In adults with septic shock, early vasopressin use vs. norepinephrine did not improve the number of kidney failure-free days, a study in JAMA concluded. 

Currently, norepinephrine is recommended as the first-line vasopressor in septic shock but early vasopressin use has been suggested as a possible alternative. Anthony C. Gordon, MD, and colleagues from the United Kingdom aimed to compare the effect of early vasopressin vs. norepinephrine on kidney failure in patients with septic shock.

They conducted a factorial, double-blind, randomized clinical trial across 18 adult intensive care units between February 2013-May 2015. Adults with septic shock requiring vasopressors despite fluid resuscitation within a maximum of 6 hours after onset were enrolled. The study patients were randomized to vasopressin + hydrocortisone (n=101), vasopressin + placebo (n=104), norepinephrine + hydrocortisone (n=101), or norepinephrine + placebo (n=103). 

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The primary outcome was kidney failure-free days during the 28-days post-randomization. This was measured as the proportion of patients who never developed kidney failure, and the median number of days alive and free of kidney failure for patients who did not survive, who experienced kidney failure, or both. 

In the vasopressin group, the number of patients who never developed kidney failure was 94/165 patients (57.0%) vs. 93/157 patients (59.2%) in the norepinephrine group (difference: −2.3%, 95% CI: −13.0% to 8.5%). The median number of kidney failure–free days for patients who did not survive, who experienced kidney failure, or both was 9 days in the vasopressin group vs. 13 days in the norepinephrine group (difference: −4 days, 95% CI: −11 to 5]).

Patients in the vasopressin group used less renal replacement therapy than in the norepinephrine group (25.4% vs. 35.3%, respectively; difference: -9.9%, 95% CI: -19.3% to -0.6%). In addition, there was no significant difference in mortality rates between groups. 

Dr. Gordon noted that although the findings do not favor the use of vasopressin to replace norepinephrine as initial treatment in this situation, “the confidence interval included a potential clinically important benefit for vasopressin, and larger trials may be warranted to assess this further.” 

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