Effect of levosimendan on renal function in background of left ventricular dysfunction: a meta-analysis of randomized trials

What should clinicians know about the renal effect and the mechanism of action of levosimendan?

“…Long et al proposed several explanations for the renoprotective effects of levosimendan, based on clinical and preclinical studies [1]. First, the enhancement of cardiac contractility (CC) and vasodilation in peripheral vessels (particularly the kidney arteries) improves kidney blood flow (KBF), relieving the renal ischemia caused by cardiac failure [1]. However, the increase in CC and improved overall KBF is not enough to impede the risk of AKI [2] and this traditional paradigm has been challenged.…”

“…The opulent oxygen supply of the cortex as initiated by an increase alone in KBF through enhancement of CC therefore has, at best, a questionable renoprotective effect [3][4][5][6]. The second hypothesis proposed by Long et al states that, in contrast to dobutamine, levosimendan preferentially acts on afferent arterioles to increase global KBF with an effect on GFR, by balancing the oxygen supply and removal of the renal medulla, in contrast to an ineffective increase in RBF as with dobutamine [1].This may go some way to explain the advantageous effects of levosimendan. In a contemporary study with a randomized clinical design drawing a parallel between dobutamine and levosimendan in another situation like cardio-renal dilemma , two studies produced comparable data [7,8] by quantifying KBF via the kidney vessels [7,8].…”

“…Furthermore, levosimendan therapy was associated with the improvement of glomerular filtration rate (GFR) and urine output [1]. Long et al proposed a number of mechanisms explaining their findings [1]. To further elucidate these mechanisms for bedside clinicians, we critically evaluate them.…”

“…Recently, some trials challenged the favorable consequences of levosimendan towards renal function. A recent meta-analysis by Long et al evaluated twentyeight studies in 5,069 patients [1]. Levosimendan reduced the serum creatinine (sCr) and the risk of acute kidney injury (AKI) patients with left ventricular dysfunction (LVD) compared with the control group [1].…”

“…The reduction of sCr was more pronounced in patients with a relatively high baseline sCr level. Furthermore, levosimendan therapy was associated with the improvement of glomerular filtration rate (GFR) and urine output [1]. Long et al proposed a number of mechanisms explaining their findings [1].…”