Diuresis to decongest patients with acute heart failure (AHF) is particularly challenging in the setting of renal dysfunction, as these patients are at risk of worsening renal function.  Small studies have suggested that low-dose dopamine or nesiritide may increase urine output and maintain renal function in such patients. The Renal Optimization Strategies Evaluation (ROSE) trial randomized 360 patients with AHF and renal dysfunction (GFR 15-60ml/min/1.73m2) to nesiritide, low-dose dopamine, or placebo in addition to an intravenous loop diuretic. Primary outcomes included urine volume and change in cystatin C at 72-hours post-randomization. Compared to placebo, patients randomized to low-dose dopamine had similar 72-hour urine volumes (8524mL vs. 8296mL, p=0.59) and cystatin C levels (0.12 vs. 0.11mg/L, p=0.72). In addition, there was no change in weight or creatinine at 72 hours. Similarly, patients randomized to low-dose nesiritide demonstrated no better 72-hour urine volumes (8574 mL vs. 8296 mL, p=0.49), cystatin C levels (0.07 vs. 0.11 mg/L, p=0.36), weight or creatinine.

Conclusion

These findings suggest neither low-dose dopamine nor nesiritide are effective as adjuvant renal therapies in patients with AHF and renal dysfunction. A therapy that allows for diuresis without angering the nephron remains elusive.

Summarized by Steven M. Bradley and Supriya Shore

Chen HH, Anstrom KJ, Givertz MM, Stevenson LW, Semigran MJ, Goldsmith SR, Bart BA, Bull DA, Stehlik J, LeWinter MM, Konstam MA, Huggins GS, Rouleau JL, O’Meara E, Tang WH, Starling RC, Butler J, Deswal A, Felker GM, O’Connor CM, Bonita RE, Margulies KB, Cappola TP, Ofili EO, Mann DL, Dávila-Román VG, McNulty SE, Borlaug BA, Velazquez EJ, Lee KL, Shah MR, Hernandez AF, Braunwald E, Redfield MM; NHLBI Heart Failure Clinical Research Network. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA. 2013 Dec 18;310(23):2533-43. doi: 10.1001/jama.2013.282190.