Relation of contrast-induced nephropathy to long-term mortality after percutaneous coronary intervention

Association of post-procedural early (within 24h) increases in serum creatinine with all-cause mortality after coronary angiography

BACKGROUND

The majority of patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) are discharged early, with only early (within 24h) serum creatinine (SCr) data available without evidence of clinical prognosis. We aimed to systemically evaluate the association between post-procedural early increase in SCr and all-cause mortality following CAG.

METHODS

We performed a retrospective sub-study analysis within a prospective observational study including 3091 consecutive patients with baseline and post-procedural early (within 24h) SCr data. The degree (mild, moderate, or large) of absolute and relative increases in SCr from baseline. The mean follow-up time was 2.49years.

RESULT

Moderate or large early increases in SCr were relatively rare (large increase: >1.0mg/dl [0.5%], >100% [0.4%]), whereas mild absolute and relative increases in SCr were more common (mild increase: 0.25 to 0.50mg/dl [4.5%], 25% to 50% [5.9%]). During the follow-up period, there were 136 post-procedural deaths (5.6%). After adjustment for confounders, mild absolute and relative increases in SCr were associated with increased mortality (hazard ratio [HR]: 1.9 and 1.8, respectively, both P<0.05). Moderate or large increases in SCr were associated with higher mortality, even higher than with pre-existing renal dysfunction (HR: 5.36 and 4.12 for moderate increase [0.5 to 1.0mg/dl] and estimated glomerular filtration rate<60ml/min).

CONCLUSION

Post-procedural mild, moderate, or large early increase in SCr, is associated with significantly increased long-term mortality. Although moderate or large increase in SCr following CAG was relatively rare, the prognosis is more serious, and is worse than that of pre-existing renal dysfunction.

CLINICAL TRIAL REGISTRATION

Predictive Value of Contrast Volume to Creatinine Clearance Ratio (PRECOMIN, ClinicalTrials.govNCT01400295).

Longitudinal Risk of Adverse Events in Patients With Acute Kidney Injury After Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry

BACKGROUND

Acute kidney injury (AKI) remains a common complication after percutaneous coronary intervention (PCI) and is associated with adverse in-hospital patient outcomes. The incidence of adverse events after hospital discharge in patients having post-PCI AKI is poorly defined, and the relationship between AKI and outcomes after hospital discharge remains understudied.

METHODS AND RESULTS

Using the National Cardiovascular Data Registry CathPCI registry, we assessed the incidence of AKI among Medicare beneficiaries after PCI from 2004 to 2009 and subsequent post-discharge adverse events at 1 year. AKI was defined using Acute Kidney Injury Network (AKIN) criteria. Adverse events included death, myocardial infarction, bleeding, and recurrent kidney injury. Using Cox methods, we determined the relationship between in-hospital AKI and risk of post-discharge adverse events by AKIN stage. In a cohort of 453 475 elderly patients undergoing PCI, 39 850 developed AKI (8.8% overall; AKIN stage 1, 85.8%; AKIN 2/3, 14.2%). Compared with no AKI, in-hospital AKI was associated with higher post-discharge hazard of death, myocardial infarction, or bleeding (AKIN 1: hazard ratio [HR], 1.53; confidence interval [CI], 1.49-1.56 and AKIN 2/3: HR, 2.13; CI, 2.01-2.26), recurrent AKI (AKIN 1: HR, 1.70; CI, 1.64-1.76; AKIN 2/3: HR, 2.22; CI, 2.04-2.41), and AKI requiring dialysis (AKIN 1: HR, 2.59; CI, 2.29-2.92; AKIN 2/3: HR, 4.73; CI, 3.73-5.99). For each outcome, the highest incidence was within 30 days.

CONCLUSIONS

Post-PCI AKI is associated with increased risk of death, myocardial infarction, bleeding, and recurrent renal injury after discharge. Post-PCI AKI should be recognized as a significant risk factor not only for in-hospital adverse events but also after hospital discharge.

