Comparison between levosimendan versus beta agonists in preservation of renal function in cardiac surgery patients with low cardiac output syndrome

Figures & data

Table 1. Comparison between Group A (control group) and Group B (study group) according to age and sex.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value*	P-value	Sig.
Age (yrs)	Mean ± SD	52.70 ± 9.78	52.27 ± 8.70	0.181^•	0.857	NS
	Range	30–69	32–70
Sex	Female	11 (36.7%)	11 (36.7%)	0.000^•	1.000	NS
	Male	19 (63.3%)	19 (63.3%)

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

•: Independent t-test.

*.Chi-square test.The table shows that there was no statistically significant difference found between the two groups according to age and sex.

Table 2. Comparison between Group A (control group) and Group B (study group) according to height and weight.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value*	P-value	Sig.
Height (cm)	Mean ± SD	170.83 ± 9.04	169.37 ± 8.89	0.634	0.529	NS
	Range	156–187	157–186
Weight (kg)	Mean ± SD	90.07 ± 12.80	84.53 ± 9.52	1.900	0.062	NS
	Range	77–120	58–97

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Independent t-test. The table shows that no statistically significant difference was found between the two groups according to height and weight.

Table 3. Comparison between Group A (control group) and Group B (study group) according to risk factors.

		Group A (Control group)		Group B (Study group)		Test value*	P-value	Sig.
		No.	%	No.	%
HTN	No	12	40.0%	12	40.0%	0.000	1.000	NS
	Yes	18	60.0%	18	60.0%
DM	No	19	63.3%	22	73.3%	0.693	0.405	NS
	Yes	11	36.7%	8	26.7%
Smoking	Non-smoker	17	56.7%	16	53.3%	0.067	0.795	NS
	Smoker	13	43.3%	14	46.7%
Dyslipidemia	No	18	60.0%	18	60.0%	0.000	1.000	NS
	Yes	12	40.0%	12	40.0%

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Chi-square test. The table shows no statistically significant difference was found between the two groups according to risk factors.

Table 4. Comparison between Group A (control group) and Group B (study group) according to type of surgery.

	Group A (Control group)		Group B (Study group)		Test value*	P-value	Sig.
	No.	%	No.	%
CABG on pump	12	40.0%	13	43.3%	0.069	0.793	NS
CABG off pump	1	3.3%	3	10.0%	1.071	0.301	NS
AVR surgery	2	6.7%	2	6.7%	0.000	1.000	NS
MVR surgery	4	13.3%	4	13.3%	0.000	1.000	NS
DVR surgery	6	20.0%	3	10.0%	1.176	0.278	NS
Combined valve and CABG	2	6.7%	3	10.0%	0.218	0.640	NS
Ascending thoracic aorta aneurysm surgery	3	10.0%	2	6.7%	0.218	0.640	NS

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Chi-square test. The table shows that no statistically significant difference was found between the two groups according to the type of surgery.

Table 5. Comparison between Group A (control group) and Group B (study group) according to bypass and clamping time.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value•	P-value	Sig.
CPB time (min)	Mean ± SD	119.03 ± 25.56	109.89 ± 22.22	1.424	0.160	NS
	Range	85–170	85–160
Clamping time (min)	Mean ± SD	81.90 ± 17.81	77.11 ± 17.08	1.025	0.310	NS
	Range	55–120	55–120

Note: P-value >0.05: non significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS). The table shows that no statistically significant difference was found between the two groups according to bypass and clamping time.

•:Independent t-test.

Table 6. Comparison between Group A (control group) and Group B (study group) according to heart rate.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value•	P-value	Sig.
HR at diagnosis of LCOS (bpm)	Mean ± SD	115.63 ± 5.51	117.50 ± 6.48	−1.202	0.234	NS
	Range	103–128	107–133
HR at 24 h of treatment (bpm)	Mean ± SD	113.70 ± 6.99	110.60 ± 6.91	1.728	0.089	NS
	Range	98–128	94–120
HR at 48 h of treatment (bpm)	Mean ± SD	104.60 ± 7.03	101.57 ± 6.89	1.677	0.099	NS
	Range	91–120	92–113
HR at the time of discharge (bpm)	Mean ± SD	91.10 ± 6.32	88.60 ± 4.19	1.806	0.076	NS
	Range	78–109	80–96

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value< 0.01: highly significant (HS). •:Independent t-test.

