Kidney Failures, Acute Clinical Trial
Official title:
Effect of Combination Intra-Renal Infusion of Fenoldopam Mesylate and High Dose Diuretics on Peak Serum Creatinine and Incidence of Renal Replacement Therapy in Patients With Early Acute Kidney Injury
Randomized prospective trial of patients with diuretic unresponsive acute kidney injury
where patients will receive standard supportive therapy with diuretics versus intra-renal
delivery of the vasodilator fenoldopam mesylate.
Patients with rising creatinine who fail to respond to bolus diuretics will be treated with
a prolonged course of diuretics or undergo placement of a catheter within the renal arteries
that allows for infusion of fenoldopam mesylate. The rational is that early delivery of a
high dose vasodilator may reverse the decline of renal function in patients with severe
acute kidney injury.
Acute kidney injury (AKI) is a common complication of hospitalized patients and is
associated with increased morbidity and mortality 1. The pathogenesis of AKI is a complex,
time dependent process involving multiple variables including significant reductions in
renal blood flow (RBF), interstitial infiltration by activated neutrophils and obstruction
of tubule lumens with necrotic debris. In both human studies and animal models, the change
in RBF is an early event with reductions in RBF between 40-50%. The mechanisms by which
blood flow falls after the onset of AKI is unknown, but release of multiple vasoconstrictors
coupled with a loss of autoregulation leads to prolonged reductions in RBF 2. The loss of
the ability to vasodilate and autoregulate renal blood flow increases the sensitivity to
additional ischemic and nephrotoxic insults.
Because reductions in RBF contribute to progression of AKI, clinical maneuvers that restore
blood flow to ischemic kidneys offer the potential to significantly reduce patient
mortality3. Consequently, numerous vasodilators have been investigated to determine whether
restoring blood flow clinically to reduces the incidence of dialysis dependent AKI. Some
agents including fenoldopam mesylate have shown encouraging results in specific
sub-populations, but the benefits of other agents including atrial natriuretic peptide were
offset by the development of systemic hypotension. The hypotenisve effects of these agents
are a significant limitation to efforts to restore blood flow to ischemic kidneys. Moreover,
the potential for additive hypotension and other side effects impedes the creation of
"cocktails" of multiple agents which could have the ability to simultaneously activate
numerous different protective pathways. Recent work using the FlowMedica Benephit catheter
has shown that intra-renal delivery of vasodilators allows for targeted organ protection
without the development of systemic side-effects. Moreover, the intra-renal delivery of
fenoldopam mesylate and other vasodilators allows for supra-pharmacologic doses leading to
and prolonged beneficial effects on RBF and GFR. We hypothesize that intra-renal delivery of
fenoldopam mesylate to patients with early AKI will significantly reduce the number patients
requiring renal replacement therapy. To investigate this hypothesis, we propose to study
patients with "diuretic-resistant" AKI and randomize patients to supportive care with
intermittent diuretics versus a 24 hour intra-renal infusion of fenoldopam mesylate in
combination with intermittent diuretic therapy. The trial will be a randomized prospective,
open-labeled study of 35 patients with early AKI defined as a 1.0 mg/dl rise in serum
creatinine above baseline and/or two consecutive hours of urine output less than 20 mls/hr.
The primary endpoint of the study will be peak serum creatinine at day #4 and the number of
patients requiring renal replacement therapy or dying within 8 days of the onset of AKI.
Additional data will be collected on the safety of implementation and the complications
associated with a 24 hour infusion of fenoldopam using the Angiodynamics Benephit catheter
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment