Short-term, high-dose Atorvastatin pretreatment to prevent contrast-induced nephropathy in patients with acute coronary syndromes undergoing percutaneous coronary intervention (from the ARMYDA-CIN [atorvastatin for reduction of myocardial damage during angioplasty--contrast-induced nephropathy] trial

The Choice of the Iodinated Radiographic Contrast Media to Prevent Contrast-Induced Nephropathy

In patients with preexisting renal impairment, particularly those who are diabetic, the iodinated radiographic contrast media may cause contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury (CI-AKI), that is, an acute renal failure (ARF), usually nonoliguric and asymptomatic, occurring 24 to 72 hours after their intravascular injection in the absence of an alternative aetiology. Radiographic contrast media have different osmolalities and viscosities. They have also a different nephrotoxicity. In order to prevent CIN, the least nephrotoxic contrast media should be chosen, at the lowest dosage possible. Other prevention measures should include discontinuation of potentially nephrotoxic drugs, adequate hydration with i.v. infusion of either normal saline or bicarbonate solution, and eventually use of antioxidants, such as N-acetylcysteine, and statins.

Statins and contrast-induced acute kidney injury with coronary angiography

BACKGROUND

Contrast-induced acute kidney injury is an adverse outcome resulting from radiocontrast medium exposure during coronary angiography and percutaneous coronary intervention.

METHODS

A systematic search was conducted to retrieve studies that investigated the impact of statin exposure before coronary angiography or percutaneous coronary intervention on the development of contrast-induced acute kidney injury. The primary outcome was the development of contrast-induced acute kidney injury. We separately analyzed statin/placebo comparisons and high-/low-dose statin comparisons.

RESULTS

Fifteen randomized controlled trials met inclusion criteria: 11 studies with statin-naïve subjects, 2 studies with chronic statin users, and 2 studies with unspecified prior statin exposure. Statin exposure reduced the risk of contrast-induced acute kidney injury relative to placebo (relative risk [RR] 0.63, P = .01) with a nonsignificant reduction in the need for hemodialysis (RR 0.25, P = .08). This benefit was also observed in high-dose versus low-dose statin trials (RR 0.46, P = .004), in statin-naïve patients (RR 0.53, P <.0001), and with all studied statins. Higher statin exposure reduced contrast-induced acute kidney injury in patients with acute coronary syndromes compared with placebo or low-dose statins (RR 0.49, P <.00001), with no significant benefit among patients undergoing elective procedures (RR 0.86, P = .50). Subgroup analyses confirmed the benefit of statins in patients with diabetes, chronic kidney disease, congestive heart failure, and those receiving >140 mL of contrast dye.

CONCLUSION

Statin therapy is effective at reducing the risk of contrast-induced acute kidney injury. It should thus be considered, at least on a short-term basis, for patients at increased risk of this complication.

A network meta-analysis on randomized trials focusing on the preventive effect of statins on contrast-induced nephropathy

Contrast-induced nephropathy is a common complication of iodinated contrast administration. Statins may reduce the risk of contrast-induced nephropathy, but data remain inconclusive. We summarized the evidence based on statins for the prevention of contrast-induced nephropathy with a network meta-analysis. Randomized trials focusing on statins were searched and pooled with random-effect odds ratios. A total of 14 trials (6,160 patients) were included, focusing on atorvastatin (high/low dose), rosuvastatin (high dose), simvastatin (high/low dose), and placebo or no statin therapy before contrast administration. The risk of contrast-induced nephropathy was reduced by atorvastatin high dose and rosuvastatin high dose, with no difference between these two agents. Results for atorvastatin low dose and simvastatin (high/low dose) in comparison to placebo were inconclusive. Atorvastatin and rosuvastatin administered at high doses and before iodinated contrast administration have a consistent and beneficial preventive effect on contrast-induced nephropathy and may actually halve its incidence.