The table shows that no statistically significant difference was found between the two groups according to heart rate.

Table 7. Comparison between Group A (control group) and Group B (study group) according to mean arterial pressure.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value•	P-value	Sig.
MAP at diagnosis of LCOS (mmHg)	Mean ± SD	70.37 ± 4.36	72.13 ± 2.87	−1.853	0.069	NS
	Range	60–76	67–78
MAP at 24 h of treatment (mmHg)	Mean ± SD	78.43 ± 5.16	76.83 ± 4.35	1.299	0.199	NS
	Range	71–93	69–86
MAP at 48 h of treatment (mmHg)	Mean ± SD	83.40 ± 5.16	83.33 ± 3.90	0.056	0.955	NS
	Range	75–96	73–90
MAP at the time of discharge (mmHg)	Mean ± SD	88.53 ± 5.72	88.73 ± 4.65	−0.149	0.882	NS
	Range	75–98	77–97

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS). MAP: mean arterial pressure.

•:Independent t-test.

The table shows that no statistically significant difference was found between the two groups according to MAP.

Table 8. Comparison between Group A (control group) and Group B (study group) according to CVP.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value•	P-value	Sig.
CVP at diagnosis of LCOS (cmH2O)	Mean ± SD	18.77 ± 2.69	17.87 ± 2.50	1.343	0.185	NS
	Range	14–24	12–23
CVP at 24 h of treatment (cmH2O)	Mean ± SD	16.77 ± 2.53	15.57 ± 2.75	1.759	0.084	NS
	Range	12–22	8–19
CVP at 48 h of treatment (cmH2O)	Mean ± SD	13.23 ± 2.10	12.23 ± 2.61	1.637	0.107	NS
	Range	10–17	7–17
CVP at thetime of discharge (cmH2O)	Mean ± SD	10.37 ± 1.54	9.60 ± 1.75	1.798	0.077	NS
	Range	7–13	7–12

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value< 0.01: highly significant (HS). •:Independent t-test.

The table shows that no statistically significant difference was found between the two groups according to CVP.

Table 9. Comparison between Group A (control group) and Group B (study group) according to SVcO2.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value•	P-value	Sig.
SvcO2 at diagnosis of LCOS (%)	Mean ± SD	49.70 ± 5.17	51.67 ± 3.72	−1.691	0.096	NS
	Range	34–58	44–58
SvcO2 at 24 h of treatment (%)	Mean ± SD	56.40 ± 5.45	58.13 ± 3.21	−1.501	0.139	NS
	Range	42–66	50–63
SvcO2 at 48 h of treatment (%)	Mean ± SD	62.30 ± 5.70	64.53 ± 4.19	−1.729	0.089	NS
	Range	50–72	55–70
SvcO2 at the time of discharge (%)	Mean ± SD	68.30 ± 5.25	69.73 ± 3.87	−1.204	0.233	NS
	Range	59–74	61–77

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS). •:Independent t-test.

The table shows that no statistically significant difference was found between the two groups according to SvCO_2.

Table 10. Comparison between Group A (control group) and Group B (study group) according to Killip Class and LVEF.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value	P-value	Sig.
Killip Class	Class II	19 (63.3%)	20 (66.7%)	0.359*	0.836	NS
	Class III	9 (30.0%)	9 (30.0%)
	Class IV	2 (6.7%)	1 (3.3%)
LVEF (%)	Mean ± SD	38.10 ± 3.08	36.40 ± 3.98	1.851•	0.069	NS
	Range	30–41	30–42

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Chi-square test; •: Independent t-test. The table shows that no statistically significant difference was found between the two groups according to Killip Class and LVEF.

Table 11. Comparison between Group A (control group) and Group B (study group) according to diuretic dose.

		Group A (Control group)	Group B (Study group)
		No. =	No. =	Test value*	P-value	Sig.
Diuretic dose at diagnosis of LCOS (mg/kg/h)	Mean ± SD	0.45 ± 0.07	0.44 ± 0.08	0.383	0.703	NS
	Range	0.32–0.55	0.22–0.57
Diuretic dose at 24 h after diagnosis of LCOS (mg/kg/h)	Mean ± SD	0.39 ± 0.10	0.35 ± 0.10	1.640	0.106	NS
	Range	0.22–0.55	0.16–0.49
Diuretic dose at 48 h after diagnosis of LCOS (mg/kg/h)	Mean ± SD	0.26 ± 0.08	0.21 ± 0.07	2.284	0.026	S
	Range	0.11–0.44	0.11–0.36

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Chi-square test. The table shows that no statistically significant difference was found between the two groups according to diuretic dosage at diagnosis of LCOS and at 24 h after diagnosis of LCOS. Diuretic consumption was significantly low in levosimendan group at 48 h after LOCS diagnosis.

