Best Vasopressor for Patients with Renal Failure
Norepinephrine is the recommended first-line vasopressor for patients with renal failure, as it provides effective blood pressure support while minimizing adverse effects on renal function compared to other vasopressors. 1
First-Line Vasopressor Selection
- Norepinephrine is the first-choice vasopressor for patients with shock, including those with impaired renal function, based on its favorable hemodynamic profile and safety record 1, 2
- Norepinephrine increases mean arterial pressure (MAP) primarily through vasoconstriction while causing less increase in heart rate compared to other vasopressors 3
- Target MAP should be 65 mmHg initially to ensure adequate organ perfusion, including to the kidneys 2, 3
- Administration requires central venous access, and arterial catheter placement is recommended for all patients requiring vasopressors 2
Second-Line Vasopressor Options
- Vasopressin (up to 0.03 U/min) can be added to norepinephrine with the intent of either raising MAP or decreasing norepinephrine dosage 1, 2
- Vasopressin may be particularly beneficial in patients with renal impairment, as it has been shown to reduce the need for renal replacement therapy compared to norepinephrine alone 4, 5
- Epinephrine can be considered as an alternative second-line agent when added to norepinephrine if additional blood pressure support is needed 1, 6
Vasopressors to Avoid in Renal Failure
- Dopamine should not be used for renal protection (strong recommendation, high quality evidence) 1
- Dopamine is associated with a higher rate of cardiac arrhythmias without mortality benefit and should only be considered in highly selected patients with low risk of tachyarrhythmias or bradycardia 1, 6
- Phenylephrine is not recommended except in specific circumstances, such as when norepinephrine causes serious arrhythmias 1, 3
Special Considerations for Renal Function
- Epinephrine may be considered in patients with refractory shock and myocardial dysfunction, but its FDA label warns that it can constrict renal blood vessels, potentially resulting in oliguria or renal impairment 7, 6
- Vasopressin has shown potential benefits for renal outcomes in septic shock, with recent evidence suggesting it may reduce the need for renal replacement therapy 4, 5
- Norepinephrine appears to have beneficial effects on urine output in septic patients with impaired renal function 8, 9
Practical Implementation
- Ensure adequate fluid resuscitation before or concurrent with vasopressor initiation to optimize renal perfusion 1, 2
- Monitor urine output, serum creatinine, and other markers of renal function closely while on vasopressor therapy 8, 9
- Titrate vasopressors to the minimum effective dose to achieve target MAP while minimizing potential adverse effects on renal function 2, 3
- Consider adding vasopressin early if the patient has risk factors for requiring renal replacement therapy 4, 5