From the Guidelines
Levophed (norepinephrine) should be used cautiously in patients with acute kidney injury (AKI) experiencing diuresis, with careful titration to achieve a target MAP of 65-70 mmHg, starting with a dose of 0.01-0.03 mcg/kg/min and not exceeding 1-2 mcg/kg/min in most cases, as recommended by the KDIGO guideline 1. While Levophed is effective at maintaining adequate renal perfusion pressure by increasing systemic vascular resistance and mean arterial pressure, it should be used in conjunction with fluids in patients with vasomotor shock with, or at risk for, AKI 1. During diuresis in AKI recovery, Levophed doses may need to be adjusted downward as intravascular volume decreases. Close monitoring of urine output, serum creatinine, blood pressure, and heart rate is essential, as excessive diuresis can lead to hypovolemia and hypotension, potentially requiring fluid replacement alongside vasopressor support 1. Levophed works by stimulating alpha-1 adrenergic receptors, causing vasoconstriction, which helps maintain renal perfusion pressure during AKI, but excessive vasoconstriction can potentially worsen renal ischemia, so balancing adequate perfusion without excessive vasoconstriction is crucial for kidney recovery 1. The use of diuretics, such as furosemide, is not recommended for the treatment of AKI, except in cases of volume overload, as they may lead to increased mortality and worsen renal function 1. In contrast, the use of vasopressors, such as Levophed, in conjunction with fluids, is recommended for patients with vasomotor shock with, or at risk for, AKI, as it can help maintain renal perfusion pressure and improve outcomes 1. Key considerations in the management of AKI include:
- Careful fluid management to avoid volume overload and hypovolemia
- Close monitoring of urine output, serum creatinine, blood pressure, and heart rate
- Avoidance of nephrotoxic medications, such as aminoglycosides, unless absolutely necessary
- Use of vasopressors, such as Levophed, in conjunction with fluids, for patients with vasomotor shock with, or at risk for, AKI.
From the Research
Levophed in AKI Diuresis
- Levophed, also known as norepinephrine, is a vasopressor that can be used in patients with acute kidney injury (AKI) and hypotension 2.
- The use of norepinephrine in AKI patients has been shown to be safe and potentially beneficial in restoring blood pressure and improving renal function 2.
- However, the addition of other vasopressors, such as vasopressin, may be helpful in individual patients, but its widespread use is not supported by evidence 2, 3.
- Diuretics, such as loop diuretics, may be used to convert oliguric AKI to non-oliguric AKI, but they are not associated with improved survival or renal function recovery 3, 4.
- Fluid management is crucial in AKI patients, and isotonic crystalloids should be used instead of colloids for initial volume expansion 5.
- Diuretics may be used to prevent or treat fluid overload, but their efficacy in critically ill AKI patients needs to be confirmed with randomized controlled trials 5.
Pathophysiology and Management
- AKI is defined by a sudden loss of excretory kidney function, and its management in critical care settings is challenging 6.
- Appropriate volume control, nephrotoxic drug management, and the timing and type of kidney support are essential in AKI management 6.
- Fluid and electrolyte management are critical, and kidney replacement therapy is frequently required in AKI patients 6.
- Long-term consequences of AKI include chronic kidney disease and cardiovascular morbidity, making prevention and early detection essential 6.