Acute Kidney Failure, Cardiogenic Shock, Cardiorenal Syndrome
Conditions
Keywords
Levosimendan, Inotropic Agent
Brief summary
To determine whether Levosimendan infusion in patients with cardiogenic shock and cardiorenal syndrome refractory to standard inotropic therapy, improves hemodynamics and renal function, whilst being safe.
Detailed description
Cardiogenic Shock or the state of systemic hypoxia albeit initially preserved intra-vascular volume and intact vascular function, is solely the result of insufficient cardiac output \[1-2\]. The ensuing centralization and redistribution of blood-volume, is induced by a stimulation of the renin-angiotensin system, as well as vasopressin and endogenous catecholamine liberation \[2-3\]. Precipitating Cardiogenic Shock has a direct effect on the kidney, also called the cardiorenal syndrome \[4\]. The overall consensus for the therapy of cardiogenic shock is the use of inotropes to increase cardiac output and reverse organ hypoxia \[2\], nevertheless their increase of myocardial and glomerular oxygen consumption make them a double edged sword to use in cardiogenic shock and more prominently in cardiogenic shock coupled with pronounced cardiorenal syndrome. Levosimendan is an inotropic agent that was developed for the treatment of severely decompensated heart failure. It exerts its inotropic effects primarily through sensitizing Troponin C to calcium and thereby increasing contraction of cardiac myofilaments during systole \[5\]. Unlike other inotropic agents, Levosimendan acts independently of the beta adrenergic receptor \[5\]. Additionally, the effect of Levosimendan could be beneficial for the kidneys function by decreasing pre-glomerular arteriolar vasotonus whilst keeping post-glomerular arteriolar vasotonus constant \[6\]. In light of the scarce but promising literature the question arises if Levosimendan can safely ameliorate cardiac and renal function concomitantly in patients presenting the combination of cardiogenic shock and cardiorenal syndrome.
Interventions
DRUGLevosimendan
Levosimendan was administered according to a standardized treatment protocol. A total dose of 12.5mg or 25mg (corresponding to one or two ampoules) was given at an infusion rate of 0.05 μg/kg/min to 0.2μg/kg/min with or without a loading dose (6 μg/kg or 3 μg/kg over 10 minutes). The decision about total dose, infusion rate and loading dose was at the discretion of the treating physician.
Sponsors
University of Zurich
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Levosimendan * Cardiogenic Shock * Continuous monitoring of cardiac output at the start of and during treatment with Levosimendan
Exclusion criteria
* Extracorporal hemodynamic support or an implanted ventricular assist device * Previous therapy with Levosimendan during the index hospitalization * Refusal of participation in the study
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Cardiac Index | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of Cardiac Index post Levosimendan Infusion up until 120 hours |
| Change in Cardiac Preload Pressures | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of Wedge Pressure/ Central Venous Pressure post Levosimendan Infusion up until 120 hours |
| Change in Mean Arterial Pressure | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of Mean Arterial Pressure post Levosimendan Infusion up until 120 hours |
| Change in Vasoactive/ Inotropic Dosage | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of Norepinephrine/ Dobuatmine Dosage post Levosimendan Infusion up until 120 hours |
| Change in Renal Function | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of eGFR (Creatinin estimated) post Levosimendan Infusion up until 120 hours |
| Change in Fluid Balance | Mixed Model Assessment at 0, 1, 2, 4, 6, 12, 24, 48, 72, 96 and 120 hours post Levosimendan Infusion | Temporal development of Fluid Balance post Levosimendan Infusion up until 120 hours |
Outcome results
None listed