Cardiac Inotropes Offer Protection of Renal Function in Patients with Kidney Transplantation

Kidney Blood Press Res. 2020;45(2):331-338 doi: 10.1159/000504543.
Abstract
INTRODUCTION:

Impaired cardiac function is one of the most concomitant symptoms in patients with kidney failure after long-term dialysis. In addition, the preservation of adequate perfusion pressure to the graft plays a significant role in the intraoperative management during kidney transplantation, but the use of positive inotropic drugs in kidney transplant patients has been studied less. We investigated the protective effects of renal function by means of cardiac inotropes in kidney transplant patients.

METHODS:

Eighty-nine patients that received kidney transplantation between April 2014 and December 2016 at Qilu Hospital were included and randomly divided into the treatment group receiving levosimendan and a control group. All kidney recipients received ABO-compatible donors. A poor outcome was defined as one of the following: delayed graft function, graft hemorrhage, or nephrectomy.

RESULTS:

The treatment group had a better composite outcome and the level of neutrophil gelatinase-associated lipocalin was also lower than in the control group.

CONCLUSION:

Inotropic drugs may play a protective role in renal function in kidney transplantation.

CET Conclusion
Reviewer: Mr John O'Callaghan, Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences University of Oxford
Conclusion: This RCT in renal transplantation examined the effect the inotrope levosimendan when administered in the perioperative period. The study does not perform well on a number of quality measures and assessment for risk of bias. There is no description of the randomisation process, so we cannot assess it for fairness or whether or not there was any allocation concealment. This is compounded by the fact that there is no flowchart in the COHORT fashion to describe the excluded patients and withdrawals/dropouts at various stages of the study. It is not clear if the analysis is by intention to treat, or per protocol. The paper does not describe any attempt to blind the patients, clinicians or data analysts to the trial allocation. A “poor outcome” in the abstract was described as delayed graft function, graft haemorrhage or nephrectomy; the first two of these three are not defined anywhere in the paper and in the methods a different description of “poor composite outcome” is given as: death, blood creatinine level >500 micromol/L, return to dialysis, or a rejection episode. The main clinical outcome of “survival” is not defined and there is no presentation of the mean follow up times or other descriptor of this. The levosimendan infusion was maintained for 24 hours and it would be good to see some haemodynamic parameters presented from this period. The results show no significant difference in patient survival but a statistically worse composite outcome in the control group compared to the treatment group. There is no breakdown of these poor outcomes presented, and given that the patient survival is the same and the serum creatinine is the same, it must come from rejection episodes, but the reader has to make this assumption themselves and there is no exploration of this issue in the discussion. Other lesser criticisms include the lack of a power calculation, absolute p-values and confidence intervals. The authors claim that the long-term prognosis after renal transplantation can be improved by the use of inotropic drugs, such as levosimendan, but I do not agree the study proves this.
Methodological quality
Jadad score 2
Allocation concealment NO
Data analysis PER PROTOCOL
Study Details
Aims: The primary objective of this study was to assess the protective efffects of the cardiac inotrope levosimendan on renal fuction in recipients of kidney transplant.
Interventions: The participants were randomly assigned to two groups: the treatment group, where the patients received standard therapy post kidney transplant including the administration of levosimendan and the control group, where the patients received standard therapy without the administration of levosimendan.
Participants: 89 renal transplant recipients were included in the study.
Outcomes: The two main outcomes of interest were survival and composite clinical outcome. A poor composite outcome referred to any one of the following: a serum creatinine level >500 µmol/L, a rejection episiode, death or return to dialysis. Participants not exhibiting any of these criteria were defined as having a good composite outcome.
Follow Up: 1 year
Metadata
Funding: Non-industry funding
Publication type: Randomised Controlled Trial
Organ: Kidney
Language: English
Author email: juntian63@sina.com
MeSH terms: Adult; Female; Humans; Kidney Function Tests; Kidney Transplantation; Male; Middle Aged; Myocardial Contraction