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Selewski DT, Goldstein SL. The role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2018; 33:13-24. [PMID: 27900473 DOI: 10.1007/s00467-016-3539-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 01/11/2023]
Abstract
Our understanding of the epidemiology and the impact of acute kidney injury (AKI) and fluid overload on outcomes has improved significantly over the past several decades. Fluid overload occurs commonly in critically ill children with and without associated AKI. Researchers in pediatric AKI have been at the forefront of describing the impact of fluid overload on outcomes in a variety of populations. A full understanding of this topic is important as fluid overload represents a potentially modifiable risk factor and a target for intervention. In this state-of-the-art review, we comprehensively describe the definition of fluid overload, the impact of fluid overload on kidney function, the impact of fluid overload on the diagnosis of AKI, the association of fluid overload with outcomes, the targeted therapy of fluid overload, and the impact of the timing of renal replacement therapy on outcomes.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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Uyar ME, Yucel P, Ilin S, Bal Z, Yildirim S, Uyar AS, Akay T, Tutal E, Sezer S. Iloprost as an acute kidney injury-triggering agent in severely atherosclerotic patients. Cardiovasc J Afr 2016; 27:128-133. [PMID: 27841898 PMCID: PMC5101430 DOI: 10.5830/cvja-2015-051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 06/14/2015] [Indexed: 01/11/2023] Open
Abstract
Background Iloprost, a stable prostacyclin analog, is used as a rescue therapy for severe peripheral arterial disease (PAD). It has systemic vasodilatory and anti-aggregant effects, with severe vasodilatation potentially causing organ ischaemia when severe atherosclerosis is the underlying cause. In this study, we retrospectively analysed renal outcomes after iloprost infusion therapy in 86 patients. Methods Eighty-six patients with PAD who received iloprost infusion therapy were retrospectively analysed. Clinical and biochemical parameters were recorded before (initial, Cr1), during (third day, Cr2), and after (14th day following the termination of infusion therapy, Cr3) treatment. Acute kidney injury (AKI) was defined according to KDIGO guidelines as a ≥ 0.3 mg/dl (26.52 μmol/l) increase in creatinine levels from baseline within 48 hours. Results: Cr2 (1.46 ± 0.1 mg/dl) (129.06 ± 8.84 μmol/l) and Cr3 (1.53 ± 0.12 mg/dl) (135.25 ± 10.61 μmol/l) creatinine levels were significantly higher compared to the initial value (1.15 ± 0.6 mg/dl) (101.66 ± 53.04 μmol/l). AKI was observed in 36 patients (41.86%) on the third day of iloprost infusion. Logistic regression analysis revealed smoking and not using acetylsalicylic acid as primary predictors (p = 0.02 and p = 0.008, respectively) of AKI during iloprost treatment. On the third infusion day, patients’ urinary output significantly increased (1813.30 ± 1123.46 vs 1545.17 ± 873.00 cm3) and diastolic blood pressure significantly decreased (70.07 ± 15.50 vs 74.14 ± 9.42 mmHg) from their initial values. Conclusion While iloprost treatment is effective in patients with PAD who are not suitable for surgery, severe systemic vasodilatation can cause renal ischaemia, resulting in nonoliguric AKI. Smoking, no acetylsalicylic acid use, and lower diastolic blood pressure are the clinical risk factors for AKI during iloprost treatment.
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Affiliation(s)
| | - Piril Yucel
- Department of Internal Medicine, Baskent University, Ankara, Turkey
| | - Sena Ilin
- Department of Internal Medicine, Baskent University, Ankara, Turkey
| | - Zeynep Bal
- Department of Internal Medicine, Baskent University, Ankara, Turkey
| | - Saliha Yildirim
- Department of Internal Medicine, Baskent University, Ankara, Turkey
| | - Ahmet Senol Uyar
- Department of Anesthesiology, Ulucanlar Eye Education and Research Hospital, Ankara, Turkey
| | - Tankut Akay
- Department of Cardiovascular Surgery, Baskent University, Ankara, Turkey
| | - Emre Tutal
- Department of Nephrology, Baskent University, Ankara, Turkey
| | - Siren Sezer
- Department of Nephrology, Baskent University, Ankara, Turkey
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Abstract
Contrast medium-induced acute kidney injury (CI-AKI) is a predominant cause of hospital-acquired renal insufficiency. With an increasing number of contrast medium-enhanced radiological procedures being performed in a rapidly increasing ageing population in the Western world, it is imperative that more attention is given to understand the aetiology of CI-AKI to devise novel diagnostic methods and to formulate effective prophylactic and therapeutic regimens to reduce its incidence and its associated morbidity and mortality. This article presents high-yield information on the above-mentioned aspects of CI-AKI, primarily based on results of randomised controlled trials, meta-analyses, systematic reviews and international consensus guidelines.
