Early introduction of tolvaptan after cardiac surgery: a renal sparing strategy in the light of the renal resistive index measured by ultrasound

Journal of Cardiothoracic Surgery

Atsushi Amano¹  Taira Yamamoto¹  Kenji Kuwaki¹  Kan Kajimoto¹  Shunya Ono¹  Tomoko S. Kato¹ 

[1]Department of Cardiovascular Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku 113-8421, Tokyo, Japan

关键词: Renal resistive index;    Tolvaptan;    Renal function;    Cardiac surgery;    Diuretics;   

Others  :  1232306
DOI  :  10.1186/s13019-015-0372-0

 received in 2015-07-01, accepted in 2015-10-28,  发布年份 2015

【 摘 要 】

Background

Renal failure is a serious complication after cardiac surgery, which can be caused by long-term intravenous (IV) loop diuretic use. Tolvaptan is an oral selective vasopressin-2 receptor antagonist used in patients irresponsive to loop diuretics. We investigated their renal perfusion changes using the resistive index (RI) postoperatively.

Methods

Serial renal RI, echocardiography, and laboratory examinations from 14 patients requiring continuous postoperative IV loop diuretics were reviewed. Eight patients received tolvaptan (Group T) and six received oral loop diuretics before the discontinuation of IV loop diuretics (Group L). The 1 ^stdata were obtained between postoperative day 0 and 2, the 2 ^ndwhen patients were still under IV loop diuretic treatment, the 3 ^rdafter the initiation of tolvaptan or oral loop diuretic, and the 4 ^thafter the discontinuation of IV diuretics.

Results

The 2 ^ndRI value was higher in Group T than Group L (0.77 ± 0.09 vs. 0.69 ± 0.01, p = 0.049) but significantly decreased after tolvaptan administration [0.77 ± 0.09 to 0.65 ± 0.05 (2 ^ndto 3 ^rd ), to 0.62 ± 0.04 (to 4 ^th ), both p = 0.006], while no such changes were seen in Group L. The serum sodium and albumin levels, and echo-derived tricuspid annular plane systolic excursion increased only in Group T (134.1 ± 1.5 to 138.8 ± 3.2 mEq/L, 3.3 ± 0.3 to 3.7 ± 0.5 g/dL, 16.4 ± 3.6 to 19.7 ± 4.2 mm, all p <0.05). The duration of IV loop diuretics tended to be shorter in Group T than Group L (5.6 ± 1.6 vs. 8.7 ± 3.6 days, p = 0.051).

Conclusions

Administration of tolvaptan in patients undergoing cardiac surgery may improve their renal perfusion, as reflected by the renal RI measured using renal Doppler ultrasound.

【 授权许可】

   
2015 Kato et al.

【 图 表 】

Fig. 1.

Fig. 2.

Fig. 3.

