Brienza Nicola, Malcangi Vincenzo, Dalfino Lidia, Trerotoli Paolo, Guagliardi Clementina, Bortone Dora, Faconda Giuseppe, Ribezzi Mario, Ancona Giovanni, Bruno Francesco, Fiore Tommaso
Anesthesia and Intensive Care Division, Emergency and Organ Transplantation Department, University of Bari, and Anesthesia and Intensive Care Division, Miulli Hospital, Acquaviva delle Fonti, Italy.
Crit Care Med. 2006 Mar;34(3):707-14. doi: 10.1097/01.CCM.0000201884.08872.A2.
Fenoldopam mesylate is a selective dopamine-1 agonist, with no effect on dopamine-2 and alpha1 receptors, producing a selective renal vasodilation. This may favor the kidney oxygen supply/demand ratio and prevent acute renal failure. The aim of the study was to investigate if fenoldopam can provide greater benefit than low-dose dopamine in early renal dysfunction of critically ill patients.
Prospective, multiple-center, randomized, controlled trial.
University and city hospital intensive care units.
One hundred adult critically ill patients with early renal dysfunction (intensive care unit stay<1 wk, hemodynamic stability, and urine output<or=0.5 mL/kg over a 6-hr period and/or serum creatinine concentration>or=1.5 mg/dL and<or= 3.5 mg/dL).
Patients were randomized to receive 2 microg/kg/min dopamine (group D) or 0.1 microg/kg/min fenoldopam mesylate (group F). Drugs were administered as continuous infusion over a 4-day period.
Systemic hemodynamic and renal function variables were recorded daily. The two groups were well matched at enrollment for illness severity and hemodynamic and renal dysfunction. No differences in heart rate or systolic, diastolic, or mean arterial pressure were observed between groups. Fenoldopam produced a more significant reduction in creatinine values compared with dopamine after 2, 3, and 4 days of infusion (change from baseline at time 2, -0.32 vs. -0.03 mg/dL, p=.047; at time 3, -0.45 vs. -0.09 mg/dL, p=.047; and at time 4, -.041 vs. -0.09 mg/dL, p=.02, in groups F and D, respectively). The maximum decrease in creatinine compared with baseline was significantly greater in group F than group D (-0.53+/-0.47 vs. -0.34+/-0.38 mg/dL, p=.027). Moreover, 66% of patients in group F had a creatinine decrease>10% of the baseline value at the end of infusion, compared with only 46% in dopamine group (chi-square=4.06, p=.04). Total urinary output during drug infusion was not significantly different between groups. After 1 day, urinary output was lower in group F compared with group D (p<.05).
In critically ill patients, a continuous infusion of fenoldopam at 0.1 microg/kg/min does not cause any clinically significant hemodynamic impairment and improves renal function compared with renal dose dopamine. In the setting of acute early renal dysfunction, before severe renal failure has occurred, the attempt to reverse renal hypoperfusion with fenoldopam is more effective than with low-dose dopamine.
甲磺酸非诺多泮是一种选择性多巴胺-1激动剂，对多巴胺-2和α1受体无作用，可产生选择性肾血管舒张。这可能有利于肾脏的氧供/需比，并预防急性肾衰竭。本研究的目的是调查在危重症患者早期肾功能不全时，甲磺酸非诺多泮是否比小剂量多巴胺能带来更大益处。
前瞻性、多中心、随机对照试验。
大学和城市医院的重症监护病房。
100例患有早期肾功能不全的成年危重症患者（重症监护病房住院时间<1周，血流动力学稳定，6小时尿量≤0.5 mL/kg和/或血清肌酐浓度≥1.5 mg/dL且≤3.5 mg/dL）。
患者被随机分为接受2μg/kg/min多巴胺治疗组（D组）或0.1μg/kg/min甲磺酸非诺多泮治疗组（F组）。药物持续输注4天。
每天记录全身血流动力学和肾功能变量。两组在入组时疾病严重程度、血流动力学和肾功能不全方面匹配良好。两组之间心率、收缩压、舒张压或平均动脉压无差异。输注2、3和4天后，与多巴胺相比，非诺多泮使肌酐值降低更显著（F组和D组在时间2时较基线的变化分别为-0.32 vs. -0.03 mg/dL，p = 0.047；时间3时为-0.45 vs. -0.09 mg/dL，p = 0.047；时间4时为-0.41 vs. -0.09 mg/dL，p = 0.02）。与基线相比，F组肌酐的最大降幅显著大于D组（-0.53±0.47 vs. -0.34±0.38 mg/dL，p = 0.027）。此外，输注结束时，F组66%的患者肌酐下降超过基线值的10%，而多巴胺组仅为46%（χ² = 4.06，p = 0.04）。药物输注期间两组总的尿量无显著差异。第1天后，F组尿量低于D组（p<0.05）。
在危重症患者中，以0.1μg/kg/min持续输注甲磺酸非诺多泮不会引起任何具有临床意义的血流动力学损害，与肾脏剂量的多巴胺相比可改善肾功能。在急性早期肾功能不全的情况下，在严重肾衰竭发生之前，用甲磺酸非诺多泮逆转肾灌注不足比小剂量多巴胺更有效。
