by Gleeson, Patrick J.;
Crippa, Ilaria Alice; Mongkolpun, Wasineenart; Cavicchi, Federica Zama; Van
Meerhaeghe, Tess; Brimioulle, Serge; Taccone, Fabio Silvio; Vincent,
Jean-Louis; Creteur, Jacques
Objectives: To
characterize renin in critically ill patients. Renin is fundamental to
circulatory homeostasis and could be a useful marker of tissue-perfusion.
However, diurnal variation, continuous renal replacement therapy and
drug-interference could confound its use in critical care practice.
Design:
Prospective observational study. Setting: Single-center, mixed medical-surgical
ICU in Europe. Patients: Patients over 18 years old with a baseline estimated
glomerular filtration rate greater than 30 mL/min/1.73 m2 and anticipated ICU
stay greater than 24 hours. Informed consent was obtained from the patient or
next-of-kin. Interventions: Direct plasma renin was measured in samples drawn
6-hourly from arterial catheters in recumbent patients and from extracorporeal
continuous renal replacement therapy circuits. Physiologic variables and use of
drugs that act on the renin-angiotensin-aldosterone system were recorded
prospectively. Routine lactate measurements were used for comparison.
Measurements and Main Results: One-hundred twelve arterial samples (n = 112) were
drawn from 20 patients (65% male; mean ± SD, 60 ± 14 yr old) with septic shock
(30%), hemorrhagic shock (15%), cardiogenic shock (20%), or no circulatory
shock (35%). The ICU mortality rate was 30%. Renin correlated significantly
with urine output (repeated-measures correlation coefficient = –0.29; p =
0.015) and mean arterial blood pressure (repeated-measures correlation
coefficient = –0.35; p < 0.001). There was no diurnal variation of renin or
significant interaction of renin-angiotensin-aldosterone system drugs with
renin in this population. Continuous renal replacement therapy renin removal
was negligible (mass clearance ± SD 4% ± 4.3%). There was a significant
difference in the rate of change of renin over time between survivors and
nonsurvivors (–32 ± 26 μU/timepoint vs +92 ± 57 μU/timepoint p = 0.03; mean ±
SEM), but not for lactate (–0.14 ± 0.04 mM/timepoint vs
+0.15 ± 0.21 mM/timepoint; p = 0.07). Maximum renin achieved significant
prognostic value for ICU mortality (receiver operator curve area under the
curve 0.80; p = 0.04), whereas maximum lactate did not (receiver operator curve
area under the curve, 0.70; p = 0.17).
Conclusions: In an
heterogeneous ICU population, renin measurement was not significantly affected
by diurnal variation, continuous renal replacement therapy, or drugs. Renin
served as a marker of tissue-perfusion and outperformed lactate as a predictor
of ICU mortality.
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