CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Low‐dose Dopamine in the Intensive Care Unit

Abstract

For much of the last four decades, low-dose dopamine has been considered the drug of choice to treat and prevent renal failure in the intensive care unit (ICU). The multifactorial etiology of renal failure in the ICU and the presence of coexisting multisystem organ dysfunction make the design and execution of clinical trials to study this problem difficult. However, in the last decade, several meta-analyses and one large randomized trial have all shown a lack of benefit of low-dose dopamine in improving renal function. There are multiple reasons for this lack of efficacy. While dopamine does cause a diuretic effect, it does very little to improve mortality, creatinine clearance, or the incidence of dialysis. Evidence is also growing of its adverse effects on the immune, endocrine, and respiratory systems. It may also potentially increase mortality in sepsis. It is the opinion of the authors that the practice of using low-dose dopamine should be abandoned. Other drugs and treatment modalities need to be explored to address the serious issue of renal failure in the ICU.

Effects of low-dose dopamine on urine output in normotensive very low birth weight neonates

“…When restricted to neonates whose starting UOP was <1.5 mL/kg/hr, we found twice the increase in UOP compared to the entire cohort that received low-dose dopamine. Our findings are consistent with previous reports in which low-dose dopamine was associated with increased UOP, but not associated with improvements in serum creatinine (8, 10, 11). …”

“…Theoretically, low-dose dopamine should result in increased UOP (13). Although there has been significant debate about its use for this purpose in pediatric and adult ICU populations (including suggestion that its use be abandoned) (6, 10, 14), there has been little study dedicated to the VLBW and ELBW neonate. There have been studies that show older animals have increased renal blood flow and naturesis secondary to dopamine compared to younger animals, suggesting a maturation of the dopamine receptor (15).…”

Perioperative Renal Pharmacological Protection During Cardiovascular Surgery

“…Some authors have even found that low-dose dopamine may actually worsen renal perfusion [72]. Finally both high-quality mRCTs and metaanalyses failed to demonstrate any effect of lowdose dopamine on incidence or clinical course of AKI or mortality [73,74].…”

Acute Kidney Injury

“…However, 'low-dose' or 'renal-dose' dopamine has not been shown to be effective in preventing AKI (Karthik and Lisbon 2006), after investigations in many different clinical scenarios and in some studies in which urine output and/or creatinine clearance improved. Dopamine (0.5-2 mg kg À1 min À1 ) has almost exclusively dopaminergic (as opposed to beta-and alpha-adrenergic) effects that include renal arterial dilation and increased renal blood flow.…”

“…In a trial of thyroxine, greater mortality was seen in the treatment arm (43 vs 13%) (Acker et al 2000). Diuretics and dopamine have also been ineffective in improving outcomes in AKI (Karthik and Lisbon 2006). Diuretics and dopamine have also been ineffective in improving outcomes in AKI (Karthik and Lisbon 2006).…”