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Eur J Cardiothorac Surg 2002;22:106-111
© 2002 Elsevier Science NL

Dopamine therapy for patients at risk of renal dysfunction following cardiac surgery: science or fiction?

Edwin B.C. Wooa, Augustine T.M. Tangb, Ahmed El Gamelc, Brian Keevild, Donna Greenhalghe, Mark Patricke, Mark T. Jonesa, Timothy L. Hoopera*

a Department of Cardiothoracic Surgery, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT, UK
b Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK
c Department of Cardiothoracic Surgery, King's College London, London, UK
d Department of Chemical Pathology, Wythenshawe Hospital, Manchester, UK
e Department of Anaesthesia, Wythenshawe Hospital, Manchester, UK

Received 13 August 2001; received in revised form 1 April 2002; accepted 3 April 2002.

* Corresponding author. Tel.: +44-161-2912511; fax: +44-161-2912530


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objectives: We aimed to evaluate the renoprotective role of renal-dose dopamine on cardiac surgical patients at high risk of postoperative renal dysfunction. The latter included older patients or those with pre-existing renal disease, elevated preoperative serum creatinine (Cr), poor ventricular function, hypertension, diabetes mellitus and unstable angina requiring intravenous therapy. Methods: Fifty patients undergoing cardiopulmonary bypass (CPB) who fulfilled the entry criteria were prospectively randomized into two groups: Group 1 received a ‘renal-dose’ (3 µg kg-1 min-1) dopamine infusion starting at anaesthetic induction for 48 h whilst saline infusion acted as placebo in Group 2. The anaesthetic and CPB regimes were standardized. Urinary excretion of retinol binding protein (RBP) indexed to Cr, an accurate and sensitive marker of early renal tubular damage, was assessed daily for 6 days. Additional outcome measures included daily fluid balance, blood urea and serum Cr. Statistical comparisons were made using ANOVA and Mann–Whitney U-test. Results: No significant difference was found between the groups in their age, gender, preoperative NYHA class, ejection fraction, baseline serum Cr and duration of CPB and aortic cross-clamping. Renal replacement therapy was not required in any instance. Both groups demonstrated a similar and significant rise in urinary RBP throughout the study period. Dopamine-treated patients achieved more negative average fluid balance than those on placebo (5 vs. 229 ml, P<0.05). Conclusions: Renal-dose dopamine therapy failed to offer additional renoprotection to patients considered at increased risk of renal dysfunction after CPB.

Key Words: Anaesthesia • Blood flow • Cardiopulmonary bypass • Kidney • Vasodilation


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Renal dysfunction following cardiopulmonary bypass (CPB) is well recognized. Its reported incidence varies considerably from 0.1% up to 39% [1,2]. It is a major contributor of postoperative morbidity and mortality with fatality rates in excess of 60% for those requiring renal replacement therapy [3]. During CPB, reduced mean arterial pressure coupled with non-pulsatile flow decrease renal perfusion by approximately 30%. Patients with normal renal function may tolerate this insult without any clinically detectable abnormality due to the large renal functional reserve. However, this may not hold true for those with pre-existing renal dysfunction and/or impaired renal perfusion perioperatively.

Dopamine is an endogenous catecholamine (3,4-dihydroxyphenylethylamine) which when used therapeutically at ‘renal dose’ (3–5 µg kg-1 min-1) results in dilation of the renal vasculature, reduction in renal vascular resistance and increased renal blood flow [4,5]. Its unique effect has been advocated for renal prophylaxis in various clinical settings including post-chemotherapy, contrast nephropathy, obstructive jaundice and organ transplantation. However, randomized studies failed to produce conclusive evidence in support of any benefit of dopamine under such circumstances [6,7]. In the realms of cardiac surgery, our group had previously demonstrated that far from being renoprotective, perioperative renal-dose dopamine enhanced CPB associated renal tubular dysfunction in low risk patients [8]. The present study goes on to examine this issue in patients who for specific reasons are considered at high risk of developing renal dysfunction following cardiac surgery.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Consecutive patients undergoing cardiac surgery under two surgeons at Wythenshawe Hospital, Manchester were screened, consented and recruited. The inclusion criteria (Table 1) reflected those patient most at risk of postoperative renal dysfunction. Subjects were randomized into two groups: Group 1 received intravenous dopamine at a rate of 3 µg kg-1 min-1 for 48 h starting at induction of anaesthesia. Control patients in Group 2 received an infusion of 0.9% saline over the same period. The study was approved and monitored by the South Manchester University Hospital ethics committee.


