Fenoldopam in cardiovascular surgery: A review

Acute kidney injury is a serious complication following cardiovascular surgery, resulting in significant in-hospital and long-term morbidity and mortality. The mortality rate is distressingly high despite improvements in intensive care and dialytic technology, but survivors experience an acceptable quality of life. Fenoldopam mesylate is a dopamine A-1 receptor agonist that decreases systemic vascular resistance while increasing renal blood flow. Fenoldopam, used as an antihypertensive drug, has recently demonstrated nephroprotective properties in critically ill patients or during major surgery. Two recent meta-analyses suggested that fenoldopam reduces the need for renal replacement therapy and mortality in critical ill patients and particularly in those undergoing cardiovascular surgery. In the first meta-analysis of 16 randomised clinical trials for a total of 1290 patients, fenoldopam usage reduced all-cause mortality (81/537 [15.1%] vs 110/581 [18.9%], OR=0.64 [0.45-0.91], p=0.01). Another meta-analysis was performed in the specific setting of cardiovascular surgery and included 1059 patients (4 trials were performed in vascular surgery and 9 in cardiac surgery). Fenoldopam dosage varied across studies, being always >0.03 μg/kg/min and most often 0.1 μg/kg/min, reaching 0.3 μg/kg/min. Fenoldopam usage reduced the risk of death and the risk of renal replacement therapy (30/528 [5.7%] in the fenoldopam group vs 71/531 [13.4%] in the control arm (OR=0.37 [0.23-0.59], p<0.001). In this article we review the evidence based medicine to support the use of fenoldopam in patients with or at risk for acute kidney injury and underline the need for a large randomized controlled study to confirm these promising results.