Statins for the Prevention of Contrast-Induced Nephropathy After Coronary Angiography/Percutaneous Interventions: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Statins have been demonstrated to prevent the development of contrast-induced nephropathy (CIN). Nevertheless, clinical research has indicated conflicting results. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the protective effects of statins on CIN and the requirement of renal replacement therapy (RRT) in patients undergoing coronary angiography/percutaneous interventions.

METHODS

PubMed, MEDLINE, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Central RCTs were searched for RCTs from inception to February 2014 to compare statins with placebo treatment for preventing CIN in patients undergoing coronary angiography/percutaneous interventions.

RESULTS

Nine RCTs were identified and analyzed in a total of 5143 patients involving 2560 patients with statin pretreatment and 2583 patients as control. Patients who received statin therapy had a 53% lower risk of CIN with different definitions (within 48 or 72 hours) compared to the control group based on a fixed effect model (risk ratio = 0.47, 95% confidence interval = 0.37-0.60, P < .0001) and were less likely to require RRT based on Peto fixed effect. Subgroup analysis showed that statin pretreatment could decrease the incidence of CIN in patients with preexisting renal dysfunction or diabetes mellitus. In addition, patients on rosuvastatin had a similar reduced incidence of CIN compared to patients on atorvastatin.

CONCLUSION

This updated meta-analysis demonstrated that preprocedural statin treatment could reduce the risk of CIN and the need for RRT in patients undergoing coronary angiography/percutaneous interventions. Moreover, statin therapy would be helpful in reducing the incidence of CIN in high-risk patients with preexisting renal dysfunction or diabetes mellitus. Additionally, rosuvastatin and atorvastatin had similar efficacies in preventing CIN development.

The Role of Statins in Preventing Contrast-Induced Acute Kidney Injury

The incidence of contrast-induced acute kidney injury (CI-AKI) is rising due to increased use of coronary angiography and percutaneous coronary intervention. Many agents, including statins, have been evaluated in several studies for the prevention of CI-AKI. To date, there have been 14 prospective randomized studies regarding the efficacy of statins on the patient. Most of these studies and 3 recent meta-analyses have concluded that statins should be used for this purpose, even in patients with reduced low-density lipoprotein cholesterol levels. However, there are also conflicting results, most likely due to marked heterogeneity of patient characteristics, dosage and administration patterns of statins, definition of CI-AKI, and different statistical analyses. In conclusion, it is uncertain whether statins should be prescribed to prevent CI-AKI in the absence of other indications.

Meta-analysis of randomized controlled trials of preprocedural statin administration for reducing contrast-induced acute kidney injury in patients undergoing coronary catheterization

Preprocedural statin administration may reduce contrast-induced acute kidney injury (CI-AKI), but current evidence is controversial. Randomized controlled trials (RCTs) comparing preprocedural statin administration before coronary catheterization with standard strategies were searched in MEDLINE/PubMed, EMBASE, Scopus, Cochrane Library, Web of Science, and ScienceDirect databases. The outcome of interest was the incidence of postprocedural CI-AKI. Prespecified subgroup analyses were performed according to baseline glomerular filtration rate (GFR), statin type, and N-acetylcysteine use. Eight RCTs were included for a total of 4,984 patients. The incidence of CI-AKI was 3.91% in the statin group (n = 2,480) and 6.98% in the control group (n = 2,504). In the pooled analysis using a random-effects model, patients receiving statins had 46% lower relative risk (RR) of CI-AKI compared with the control group (RR 0.54, 95% confidence interval [CI] 0.38 to 0.78, p = 0.001). A moderate degree of non-significant heterogeneity was present (I(2) = 41.9%, chi-square = 12.500, p = 0.099, τ² = 0.100). In the subanalysis based on GFR, the pooled RR indicated a persistent benefit with statins in patients with GFR <60 ml/min (RR 0.67, 95% CI 0.45 to 1.00, p = 0.050) and a highly significant benefit in patients with GFR ≥60 ml/min (RR 0.40, 95% CI 0.27 to 0.61, p <0.0001). Statin type and N-acetylcysteine or hydration did not significantly influence the results. In conclusion, preprocedural statin use leads to a significant reduction in the pooled RR of CI-AKI.

