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In Reply: Dr Kielstein and colleagues speculate that higher baseline levels of the endogenous NOS inhibitor ADMA in patients with renal dysfunction might explain the nonstatistically significant interaction suggesting harm with L-NMMA in patients with higher baseline creatinine levels in TRIUMPH and the negative result overall in the trial. Our understanding of these data is limited by the absence of renal function data prior to the development of shock. In addition, patients in cardiogenic shock have abnormal and unstable renal function, so accurate estimation of baseline renal function is impossible. Furthermore, the preliminary single-center studies that found benefit of NOS inhibition in cardiogenic shock included patients with levels of renal dysfunction that were similar to TRIUMPH.^1-2

We now have baseline creatinine data on over 95% of trial patients. Renal insufficiency was defined as a serum creatinine level of 1.7 mg/dL or higher. Among patients with renal insufficiency, death occurred in . . . [Full Text of this Article]

Robert A. Harrington, MD; John H. Alexander, MD
Duke University
Durham, North Carolina

Judith S. Hochman, MD
judith.hochman@med.nyu.edu

Harmony R. Reynolds, MD
New York University
New York, New York

Vladimir Dzavik, MD
University of Toronto
Toronto, Ontario, Canada

Frans J. Van de Werf, MD
University Hospital of Gasthuisberg
Leuven, Belgium

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