Platelet to Lymphocyte Ratio Predicts Contrast-Induced Nephropathy in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

We investigated the relationship between platelet to lymphocyte ratio (PLR) and contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). We enrolled 5719 patients in 3 tertiary hospitals from January 2005 to December 2010. The PLR was calculated as the ratio of platelet to lymphocyte counts on admission. Serum creatinine level was measured before and within 72 hours after contrast medium administration. To evaluate the relation between PLR and CIN, the 5719 patients were divided into a CIN group and a non-CIN group. Contrast-induced nephropathy occurred in 252 (4.4%) patients. Patients in the CIN group had significantly higher PLR than those in the non-CIN group (173.8 [62.3] and 116.2 [51.7], respectively; P < .001). In logistic regression analysis, PLR was an independent predictor of CIN (odds ratio: 1.432, 95% confidence interval: 1.205-1.816, P = .031), along with age, diabetes mellitus, creatinine, estimated glomerular filtration rate, and neutrophil to lymphocyte ratio. In conclusion, a higher PLR was an independent risk factor for the development of CIN in patients with STEMI undergoing pPCI.

Pre-procedural peripheral endothelial function is associated with increased serum creatinine following percutaneous coronary procedure in stable patients with a preserved estimated glomerular filtration rate

BACKGROUND

Worsening renal function, indicated by increased serum creatinine (SCr), is a common complication of percutaneous coronary procedures. Risk factors for increased SCr overlap with coronary risk factors involved in endothelial dysfunction. We hypothesized that endothelial dysfunction, measured using the reactive hyperemia peripheral arterial tonometry index (RHI), can predict periprocedure-increased SCr.

METHODS

RHI was assessed before elective coronary procedures in 316 consecutive stable patients with a preserved estimated glomerular filtration rate (eGFR, >60mL/min/1.73m²). SCr was measured before and 2 days after procedures.

RESULTS

There was no significant correlation between natural logarithmic transformations of RHI (Ln-RHI) and basal Ln-eGFR. Periprocedure increase in SCr was observed in 148 (47%) patients. The increased SCr group had significantly lower Ln-RHI [0.48 (0.36, 0.62) vs. 0.59 (0.49, 0.76), p<0.001]. Multivariate linear regression analysis identified body mass index (BMI) (β=0.148, p=0.005) and Ln-RHI (β=-0.365, p<0.001) as significant determinants of percent changes in SCr. Multivariate logistic regression analysis identified Ln-RHI (per 0.1) [odds ratio (OR) 0.672, 95% confidence interval (95% CI) 0.586-0.722; p<0.001], Ln-B-type natriuretic peptide (OR: 1.484, 95% CI: 1.130-1.974; p=0.004), current smoking (OR: 2.563, 95% CI: 1.379-4.763, p=0.003), BMI (OR: 1.113, 95% CI: 1.031-1.203; p=0.007), coronary intervention (OR: 1.736, 95% CI: 1.036-2.909; p=0.036), and Ln-hemoglobin A1c (OR: 6.728, 95% CI: 1.093-41.392, p=0.040) as independent determinants of increased SCr. Receiver-operating characteristics curve analysis showed that Ln-RHI correlated significantly with increased SCr (area under the curve, 0.684, 95% CI: 0.626-0.742, p<0.001). The optimum cut-off point of Ln-RHI for the periprocedure increased SCr was 0.545.

CONCLUSIONS

Pre-procedure measurement of endothelial function by RHI is an effective strategy to assess the patient's risk conditions for worsening renal function after percutaneous coronary procedures.

Pre-Procedural Risk Score of Contrast-Induced Nephropathy in Elderly Patients Undergoing Elective Coronary Angiography

To establish a scoring model to predict the risk of contrast-induced nephropathy (CIN) in elderly patients undergoing elective coronary angiography (CAG).A total of 1286 patients aged > 65 years who had undergone elective CAG between August 2009 and February 2013 were enrolled in this study. They were randomly (3:2) assigned to a development (n = 756) or validation dataset (n = 530). Independent predictors of CIN were identified by using logistic regression and were assigned a weighted integer, which was used to establish a score model.CIN incidence in the development set was 6.3%. The risk score model contained 3 variables (with the weighted integer): age > 75 years (1.5), creatinine clearance (CrCl) < 60 mL/minute (1), and congestive heart failure (CHF) (1.5). CIN incidence was 3.1%, 9.1%, and 29.0% in the low-risk group (≤ 1), moderate risk group (1 - 3), and high-risk group (≥ 3), respectively. The risk model demonstrated good prediction value in the development (c-statistic = 0.727) and validation (c-statistic = 0.695) datasets. Compared to the non-CIN group, the CIN group had a significantly higher rate of inhospital major adverse cardiac events (P < 0.01).The risk score model with 3 variables, namely age > 75 years, CrCl < 60 mL/minute, and CHF, is a clinical prediction tool for CIN in elderly patients before elective CAG. CIN is one of the independent risk factors of major adverse cardiac events (MACE).