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Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ammara Usman
- University Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan R. Boyle
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul D. Hayes
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard J. Solomon
- University of Vermont College of Medicine, Division of Nephrology, Fletcher Allen Health Care, Burlington, Vt., USA
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Choi MR, Kouyoumdzian NM, Rukavina Mikusic NL, Kravetz MC, Rosón MI, Rodríguez Fermepin M, Fernández BE. Renal dopaminergic system: Pathophysiological implications and clinical perspectives. World J Nephrol 2015; 4:196-212. [PMID: 25949933 PMCID: PMC4419129 DOI: 10.5527/wjn.v4.i2.196] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 08/29/2014] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Fluid homeostasis, blood pressure and redox balance in the kidney are regulated by an intricate interaction between local and systemic anti-natriuretic and natriuretic systems. Intrarenal dopamine plays a central role on this interactive network. By activating specific receptors, dopamine promotes sodium excretion and stimulates anti-oxidant and anti-inflammatory pathways. Different pathological scenarios where renal sodium excretion is dysregulated, as in nephrotic syndrome, hypertension and renal inflammation, can be associated with impaired action of renal dopamine including alteration in biosynthesis, dopamine receptor expression and signal transduction. Given its properties on the regulation of renal blood flow and sodium excretion, exogenous dopamine has been postulated as a potential therapeutic strategy to prevent renal failure in critically ill patients. The aim of this review is to update and discuss on the most recent findings about renal dopaminergic system and its role in several diseases involving the kidneys and the potential use of dopamine as a nephroprotective agent.
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Abstract
Background The hydraulic behavior of the renal compartment is poorly understood. In particular, the role of the renal capsule on the intrarenal pressure has not been thoroughly addressed to date. We hypothesized that pressure and volume in the renal compartment are not linearly related, similar to other body compartments. Methods The pressure-volume curve of the renal compartment was obtained by injecting fluid into the renal pelvis and recording the rise in intrarenal pressure in six anesthetized and mechanically ventilated piglets, using a catheter Camino 4B® inserted into the renal parenchyma. Results In healthy kidneys, pressure has a highly nonlinear dependence on the injected volume, as revealed by an exponential fit to the data (R2 = 0.92). On the contrary, a linear relation between pressure and volume is observed in decapsulated kidneys. We propose a biomechanical model for the renal capsule that is able to explain the nonlinear pressure-volume dependence for moderate volume increases. Conclusions We have presented experimental evidence and a theoretical model that supports the existence of a renal compartment. The mechanical role of the renal capsule investigated in this work may have important implications in elucidating the role of decompressive capsulotomy in reducing the intrarenal pressure in acutely injured kidneys.
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Ressia L, Calevo MG, Lerzo F, Carleo AM, Petrucci L, Montobbio G. Beneficial effect of fenoldopam mesylate in preventing peak blood lactate level during cardiopulmonary bypass for paediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2014; 19:178-82. [DOI: 10.1093/icvts/ivu114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Pohlmann A, Cantow K, Hentschel J, Arakelyan K, Ladwig M, Flemming B, Hoff U, Persson PB, Seeliger E, Niendorf T. Linking non-invasive parametric MRI with invasive physiological measurements (MR-PHYSIOL): towards a hybrid and integrated approach for investigation of acute kidney injury in rats. Acta Physiol (Oxf) 2013; 207:673-89. [PMID: 23336404 DOI: 10.1111/apha.12065] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/17/2012] [Accepted: 01/16/2013] [Indexed: 01/11/2023]
Abstract
Acute kidney injury of various origins shares a common link in the pathophysiological chain of events: imbalance between renal medullary oxygen delivery and oxygen demand. For in vivo assessment of kidney haemodynamics and oxygenation in animals, quantitative but invasive physiological methods are established. A very limited number of studies attempted to link these invasive methods with parametric Magnetic Resonance Imaging (MRI) of the kidney. Moreover, the validity of parametric MRI (pMRI) as a surrogate marker for renal tissue perfusion and renal oxygenation has not been systematically examined yet. For this reason, we set out to combine invasive techniques and non-invasive MRI in an integrated hybrid setup (MR-PHYSIOL) with the ultimate goal to calibrate, monitor and interpret parametric MR and physiological parameters by means of standardized interventions. Here we present a first report on the current status of this multi-modality approach. For this purpose, we first highlight key characteristics of renal perfusion and oxygenation. Second, concepts for in vivo characterization of renal perfusion and oxygenation are surveyed together with the capabilities of MRI for probing blood oxygenation-dependent tissue stages. Practical concerns evoked by the use of strong magnetic fields in MRI and interferences between MRI and invasive physiological probes are discussed. Technical solutions that balance the needs of in vivo physiological measurements together with the constraints dictated by small bore MR scanners are presented. An early implementation of the integrated MR-PHYSIOL approach is demonstrated including brief interventions of hypoxia and hyperoxia.