Figure 1. Comparison between Group A (control group) and Group B (study group) according to dose of diuretics used, showing that levosimendan group had significantly less dose of diuretics at 48-h interval from the time of diagnosis of LCOS compared to beta-agonist group, while diuretics consumption was comparable in both groups at the time of diagnosis of LCOS and 24 h later.

Table 12. Comparison between Group A (control group) and Group B (study group) according to serum creatinine level.

		Group A (Control group)	Group B (Study group)
		No. = 30	No. = 30	Test value	P-value	Sig.
Creatinine level at diagnosis of LCOS (mg/dl)	Mean ± SD	1.33 ± 0.48	1.21 ± 0.48	1.008•	0.317	NS
	Range	0.7–2.6	0.54–2
AKI at diagnosis of LCOS	No	21 (70.0%)	21 (70.0%)	0.000*	1.000	NS
	Yes	9 (30.0%)	9 (30.0%)
Creatinine level at 24 h after diagnosis of LCOS (mg/dl)	Mean ± SD	1.55 ± 0.78	1.40 ± 0.70	0.785•	0.436	NS
	Range	0.7–4.1	0.6–3.3
Creatinine level at 48 h after diagnosis of LCOS (mg/dl)	Mean ± SD	1.53 ± 0.72	1.18 ± 0.49	2.193•	0.032	S
	Range	0.6–3.1	0.53–2.7
Creatinine level at time of ICU discharge (mg/dl)	Mean ± SD	1.27 ± 0.52	0.90 ± 0.19	3.637•	0.001	HS
	Range	0.6–2.5	0.55–1.3
Renal failure at ICU discharge	No	26 (86.7%)	30 (100.0%)	4.286*	0.038	S
	Yes	4 (13.3%)	0 (0.0%)

Note: P-value >0.05: non-significant (NS); P-value <0.05: significant (S); P-value <0.01: highly significant (HS).

*: Chi-square test. •: Independent t-test. The table shows that highly statistically significant difference was found between the two groups according to creatinine level at the time of discharge. Statistically significant difference was found between the two groups according to the creatinine level at 48 h after diagnosis of LCOS and incidence of renal failure at discharge.

Figure 2. Comparison between Group A (control group) and Group B (study group) according to serum creatinine level showing that levosimendan group had significantly lower serum creatinine level at 48-h interval from the time of diagnosis of LCOS and a highly significant differences compared to beta-agonist group at the time of ICU discharge, while serum creatinine level was comparable in both groups at the time of diagnosis of LCOS and 24 h later.

Figure 3. Bar chart comparing Group A (control group) to Group B (study group) according to the incidence of AKI at the time of diagnosis of LCOS and renal failure at the time of patient discharge from hospital. Thirty percent of patients in both groups developed AKI at the time of diagnosis of LCOS, while 13.3% of beta-agonist group discharged from ICU were with renal failure and none of levosimendan group were in renal failure state at the time of ICU discharge.

Killip classification for heart failure (HF): Zafari 2019.

Class I	No clinical signs of heart failure
Class II	Findings consistent with mild-to-moderate heart failure (e.g. S3 gallop lung rales less than one-half way up the posterior lung fields or jugular venous distension)
Class III	Acute pulmonary edema
Class IV	Cardiogenic shock

Acute kidney failure (AKI) score: Palevsky 2021.

	Serum creatinine (SCr) criteria	Urine output criteria
Stage 1	Increase ≥0.3 mg/dl within 48 h or increase ≥1.5 to 1.9 × reference SCr	<0.5 mL/kg/h for >6 consecutive hours
Stage 2	Increase ≥2 to 2.9 × reference SCr	<0.5 mL/kg/h for >12 h
Stage 3	Increase ≥3 × reference SCr or 1.5-fold increase to ≥4 mg/dl	<0.3 mL/kg/h for >24 h or anuria 12 h