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Perioperative Kidney protection..Pharmacology agents



Diuretics (furosemide/mannitol)

While use of diuretics may improve urine output in the setting of acute kidney injury, again there is no evidence to support that they confer any improvement in outcomes measured (including need for RRT and mortality) . Furthermore, use of furosemide has been shown to be not only ineffective but also detrimental, associated with higher postoperative serum creatinine levels in cardiac patients . Of note, mannitol is often added to the priming solution used in CPB surgery. Although initially shown to confer some preventive benefits in children undergoing CPB surgery, these results have not been reproduced in repeat studies, with a suggestion that mannitol is actually associated with increased tubular injury when given in combination with dopamine .

Theophylline

Theophylline, an adenosine antagonist, in theory is proposed to preserve renal blood flow by attenuating vasoconstriction of renal vessels . Several small studies have been conducted using theophylline in contrast-induced nephropathy; however, a meta-analysis in 2005 was inconclusive and recommended that a RCT in this area with a defined hydration protocol would be of benefit . In the setting of CPB surgery, an infusion of theophylline conferred no benefit in reducing the incidence of AKI 

N-acetylcysteine

The role of N-acetlycysteine, an antioxidant most commonly used to enhance formation of glutathione after paracetamol overdose, has not been shown to confer any protective benefits in the perioperative period . As mentioned above, there may be some role for this agent in contrast-induced nephropathy 

Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore P, Oudemas-van Straated HM, Ronco C, Schetz MRC, Wottiez AJ: Prevention of acute kidney injury and protection of renal function in ITU.
Intensive Care Med 2010, 36:392-411

Carcoana OV, Hines RL: Is renal dose dopamine protective or therapeutic? Yes.
Crit Care Clin 1996, 12:677-685. 

Bagshaw SM, Ghali A: Theophylline for prevention of contrast-induced nephrology.
Arch Intern Med 2005, 165:1087-1093. OpenURL

Kramer BK, Preuner J, Ebenburger A, Kaiser M, Bergner U, Eilles C, Kammerl MC, Riegger GAJ, Birnbaum DE: Lack of renoprotective effect of theophylline during aortocoronary bypass surgery.
Nephrol Dial Transplant 2002, 17:910-915.

Nigwekar SU, Kandula P: N-acetylcysteine in cardiovascular-surgery-associated renal failure: a meta-analysis.Ann Thorac Surg 2009, 87:139-147






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