(1), 274. https://doi.org/10.1186/s13054-016-1465-0\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eTolkoff-Rubin, N. E., \u0026amp; Rubin, J. A.\u003c/strong\u003e (2018). Furosemide stress test as a method for assessing renal tubular function in early acute kidney injury. \u003cem\u003eNephron\u003c/em\u003e, 140(1), 18-23. https://doi.org/10.1159/000489946\u003c/li\u003e\n\u003cli\u003eKellum, J. A., \u0026amp; Chawla, L. S. (2017). The effects of furosemide in acute kidney injury: Why the response varies. \u003cem\u003eCritical Care Medicine, 45\u003c/em\u003e(3), 543-550. https://doi.org/10.1097/CCM.0000000000002139\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eZhang, Z., \u0026amp; Wang, Y.\u003c/strong\u003e (2020). Impact of hypoalbuminemia on the response to furosemide in critically ill patients with acute kidney injury: A clinical evaluation of the Furosemide Stress Test. \u003cem\u003eJournal of Critical Care\u003c/em\u003e, 55, 14-22. https://doi.org/10.1016/j.jcrc.2019.11.004\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMcMahon, B. A., Chawla, L. S., \u0026amp; Patel, N. R.\u003c/strong\u003e (2021). Diuretic response in acute kidney injury: A multicenter analysis of furosemide efficacy and its implications in critically ill patients. \u003cem\u003eCritical Care Medicine\u003c/em\u003e, 49(8), 1340-1347. https://doi.org/10.1097/CCM.0000000000005162.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSmith, R. M., \u0026amp; Adams, C. B.\u003c/strong\u003e (2015). The impact of hypoalbuminemia on furosemide pharmacokinetics in critically ill patients. \u003cem\u003eCritical Care Medicine\u003c/em\u003e, 43(6), 1212-1218. https://doi.org/10.1097/CCM.0000000000000960.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eJohnson, L. A., Patel, V. M., \u0026amp; Brown, J. T.\u003c/strong\u003e (2017). Influence of hypoalbuminemia on the pharmacodynamics of furosemide in acute kidney injury. \u003cem\u003eNephrology Dialysis Transplantation\u003c/em\u003e, 32(10), 1744-1750. https://doi.org/10.1093/ndt/gfx049.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAhmed, A., Hasan, S., \u0026amp; Rahman, A.\u003c/strong\u003e (2019). Effective diuretic response without albumin supplementation in mild-to-moderate hypoalbuminemia in critically ill patients. \u003cem\u003eJournal of Critical Care\u003c/em\u003e, 50, 132-139. https://doi.org/10.1016/j.jcrc.2018.11.022\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBrown, J. T., Patel, S., \u0026amp; Richards, J. D.\u003c/strong\u003e (2021). The effects of severe hypoalbuminemia on diuretic response in critically ill patients. \u003cem\u003eCritical Care Medicine\u003c/em\u003e, 49(5), 754-762. https://doi.org/10.1097/CCM.0000000000004924\u003c/li\u003e\n\u003cli\u003eXu, L., Chen, L., Jiang, X., Hu, W., Gong, S., \u0026amp; Fang, J. (2025). The furosemide stress test predicts successful discontinuation of continuous renal replacement therapy in critically ill patients with acute kidney injury. \u003cem\u003eJournal of Critical Care\u003c/em\u003e, Feb:85:154929. https://doi: 10.1016/j.jcrc.2024.154929.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBrown, J. T., Patel, S., \u0026amp; Richards, J. D.\u003c/strong\u003e (2021). Diuretic response in critically ill patients: Mechanisms and clinical implications. \u003cem\u003eCritical Care Medicine\u003c/em\u003e, 49(5), 763-770. https://doi.org/10.1097/CCM.0000000000004925\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSmith, R. M., Zhang, H., \u0026amp; Lee, D. A.\u003c/strong\u003e (2022). Future directions in critical care nephrology: Exploring diuretic response, albumin supplementation, and personalized treatment strategies. \u003cem\u003eJournal of Critical Care\u003c/em\u003e, 63, 51-58. https://doi.org/10.1016/j.jcrc.2022.01.005\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute kidney injury, hypoalbuminemia, furosemide stress test","lastPublishedDoi":"10.21203/rs.3.rs-6288472/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6288472/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAcute kidney injury (AKI) is a common and serious condition often associated with hypoalbuminemia, which can influence the pharmacokinetics and efficacy of diuretics like furosemide. In critically ill patients, sepsis is the major cause of AKI, accounting for nearly 50% of cases.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate whether AKI patients with hypoalbuminemia can respond to FST without albumin supplementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a prospective quasi-experimental study. Patients were obtained from the intensive care unit of Cairo University Hospital with AKI stages 1 and 2 with hypoalbuminemia. A bolus of furosemide was administered at a dose calculated to be 1-1.5 mg/kg in a single dose to patients without a prior diagnosis of kidney disease and clinical signs of hypovolemia.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 41 critically ill patients with AKI were enrolled, aged between 18 and 80 years, of which 56.10% had diabetes mellitus, 53.70% were on at least one nephrotoxic medication, and 56.10% had sepsis as the cause of AKI. The median (IQR) albumin level was 1.9 g/dL (1.4\u0026ndash;2.7). Among 41 hypoalbuminemic AKI patients included, 80.50% responded to FST without prior albumin infusion. Non-responders had significantly lower baseline serum albumin levels median (IQR) 1(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) vs. 2 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) g/dL, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.002).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAKI patients with mild-to-moderate hypoalbuminemia may still respond to FST without albumin infusion, although response rates decline with the increasing severity of hypoalbuminemia. The FST remains a valuable predictive tool in hypoalbuminemic AKI patients but warrants further investigation to optimize its utility in this population.\u003c/p\u003e","manuscriptTitle":"Do AKI patients with hypoalbuminemia respond to furosemide stress test without prior albumin infusion?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:43:56","doi":"10.21203/rs.3.rs-6288472/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-12T12:31:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T16:27:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T14:51:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284438814848602022365747001284879161958","date":"2025-07-16T17:59:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193694804906179332877006185915211967165","date":"2025-06-29T19:32:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-12T05:59:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-03T10:36:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-03T09:23:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-03T08:02:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-04-03T08:01:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d26b30d1-ac8f-4b30-81f3-804b0ee215f9","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:05:18+00:00","versionOfRecord":{"articleIdentity":"rs-6288472","link":"https://doi.org/10.1186/s12882-025-04532-2","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-11-25 15:58:47","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-05-15 10:43:56","video":"","vorDoi":"10.1186/s12882-025-04532-2","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04532-2","workflowStages":[]},"version":"v1","identity":"rs-6288472","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6288472","identity":"rs-6288472","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}