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  		Table 1. Inclusion criteriaa

 
All patients received fentanyl-based general anaesthesia in combination with vecuronium as muscle relaxant. The core temperature of the patients was allowed to drift to 32 °C during CPB. Alpha-stat pH management was employed. The pump flow rate was set at 2.5 l min-1 m2 and the mean perfusion pressure was maintained at 65 mmHg by administration of metaraminol or isoflurane into the bypass circuit. All the patients received 200 mg Netilmicin as prophylaxis.

In the first six postoperative days, daily blood and urine samples were taken for measurement of blood urea, serum creatinine, and urinary retinol binding protein to urinary creatinine ratio (Ur RBP/Ur Cr). Patients' daily fluid balance and diuretic use were also recorded.

All urine samples were collected early in the morning and a 2 ml aliquot was frozen and stored until analysis. The urinary level of RBP was measured using a commercially available reagent kit (Randox Laboratories, Antrim, UK) based on an ELISA technique. The technique details have been previously reported [8].

The statistical power calculation was performed at the conception stage utilizing expected differences in outcome based on our previous work in related subjects which employed similar methodology [8]. This suggested that a sample size of 14 in each group would have 90% power to detect a probability of 0.9 that an observation (e.g. urinary markers of differential renal injury) in the control group was less than a corresponding observation in the dopamine group using an appropriate test with a 0.05 two-sided significance level. To allow for a generous safety margin, we decided to aim for 20 patients in each study group. Chi-square tests were applied to compare differences between the groups with respect to gender, hypertensive status, and usage of aprotinin. The Mann–Whitney U-test was applied to non-parametric data concerning NYHA grade, Canadian Cardiovascular Society (CCS) symptom score for severity of angina and diuretic usage. The remaining data were analyzed with an unpaired two-tailed t-test and repeated measures ANOVA on raw or naturally transformed (natural log detransformed) data.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Forty-two of the 50 patients enrolled completed the study: 20 patients in the treatment group and 22 in the control group. Eight patients were excluded either due to death or major hemodynamic instability that might affect renal perfusion. Five patients were excluded from the treatment group, of which two died from cardiac failure and three had re-sternotomy for hemostasis. Three patients were excluded from the control group, of which one patient had intra-operative circulatory arrest, one patient had re-sternotomy for hemostasis and one patient required the insertion of an intra-aortic balloon pump. Of the cohort that completed the study in the control group, 16 patients had isolated coronary surgery, four had isolated valve replacement and two had combined valve and coronary surgery. In the treatment group the corresponding figures were 17, three and zero, respectively. None of the studied patients required postoperative renal replacement. Patients in the treatment group were discharged on average after 8.6 days while those in the control group were discharged after 9.8 days (P=0.26).

All major complications occurred in control patients: three developed neurological complications including one with mild left hemiparesis, another with previous right occipital trauma who developed left occipital infarct resulting in cortical blindness, and a third who was ventilated for 5 days whilst slowly regaining consciousness. Furthermore, an asthmatic patient had difficulty weaning from the ventilator and required respiratory support for 8 days.

The group's demographic characteristics are displayed in Table 2. There was no statistically significant difference between their age, gender, body mass index, preoperative cardiac status, and creatinine level. A borderline significant difference in preoperative diastolic blood pressure was found with higher values recorded in the controls. None of the patients received intravenous contrast media in the 5 days prior to surgery.


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  		Table 2. Demographic and perioperative dataa

 
Operative and postoperative data are presented in Tables 2 and 3, and Fig. 1 . Fig. 1 shows the Ur RBP/Ur Cr in the two groups. Postoperatively the treatment group had a higher Ur RBP/Ur Cr ratio than controls but this failed to achieve statistical significance either in the overall values (P=0.42) or in time trends (P=0.27). The average ratio over the seven time points in Fig. 1 is akin to ‘area under the curve’ analysis. The geometric mean for the two groups was 952 and 813 µmol mmol-1, respectively, with no statistically significant difference.


