Intraoperative Dobutamine Plus Norepinephrine to Prevent Postoperative Acute Kidney Injury in Septic Shock: A Randomized Clinical Trial.

Summary

In this multicenter randomized trial of 584 adults with septic shock undergoing surgical source control, intraoperative dobutamine plus norepinephrine reduced new-onset or worsening acute kidney injury within 7 postoperative days from 34.7% to 22.8% compared with norepinephrine alone. Stage 2 and stage 3 acute kidney injury were also reduced, although tachycardia occurred more frequently with dobutamine.

Key Findings

• Postoperative new-onset or worsening acute kidney injury occurred in 22.8% with dobutamine plus norepinephrine versus 34.7% with norepinephrine alone; adjusted risk ratio was 0.64.
• Stage 2 acute kidney injury occurred in 4.8% versus 9.9%, and stage 3 acute kidney injury occurred in 7.9% versus 13.6%, respectively.
• Postoperative day 1 SOFA scores were lower and early urine output was higher with combination therapy, but tachycardia was more frequent.

Clinical Implications

For adults with septic shock undergoing surgical source control, intraoperative dobutamine added to norepinephrine may reduce postoperative acute kidney injury, particularly when persistent hypoperfusion or cardiac dysfunction is present. Clinicians should balance this potential renal benefit against the increased risk of tachycardia and await further studies addressing mortality and broader patient populations.

Limitations

• The trial was open-label, allowing potential performance and treatment-cointervention bias.
• The study was conducted in Chinese tertiary hospitals and was not designed to establish mortality benefit or long-term renal outcomes.

Future Directions

Future trials should evaluate whether the reduction in acute kidney injury translates into lower mortality, shorter hospitalization, or improved long-term kidney recovery. Studies should also identify the hemodynamic and echocardiographic phenotypes most likely to benefit and quantify the optimal dobutamine dose.