Effects of human atrial natriuretic peptide in patients after coronary artery bypass surgery

Low-dose atrial natriuretic peptide for prevention or treatment of acute kidney injury: a systematic review and meta-analysis

Background

Theoretically, atrial natriuretic peptide (ANP), especially low-dose ANP, is beneficial in acute kidney injury (AKI). In this study, we examined whether low-dose ANP is effective in preventing or treating AKI by conducting an updated systematic review for randomized controlled trials (RCTs).

Method

We searched the Excerpta Medica database (EMBASE), PubMed, and Cochrane CENTRAL databases for RCTs that compare the effects of low-dose ANP (≤ 50 ng/kg/min) with a placebo or conventional therapy in at-risk patients or patients with AKI. The primary outcome was the incidence of new AKI (in prevention RCTs), while the secondary outcomes were in-hospital mortality rate, renal replacement therapy (RRT) requirement, length of hospital and intensive care unit (ICU) stay, incidence of hypotension, and peak serum creatinine levels. The risk-of-bias was evaluated using the Cochrane Collaboration risk-of-bias tool. Trial sequential analysis (TSA) was used for each outcome of interest.

Results

A total of 18 RCTs (16 prevention and two treatment trials) fulfilled our inclusion criteria. In prevention RCTs, the incidence of new AKI was significantly low in the low-dose ANP group (relative risk [RR] = 0.51; 95% confidence interval [CI] = 0.36–0.72; P = 0.0001) compared to the control group. In addition, the low-dose ANP group showed a significantly reduced RRT requirement in both prevention (RR = 0.17; 95% CI = 0.04–0.64; P = 0.009) and treatment (RR = 0.43; 95% CI = 0.20–0.93; P = 0.03) RCTs. Among secondary outcomes, in some cases, low-dose ANP was associated with a reduction in ICU and in-hospital stay. The risk-of-bias assessment and TSA results indicated that the sample sizes and qualities of the RCTs were insufficient to conclude the efficacy of low-dose ANP.

Conclusion

Low-dose ANP might be effective in preventing or treating AKI. However, the evidence accumulated so far is not strong enough to demonstrate ANP’s beneficial effects. The next step is to elucidate the effects of low-dose ANP by conducting multicenter, high-quality, large-sample RCTs.

Trial registration

PROSPERO registry CRD42017068568. Registered 20 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2330-z) contains supplementary material, which is available to authorized users.

Prevention of Cardiac Surgery-Associated Acute Kidney Injury

Numerous strategies have been evaluated to prevent early CSA-AKI. Although correction of hemodynamic problems is paramount, there are no clinical studies that compare different hemodynamic management or monitoring strategies with regard to their effect on kidney function. Pharmacologic strategies including diuretics, different classes of vasodilators and drugs with anti-inflammatory effects such as N-acetyl-cysteine, do not appear to be effective. Most of the studies are underpowered and use physiological rather than clinical endpoints. Further trials are warranted with fenoldopam and nesiritide (rhBNP). Observational and underpowered randomized studies show beneficial renal effects of off-pump technique and avoidance of aortic manipulation. There is very limited evidence for preoperative fluid loading and preemptive RRT. Potentially nephrotoxic agents should be used with caution in patients at risk of CSA-AKI. Tranexamic acid or aminocaproic acid should be preferred over aprotinin. No pharmacologic intervention has been adequately tested in the prevention of late CSA-AKI. A single-center study, including a predominance of patients after cardiac surgery, showed a decrease of kidney injury with tight glycemic control.

Acute Kidney Injury in Cardiac Surgery and Cardiac Intensive Care

Acute kidney injury (AKI) is a serious postoperative complication following cardiac surgery. Despite the incidence of AKI requiring temporary renal replacement therapy being low, it is nonetheless associated with high morbidity and mortality. Therefore, preventing AKI associated with cardiac surgery can dramatically improve outcomes in these patients. The pathogenesis of AKI is multifactorial and many attempts to prevent or treat renal injury have been met with limited success. In this article, we will discuss the incidence and risk factors for cardiac surgery associated AKI, including the pathophysiology, potential biomarkers of injury, and treatment modalities.