Benefit of statin pretreatment in prevention of contrast-induced nephropathy in different adult patient population: systematic review and meta-analysis

Objective

Previous studies have suggested that statin pretreatment prevents contrast-induced nephropathy (CIN). However, single randomised trials are limited in their number of patients. This meta-analysis aims to assess the role of statin use in CIN prevention, as well as to determine patient subgroups that will benefit from statin pre-treatment.

Methodology

We searched PubMed, EMBASE, Web of science and the Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCT) comparing statin pretreatment versus placebo for preventing CIN. Our main outcome was the risk of CIN within 1–5 days after contrast administration.

Results

Data analysed from nine randomised studies with a total of 5143 patients, where 2559 received statins and 2584 received placebo, showed that statin pretreatment was associated with significant reduction in risk of CIN (MH-RR=0.47, 95% CI 0.34 to 0.64, Z=4.49, p<0.00001). This beneficial effect of statin was also seen in patients with baseline renal impairment (MH-RR=0.46, 95% CI 0.29 to 0.72, p=0.0008) and also those who were cotreated with NAC (MH-RR=0.46, 95% CI 0.25 to 0.83, p=0.01).

Conclusions

Statin pretreatment leads to significant reduction in CIN, and should be strongly considered in all patients who are planned for diagnostic and interventional procedures involving contrast-media administration.

Acute kidney injury by radiographic contrast media: pathogenesis and prevention

It is well known that iodinated radiographic contrast media may cause kidney dysfunction, particularly in patients with preexisting renal impairment associated with diabetes. This dysfunction, when severe, will cause acute renal failure (ARF). We may define contrast-induced Acute Kidney Injury (AKI) as ARF occurring within 24-72 hrs after the intravascular injection of iodinated radiographic contrast media that cannot be attributed to other causes. The mechanisms underlying contrast media nephrotoxicity have not been fully elucidated and may be due to several factors, including renal ischaemia, particularly in the renal medulla, the formation of reactive oxygen species (ROS), reduction of nitric oxide (NO) production, and tubular epithelial and vascular endothelial injury. However, contrast-induced AKI can be prevented, but in order to do so, we need to know the risk factors. We have reviewed the risk factors for contrast-induced AKI and measures for its prevention, providing a long list of references enabling readers to deeply evaluate them both.

The Prevention of Contrast-Induced Nephropathy

Objective: Contrast-induced nephropathy (CIN) is a complication which may develop after exposure to iodinated contrast media. The resulting acute kidney injury (AKI) is associated with an increase in both short- and long-term morbidity and mortality, increased hospital length of stay, and greater health care costs. The pathophysiological mechanism associated with the development of CIN remains unknown. This narrative review summarizes the pathophysiology, risk factors, and current evidence for the prevention of CIN. Data Sources: A MEDLINE literature search (2004-May 2014) was performed using search terms contrast-induced nephropathy and prevention. Additional references were identified from literature citations, review articles, and meta-analyses. Study Selection and Data Extraction: Abstracts of English-language human clinical trials that examined therapies for the prevention of CIN were evaluated. Studies that did not investigate a preventative intervention for CIN were excluded. Emphasis was placed on recent publications. Data Synthesis: A multitude of therapies focused on the prevention of CIN have been investigated. Unfortunately, many of these studies have produced negative and/or inconsistent results. There is a paucity of adequately designed clinical studies evaluating strategies for the prevention of CIN. However, the best data supports use of preprocedural hydration with isotonic solution as the standard of care for prophylaxis. Conclusion: Given the poor prognosis associated with CIN, there is need for improved methods to prevent it. At present, the best tools to protect patients from unnecessary risk for CIN are careful assessment of renal function, judicious use of procedures that utilize contrast media, and adequate hydration with isotonic solution.