Contrast-Induced Acute Kidney Injury: An Update

Contrast-induced acute kidney injury (CI-AKI) is defined as an abrupt deterioration in renal function associated with the administration of iodinated contrast media. This type of acute kidney injury is frequently encountered as a complication of percutaneous coronary intervention (PCI) and is associated with adverse short- and long-term outcomes including mainly mortality, cardiovascular morbidity and prolongation of hospitalization. The incidence of CI-AKI after PCI ranges from 2 to 20 % according to baseline kidney function. It may also range according to the clinical setting, being higher after emergency PCI. The primary manifestation is a small decline in kidney function, occurring 1 to 3 days after the procedure. Kidney function usually returns to preexisting levels within 7 days. Incidence of acute renal failure requiring dialysis following PCI is rare (<1 %). The present article aims to review up-to-date published data concerning diagnosis, definition, epidemiology and prognosis of this novel in-hospital epidemic.

Ad hoc vs. Non-ad hoc Percutaneous Coronary Intervention Strategies in Patients With Stable Coronary Artery Disease

BACKGROUND

Few studies have evaluated the prevalence and clinical outcomes of ad hoc percutaneous coronary intervention (PCI), performing diagnostic coronary angiography and PCI in the same session, in stable coronary artery disease (CAD) patients.Methods and Results:From the CREDO-Kyoto PCI/CABG registry cohort-2, 6,943 patients were analyzed as having stable CAD and undergoing first PCI. Ad hoc PCI and non-ad hoc PCI were performed in 1,722 (24.8%) and 5,221 (75.1%) patients, respectively. The cumulative 5-year incidence and adjusted risk for all-cause death were not significantly different between the 2 groups (15% vs. 15%, P=0.53; hazard ratio: 1.15, 95% confidence interval: 0.98-1.35, P=0.08). Ad hoc PCI relative to non-ad hoc PCI was associated with neutral risk for myocardial infarction, any coronary revascularization, and bleeding, but was associated with a trend towards lower risk for stroke (hazard ratio: 0.78, 95% confidence interval: 0.60-1.02, P=0.06).

CONCLUSIONS

Ad hoc PCI in stable CAD patients was associated with at least comparable 5-year clinical outcomes as with non-ad hoc PCI. Considering patients' preference and the cost-saving, the ad hoc PCI strategy might be a safe and attractive option for patients with stable CAD, although the prevalence of ad hoc PCI was low in the current study population.

Sodium Bicarbonate-Ascorbic Acid Combination for Prevention of Contrast-Induced Nephropathy in Chronic Kidney Disease Patients Undergoing Catheterization

BACKGROUND

Sodium bicarbonate and ascorbic acid have been proposed to prevent contrast-induced nephropathy (CIN). The present study evaluated the effect of their combined use on CIN incidence.Methods and Results:We prospectively enrolled 429 patients with chronic kidney disease (CKD: baseline estimated glomerular filtration rate <60 mL/min/1.73 m²) prior to elective coronary catheterization. CIN was defined as absolute (≥0.5 mg/dL) or relative (≥25%) increase in serum creatinine within 72 h. In the saline hydration (n=218) and combined sodium bicarbonate+ascorbic acid (n=211) groups, a total of 1,500-2,500 mL 0.9% saline was given before and after the procedure. In addition, the combination group received 20 mEq sodium bicarbonate and 3 g ascorbic acid i.v. before the procedure, followed by 2 g ascorbic acid after the procedure and a further 2 g after 12 h. There were no significant differences between the basic characteristics and contrast volume in the 2 groups. CIN occurred in 19 patients (8.7%) in the saline group, and in 6 patients (2.8%) in the combined treatment group (P=0.008).

CONCLUSIONS

Combined sodium bicarbonate and ascorbic acid could prevent CIN following catheterization in CKD patients.

Bilirubin Levels are Associated With Contrast-Induced Nephropathy in Peripheral Artery Disease

The relationship between contrast-induced nephropathy (CIN) and oxidative mechanisms is well documented. Our aim was to demonstrate the possible relationship between CIN and serum bilirubin as an antioxidant molecule. This retrospective study included 359 patients with peripheral artery disease (PAD) who underwent peripheral diagnostic angiography; 179 developed CIN after the intervention and another 180 were the control group, matched for age, gender, and cardiovascular risk factors. Baseline, 48- to 72-hour, and 30-day laboratory values, major adverse cardiovascular events, and dialysis requirements were recorded. Patients with CIN had significantly higher levels of uric acid, red cell distribution width, and neutrophil-to-lymphocyte ratio (NLR) but lower total bilirubin compared to the control patients ( P < .05). Multivariate logistic regression analysis showed that diabetes mellitus, left ventricular ejection fraction, uric acid, NLR, and total bilirubin levels were independent predictors of CIN development ( P = .01, P = .001, P = .001, P = .01, and P = .001, respectively). This study demonstrated that decreased total bilirubin was associated with CIN development after the administration of radiocontrast agents in patients with PAD.

Long-Term Adverse Effects of Low-Osmolar Compared With Iso-Osmolar Contrast Media After Coronary Angiography

The relative incidence of long-term adverse effects between low-osmolar contrast media (LOCM) and iso-osmolar contrast media (IOCM) after coronary angiography is still unclear. We analyzed cardiology patients undergoing coronary angiography from January 2006 to July 2013 using either LOCM (iohexol, iopromide) or IOCM (iodixanol) at a single institution. For each contrast medium, primary (all-cause mortality, n = 6,992) and secondary outcomes (long-term renal injury and cardiovascular events beyond 90 days, n = 2,792) were recorded. Inverse probability weighing (IPW) was applied to minimize the selection bias between groups. Unadjusted all-cause mortality was significantly lower for LOCM versus IOCM (hazard ratio [HR] 0.28, 95% CI 0.23 to 0.34). After multivariate Cox regression or IPW, all-cause mortality became comparable and lost statistical significance. Chronic kidney disease subgroup had higher mortality risk when receiving LOCM compared with IOCM (regression adjusted HR 1.80, 95% CI 0.95 to 3.42; IPW-adjusted HR 1.57, 95% CI 0.99 to 2.48). In conclusion, after coronary angiography, patients receiving LOCM had comparable overall long-term mortality compared with IOCM after adjustment. LOCM tended to induce higher long-term mortality than IOCM in chronic kidney disease cohorts.

Coronary artery calcification scores improve contrast-induced nephropathy risk assessment in chronic kidney disease patients

BACKGROUND

Coronary artery calcification (CAC) is an independent predictor of cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. The aim of the present study was to evaluate the predictive value of CAC scores for the incidence of contrast-induced nephropathy (CIN) after cardiac catheterization in non-dialyzed CKD patients.

METHODS

The present study evaluated a total of 140 CKD patients who underwent cardiac catheterization. Patients were stratified into two groups based on the optimal cut-off value of the CAC score, which was graded by a non-triggered, routine diagnostic chest computed tomography scan: CAC score ≥8 (high CAC group); and CAC score <8 (low CAC group). CIN was defined as an increase of >10 % in the baseline serum cystatin C level at 24 h after contrast administration.

RESULTS

The mean estimated glomerular filtration rate levels were 41.1 mL/min/1.73 m², and the mean contrast dose administered was 37.5 mL. Patients with high CAC scores exhibited a higher incidence of CIN than patients with low CAC scores (25.5 vs. 3.2 %, p < 0.001). After multivariate adjustment for confounders, the CAC score predicted CIN (odds ratio 1.68, 95 % confidence interval 1.28-2.21, p < 0.001). Moreover, the C-index for CIN prediction significantly increased when the CAC scores were added to the Mehran risk score (0.855 vs. 0.760, p = 0.023).

CONCLUSION

CAC scores, as evaluated using semi-quantitative methods, are a simple and powerful predictor of CIN. Incorporating the CAC score in the Mehran risk score significantly improved the predictive ability to predict CIN incidence.

