2013 and 2014 review of evidence for possible beneficial effects of diuretics and dopamine in patients with decompensated heart failure(HF) and acute kidney injury ( AKI)
Loop diuretics (furosemide, bumetanide, torsemide, ethacrynic acid) have long been used to “convert” oliguric to nonoliguric AKI. However, it is most likely that oliguric patients who respond to diuretics have a lesser renal injury than those who do not, with an intrinsically more favorable outcome. Moreover there is evidence that “forced” diuresis may exacerbate hypovolemia and renal injury. Once dialysis is required, high dose furosemide does not alter the natural history of AKI.
Dopaminergic agents (dopamine, fenoldopam) potentially confer renal protection by increasing renal blood flow (RBF), diuresis and saliuresis. By activating cyclic AMP they “turn off” the energy-dependent tubular sodium pump and thereby decrease tubular oxygen consumption; increased intratubular urine flow protects against tubular obstruction.In part this may be because there is very wide variability in dopamine pharmacokinetics, i.e. some patients given low dose dopamine may achieve high plasma levels, i.e. in the beta- or alpha-adrenergic range.
The Heart Failure clinical Research Network , funded by the National Heart,Lung and blood Institute in the USA , addressed the possibility that low dose dopamine or low- dose nesiritide could safely augment the diuresis induced by loop diuretics in patients with decompensated HF. The trial , in 360 patients , showed no evidence that diuresis or decongestion was enhanced by such combined therapy or that renal function was better preserved .
The is that we should continue what we are doing maintain aggressive approach to diuretic therapy , and perhaps concern ourselves less when renal function transiently worsen .
Despite more than thirty years of use as a renal vasodilator , low dose dopamine (2Mic/kg/m) has shown no evidence of benefit in patients with acute oliguric renal failure on the basis of its action on dopaminergic renal receptors . In fact , low -dose dopamine can have deleterious effects on hemodynamics ( decreased splanchnic blood flow ) immune function ( inhibition of T-cell lymphocyte function ) and endocrine function ( inhibition of thyroid _stimulating hormone release from the pituitary ) .
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