A Practical Approach to Preventing Renal Complications in the Catheterization Laboratory

Kidney injury following cardiac catheterization is an infrequent, though persistent, complication, which in some cases may be preventable. Patients at increased risk for renal complications following catheterization can be identified through individual and procedural risk factors, and several risk-prediction models are readily available. The authors advocate for the development of an easily implemented and standardized protocol, readily accessible to catheterization laboratory staff, for the identification and treatment of those patients who may be at increased risk for renal complications following cardiac catheterization.

Pharmacologic Prophylaxis for Contrast-Induced Acute Kidney Injury

In the effort to prevent contrast-induced acute kidney injury (CI-AKI), several pharmacologic agents have been tested for their single or combined nephroprotective properties. To date, however, no drug has been officially approved for this aim. This article focuses on the three agents that have been most extensively studied: statins, N-acetylcysteine, and ascorbic acid. Particular attention is paid to the impact of these drugs on the CI-AKI prevention and improved prognosis.

Contrast-induced Nephropathy

Contrast-induced nephropathy (CIN) is a serious complication of angiographic procedures resulting from the administration of contrast media (CM). It is the third most common cause of hospital acquired acute renal injury and represents about 12% of the cases. CIN is defined as an elevation of serum creatinine (Scr) of more than 25% or ≥0.5 mg/dl (44 μmol/l) from baseline within 48 h. More sensitive markers of renal injury are desired, therefore, several biomarkers of tubular injury are under evaluation. Multiple risk factors may contribute to the development of CIN; these factors are divided into patient- and procedure-related factors. Treatment of CIN is mainly supportive, consisting mainly of careful fluid and electrolyte management, although dialysis may be required in some cases. The available treatment option makes prevention the corner stone of management. This article will review the recent evidence concerning CIN incidence, diagnosis, and prevention strategies as well as its treatment and prognostic implications.

Red Cell Distribution Width Predicts Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

We investigated the relationship between red cell distribution width (RDW) and contrast-induced nephropathy (CIN) in patients (aged 61 ± 12, 69% men) with acute coronary syndrome (ACS). Consecutive patients diagnosed with ACS (n = 662) who underwent percutaneous coronary intervention (PCI) were included in the study. Patients were divided into 2 groups: CIN and no CIN. Contrast-induced nephropathy was defined as an increase in serum creatinine level of ≥0.5 mg/dL or ≥25% above baseline within 72 hours after PCI. Contrast-induced nephropathy occurred in 81 (12.2%) patients. Red cell distribution width, creatinine, and high-sensitivity C-reactive protein levels were significantly higher in the CIN group than in the no-CIN group. Multivariate regression analysis revealed that baseline RDW level (odds ratio 1.379, 95% confidence interval 1.084-1.753, P = .009), age ( P = .025), creatinine ( P = .004), and left ventricular ejection fraction ( P = .011) were independent risk factors for the development of CIN. In conclusion, increased RDW levels are independently associated with a greater risk of CIN in patients undergoing PCI for ACS.

Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention

Radiocontrast media (RCM) are medical drugs used to improve the visibility of internal organs and structures in X-ray based imaging techniques. They may have side effects ranging from itching to a life-threatening emergency, known as contrast-induced nephropathy (CIN). We define CIN as acute renal failure occurring within 24-72 hrs of exposure to RCM that cannot be attributed to other causes. It usually occurs in patients with preexisting renal impairment and diabetes. The mechanisms underlying CIN include reduction in medullary blood flow leading to hypoxia and direct tubule cell damage and the formation of reactive oxygen species. Identification of patients at high risk for CIN is important. We have reviewed the risk factors and procedures for prevention, providing a long list of references enabling readers a deep evaluation of them both. The first rule to follow in patients at risk of CIN undergoing radiographic procedure is monitoring renal function by measuring serum creatinine and calculating the eGFR before and once daily for 5 days after the procedure. It is advised to discontinue potentially nephrotoxic medications, to choose radiocontrast media at lowest dosage, and to encourage oral or intravenous hydration. In high-risk patients N-acetylcysteine may also be given.

The incidence of kidney injury for patients treated with a high-potency versus moderate-potency statin regimen after an acute coronary syndrome

BACKGROUND

Observational studies have raised concerns that high-potency statins increase the risk of acute kidney injury. We therefore examined the incidence of kidney injury across 2 randomized trials of statin therapy.

