Purpose To describe our experience with nesiritide (Natrecore, Scios Inc) treatment for cor pulmonale as a consequence of bronchopulmonary dysplasia (BPD) and discuss the associated literature.
Introduction Nesiritide is recombinant BNP. It is approved for the treatment of acute exacerbations of CHF in hospitalized adult patients. The receptor for BNP is a membrane-bound G protein that catalyzes the conversion of GTP to cGMP in the pathway to smooth muscle relaxation. The effect of BNP on pulmonary vasculature has been described in an animal model, as well as effects on pulmonary vascular smooth muscle remodeling.
Method Case report and literature review. The patient was born at 23 weeks at 635 g. He had a very complicated neonatal course. He successfully extubated on DOL 85 but continued to require respiratory support. By 4 months of life, his respiratory condition progressively worsened. Echocardiogram showed pulmonary hypertension. Repeated studies showed progressive worsening of RV function. He was treated with steroids, inhaled NO, and sildenafil but was resistant to maximal medical therapy. It was decided to give nesiritide as a compassionate-use experimental rescue therapy. The dosing regimen included a 1 μg/kg bolus, followed by continuous infusion of 0.01 μg/kg/min. The infusion rate was increased every hour in 0.005 μg/kg/min increments with concurrent administration of a bolus of 1 μg/kg until a maximum dose of 0.03 μg/kg/min. Other treatments were continued in addition to nesiritide treatment.
Results During the course of nesiritide treatment, the child's condition improved. There was echocardiographic evidence of decreased pulmonary pressure and improved ventricular function. No adverse reactions occurred during the treatment. Specifically, there was no hypotension, vomiting, arrhythmia, or changes in renal function. No changes in renal function occurred in the months subsequent to treatment. The child was eventually discharged to home. At 17 months of life, he no longer requires mechanical ventilation and has no evidence of cardiac problems.
Conclusion This case report illustrates that nesiritide can be safely administered to critically ill infants with pulmonary hypertension and cor pulmonale. The medication may have been beneficial for this patient. However, further study is required to evaluate the safety and efficacy of nesiritide for these patients.
Dr. Reynolds has a grant from Scios, Inc for a different project. This project was not funded or approved by Scios. This report describes an unapproved, off-label, experimental use for this medication.
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