Carperitide Increases the Need for Renal Replacement Therapy After Cardiovascular Surgery

OBJECTIVES

Acute kidney injury is a common complication after aortic surgery. Carperitide, a human atrial natriuretic peptide, was reported to be effective for preventing acute kidney injury after cardiac surgery. However, most studies were from single centers, and results of meta-analyses are subject to publication bias. The aim of the present study was to investigate whether carperitide preserved renal function in patients undergoing cardiovascular surgery.

DESIGN

Retrospective cohort study.

SETTING

Participating hospitals (N = 281) in a national database from 2010 to 2013.

PARTICIPANTS

Adult patients (N = 47,032) who underwent cardiovascular surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main intervention variable investigated was the use of carperitide on the day of surgery. Assessed outcomes included receiving renal replacement therapy within 21 days of surgery and in-hospital mortality. Data were available for 47,032 patients, of whom 2,186 (4.6%) received carperitide on the day of surgery. Multivariate logistic regression analysis revealed that carperitide was significantly associated with a greater likelihood of receiving renal replacement therapy within 21 days of surgery, but not with in-hospital mortality.

CONCLUSIONS

In patients undergoing cardiovascular surgery, carperitide significantly increased the odds of receiving renal replacement therapy within 21 days after surgery.

Reduction in the incidence of acute kidney injury after aortic arch surgery with low-dose atrial natriuretic peptide: a randomised controlled trial

BACKGROUND

Acute kidney injury (AKI) after surgery is associated with an increased risk of adverse events and death. Atrial natriuretic peptide (ANP) dilates the preglomerular renal arteries and inhibits the renin-angiotensin axis. A low-dose ANP infusion increases glomerular filtration rate after cardiovascular surgery, but it is not known whether it reduces the incidence of AKI or the mortality rate.

OBJECTIVE

To evaluate whether an intravenous ANP infusion prevents AKI in patients undergoing aortic arch surgery requiring hypothermic circulatory arrest.

DESIGN

A randomised controlled study.

SETTING

Operating room and intensive care unit at Kawasaki Saiwai Hospital, Kanagawa, Japan.

PATIENTS

Forty-two patients with normal preoperative renal function undergoing elective repair of an aortic arch aneurysm.

INTERVENTION

Patients were assigned randomly to receive a fixed dose of ANP (0.0125 μg (-1) kg(-1)  min) or placebo. The infusion was started after induction of anaesthesia and continued for 24  h postoperatively.

MAIN OUTCOME MEASURES

The primary end-point was the incidence of AKI within 48 h after surgery.

RESULTS

AKI developed in 30% of patients who received ANP compared with 73% of patients who received placebo (P = 0.014). Intraoperative urine output was almost 1 l greater in patients who received ANP (1865 ± 1299 versus 991 ± 480  ml in the control group, P = 0.005). However, there were no differences in mean arterial pressure or number of episodes of hypotension between the groups. Length of hospital and intensive care stays were not significantly different, nor was there a difference in 30-day mortality. No patients required haemodialysis or continuous renal replacement therapy.

CONCLUSION

We found that an intravenous infusion of ANP at 0.0125  μg  kg(-1)  min(-1) is an effective intervention for reducing the incidence of postoperative AKI, and appears to afford a degree of renal protection during and after cardiovascular surgery.

TRIAL REGISTRATION

Kawasaki ANP trial, UMIN Clinical Trials Registry ID: UMIN000011650.

Pharmacological therapies for the prevention of acute kidney injury following cardiac surgery: a systematic review