METHODS AND RESULTS

PROVE IT-TIMI 22 enrolled 4162 subjects after an acute coronary syndrome (ACS) and randomized them to atorvastatin 80 mg/day versus pravastatin 40 mg/day. A-to-Z enrolled 4497 subjects after ACS and randomized them to a high-potency (simvastatin 40 mg/day × 1 months, then simvastatin 80 mg/day) versus a delayed moderate-potency statin strategy (placebo × 4 months, then simvastatin 20 mg/day). Serum creatinine was assessed centrally at serial time points. Adverse events (AEs) relating to kidney injury were identified through database review. Across both trials, mean serum creatinine was similar between treatment arms at baseline and throughout follow-up. In A-to-Z, the incidence of a 1.5-fold or ≥ 0.3 mg/dL rise in serum creatinine was 11.4% for subjects randomized to a high-potency statin regimen versus 12.4% for those on a delayed moderate-potency regimen (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.76 to 1.10; P=0.33). In PROVE IT-TIMI 22, the incidence was 9.4% for subjects randomized to atorvastatin 80 mg/day and 10.6% for subjects randomized to pravastatin 40 mg/day (OR, 0.88; 95% CI, 0.71 to 1.09; P=0.25). Consistent results were observed for different kidney injury thresholds and in individuals with diabetes mellitus or with moderate renal dysfunction. The incidence of kidney injury-related adverse events (AEs) was not statistically different for patients on a high-potency versus moderate-potency statin regimen (OR, 1.06; 95% CI, 0.68 to 1.67; P=0.78).

CONCLUSIONS

For patients enrolled in 2 large randomized trials of statin therapy after ACS, the use of a high-potency statin regimen did not increase the risk of kidney injury.

Prophylaxis of contrast-induced nephrotoxicity

Contrast-induced nephrotoxicity (CIN) is a form of acute kidney injury that follows intravascular contrast media exposure. CIN may be preventable because its risk factors are well established and the timing of renal insult is commonly known in advance. However, contrast-induced nephrotoxicity is still the third leading cause of iatrogenic renal failure. This important complication accounts up to 10% of acute renal failure cases in hospitalized patients and it is associated with increased short- and long-term morbidity and mortality. Prolonged hospitalization follows and overall increases healthcare resource utilization. This paper will discuss the various prophylactic procedures tested in clinical trials.

The pleiotropic effects of the hydroxy-methyl-glutaryl-CoA reductase inhibitors in renal disease

It is well known that statins exert their main effect by inhibiting cholesterol synthesis through the inhibition of the 3-hydroxy-3-methyl-glutaryl-CoA reductase enzyme. The pleiotropic effects of statins, which are independent of their inhibition of cholesterol synthesis, have explained many of the beneficial effects of these drugs in a variety of disorders such as malignancies, infection, and sepsis, as well as in cardiovascular and rheumatologic disorders. However, the role of these drugs in renal disorders remains controversial. In the present review, we examine the most recent findings involving statins and renal disease among different clinical scenarios, including chronic kidney disease, contrast-induced nephropathy, renal injury after coronary artery bypass surgery, and renal transplant patients.

Pharmacological strategies to prevent contrast-induced acute kidney injury

Contrast-induced acute kidney injury (CI-AKI) is the most common iatrogenic cause of acute kidney injury after intravenous contrast media administration. In general, the incidence of CI-AKI is low in patients with normal renal function. However, the rate is remarkably elevated in patients with preexisting chronic kidney disease, diabetes mellitus, old age, high volume of contrast agent, congestive heart failure, hypotension, anemia, use of nephrotoxic drug, and volume depletion. Consequently, CI-AKI particularly in high risk patients contributes to extended hospitalizations and increases long-term morbidity and mortality. The pathogenesis of CI-AKI involves at least three mechanisms; contrast agents induce renal vasoconstriction, increase of oxygen free radicals through oxidative stress, and direct tubular toxicity. Several strategies to prevent CI-AKI have been evaluated in experimental studies and clinical trials. At present, intravascular volume expansion with either isotonic saline or sodium bicarbonate solutions has provided more consistent positive results and was recommended in the prevention of CI-AKI. However, the proportion of patients with risk still develops CI-AKI. This review critically evaluated the current evidence for pharmacological strategies to prevent CI-AKI in patients with a risk of developing CI-AKI.