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  		Table 3. Measured variablesa

 


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  		Fig. 1. Urinary retinal binding protein levels in the two groups. Ur RBP/Ur Cr for the two groups; data points are geometric mean±95% confidence interval. There is no statistically significant difference between the groups overall or in time trends.

 
No significant difference was observed in aprotinin usage, cross-clamp time and CPB time (Table 2). There was, however, a borderline significant (P=0.046) difference in fluid balance between the two groups (Table 3): the control group retained more fluid than the treatment group (229±290 vs. 5±293 ml, respectively); this difference is, however, clinically insignificant. Throughout the study period there was no significant difference in blood urea and serum creatinine levels between the groups overall or in their time trend.

A loop diuretic was used exclusively to induce postoperative diuresis. Average diuretic usage was expressed as mg frusemide per patient per day over the study period. Patients in Group 1 received on average 19.1 mg day-1 while those in Group 2 received 19.8 mg day-1 (P=0.92) (Table 2). Not every patient received postoperative diuretic treatment.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Renal failure is a well recognized complication following cardiac surgery. The wide variation in the reported incidence is probably a reflection of the different criteria used by various authors. These range from isolated sustained oliguria to full blown acute renal failure requiring hemo-filtration or hemo-dialysis. The latter occurs in less than 1% of all cases [3]. The scale of this problem is likely to increase with more referral of high risk and elderly patients for cardiac surgery ultimately leading to higher mortality, morbidity and consumption of healthcare resources.

The cause of renal dysfunction after open heart surgery is probably multi-factorial. Central to this is the activation of inflammatory cascades and renal ischemia from reduction of kidney blood flow during CPB. This may be exacerbated by the use of inoconstrictor or other vasopressing agents for postoperative circulatory support. Various approaches have been taken to counteract such insults with variable success. Among these dopamine through its perceived influence on renal perfusion has gained popularity with clinicians. This endogenous catecholamine is thought to exert a dose dependent effect: at levels above 7 µg kg-1 min-1 stimulation of the cardiac ß1 receptors will result in a rise in blood pressure; however, at lower dosage (2–5 µg kg-1 min-1) it stimulates mainly the dopaminergic receptors causing vasodilation and a reduction in diastolic blood pressure. This vasodilating effect is said to be renal specific, which in turn forms the basis for its ‘renal protection’ role. Furthermore, there is a suggestion that renal-dose dopamine may also ameliorate the mesenteric and renal vaso-constrictive property of noradrenaline [9]. However, dopamine even when used at ‘renal dose’ potentially has multiple unwanted effects: its systemic ß-agonist activity can increase myocardial oxygen consumption, induce sinus tachycardia and ventricular extrasystole and promote cardiac arrhythmia [10].

In clinical practice, renal-dose dopamine has been widely used for ‘renal protection’ in various settings including major surgery. However, studies evaluating the role of ‘renal-dose’ dopamine have so far failed to demonstrate any conclusive benefit in patients undergoing cardiac, abdominal aortic and liver transplantation surgery.

The renal vasodilating effect of dopamine is well documented [10,11]. The assumption is that the augmented renal blood flow is renal protective. However, these studies either reported concurrent augmentation of cardiac index [9,10] or no data on hemodynamic effects were given [10,11]. It is only in animal studies when the hemodynamic effect of dopamine may be excluded that its effect on renal vascular tone can be observed. Steinhausen and colleagues reported that low concentrations of dopamine (1–30 µM) cause an increase in the diameter of rat renal arcuate, interlobar, and afferent and efferent arterioles [12]. The enhanced renal blood flow caused by dopamine has not been translated into a reduction in renal complication in surgical patients. Recent randomized studies examining the effect of dopamine at 3 µg kg-1 min-1 have failed to demonstrate improvement in creatinine clearance, urine output and incidence of renal failure in liver transplant [7], vascular surgical [13] and jaundice [6] patients. These findings were supported by a recently published sizeable randomized study in the ICU setting. Dopamine infusion at 2 µg kg-1 min-1 confers no benefit for the patients in terms of peak creatinine rise, incidence of renal replacement therapy, and total ICU and hospital stay [14]. In the cardiac arena where the hemodynamics of critically ill patients are in constant flux, dopamine at a low dose (200 µg min-1) may confer its beneficial effect by increasing cardiac index [5]. However, in another study of patients undergoing coronary surgery, dopamine at the same dose increased cardiac index but had no effect on urine output, creatinine and free water clearance, or the incidence of renal insufficiency [15]. Evidence so far has suggested that dopamine is essentially a weak inotrope and a potent diuretic. Although laboratory data have supported dopamine's claim of renal vascular dilation, clinical studies seem to indicate that dopamine only improves renal blood flow when cardiac performance is augmented in parallel. Furthermore, we previously found that renal-dose dopamine given prophylactically in fact exacerbated the degree of renal tubular damage after CPB: patients in the treatment group had significantly higher Ur RBP/Ur Cr than well matched controls. This was observed in subjects with normal heart and kidney functions preoperatively who were not considered at risk of developing postoperative renal dysfunction [8]. The situation may be very different when pre-existing renal disease or other factors predispose them to perioperative renal failure for which renal-dose dopamine may confer a benefit. The inclusion criteria for the present study were based on published independent risk factors for post-CPB renal dysfunction. These included pre-existing renal dysfunction, age >70 years, diabetes mellitus, ejection fraction <40%, hypertension and unstable angina [16–20].

