Risk of worsening renal function with nesiritide following cardiac surgery

The relationship between the perioperative use of nesiritide and the development of postoperative renal insufficiency in open-heart surgery (OHS) patients is discussed.

Postoperative renal dysfunction occurs in about 8% of patients who undergo elective coronary bypass surgery. The worsening of renal function is associated with increased length of stay and mortality. Nesiritide, a vasodilator, improves the hemodynamic profile and symptoms in patients with acute decompensated heart failure (ADHF). Because patients undergoing OHS have physiological characteristics similar to ADHF, it is theorized that nesiritide could preserve renal function by opposing the neurohormonal response to OHS. However, there has been recent attention on the potential nephrotoxic effects of nesiritide in patients with heart failure, although the association between these effects and nesiritide is unclear. There is little clinical evidence supporting the use of nesiritide in OHS patients. Three small studies have demonstrated beneficial hemodynamic effects of nesiritide; one prospective, controlled trial evaluated the effect of nesiritide on renal function and found no significant difference between nesiritide and placebo; and two small studies demonstrated renal-protective effects of nesiritide in cardiac surgery patients.

Evidence of the clinical benefit of nesiritide on renal function in patients undergoing OHS is controversial. A prospective, controlled trial is needed to determine the effect of nesiritide on renal function. Regardless, it is recommended that patients at risk for worsening renal function after OHS should be identified and targeted for interventions aimed at preserving renal function and improving outcomes.