Salvianolic Acid B Prevents Iodinated Contrast Media-Induced Acute Renal Injury in Rats via the PI3K/Akt/Nrf2 Pathway

Contrast-induced acute renal injury (CI-AKI) has become a common cause of hospital-acquired renal failure. However, the development of prophylaxis strategies and approved therapies for CI-AKI is limited. Salvianolic acid B (SB) can treat cardiovascular-related diseases. The aim of the present study was to assess the effect of SB on prevention of CI-AKI and explore its underlying mechanisms. We examined its effectiveness of preventing renal injury in a novel CI-AKI rat model. Compared with saline, intravenous SB pretreatment significantly attenuated elevations in serum creatinine and the histological changes of renal tubular injuries, reduced the number of apoptosis-positive tubular cells, activated Nrf2, and lowered the levels of renal oxidative stress induced by iodinated contrast media. The above renoprotection of SB was abolished by the PI3K inhibitor (wortmannin). In HK-2 cells, SB activated Nrf2 and decreased the levels of oxidative stress induced by hydrogen peroxide and subsequently improved cell viability. The above cytoprotection of SB was blocked by the PI3K inhibitor (wortmannin) or siNrf2. Thus, our results demonstrate that, due to its antioxidant properties, SB has the potential to effectively prevent CI-AKI via the PI3K/Akt/Nrf2 pathway.

Safe limits of contrast vary with hydration volume for prevention of contrast-induced nephropathy after coronary angiography among patients with a relatively low risk of contrast-induced nephropathy

BACKGROUND

Few studies have investigated the safe limits of contrast to prevent contrast-induced nephropathy (CIN) based on hydration data. We aimed to investigate the relative safe maximum contrast volume adjusted for hydration volume in a population with a relatively low risk of CIN.

METHODS AND RESULTS

The ratios of contrast volume-to-creatinine clearance (V/CrCl) and hydration volume to body weight (HV/W) were determined in patients undergoing cardiac catheterization. Receiver-operator characteristic curve analysis based on the maximum Youden index was used to identify the optimal cutoff for V/CrCl in all patients and in HV/W subgroups. Eighty-six of 3273 (2.6%) patients with mean CrCl 71.89±27.02 mL/min developed CIN. Receiver-operator characteristic curve analysis indicated that a V/CrCl ratio of 2.44 was a fair discriminator for CIN in all patients (sensitivity, 73.3%; specificity, 70.4%). After adjustment for other confounders, V/CrCl >2.44 continued to be significantly associated with CIN (adjusted odds ratio, 4.12; P<0.001) and the risk of death (adjusted hazard ratio, 2.62; P<0.001). The mean HV/W was 12.18±7.40. We divided the patients into 2 groups (HV/W ≤12 and >12 mL/kg). The best cutoff value for V/CrCl was 1.87 (sensitivity, 67.9%; specificity, 64.4%; adjusted odds ratio, 3.24; P=0.011) in the insufficient hydration subgroup (HV/W, ≤12 mL/kg; CIN, 1.32%) and 2.93 (sensitivity, 69.0%; specificity, 65.0%; adjusted odds ratio, 3.04; P=0.004) in the sufficient hydration subgroup (HV/W, >12 mL/kg; CIN, 5.00%).

CONCLUSIONS

The V/CrCl ratio adjusted for HV/W may be a more reliable predictor of CIN and even long-term outcomes after cardiac catheterization. We also found a higher best cutoff value for V/CrCl to predict CIN in patients with a relatively sufficient hydration status, which may be beneficial during decision-making about contrast dose limits in relatively low-risk patients with different hydration statuses.

Valsartan protects HK-2 cells from contrast media-induced apoptosis by inhibiting endoplasmic reticulum stress

Contrast-induced acute kidney injury (CI-AKI) is associated with increasing in-hospital and long-term adverse clinical outcomes in high-risk patients undergoing percutaneous coronary intervention (PCI). Contrast media (CM)-induced renal tubular cell apoptosis is reported to participate in this process by activating endoplasmic reticulum (ER) stress. An angiotensin II type 1 receptor (AT1R) antagonist can alleviate ER stress-induced renal apoptosis in streptozotocin (STZ)-induced diabetic mice and can reduce CM-induced renal apoptosis by reducing oxidative stress and reversing the enhancement of bax mRNA and the reduction of bcl-2 mRNA, but the effect of the AT1R blocker on ER stress in the pathogenesis of CI-AKI is still unknown. In this study, we explored the effect of valsartan on meglumine diatrizoate-induced human renal tubular cell apoptosis by measuring changes in ER stress-related biomarkers. The results showed that meglumine diatrizoate caused significant cell apoptosis by up-regulating the expression of ER stress markers, including glucose-regulated protein 78 (GRP78), activating transcription factor 4 (ATF4), CCAAT/enhancer-binding protein-homologous protein (CHOP) and caspase 12, in a time- and dose-dependent manner, which could be alleviated by preincubation with valsartan. In conclusion, valsartan had a potential nephroprotective effect on meglumine diatrizoate-induced renal cell apoptosis by inhibiting ER stress.