Post-cardiac surgery acute kidney injury (AKI) is common and is associated with a significant increase in morbidity and mortality. We aimed to systematically review randomised trials that assessed the renoprotective utility of pharmacological agents in patients undergoing cardiac surgery. We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials for randomised controlled trials comparing renoprotective pharmacological interventions with control in adult patients undergoing cardiac surgery with cardiopulmonary bypass. We extracted data for mortality, need for renal replacement therapy (RRT), incidence of AKI, and creatinine clearance at 24-48 h. About 49 randomised controlled trials involving 4605 patients were included. Pharmacological interventions included dopamine, fenoldopam, calcium channel antagonists, natriuretic peptides, diuretics, and N-acetylcysteine. Most trials were of poor quality, with small sample sizes, under-reporting of randomisation procedure, allocation concealment and method of blinding. No pharmacological intervention significantly reduced mortality. Fenoldopam and Atrial Natriuretic Peptide (ANP) reduced the need for renal replacement therapy by 5% (NNT 20, 95% CI 11.3, 83.0) and 3.5% (NNT 29, 95% CI 17.1, 84.4), respectively. Brain Natriuretic Peptide resulted in a 10% reduction in the incidence of AKI (NNT 11, 95% CI 6.2, 32.0). Dopamine caused a significant reduction in creatinine clearance (-4.26 ml/min, 95% CI -7.14, -1.39). The quality of studies that have assessed pharmacological renoprotective agents in cardiac surgery is generally poor. Fenoldopam, ANP and BNP show evidence of renoprotection. Randomised studies evaluating the effect of novel renoprotective agents that are powered to detect clinically relevant differences in outcomes are required.

Cardiovascular and renal effects of carperitide and nesiritide in cardiovascular surgery patients: a systematic review and meta-analysis

INTRODUCTION

Acute kidney injury (AKI) following cardiovascular surgery is a common disease process and is associated with both morbidity and mortality. The aim of our study was to evaluate the cardiovascular and renal effects of an atrial natriuretic peptide (ANP, carperitide) and a B-type (or brain) natriuretic peptide (BNP, nesiritide) for preventing and treating AKI in cardiovascular surgery patients.

METHODS

Electronic databases, including PubMed, EMBASE and references from identified articles were used for a literature search.

RESULTS

Data on the infusion of ANP or BNP in cardiovascular surgery patients was collected from fifteen randomized controlled trials and combined. The infusion of ANP or BNP increased the urine output and creatinine clearance or glomerular filtration rate, and reduced the use of diuretics and the serum creatinine levels. A meta-analysis showed that ANP infusion significantly decreased peak serum creatinine levels, incidence of arrhythmia and renal replacement therapy. The meta-analysis also showed that ANP or BNP infusion significantly decreased the length of ICU stay and hospital stay compared with controls. However, the combined data were insufficient to determine how ANP or BNP infusion during the perioperative period influences long-term outcome in cardiovascular surgery patients.

CONCLUSIONS

The infusion of ANP or BNP may preserve postoperative renal function in cardiovascular surgery patients. A large, multicenter, prospective, randomized controlled trial will have to be performed to assess the therapeutic potential of ANP or BNP in preventing and treating AKI in the cardiovascular surgical setting.

Acute renal failure in hospitalized patients: part II

BACKGROUND

Acute renal failure (ARF) is a common condition in hospitalized patients. Research has been unable to identify the optimal target for therapeutic intervention; hence, effective prevention of and/or treatment for ARF remain elusive.

OBJECTIVE

To examine the usefulness of current and potential pharmacologic treatments in seriously ill, hospitalized patients.

DATA SOURCES

A MEDLINE search (1996-June 2002) was conducted using the search terms kidney (drug effects) and acute kidney failure (drug therapy). Bibliographies of selected articles were also examined to include all relevant investigations.

STUDY SELECTION AND DATA EXTRACTION

Review articles, meta-analyses, and clinical trials describing prevention of and treatment for hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available.

CONCLUSIONS

Appropriate management of ARF includes prospective identification of at-risk patients, fluid administration, and optimal hemodynamic support. Drug treatments, including low-dose dopamine and diuretics, have demonstrated extremely limited benefits and have not been shown to improve patient outcome. Experimental agents influence cellular processes of renal dysfunction and recovery; unfortunately, relatively few drugs show promise for the future.

Perioperative renal protection

Acute renal failure continues to complicate the postoperative courses of our vascular and cardiac surgical patients, dramatically increasing mortality and decreasing quality of life when it occcurs. In spite of better understanding of the disease, few gains have been made in its prevention. We review its pathophysiology and discuss the most recent developments that may eventually lead to perioperative renal protection.