Published accounts indicate that renal dysfunction post-cardiac surgery has glomerular and tubular components [21,22]. Creatinine clearance is considered a suitable surrogate for Inulin clearance in the measurement of the glomerular filtration rate (GFR). Due to the large renal reserve, any changes in serum creatinine or creatinine clearance tend to occur late and they have been considered to be less sensitive for subtle and early renal dysfunction [23]. Accurate and sensitive methods of detecting tubular injury were developed in the 1980s. These methods are based either on the ability of the proximal tubular cells to reabsorb low molecular mass proteins (e.g. ß2-microglobulin and RBP) or on the leakage of intracellular proteins of high molecular mass from the damaged tubules (e.g. N-acetyl-ß-D-glucosaminidase and glutamyltranspeptidase). Urinary excretion of RBP was chosen for our study as it was found to be the most stable in acidic urine.

The present study confirmed that Ur RBP/Ur Cr peaked on postoperative day 1 in both groups before returning towards preoperative baseline values on day 6, a familiar pattern observed in our previous work. There is a trend towards greater excretion in the dopamine-treated group suggesting again further exacerbation of CPB associated renal tubular injury. However, this difference was not statistically significant primarily as a result of wide data scatter, which in turn may be accountable for by our pragmatic inclusion criteria leading to a rather heterogeneous group. Whilst each subject was considered at increased risk of postoperative renal failure, they were likely to have diverse aetiology and wide-ranging renal functional reserve, an example of which is a patient with diabetes mellitus. It has been shown previously that diabetics have supra-normal urinary excretion of RBP [24]. The degree of raised urinary RBP excretion is related to the duration of diabetes and its control [24]. Diabetic subjects may have subtle proximal tubular dysfunction and remain non-microalbuminuric [25]. To overcome this limitation, it will be necessary to focus on specific groups such as those with elevated preoperative serum creatinine. An interesting observation gained from the present study and our previous work is that the peak values of Ur RBP/Ur Cr appear to be considerably higher in patients at increased risk of renal failure. The increased excretion also seems to extend further into the postoperative period. The exaggerated time-excretion integral would support a quantitative role for Ur RBP/Ur Cr in the assessment of renal tubular dysfunction.

Renal-dose dopamine may be effective in situations when the combination of an inotrope and a diuretic is required such as development of oliguria after cardiac surgery despite adequate filling. Our results indicated that patients in the treatment arm had a persistently more negative fluid balance. Since diuretic usage in both groups was comparable, the difference in fluid balance was most likely to be dopamine related. The disparity in fluid balance peaked on the 4th postoperative day (Table 3) suggesting that the diuretic action of dopamine may endure well beyond the period of its administration.

In conclusion, for cardiac surgical patients considered at increased risk of postoperative renal dysfunction, perioperative administration of renal-dose dopamine did not confer protection against CPB associated tubular damage as measured by Ur RBP/Ur Cr. We do not recommend the use of renal-dose dopamine as routine prophylaxis in this setting.


   Acknowledgments
 
We are grateful to all the nursing staff at Wythenshawe Hospital for their assistance during the study, Dr Raj Debray for his contribution in the running of the study and Mrs J Morris for carrying out the statistical analysis.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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