Contrast-induced nephropathy in percutaneous coronary interventions: pathogenesis, risk factors, outcome, prevention and treatment

Contrast-induced nephropathy (CIN) is a well-known adverse event of therapeutic and diagnostic procedures requiring the administration of contrast medium (CM). The lack of a universal CIN definition and glomerular filtration rate markers that vary have resulted in a variety of reported incidences. The development of CIN is associated with an increase in the length of hospital stay and the risk of death. Preexisting renal dysfunction, age, diabetes, congestive heart failure and the volume of CM administered are all associated with a risk for developing CIN. The literature suggests the use of low-osmolarity CM and supports volume supplementation before administration. Moreover, other strategies to avoid CIN, including treatment with N-acetylcysteine and sodium bicarbonate have variable levels of evidence. This review examines the main components of the pathogenesis and risk factors of CIN and possible preventive measures and therapies.

Contrast media induced nephropathy: a literature review of the available evidence and recommendations for practice

BACKGROUND

Contrast media induced nephropathy (CIN) is a sudden compromise of renal function 24-48 h after administering contrast medium during a CT scan or angiography. CIN accounts for 10% of hospital acquired renal failure and is ranked the third cause of acquiring this condition. Identifying patients at risk through proper screening can reduce the occurrence of this condition.

PURPOSE

This review paper aims to critique current evidence, provide a better understanding of CIN, inform nursing practice and make recommendations for bedside nurses and future research.

METHOD

An integrative review of the literature was made using the key terms: "contrast media", "nephritis", "nephropathy", "contrast media induced nephropathy scores", "acute kidney failure", "acute renal failure" and "acute kidney injury". MeSH key terms used in some databases were: "prevention and control", "acute kidney failure" and "treatment". Databases searched included Medline, CINAHL and Academic Search Complete, and references of relevant articles were also assessed. The search included all articles between the years 2000 and 2013.

RESULTS

Sixty-seven articles were obtained as a result of the search, including RCTs, systematic reviews, and retrospective studies.

CONCLUSION

Contrast media induced nephropathy is an iatrogenic complication occurring secondary to diagnostic or therapeutic procedures. At times it is unavoidable but a systematic method of risk assessment should be adopted to identify high risk patients for tailored and targeted approaches to management interventions.

CLINICAL IMPLICATIONS

As the use of contrast media is increasing for diagnostic purposes, it is important that nurses be aware of the risk factors for CIN, identify and monitor high risk patients to prevent deterioration in renal function when possible.

Short-term rosuvastatin therapy for prevention of contrast-induced acute kidney injury in patients with diabetes and chronic kidney disease

OBJECTIVES

This study sought to evaluate the safety and efficacy of rosuvastatin in preventing contrast-induced acute kidney injury (CI-AKI) in patients with diabetes mellitus (DM) and chronic kidney disease (CKD).

BACKGROUND

CI-AKI is an important complication after contrast medium injection. While small studies have shown positive results with statin therapy, the role of statin therapy in prevention of CI-AKI remains unknown.

METHODS

We randomized 2,998 patients with type 2 DM and concomitant CKD who were undergoing coronary/peripheral arterial angiography with or without percutaneous intervention to receive rosuvastatin, 10 mg/day (n = 1,498), for 5 days (2 days before, and 3 days after procedure) or standard-of-care (n = 1,500). Patients' renal function was assessed at baseline, 48 h, and 72 h after exposure to contrast medium. The primary endpoint of the study was the development of CI-AKI, which was defined as an increase in serum creatinine concentration ≥0.5 mg/dl (44.2 μmol/l) or 0.25% above baseline at 72 h after exposure to contrast medium.

