Can the use of low-dose dopamine for treatment of acute renal failure be justified?

Abstract

SummaryThe use of dopamine for the prevention and treatment of acute renal failure is widespread. Its use is based on physiology suggesting selective renal vasodilation when it is infused at low dose. This article reviews the available data on the clinical use of dopamine. When used to prevent acute renal failure in high-risk treatments there is no evidence of benefit of dopamine but, given the low incidence of significant renal failure, the studies are underpowered. In treatment of acute renal failure, the quality of the data is poor. Only in one small randomised trial of moderate acute renal failure in patients with malaria was a clinically significant benefit of dopamine shown. The rest of the data, in the form of case series, showed either no benefit of dopamine or small benefits of little clinical significance. Again, these studies are of insuYcient power for conclusions to be drawn as to the overall benefits and risks. We conclude that benefits of dopamine use cannot be ruled out by currently available data but its use cannot be advised until trials examining clincally important endpoints in large numbers of patients have been performed. Keywords: dopamine; renal failureThe use of dopamine for prevention and treatment of acute renal failure is based on its ability to increase renal blood flow in animals 1 and in normal human subjects.2 3 Early case reports 4 appeared to confirm the benefit of dopamine which has become widely used for the treatment of patients with acute renal failure. However, more recently the benefits of dopamine have been questioned, 5 and more attention given to its risks. 6 Denton et al 7 concluded that renal dose dopamine "should not be used for its selective renal vasodilatory actions in patients with acute renal failure until its eYcacy is established conclusively." We have reviewed the published literature using a Medline search and tracing back references from recent publications to determine whether the current use of dopamine for management of acute renal failure can be justified by the currently available evidence. The normal physiology of dopamine,The eVects of dopamine infusion are complex as it acts on a number of different receptors which have opposing actions. ; they also inhibit aldosterone production in the adrenal gland.10 Given the complexity of dopamine's actions it is unsurprising that there is overlap of the doses at which its various eVects are seen and no dose is specifically renal in action. 12In normal animals, dopamine infusion increases renal blood flow, although this is dose-dependent and the dose range varies between species.13 In man, lowdose dopamine (0.5-3.0 µg/kg/min) increases renal blood flow, measured using p-aminohippuric acid clearance, 2 by stimulation of DA 1 receptors. 14 In normal dogs low-dose dopamine results in an increase in glomerular filtration rate (GFR).10 Evidence of a change in GFR in man is conflicting. McDonald et al 2 found an increase in inulin clearance from 109 to 126 ml/min with dopamine infused up to 7.1 µg/kg/min in normal hu...

Effect of fenoldopam on renal function after nephrotomy in normal dogs

“…Differential receptor activation explains the distinct cardiovascular and renal responses observed with various doses of dopamine. Dopaminergic effects generally predominate, but, at higher doses, adrenoceptors are activated, which may result in tachyarrhythmias, hypotension, myocardial or splanchnic ischemia, systemic vasoconstriction, or reduced GFR 8‐11 …”

“…Dopaminergic effects generally predominate, but, at higher doses, adrenoceptors are activated, which may result in tachyarrhythmias, hypotension, myocardial or splanchnic ischemia, systemic vasoconstriction, or reduced GFR. [8][9][10][11] Fenoldopam mesylate is a specific DA-1 agonist that selectively vasodilates renal arterioles to increase blood flow and improve renal function. Fenoldopam has been reported as a potent renal vasodilator in several species, including humans, monkeys, dogs, and rats, resulting in increased renal blood flow (RBF), decreased renal vascular resistance, and increased GFR.…”

Evaluation of Brooke Formula Plus Dopamine in Burn Resuscitation

“…It is hard to find studies proving that renal dose dopamine either prevents or cures acute renal failure. [10,11] In the absence of scientific evidence, renal dose dopamine is going out of favour from most units nowadays. However, pharmacologically, low dose dopamine does have renal vasodilator effect.…”

Preventing renal failure in the critically ill

“…The belief that low dose dopamine is beneficial was based on the physiological and pharmacological properties of dopamine and on personal anecdotes, but there is a lack of clinical trials, those available being of poor quality 1. The recent publication of a high quality randomised, double blind, placebo controlled study2 showing no benefit of “low dose” dopamine has, therefore, killed—or at least mortally wounded given that it takes time for cardiac surgeons to catch up—one of critical care's sacred cows.…”

“…The weight of evidence has long been against the use of dopamine, especially as its adverse effects (inappropriate vasoconstriction, tachyarrhythmias, reduced respiratory drive, increased intrapulmonary shunt, altered immune and endocrine responses, and reduced splanchnic perfusion) are well recognised 1. Low dose dopamine can no longer be considered to “do no harm and possibly do some good,” as we were taught, and this study conclusively shows that dopamine has no role in preventing acute renal failure in critical illness.…”