The effects of vasopressor choice on renal outcomes in septic shock: a systematic review of randomised trials as a guide for future research

Abstract Background Patients with septic shock are high risk for developing acute kidney injury (AKI), with its associated morbidity. This systematic review assessed the evidence for an effect on renal outcomes from choice of vasopressor. Methods Searches were conducted on Medline, Embase, Cochrane Central, congress abstracts and trial registries. The search strategy included septic shock, vasopressor agents and renal impairment. Inclusion criteria were non-crossover randomised controlled trials of adult septic shock comparing individual or combinations of vasopressors and placebo controlled trials. Primary outcome was the incidence of AKI in study participants. Secondary outcomes were AKI duration, renal replacement therapy (RRT) rate, RRT duration, renal failure free days, requirement for long term RRT and Major Adverse Kidney Events (MAKE) at 30 and 90 days. Results A total of 4259 patients, from 17 studies, were included. Vasopressin and terlipressin studies predominated. In 8 studies reporting AKI rate, no effect was seen relating to vasopressor choice. RRT rate was the most reported secondary outcome. Of five studies that investigated the role of vasopressin, only one showed significant benefit. Alongside limited reporting, no conclusive benefit was demonstrated in other secondary outcomes. No studies reported requirement for long term RRT, MAKE 30 or 90. Conclusions This is the first systematic review focussed on renal outcomes with differential vasopressor therapy in septic shock. It illustrates the paucity of evidence supporting a particular vasopressor. Also highlighted are problems of population and study heterogeneity, as well as the focus on RRT as a proxy for renal outcomes. Standardised renal outcome reporting, large and appropriately powered trials and focussed sub-population studies are required to further inform renal focussed vasopressor research and practice. Trial registration This systematic review was prospectively registered on PROSPERO (CRD42023481778).