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Affiliation(s)
- A. Pohlmann
- Berlin Ultrahigh Field Facility (B.U.F.F.); Max Delbrück Center for Molecular Medicine; Berlin; Germany
| | - K. Cantow
- Institute of Physiology; Charité - Universitätsmedizin Berlin; Campus Mitte, and Center for Cardiovascular Research; Berlin; Germany
| | - J. Hentschel
- Berlin Ultrahigh Field Facility (B.U.F.F.); Max Delbrück Center for Molecular Medicine; Berlin; Germany
| | | | - M. Ladwig
- Institute of Physiology; Charité - Universitätsmedizin Berlin; Campus Mitte, and Center for Cardiovascular Research; Berlin; Germany
| | - B. Flemming
- Institute of Physiology; Charité - Universitätsmedizin Berlin; Campus Mitte, and Center for Cardiovascular Research; Berlin; Germany
| | - U. Hoff
- Nephrology and Intensive Care Medicine; Charité - Universitätsmedizin Berlin; Campus Virchow-Klinikum, and Center for Cardiovascular Research; Berlin; Germany
| | - P. B. Persson
- Institute of Physiology; Charité - Universitätsmedizin Berlin; Campus Mitte, and Center for Cardiovascular Research; Berlin; Germany
| | - E. Seeliger
- Institute of Physiology; Charité - Universitätsmedizin Berlin; Campus Mitte, and Center for Cardiovascular Research; Berlin; Germany
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Role of medullary blood flow in the pathogenesis of renal ischemia-reperfusion injury. Curr Opin Nephrol Hypertens 2012; 21:33-8. [PMID: 22080855 DOI: 10.1097/mnh.0b013e32834d085a] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Renal ischemia-reperfusion injury (IRI) is a common cause of acute kidney injury (AKI). Alterations in renal medullary blood flow (MBF) contribute to the pathogenesis of renal IRI. Here we review recent insights into the mechanisms of altered MBF in the pathogenesis of IRI. RECENT FINDINGS Although cortical blood flow fully recovers following 30-45 min of bilateral IRI, recent studies have indicated that there is a prolonged secondary fall in MBF that is associated with a long-term decline in renal function. Recent findings indicate that angiopoietin-1, atrial natriuretic peptide, heme oxygenase-1, and the gasotransmitters CO and H(2)S, may limit the severity of IRI by preserving MBF. Additional studies have also suggested a role for cytochrome P450-derived 20-HETE in the postischemic fall in MBF. SUMMARY Impaired MBF contributes to the pathogenesis of renal IRI. Measurement of renal MBF provides valuable insight into the underlying mechanisms of many renoprotective pathways. Identification of molecules that preserve renal MBF in IRI may lead to new therapies for AKI.
