After the Rebranding and Cost Increase, the Use of Vasopressin Continues to Increase Yearly Especially in Case of Acute Kidney Injury With Septic Shock: Is There Recent Data Justifying It?

Abstract

Sacha et al (1) showed that vasopressin was utilized in 42.6% of acute kidney injury (AKI) before and increased to 54.6 % after rebranding, which seems to be high despite the cost increase. We reviewed potential justifications for the vasopressin increased use in AKI during septic shock (SS) after rebranding (2). Just after rebranding in 2016, Gordon et al (2) reported the results of the multicenter trial Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock (VANISH), which compared the effect of these two vasopressors on AKI in adult patients with SS. Rationale for this study was the landmark Vasopressin and Septic Shock Trial (VASST), done in 2014 before rebranding. This study found an association between low-dose vasopressin (0.01-0.03 U/min) and decreased mortality in less severe SS but no difference between vasopressin and norepinephrine on global mortality or organ dysfunction rates (3). Post hoc analysis of the VASST study suggested that vasopressin treatment is associated with reduced progression to AKI, decreased need for renal replacement therapy (RRT), and reduced mortality in SS patients at risk of AKI (4). This concurred with earlier small clinical studies, demonstrating improvement in creatinine clearance (CCL) in vasopressin-treated patients (4). In the VANISH study, there were fewer RRTs in the vasopressin group (2).Unfortunately, the VANISH study did not find a difference in the number of kidney failure-free days in surviving patients receiving vasopressin or norepinephrine (2). The reduction in the number of RRTs in the vasopressin group but without any difference in the number of kidney failure-free days in survivors between groups had procured only some meager scientific solace (4). Many meta-analyses, however, did not reveal any significant improvements with vasopressin regarding AKI (4). Since rebranding, only one study has shown a favorable effect of vasopressin on AKI risk in sepsis. This was a study performed in an ovine model of sepsis by Okazaki et al (5). This study showed that vasopressin infusion did not significantly affect renal medullary perfusion or Po 2 and induced a sustained (6 hr) ~2.5-fold increase in CCL (5). Vasopressin reduced sepsis-induced mesenteric hyperemia (+61 ± 13 to +9% ± 6%) (5). Norepinephrine transiently (2 hr) improved CCL (by ~3.5-fold) but worsened renal medullary ischemia (to -64% ± 7%) and hypoxia (to -71% ± 6%) (5). Therefore, clearly, low-dose vasopressin (0.03 international units [IU]/min [0.03-0.05 IU/min]) as first vasopressor

The authors reply

“…Sang Ling, PhD 1 Zhanqi Zhao, PhD 2,3 With Electrical Impedance Tomography at Different Days Are Not Comparable To the Editor: W e have read the article from Cardinale et al (1), recently published in Critical Care Medicine. The authors calculated the changes of endexpiratory lung impedance (EELI) measured with electrical impedance tomography (EIT) between consecutive days.…”

“…We appreciate the interest of Honore et al (1) in our article recently published in Critical Care Medicine , evaluating the association between vasopressin rebranding and its utilization in patients with septic shock (2). We are similarly interested in the discussion of vasopressin utilization in patients with acute kidney injury (AKI, termed “acute kidney failure” in our study) but want to emphasize that our results reported in Table 1 reflect characteristics in patients with septic shock prior to and after vasopressin rebranding.…”