Milrinone vs Dobutamine for the Management of Cardiogenic Shock :  Implications of Renal Function and Injury

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Abstract

Background

Cardiogenic shock is associated with poor clinical outcomes. There is a paucity of prospective data examining the efficacy and safety of inotropic therapy in patients with cardiogenic shock and renal dysfunction.

Objectives

This study sought to examine the treatment effect of milrinone compared to dobutamine in relation to renal function.

Methods

In this post hoc analysis of the DOREMI (Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock) trial, we examined clinical outcomes with milrinone compared to dobutamine after stratification based on baseline estimated glomerular filtration rate (eGFR) 60 ml/min/1.73 m ² and acute kidney injury (AKI). The primary outcome was the composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke, or initiation of renal replacement therapy.

Results

Baseline eGFR <60 ml/min/1.73 m ² and AKI were observed in 78 (45%) and 124 (65%) of patients, respectively. The primary outcome and death from any cause occurred in 99 (52%) and 76 (40%) patients, respectively. eGFR <60 ml/min/1.73 m ² did not appear to modulate the treatment effect of milrinone compared to dobutamine. In contrast, there was a significant interaction between the treatment effect of milrinone compared to dobutamine and AKI with respect to the primary outcome ( P interaction = 0.02) and death ( P interaction = 0.04). The interaction was characterized by lower risk of primary outcome and death with milrinone compared to dobutamine in patients without, but not with, AKI.

Conclusions

In patients requiring inotropic support for cardiogenic shock, baseline renal dysfunction and AKI are common. A modulating effect of AKI on the relative efficacy of milrinone compared to dobutamine was observed, characterized by attenuation of a potential clinical benefit with milrinone compared to dobutamine in patients who develop AKI.

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Most cited references 21

Record: found
Abstract: found
Article: not found

A new equation to estimate glomerular filtration rate.

Andrew Levey, Lesley Stevens, Christopher H Schmid … (2009)

Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. National Institute of Diabetes and Digestive and Kidney Diseases.

0 comments Cited 6063 times – based on 0 reviews      Review now

Record: found
Abstract: found
Article: found

KDIGO Clinical Practice Guidelines for Acute Kidney Injury

Arif Khwaja, A. Khwaja (2012)

0 comments Cited 2680 times – based on 0 reviews      Review now

Record: found
Abstract: found
Article: not found

Cardiorenal syndrome.

Claudio Ronco, Mikko Haapio, Andrew House … (2008)

The term cardiorenal syndrome (CRS) increasingly has been used without a consistent or well-accepted definition. To include the vast array of interrelated derangements, and to stress the bidirectional nature of heart-kidney interactions, we present a new classification of the CRS with 5 subtypes that reflect the pathophysiology, the time-frame, and the nature of concomitant cardiac and renal dysfunction. CRS can be generally defined as a pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of 1 organ may induce acute or chronic dysfunction of the other. Type 1 CRS reflects an abrupt worsening of cardiac function (e.g., acute cardiogenic shock or decompensated congestive heart failure) leading to acute kidney injury. Type 2 CRS comprises chronic abnormalities in cardiac function (e.g., chronic congestive heart failure) causing progressive chronic kidney disease. Type 3 CRS consists of an abrupt worsening of renal function (e.g., acute kidney ischemia or glomerulonephritis) causing acute cardiac dysfunction (e.g., heart failure, arrhythmia, ischemia). Type 4 CRS describes a state of chronic kidney disease (e.g., chronic glomerular disease) contributing to decreased cardiac function, cardiac hypertrophy, and/or increased risk of adverse cardiovascular events. Type 5 CRS reflects a systemic condition (e.g., sepsis) causing both cardiac and renal dysfunction. Biomarkers can contribute to an early diagnosis of CRS and to a timely therapeutic intervention. The use of this classification can help physicians characterize groups of patients, provides the rationale for specific management strategies, and allows the design of future clinical trials with more accurate selection and stratification of the population under investigation.

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Author and article information

Contributors

Juan J. Russo

Journal

Journal ID (nlm-ta): JACC Adv

Journal ID (iso-abbrev): JACC Adv

Title: JACC: Advances

Publisher: Elsevier

ISSN (Electronic): 2772-963X

Publication date PMC-release: 05 July 2023

Publication date Collection: July 2023

Publication date (Electronic): 05 July 2023

Volume: 2

Issue: 5

Electronic Location Identifier: 100393

Affiliations

[a ]CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

[b ]Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

[c ]School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada

[d ]Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada

[e ]Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA

Author notes

[∗ ] Address for correspondence: Dr Juan J. Russo, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada. jrusso@ 123456ottawaheart.ca

Article

Publisher Item ID: S2772-963X(23)00235-1 Publisher ID: 100393

DOI: 10.1016/j.jacadv.2023.100393

PMC ID: 11198346

PubMed ID: 38938997

SO-VID: 9e74bb43-34db-4c36-a74c-a3686dc932bb

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 28 June 2022

Date revision received : 22 March 2023

Date accepted : 6 April 2023

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Milrinone vs Dobutamine for the Management of Cardiogenic Shock : Implications of Renal Function and Injury

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