Fenoldopam Infusion for Renal Protection in High-Risk Cardiac Surgery Patients: A Randomized Clinical Study

Cogliati, Andrea A.; Vellutini, Raffaella; Nardini, Antonia; Urovi, Sali; Hamdan, Mazen; Landoni, Giovanni; Guelfi, P.

doi:10.1053/j.jvca.2007.02.022

Cited by 86 publications

(33 citation statements)

References 16 publications

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“…Innovative approaches using catheter-based infusion of fenoldopam directly into the renal vessels are being investigated. 34 Further adequately powered studies are warranted before broad recommendations can be made.…”

Section: Perioperative Management Of Aki-cpbmentioning

confidence: 99%

Cardiopulmonary Bypass–associated Acute Kidney Injury

Kumar

Suneja

Riou³

2011

Anesthesiology

171

115

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APPROXIMATELY 300,000 patients undergo cardiac surgical procedures each year in the United States. More than 80% of routine cardiac surgical procedures are performed using cardiopulmonary bypass (CPB).1 Acute kidney injury (AKI; previously referred to as acute renal failure) after CPB is a well-known, yet incompletely understood, entity that has significant implications on both short-and long-term outcomes. The development of AKI after CPB is associated with a significant increase in infectious complications, an increase in length of hospital stay, and greater mortality when compared with patients without AKI-CPB.2 The incidence of AKI-CPB averages 20 -30%, depending on the definition used and the duration of the postoperative period studied.3,4 Furthermore, more patients with AKI-CPB who require dialysis remain dialysis dependant. For all patients undergoing CPB, the risk of AKI-CPB is the least in those who undergo coronary artery bypass grafting (CABG) only; the risk increases for patients undergoing valve replacement surgery; and the risk is the greatest after combined CABGvalve procedures. 4 There has not been a significant reduction in mortality, despite many recent advances in our understanding of the causative pathophysiology and pharmacotherapeutics of AKI-CPB. Furthermore, advances in renal replacement therapies (RRTs) have not significantly altered the overall mortality associated with AKI-CPB.In this review, we will focus on the current definitions of AKI, pathophysiologic features, and risk factors for developing AKI-CPB. We will also discuss perioperative strategies and emerging concepts that add to our understanding of this complex entity to help better manage patients at risk for AKI-CPB. Defining AKIAKI is a complex diagnosis and has been described using several definitions and diagnostic criteria, ranging from a 25% increase in baseline serum creatinine (sCr) to the need for hemodialysis.3,4 The requirement for a consensus definition addressing early detection and grading of severity of AKI led to the development of the Risk-Injury-Failure-Loss-End stage kidney disease (RIFLE) classification by the Acute Dialysis Quality Initiative. 5 To further refine the scoring, the Acute Kidney Injury Network (AKIN) proposed a modification of the RIFLE classification, known as the AKIN classification. 6 The RIFLE and AKIN classifications have been used and validated in prospective studies 7 in patients with AKI after cardiac surgery.The differences between RIFLE and AKIN staging criteria are subtle. Stage 1 in the AKIN classification has been broadened to include patients with an increase in sCr of at least 26.5 M (0.3 mg/dl) greater than baseline because there is accumulating evidence that even minor increments in sCr concentration are associated with adverse outcomes. 6 In contrast, the "risk" stage of RIFLE classification requires a 50% increase in sCr over baseline. Urine output over time is retained in both classification systems because it may precede the increase in sCr, especially in critically ill ...

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Section: Perioperative Management Of Aki-cpbmentioning

confidence: 99%

Cardiopulmonary Bypass–associated Acute Kidney Injury

Kumar

Suneja

Riou³

2011

Anesthesiology

171

115

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“…Fenoldopam is a selective dopamine-1 receptor agonist with no β-1 or α-adrenergic receptor agonistic eff ects and similar to dopamine, it increases renal plasma fl ow with no eff ects on GFR, as demonstrated in healthy volunteers [25]. In three pre ventive, randomized controlled trials in abdomi nal aortic surgery [26] and high-risk cardiac surgery [27], fenoldopam improved creatinine clearance compared to placebo. Th ese bene fi cial eff ects on renal outcome with fenoldopam and the lack of similar benefi cial eff ects with dopamine (see above), despite similar pharmacological actions, could be explained by the fact that the potential preventive renal eff ects with dopamine and fenoldopam were evaluated in low-risk and high-risk patients, respect ively.…”

