The effect of catecholamine versus non-catecholamine vasopressors on renal function and recovery in vasodilatory shock: A systematic review of preclinical and clinical studies

Abstract

Background: Acute kidney injury (AKI) is a common complication of vasodilatory shock. AKI is associated with an increased risk of death, prolonged hospital stays, and subsequent transition to chronic kidney disease. Catecholamines have historically been used as the first-line vasopressors for vasodilatory shock; however, they may adversely affect renal function and recovery.Objectives: To compare the effects of catecholamine and non-catecholamine vasopressors on AKI risk and recovery in preclinical and clinical studies of vasodilatory shock.Methods: Medline, Embase, and Cochrane Central Register of Controlled Trials were systematically searched to identify studies reporting renal outcomes associated with catecholamine (norepinephrine, epinephrine, metaraminol, phenylephrine, dopamine) and non-catecholamine vasopressors (vasopressin, angiotensin II), in preclinical models or adult cohorts of vasodilatory shock. Two independent reviewers screened studies and extracted data using a prespecified form for qualitative synthesis and risk of bias assessment.Results: Of 3,504 citations, 90 studies were eligible for inclusion: 41 preclinical studies, 17 non-randomized clinical studies, 28 randomized clinical studies, and 4 post-hoc analyses. Risk of bias was generally low in preclinical studies and low to moderate in clinical studies. In preclinical studies, catecholamine vasopressors exacerbated medullary hypoxia and intrarenal inflammation compared to non-catecholamine vasopressors. In clinical studies, catecholamines were associated with higher serum creatinine, lower urine output, and increased requirements for renal replacement therapy (RRT) compared to non-catecholamine vasopressors. In patients on high dose catecholamines, adjunctive angiotensin II was associated with improved RRT liberation.Conclusions: Preclinical and clinical studies suggest that non-catecholamine vasopressors may confer renal benefits compared to catecholamine vasopressors. These hypothesis-generating observations suggest the need for comparative studies focused on renal outcomes.Systematic Review Registration: PROSPERO 2024 CRD42024527773.