Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Abstract

Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.

The Importance of Prognostic Nutritional Index in Predicting Acute Renal Failure After On-Pump Coronary Artery Bypass Operations in Patients with Insulin-Dependent Diabetes Mellitus

“…As a result of increased hemolysis due to the use of blood products, renal injury may occur due to hemolysis-derived products [Freeland 2015]. Inotropic support may cause renal damage due to vasoconstrictive effects [Chen 2021]. In our study, we identified increased blood product and inotropic support use as independent predictors in predicting the development of AKI.…”

Risk Factors for Acute Kidney Injury Requiring Renal Replacement Therapy after Orthotopic Heart Transplantation in Patients with Preserved Renal Function

“…Based on the literature research, the following five of the nine significant variables were included into multivariate binary logistic regression (see Table 3 ): ECMO [ 9 , 10 , 11 ], all cause infection after surgery [ 12 , 13 ], levosimendan [ 14 , 15 , 16 ], duration of NE therapy [ 17 , 18 , 19 ] and increase in Tacrolimus plasma levels [ 18 , 20 , 21 ]. Evidence for the choice to include these five variables can be found as references next to each variable.…”

Levosimendan in Europe and China: An Appraisal of Evidence and Context

“…A further contribution to understanding the renal effects of levosimendan may be found in the work of Chen et al, who conducted a network meta-analysis of 29 published trials to provide direct comparisons of levosimendan versus placebo or inotropes in patients undergoing cardiac surgery. [ 63 ] They concluded that, compared with placebo, the use of levosimendan significantly decreases the risks of mortality (OR 0.74; 95% CI [0.56–0.97]) and acute renal injury (OR 0.61; 95% CI [0.45–0.82]), especially in patients with low systolic function. [ 63 ] Comparisons with milrinone, dopamine, dobutamine and fenoldopam identified levosimendan as the best treatment based on p-values.…”