Contrast-induced nephropathy in patients with chronic kidney disease and peripheral arterial disease

Background

The risk for contrast-induced nephropathy (CIN) after intra-arterial application of an iodine-based contrast material is unknown for patients with chronic kidney disease (CKD) and peripheral arterial disease (PAD).

Purpose

To investigate the incidence of CIN in patients with CKD and PAD.

Material and Methods

This retrospective study was approved by the local ethics committee. One hundred and twenty patients with 128 procedures (73 with baseline eGFR in the range of 45–60 mL/min/1.73m², 55 with eGFR < 45 mL/min/1.73m²) were evaluated. All patients received intra-arterially an iodine-based low-osmolar contrast material (CM) after adequate intravenous hydration with isotonic NaCl 0.9% solution. CIN was defined as an increase in serum creatinine of more than 44 μmol/L within 4 days. The influence of patient-related risk factors (age, weight, body mass index, eGFR, serum creatinine, hypertension, diabetes mellitus, coronary heart disease, heart failure) and therapy-related risk factors (amount of CM, nephrotoxic drugs, number of CM applications) on CIN were examined.

Results

CIN developed in 0% (0/73) of procedures in patients with PAD and an eGFR in the range of 45–60 mL/min/1.73m² and in 10.9% (6/55) of procedures in patients with an eGFR <45 mL/min/1.73m². No risk factor significantly influenced the development of CIN, although baseline serum creatinine (P = 0.06) and baseline eGFR (P = 0.10) showed a considerable dependency.

Conclusion

Patients with an eGFR in the range of 45–60 mL/min/1.73m² and PAD seem not at risk for CIN after intra-arterial CM application and adequate hydration. Whereas, an eGFR < 45 mL/min/1.73m² correlated with a risk of 10.9% for a CIN.

Development and validation of a pre-percutaneous coronary intervention risk model of contrast-induced acute kidney injury with an integer scoring system

Previous models for contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) include procedure-related variables in addition to pre-procedural variables. We sought to develop a risk model for CI-AKI based on pre-procedural variables and compare its predictability with a conventional risk model and also to develop an integer score system based on selected variables. A total of 5,936 consecutive PCIs registered in the Japanese Cardiovascular Database were analyzed (derivation cohort, n = 3,957; validation cohort, n = 1,979). CI-AKI was defined as an increase in serum creatinine of 50% or 0.3 mg/dl compared with baseline. From the derivation cohort, 2 different CI-AKI risk models were generated using logistic regression analyses: a pre-procedural model and a conventional model including both pre-procedural and procedure-related variables. The predictabilities of the models were compared by c-statistics. An integer score was assigned to each variable in proportion to each estimated regression coefficient for the final model. In our derivation cohort, the proportion of CI-AKI was 9.0% (n = 358). Predictors for CI-AKI included older age, heart failure, diabetes, previous PCI, hypertension, higher baseline creatinine level, and acute coronary syndrome. Presence of procedure-related complications and insertion of intra-aortic balloon pumping were included as procedure-related variables in the conventional model. Both the conventional model (c-statistics 0.789) and the pre-procedural model (c-statistics 0.799) demonstrated reasonable discrimination. The integer risk-scoring method demonstrated good agreement between the expected and observed risks of CI-AKI in the validation cohort. In conclusion, the pre-procedural risk model for CI-AKI had acceptable discrimination compared with the conventional model and may aid in risk stratification of CI-AKI before PCI.

Trimetazidine Decreases Risk of Contrast-Induced Nephropathy in Patients With Chronic Kidney Disease

Objectives:

We sought to synthesize and analyze the available data from randomized controlled trials (RCTs) for trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN).

Background:

Contrast-induced nephropathy after coronary angiography is associated with poor outcomes. Trimetazidine is an anti-ischemic drug that might reduce incidence of CIN, but current data are inconclusive.