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Zangrillo A, Biondi-Zoccai GGL, Frati E, Covello RD, Cabrini L, Guarracino F, Ruggeri L, Bove T, Bignami E, Landoni G. Fenoldopam and acute renal failure in cardiac surgery: a meta-analysis of randomized placebo-controlled trials. J Cardiothorac Vasc Anesth 2012; 26:407-13. [PMID: 22459931 DOI: 10.1053/j.jvca.2012.01.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Because at present no pharmacologic prevention or treatment of acute kidney injury seems to be available, the authors updated a meta-analysis to investigate the effects of fenoldopam in reducing acute kidney injury in patients undergoing cardiac surgery, focusing on randomized placebo-controlled studies only. DESIGN A meta-analysis of randomized, placebo-controlled trials. SETTING Hospitals. PARTICIPANTS A total of 440 patients from 6 studies were included in the analysis. INTERVENTIONS None. The ability of fenoldopam to reduce acute kidney injury in the perioperative period when compared with placebo was investigated. MEASUREMENTS AND MAIN RESULTS Google Scholar and PubMed were searched (updated January 1, 2012). Authors and external experts were contacted. Pooled estimates showed that fenoldopam consistently and significantly reduced the risk of acute kidney injury (odds ratio [OR] = 0.41; 95% confidence interval [CI], 0.23-0.74; p = 0.003), with a higher rate of hypotensive episodes and/or use of vasopressors (30/109 [27.5%] v 21/112 [18.8%]; OR = 2.09; 95% CI, 0.98-4.47; p = 0.06) and no effect on renal replacement therapy, survival, and length of intensive care unit or hospital stay. CONCLUSIONS This analysis suggests that fenoldopam reduces acute kidney injury in patients undergoing cardiac surgery. Because the number of the enrolled patients was small and there was no effect on renal replacement therapy or survival, a large, multicenter, and appropriately powered trial is needed to confirm these promising results.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia, Intensive Care, Università Vita-Salute San Raffaele, Milan, Italy
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Monedero P, García-Fernández N, Pérez-Valdivieso JR, Vives M, Lavilla J. [Acute kidney injury]. ACTA ACUST UNITED AC 2011; 58:365-74. [PMID: 21797087 DOI: 10.1016/s0034-9356(11)70086-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is defined as an abrupt decline in the glomerular filtration rate with accumulation of nitrogenous waste products and the inability to maintain fluid and electrolyte homeostasis. Occurring in 7% of all hospitalized patients and 28% to 35% of those in intensive care units, AKI increases hospital mortality. Early evaluation should include differentiating prerenal and postrenal components from intrinsic renal disease. Biological markers can give early warning of AKI and assist with differential diagnosis and assessment of prognosis. The most effective preventive measure is to maintain adequate circulation and cardiac output, avoiding ischemia- or nephrotoxin-induced injury. To that end, patients and situations of risk must be identified, hemodynamics and diuresis monitored, hypovolemia reversed, and nephrotoxins avoided. Protective agents such as sodium bicarbonate, mannitol, prostagiandins, calcium channel blockers, N-acetyl-L-cysteine, sodium deoxycholate, allopurinol, and pentoxifylline should be used. Treatment includes the elimination of prerenal and postrenal causes of AKI; adjustment of doses according to renal function; avoidance of both overhydration and low arterial pressure; maintenance of electrolytic balance, avoiding hyperkalemia and correcting hyperglycemia; and nutritional support, assuring adequate protein intake. For severe AKI, several modalities of renal replacement therapy, differentiated by mechanism and duration, are available. Timing--neither the best moment to start dialysis nor the optimal duration--has been not established. Early detection of AKI is necessary for preventing progression and starting renal replacement therapy at adjusted doses that reflect metabolic requirements.
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Affiliation(s)
- P Monedero
- Departamento de Anestesiologia y Reanimación de la Universidad de Navarra, Pamplona.
