Evaluation of Angiotensin II in Patients With Catecholamine-Resistant Vasodilatory Shock Requiring Continuous Renal Replacement Therapy (ANGEL CRRT)

Abstract

Objective

To compare clinical outcomes of patients with catecholamine-resistant vasodilatory shock (CRVS) receiving continuous renal replacement therapy who receive adjunctive angiotensin II (ANGII) to those who do not.

Design

Retrospective cohort analysis.

Setting

Multicenter, single health system consisting of one academic medical center and four community hospitals.

Participants

Critically ill adult patients with CRVS (norepinephrine or equivalent dose ≥0.5 mcg/kg/min).

Interventions

Adjunctive ANGII versus standard-of-care (SOC) vasopressors alone (norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine).

Measurements and Main Results

The primary outcome was intensive care unit mortality. Secondary outcomes included 30-day mortality, Sequential Organ Failure Assessment (SOFA) score at 72 hours, time to shock resolution, and adverse effects. A multivariate logistic regression was used for the primary analysis. The study included 265 patients, of which 70 received ANGII and 195 received SOC. Intensive care unit and 30-day mortality were lower in patients that received ANGII (61.4% v 75.4%, adjusted odds ratio 0.438, 95% confidence interval: 0.239-0.805, p = 0.008; and 67.1% v 78.5%, adjusted odds ratio 0.479, 95% confidence interval: 0.256-0.898, p = 0.022). Differences in time to shock reversal and SOFA score at 72 hours were not statistically significant. The adverse effects evaluated were not statistically significant, apart from an increase in fungal infections in the ANGII group (17.1% v 7.2%, p = 0.016).

Conclusions

ANGII was associated with lower mortality in patients who received renal replacement therapy compared to SOC. This evaluation reaffirms a subgroup of patients that may benefit from the addition of ANGII.