Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II.

• Authors: James A. Tumlin, University of Tennessee; Raghavan Murugan, University of Pittsburgh; Adam M. Deane, University of Melbourne; Marlies Ostermann, King's College London; Laurence W. Busse, Emory University; Kealy R. Ham, University of Minnesota; Kianoush Kashani, Mayo Clinic, Rochester, MN.; Harold M. Szerlip, Baylor University; John R. Prowle, The Royal London Hospital; Azra Bihorac, University of Florida; Kevin W. Finkel, University of Texas; Alexander Zarbock, University Hospital Münster; Lui G. Forni, University of Surrey; Shannan J. Lynch, La Jolla Pharmaceutical Company; Jeff Jensen, La Jolla Pharmaceutical Company; Stew Kroll, La Jolla Pharmaceutical Company; Lakhmir S. Chawla, La Jolla Pharmaceutical Company; George F. Tidmarsh, La Jolla Pharmaceutical Company; Rinaldo Bellomo, The University of Melbourne
• Journal Title: Critical Care Medicine
• Volume: Volume 46, Number 6
• Publisher: Lippincott, Williams & Wilkins | 2018, Pages 949-957
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1097/CCM.0000000000003092
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, General
• Keywords: acute kidney injury; sepsis; vasodilatory shock; angiotensin II; renal replacement therapy; acute renal disease

Abstract

OBJECTIVE: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. DESIGN: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. SETTING: ICUs. PATIENTS: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively). INTERVENTIONS: IV angiotensin II or placebo. MEASUREMENTS AND MAIN RESULTS: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%-67%) and 30% (95% CI, 19%-41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%-54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%-27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%-68%) and 22% (95% CI, 12%-34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively. CONCLUSIONS: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.