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High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated lipocaline and cystatin C levels in pediatric cardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R160. [PMID: 21714857 PMCID: PMC3219034 DOI: 10.1186/cc10295] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 05/17/2011] [Accepted: 06/29/2011] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The aim of the study was to evaluate the effects of high-dose fenoldopam, a selective dopamine-1 receptor, on renal function and organ perfusion during cardiopulmonary bypass (CPB) in infants with congenital heart disease (CHD). METHODS A prospective single-center randomized double-blind controlled trial was conducted in a pediatric cardiac surgery department. We randomized infants younger than 1 year with CHD and biventricular anatomy (with exclusion of isolated ventricular and atrial septal defect) to receive blindly a continuous infusion of fenoldopam at 1 μg/kg/min or placebo during CPB. Perioperative urinary and plasma levels of neutrophil gelatinase-associated lipocaline (NGAL), cystatin C (CysC), and creatinine were measured to assess renal injury after CPB. RESULTS We enrolled 80 patients: 40 received fenoldopam (group F) during CPB, and 40 received placebo (group P). A significant increase of urinary NGAL and CysC levels from baseline to intensive care unit (ICU) admission followed by restoration of normal values after 12 hours was observed in both groups. However, urinary NGAL and CysC values were significantly reduced at the end of surgery and 12 hours after ICU admission (uNGAL only) in group F compared with group P (P = 0.025 and 0.039, respectively). Plasma NGAL and CysC tended to increase from baseline to ICU admission in both groups, but they were not significantly different between the two groups. No differences were observed on urinary and plasma creatinine levels and on urine output between the two groups. Acute kidney injury (AKI) incidence in the postoperative period, as indicated by pRIFLE classification (pediatric score indicating Risk, Injury, Failure, Loss of function, and End-stage kidney disease level of renal damage) was 50% in group F and 72% in group P (P = 0.08; odds ratio (OR), 0.38; 95% confidence interval (CI), 0.14 to 1.02). A significant reduction in diuretics (furosemide) and vasodilators (phentolamine) administration was observed in group F (P = 0.0085; OR, 0.22; 95% CI, 0.07 to 0.7). CONCLUSIONS The treatment with high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery for CHD with biventricular anatomy significantly decreased urinary levels of NGAL and CysC and reduced the use of diuretics and vasodilators during CPB. TRIAL REGISTRATION Clinical Trial.Gov NCT00982527.
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Simmons JW, Chung KK, Renz EM, White CE, Cotant CL, Tilley MA, Hardin MO, Jones JA, Blackbourne LH, Wolf SE. Fenoldopam use in a burn intensive care unit: a retrospective study. BMC Anesthesiol 2010; 10:9. [PMID: 20576149 PMCID: PMC2904291 DOI: 10.1186/1471-2253-10-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Accepted: 06/24/2010] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Fenoldopam mesylate is a highly selective dopamine-1 receptor agonist approved for the treatment of hypertensive emergencies that may have a role at low doses in preserving renal function in those at high risk for or with acute kidney injury (AKI). There is no data on low-dose fenoldopam in the burn population. The purpose of our study was to describe our use of low-dose fenoldopam (0.03-0.09 mug/kg/min) infusion in critically ill burn patients with AKI. METHODS We performed a retrospective analysis of consecutive patients admitted to our burn intensive care unit (BICU) with severe burns from November 2005 through September 2008 who received low-dose fenoldopam. Data obtained included systolic blood pressure, serum creatinine, vasoactive medication use, urine output, and intravenous fluid. Patients on concomitant continuous renal replacement therapy were excluded. Modified inotrope score and vasopressor dependency index were calculated. One-way analysis of variance with repeated measures, Wilcoxson signed rank, and chi-square tests were used. Differences were deemed significant at p < 0.05. RESULTS Seventy-seven patients were treated with low-dose fenoldopam out of 758 BICU admissions (10%). Twenty (26%) were AKI network (AKIN) stage 1, 14 (18%) were AKIN stage 2, 42 (55%) were AKIN stage 3, and 1 (1%) was AKIN stage 0. Serum creatinine improved over the first 24 hours and continued to improve through 48 hours (p < 0.05). There was an increase in systolic blood pressure in the first 24 hours that was sustained through 48 hours after initiation of fenoldopam (p < 0.05). Urine output increased after initiation of fenoldopam without an increase in intravenous fluid requirement (p < 0.05; p = NS). Modified inotrope score and vasopressor dependency index both decreased over 48 hours (p < 0.0001; p = 0.0012). CONCLUSIONS These findings suggest that renal function was preserved and that urine output improved without a decrease in systolic blood pressure, increase in vasoactive medication use, or an increase in resuscitation requirement in patients treated with low-dose fenoldopam. A randomized controlled trial is required to establish the efficacy of low-dose fenoldopam in critically ill burn patients with AKI.
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Affiliation(s)
- John W Simmons
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
| | - Kevin K Chung
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA
| | - Evan M Renz
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas, 78229, USA
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA
| | - Christopher E White
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas, 78229, USA
| | - Casey L Cotant
- Wilford Hall Medical Center, 2200 Bergquist Drive, San Antonio, Texas, 78236, USA
| | - Molly A Tilley
- Wilford Hall Medical Center, 2200 Bergquist Drive, San Antonio, Texas, 78236, USA
| | - Mark O Hardin
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
| | - John A Jones
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
| | - Lorne H Blackbourne
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
| | - Steven E Wolf
- United States Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas, 78234, USA
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas, 78229, USA
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