Early introduction of tolvaptan after cardiac surgery: a renal sparing strategy in the light of the renal resistive inde
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RESEARCH ARTICLE
Open Access
Early introduction of tolvaptan after cardiac surgery: a renal sparing strategy in the light of the renal resistive index measured by ultrasound Tomoko S. Kato*†, Shunya Ono†, Kan Kajimoto, Kenji Kuwaki, Taira Yamamoto and Atsushi Amano
Abstract Background: Renal failure is a serious complication after cardiac surgery, which can be caused by long-term intravenous (IV) loop diuretic use. Tolvaptan is an oral selective vasopressin-2 receptor antagonist used in patients irresponsive to loop diuretics. We investigated their renal perfusion changes using the resistive index (RI) postoperatively. Methods: Serial renal RI, echocardiography, and laboratory examinations from 14 patients requiring continuous postoperative IV loop diuretics were reviewed. Eight patients received tolvaptan (Group T) and six received oral loop diuretics before the discontinuation of IV loop diuretics (Group L). The 1st data were obtained between postoperative day 0 and 2, the 2nd when patients were still under IV loop diuretic treatment, the 3rd after the initiation of tolvaptan or oral loop diuretic, and the 4th after the discontinuation of IV diuretics. Results: The 2nd RI value was higher in Group T than Group L (0.77 ± 0.09 vs. 0.69 ± 0.01, p = 0.049) but significantly decreased after tolvaptan administration [0.77 ± 0.09 to 0.65 ± 0.05 (2nd to 3rd), to 0.62 ± 0.04 (to 4th), both p = 0.006], while no such changes were seen in Group L. The serum sodium and albumin levels, and echo-derived tricuspid annular plane systolic excursion increased only in Group T (134.1 ± 1.5 to 138.8 ± 3.2 mEq/L, 3.3 ± 0.3 to 3.7 ± 0.5 g/dL, 16.4 ± 3.6 to 19.7 ± 4.2 mm, all p 3b. Preoperative general conditions including heart failure severity, as reflected by NYHA class as well as the EuroScore and Japan Score [21–23] tended to be worse in patients treated with tolvaptan; however, the differences were not statistically different. Patients in Group T less frequently underwent coronary bypass surgery alone than those in Group L. This means patients treated with tolvaptan tended to have a disease affecting their right heart function, although the number of patients in each group was not statistically sufficient. Serial changes in renal RI, echocardiographic and laboratory values
Serial changes of ultrasound-derived parameters and laboratory values obtained from both groups are shown in Table 2. In Group T, the 2nd RI values increased during continuous IV loop diuretics from the 1st RI (p = 0.025); however, the 3rd and 4th RI values decreased after tolvaptan administration (p = 0.006, p = 0.006, vs. 2nd value, respectively) (Fig. 2). In contrast, the serial changes in RI values were not significant in Group L. When we compared the RI values at each time point between the groups, the 2nd RI, which was the value measured during
continuous IV diuretic treatment before oral diuretic administration, were higher in Group T than that in Group L. However, after the initiation of oral diuretics (tolvaptan for Group T, loop diuretics for Group
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