Angiotensin in shock

ABSTRACT

Angiotensin II is a potent vasoconstrictor agent, but until recently there has been little interest in using it as a therapeutic agent in hypotensive conditions. In an ovine model of sepsis with acute kidney injury, we demonstrated that angiotensin II restored arterial pressure and improved renal function, without adverse effects. Importantly, unlike noradrenaline, angiotensin II did not worsen sepsis-induced renal medullary hypoxia. Following these preclinical studies, angiotensin II was developed as a treatment (Giapreza®) for vasodilatory shock. The safety and efficacy of angiotensin II have been examined in numerous clinical trials that indicate it effectively restores arterial pressure in patients with sepsis, COVID-19, and postoperative vasoplegia. In the ATHOS-3 trial, in those patients who received renal replacement therapy, 28-day survival was greater with earlier liberation from renal replacement therapy. In those patients with increased plasma renin concentrations, mortality was reduced, and release from renal replacement therapy and ICU discharge occurred earlier. Thus, angiotensin II appears to be an effective treatment for vasodilatory shock, and further examination of its efficacy as a primary vasopressor and optimization of the choice of patient based on renin levels is warranted. © 2023 Elsevier Inc. All rights reserved.