Section: Eff Ects Of Dopaminergic Agents On Renal Oxygenation In the mentioning

confidence: 99%

Renal Oxygenation in Clinical Acute Kidney Injury

Ricksten¹,

Bragadottir²,

Redfors³

2013

Annual Update in Intensive Care and Emergency Medicine 2013

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Renal oxygenation is defi ned as the relationship between renal oxygen delivery (DO 2 ) and renal oxygen consumption (VO 2 ) and it can easily be shown that the inverse of this relationship is equivalent to renal extraction of O 2 (O 2 Ex). An increase in renal O 2 Ex means that renal DO 2 has decreased in relation to renal VO 2 , i. e., renal oxygenation is impaired, and vice versa. When compared to other major organs, renal VO 2 is relatively high, second only to the heart. In sedated, mechanically ventilated patients, renal VO 2 is two-thirds (10 ml/min) that of myocardial oxygen consumption (15 ml/min) (Table 1) [1,2]. Renal blo od fl ow, w hich accounts for approximately 20 % of cardiac output, is three times higher than myocardial blood fl ow in this group of patients. Renal O 2 Ex in the non-failing kidney is therefore low, 10 %, compared with, e.g., the heart, in which O 2 E X is 55 % (Table 1). Determin a nts of renal oxygenationIt is well known from experimental studies that tubular sodium reabsorption is the major determinant of renal VO 2 [3] and tha t under normal physiological conditions, approximately 80 % is used to drive active tubular transport of particularly sodium, but also glucose, amino acids and other solutes. Tubular transport processes are highly load-dependent and it has been shown in experimental studies [4] and in p atients [2,[5][6][7] that the re i s a close linear correlation between glomerular fi ltration rate (GFR), renal sodium reabsorption and renal VO 2 (Fig. 1). Th e fi l tered load of sodium is, thus, an important determi nant of renal VO 2 and maneuvers that decrease GFR and the tubular sodium load act to decrease tubular sodium reabsorption and renal VO 2 , and vice versa [8]. It has b een shown that renal O 2 Ex remains stable over a wide range of renal blood fl ows, which means that changes in renal DO 2 , caused by changes in renal blood fl ow, are directly off set by changes in renal VO 2 [9], i. e., r enal VO 2 is fl ow-dependent. Th us, unlike other organs where increases in blood fl ow will improve oxygenation, increased renal blood fl ow augments GFR and the fi ltered load of sodium, which will increase renal VO 2 . Due to this fl ow-dependency of renal VO 2 , renal oxygenation will re main constant, as long as renal blood fl ow and GFR change in parallel. Regional intrarenal oxygenation and medullary hypoxiaTh e relatively high renal blood fl ow is directed preferentially to the cortex to optimize the fi ltration process and solute reabsorption. In contrast, blood fl ow in the outer medulla is less than 50 % of the cortical blood fl ow to preserve osmotic gradients and to enhance urinary concentration [10]. Th e combi nation of low me dullary perfusion, high oxygen consumption of the medullary thick ascending limbs (mTAL) and the countercurrent exchange of oxygen within the vasa recta, results in a poorly oxygenated outer medulla [11]. Oxygen av ailability is, therefore, low in the outer medulla, which has an oxygen tissue partial pressure (PO 2 ) of 10-20 mm Hg ...

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“…1). A total of 70 studies (5,554 patients) met eligibility criteria [17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86] (table 1). …”

Section: Resultsmentioning

confidence: 99%

Prevention and Treatment of Acute Kidney Injury in Patients Undergoing Cardiac Surgery: A Systematic Review

et al. 2010

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Background: Acute kidney injury (AKI) is common in patients undergoing cardiac surgery and is associated with a high rate of death, long-term sequelae and healthcare costs. We conducted a systematic review of randomized controlled trials for strategies to prevent or treat AKI in cardiac surgery. Methods: We screened Medline, Scopus, Cochrane Renal Library, and Google Scholar for randomized controlled trails in cardiac surgery for prevention or treatment of AKI in adults. Results: We identified 70 studies that contained a total of 5,554 participants published until November 2008. Most studies were small in sample size, were single-center, focused on preventive strategies, and displayed wide variation in AKI definitions. Only 26% were assessed to be of high quality according to the Jadad criteria. The types of strategies with possible protective efficacy were dopaminergic agents, vasodilators, anti-inflammatory agents, and pump/perfusion strategies. When analyzed separately, dopamine and N-acetylcysteine did not reduce the risk for AKI. Conclusions: This summary of all the literature on prevention and treatment strategies for AKI in cardiac surgery highlights the need for better information. The results advocate large, good-quality, multicenter studies to determine whether promising interventions reliably reduce rates of acute renal replacement therapy and mortality in the cardiac surgery setting.

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Fenoldopam Infusion for Renal Protection in High-Risk Cardiac Surgery Patients: A Randomized Clinical Study

Cited by 86 publications

References 16 publications

Cardiopulmonary Bypass–associated Acute Kidney Injury

Cardiopulmonary Bypass–associated Acute Kidney Injury

Renal Oxygenation in Clinical Acute Kidney Injury

Prevention and Treatment of Acute Kidney Injury in Patients Undergoing Cardiac Surgery: A Systematic Review

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