【 参考文献 】

• [1]Marui A, Okabayashi H, Komiya T, Tanaka S, Furukawa Y, Kita T et al.. CREDO-Kyoto Investigators. Impact of occult renal impairment on early and late outcomes following coronary artery bypass grafting. Interact Cardiovasc Thorac Surg. 2013; 17:638-43.
• [2]Dardashti A, Ederoth P, Algotsson L, Brondén B, Bjursten H. Incidence, dynamics, and prognostic value of acute kidney injury for death after cardiac surgery. J Thorac Cardiovasc Surg. 2014; 147:800-807.
• [3]Li SY, Chen JY, Yang WC, Chuang CL. Acute kidney injury network classification predicts in-hospital and long-term mortality in patients undergoing elective coronary artery bypass grafting surgery. Eur J Cardiothorac Surg. 2011; 39:323-328.
• [4]El-Refai M, Krivospitskaya O, Peterson EL, Wells K, Williams LK, Lanfear DE. Relationship of loop diuretic dosing and acute changes in renal function during hospitalization for heart failure. J Clin Exp Cardiolog. 2011;2:1000164.
• [5]Felker GM, O’Connor CM, Braunwald E. Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil? Circ Heart Fail. 2009; 2:56-62.
• [6]Francis GS, Benedict C, Johnstone DE, Kirlin PC, Nicklas J, Liang CS et al.. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation. 1990; 82:1724-9.
• [7]Chiong JR, Cheung RJ. Loop diuretic therapy in heart failure: the need for solid evidence on a fluid issue. Clin Cardiol. 2010; 33:345-52.
• [8]Matsuzaki M, Hori M, Izumi T, Fukunami M. Efficacy and safety of tolvaptan in heart failure patients with volume overload despite the standard treatment with conventional diuretics: a phase III, randomized, double-blind, placebo-controlled study (QUEST study). Cardiovasc Drugs Ther. 2011; 25 Suppl 1:S33-45.
• [9]Watanabe K, Dohi K, Sugimoto T, Yamada T, Sato Y, Ichikawa K et al.. Short-term effects of low dose tolvaptan on hemodynamic parameters in patients with chronic heart failure. J Cardiol. 2012; 60:462-9.
• [10]Udelson JE, Orlandi C, Ouyang J, Krasa H, Zimmer CA, Frivoid G et al.. Acute hemodynamic effects of tolvaptan, a vasopressin V2 receptor blocker, in patients with symptomatic heart failure and systolic dysfunction: an international, multicenter, randomized, placebo-controlled trial. J Am Coll Cardiol. 2008; 52:1540-5.
• [11]Tominaga N, Kida K, Matsumoto N, Akashi YJ, Miyake F, Kimura K, et al. Safety of add-on tolvaptan in patients with furosemide-resistant congestive heart failure complicated by advanced chronic kidney disease: a sub-analysis of a pharmacokinetics/ pharmacodynamics study. Clin Nephrol. 2015. [Epub ahead of print].
• [12]Shirakabe A, Hata N, Yamamoto M, Kobayashi N, Shinada T, Tomita K et al.. Immediate administration of tolvaptan prevents the exacerbation of acute kidney injury and improves the mid-term prognosis of patients with severely decompensated acute heart failure. Circ J. 2014; 78:911-21.
• [13]Kawai T, Kamide K, Onishi M, Yamamoto-Hanasaki H, Baba Y, Hongyo K et al.. Usefulness of the resistive index in renal Doppler ultrasonography as an indicator of vascular damage in patients with risks of atherosclerosis. Nephrol Dial Transplant. 2011; 26:3256-62.
• [14]Ikee R, Kobayashi S, Hemmi N, Imakiire T, Kikuchi Y, Moriya H et al.. Correlation between the resistive index by Doppler ultrasound and kidney function and histology. Am J Kidney Dis. 2005; 46:603-9.
• [15]Bigé N, Lévy PP, Callard P, Faintuch JM, Chigot V, Jousselin V et al.. Renal RI is associated with severe histological changes and poor renal outcome during chronic kidney disease. BMC Nephrol. 2012; 13:139. BioMed Central Full Text
• [16]Granata A, Zanoli L, Clementi S, Fatuzzo P, Di Nicolò P, Fiorini F. Resistive intrarenal index: myth or reality? Br J Radiol. 2014; 87:20140004.
• [17]Tublin ME, Bude RO, Platt JF. Review. The resistive index in renal Doppler sonography: where do we stand? AJR Am J Roentgenol. 2003; 180:885-92.
• [18]Keogan M, Kliewer M, Hertzberg B, DeLong DM, Tupler RH, Carroll BA. Renal resistive indexes: variability in Doppler US measurement in a healthy population. Radiology. 1996; 199:165-169.
• [19]Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al.. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005; 18:1440-63.
• [20]Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23:685-713.
• [21]Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999; 16(1):9-13.
• [22]Motomura N, Miyata H, Tsukihara H, Takamoto S. Japan Cardiovascular Surgery Database Organization. Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery. Circulation. 2008; 118:S153-9.
• [23]Motomura N, Miyata H, Tsukihara H, Okada M, Takamoto S. Japan Cardiovascular Surgery Database Organization. First report on 30-day and operative mortality in risk model of isolated coronary artery bypass grafting in Japan. Ann Thorac Surg. 2008; 86:1866-72.
• [24]Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol. 2006; 1:19-32.
• [25]Hix JK, Thakar CV, Katz EM, Yared J-P, Sabik J, Paganini EP. Effect of off-pump coronary bypass graft surgery on postoperative acute kidney injury and mortality. Crit Care Med. 2006; 34:2979-2983.
• [26]Sato Y, Kato TS, Oishi A, Yamamoto T, Kuwaki K, Inaba H et al.. Preoperative factors associated with postoperative requirements of renal replacement therapy following cardiac surgery. Am J Cardiol. 2015; 116:294-300.
• [27]Radermacher J, Ellis S, Haller H. Renal resistance index and progression of renal disease. Hypertension. 2002; 39:699-703.
• [28]Radermacher J, Mengel M, Ellis S, Stuht S, Hiss M, Schwarz A et al.. The renal arterial resistance index and renal allograft survival. N Engl J Med. 2003; 349:115-24.
• [29]Kato TS, Cheema FH, Yang J, Kawano Y, Takayama H, Naka Y et al.. Preoperative serum albumin levels predict 1-year postoperative survival of patients undergoing heart transplantation. Circ Heart Fail. 2013; 6:785-91.
• [30]Bavishi C, Ather S, Bambhroliya A, Jneid H, Virani SS, Bozkurt B et al.. Prognostic significance of hyponatremia among ambulatory patients with heart failure and preserved and reduced ejection fractions. Am J Cardiol. 2014; 113:1834-8.
• [31]Bagshaw SM, Delaney A, Jones D, Ronco C, Bellomo R. Diuretics in the management of acute kidney injury: a multinational survey. Contrib Nephrol. 2007; 156:236-49.
• [32]Sato N, Kajimoto K, Asai K, Mizuno M, Minami Y, Nagashima M et al.. Acute decompensated heart failure syndromes (ATTEND) registry. A prospective observational multicenter cohort study: rationale, design, and preliminary data. Am Heart J. 2010; 159:949-955.
• [33]Romanovsky A, Bagshaw S, Rosner MH. Hyponatremia and congestive heart failure: a marker of increased mortality and a target for therapy. Int J Nephrol. 2011; 732746:7.
• [34]Gheorghiade M, Gattis WA, O’Connor CM, Adams KF, Elkayam U, Barbagelata A et al.. Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure. JAMA. 2001; 291:1963-1971.
• [35]Konstam MA, Gheorghiade M, Burnett JC, Grinfeld L, Maggioni AP, Swedberg K et al.. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST outcome trial. JAMA. 2007; 297:1319-31.
• [36]Bossard G, Bourgoin P, Corbeau JJ, Huntzinger J, Beydon L et al.. Early detection of postoperative acute kidney injury by Doppler renal resistive index in cardiac surgery with cardiopulmonary bypass. Br J Anaesth. 2011; 107:891-8.
• [37]Corradi F, Brusasco C, Vezzani A, Palermo S, Altomonte F, Moscatelli T et al.. Hemorrhagic shock in polytrauma patients: early detection with renal doppler resistive index measurements. Radiology. 2011; 260:112-18.
• [38]Izumi M, Sugiura T, Nakamura H, Nagatoya K, Imai E, Hori M. Differential diagnosis of pre- renal azotemia from acute tubular necrosis and prediction of recovery by Doppler ultrasound. Am J Kidney Dis. 2000; 35:713-719.