Methods:

We searched MEDLINE/PubMed, EMBASE, Scopus, Cochrane Library, Web of Science, and ScienceDirect electronic databases for RCTs comparing intravenous hydration with normal saline (NS) and/or N-acetyl cysteine (NAC) versus TMZ plus NS ± NAC for prevention of CIN. We used RevMan 5.2 for statistical analysis with the fixed effects model.

Results:

Of the 808 studies, 3 RCTs met criteria with 290 patients in the TMZ plus NS ± NAC group and 292 patients in the NS ± NAC group. The mean age of patients was 59.5 years, and baseline serum creatinine ranged from 1.3 to 2 mg/dL. Trimetazidine significantly reduced the incidence of CIN by 11% (risk difference 0.11; 95% confidence interval, 0.16-0.06; P < .01). There was no significant heterogeneity between the studies (I2 statistic = 0). The number needed to treat to prevent 1 episode of CIN was 9.

Conclusions:

The addition of TMZ to NS ± NAC significantly decreased the incidence of CIN in patients undergoing coronary angiography. In conclusion, TMZ could be considered as a potential tool for prevention of CIN in patients with renal dysfunction.

Hyperuricemia Is an Independent Predictor of Contrast-Induced Acute Kidney Injury and Mortality in Patients Undergoing Percutaneous Coronary Intervention

We investigated whether hyperuricemia is an independent predictor of contrast-induced acute kidney injury (CI-AKI) and mortality in patients undergoing percutaneous coronary intervention (PCI). In a single-center study of 1772 patients undergoing PCI, the development of CI-AKI and mortality during a 2.8-year median follow-up period was assessed. The incidence of CI-AKI was significantly higher in the hyperuricemic group than in the normouricemic group (5.78% vs 1.76%, P < .001). According to multivariate analysis (after adjusting for potential confounding factors), hyperuricemia predicted CI-AKI (odds ratio: 1.962; 95% confidence interval [CI]: 1.014-3.798; P = .045). The other risk factors for CI-AKI were >75 years, emergent PCI, chronic kidney disease (CKD), and anemia. Hyperuricemia with a tendency toward significantly independently predicted long-term mortality, after adjusting for CI-AKI, CKD, and emergent PCI (hazard ratio: 1.571; 95% CI: 1.006-2.452; P = .047). In patients undergoing PCI, hyperuricemia is associated with a risk of CI-AKI. Furthermore, after adjusting for other variables, including CI-AKI and CKD, long-term mortality after PCI was higher in those with hyperuricemia than with normouricemia.

Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) represents an important adverse effect of contrast media (CM) administration. Contrast-induced nephropathy is associated with prolonged hospitalization as well as increased cardiovascular morbidity, renal morbidity, and all-cause mortality. Several risk factors may predict CIN incidence, and various scores and ratios have been proposed to identify high-risk patients. Novel biomarkers may provide an earlier diagnosis of CIN. A multifactorial approach is required for CIN prevention including hydration, administration of low- or iso-osmolar CM, minimizing CM volume, and statin administration. Renal function may deteriorate after CM administration, even in the absence of CIN. Therefore, this deterioration may not be an “all or none” phenomenon; it may well occur in many patients receiving CM, with/without CIN, and may prove to be an underestimated risk factor. Patients should be followed up for longer periods as outpatients after CM exposure to assess kidney function and predict subsequent increased morbidity and mortality.

Mild to Moderate Renal Impairment Is Associated With No-Reflow Phenomenon After Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

We investigated whether admission estimated glomerular filtration rate (eGFR) values are associated with no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Patients (n = 673; 59 ± 13 years; 77.1% men) were stratified into 3 groups according to eGFR at admission: normal renal function (eGFR ≥ 90 mL/min/1.73 m2), mild renal impairment (eGFR 60-89 mL/min/1.73 m2), and moderate renal impairment (eGFR 30-59 mL/min/1.73 m2). No-reflow phenomenon was defined as thrombolysis in myocardial infarction flow grade <3 after pPCI. The rate of no-reflow gradually increased from the normal renal function group to the moderate impaired renal function group ( P < .001). Multivariate analysis showed that eGFR (odds ratio [OR] 0.942, P < .001), Killip ≥2 class (OR 3.968, P = .008), left ventricular ejection fraction (OR 0.959, P = .034), and early patency of infarct vessel (OR 0.186, P < .001) were independent predictors of no-reflow phenomenon. Mild to moderate renal impairment at admission is independently associated with no-reflow phenomenon after pPCI.