RESULTS

Patients randomized to the rosuvastatin group had a significantly lower incidence of CI-AKI than controls (2.3% vs. 3.9%, respectively; p = 0.01). During 30 days' follow-up, the rate of worsening heart failure was significantly lower in the patients treated with rosuvastatin than that in the control group (2.6% vs. 4.3%, respectively; p = 0.02).

CONCLUSIONS

Rosuvastatin significantly reduced the risk of CI-AKI in patients with DM and CKD undergoing arterial contrast medium injection. (Rosuvastatin Prevent Contrast Induced Acute Kidney Injury in Patients With Diabetes [TRACK-D]; NCT00786136).

Early high-dose rosuvastatin for contrast-induced nephropathy prevention in acute coronary syndrome: Results from the PRATO-ACS Study (Protective Effect of Rosuvastatin and Antiplatelet Therapy On contrast-induced acute kidney injury and myocardial damage in patients with Acute Coronary Syndrome)

OBJECTIVES

This study sought to determine if in addition to standard preventive measures on-admission, high-dose rosuvastatin exerts a protective effect against contrast-induced acute kidney injury (CI-AKI).

BACKGROUND

Patients with acute coronary syndrome (ACS) are at high risk for CI-AKI, and the role of statin pre-treatment in preventing renal damage remains uncertain.

METHODS

Consecutive statin-naïve non-ST elevation ACS patients scheduled to undergo early invasive strategy were randomly assigned to receive rosuvastatin (40 mg on admission, followed by 20 mg/day; statin group n = 252) or no statin treatment (control group n = 252). CI-AKI was defined as an increase in creatinine concentration of ≥0.5 mg/dl or ≥25% above baseline within 72 h after contrast administration.

RESULTS

The incidence of CI-AKI was significantly lower in the statin group than in controls (6.7% vs. 15.1%; adjusted odds ratio: 0.38; 95% confidence interval [CI]: 0.20 to 0.71; p = 0.003). The benefits against CI-AKI were consistent, even applying different CI-AKI definition criteria and in all the pre-specified risk categories. The 30-day incidence of adverse cardiovascular and renal events (death, dialysis, myocardial infarction, stroke, or persistent renal damage) was significantly lower in the statin group (3.6% vs. 7.9%, respectively; p = 0.036). Moreover, statin treatment given on admission was associated with a lower rate of death or nonfatal myocardial infarction at 6 month follow-up (3.6% vs. 7.2%, respectively; p = 0.07).

CONCLUSIONS

High-dose rosuvastatin given on admission to statin-naïve patients with ACS who are scheduled for an early invasive procedure can prevent CI-AKI and improve short-term clinical outcome. (Statin Contrast Induced Nephropathy Prevention [PRATO-ACS]; NCT01185938).

Radiographic contrast-media-induced acute kidney injury: pathophysiology and prophylactic strategies

Contrast-induced acute kidney injury (CI-AKI) is one of the most widely discussed and debated topics in cardiovascular medicine. With increasing number of contrast-media- (CM-) enhanced imaging studies being performed and growing octogenarian population with significant comorbidities, incidence of CI-AKI remains high. In this review, pathophysiology of CI-AKI, its relationship with different types of CM, role of serum and urinary biomarkers for diagnosing CI-AKI, and various prophylactic strategies used for nephroprotection against CI-AKI are discussed in detail.

Effects of adding statins before surgery on mortality and major morbidity: a meta-analysis

OBJECTIVE

To re-evaluate the effects of adding a statin before surgery on mortality at 30 days and at 1 year and on major morbidity at 0-30 days.

DESIGN

A meta-analysis of parallel, randomized, controlled trials published in English.

SETTING

A university-based electronic search.

PARTICIPANTS

Adult patients undergoing any type of procedure.

INTERVENTION

Adding a statin before a procedure compared to a placebo or no intervention.

MEASUREMENTS AND MAIN RESULTS

A search for all randomized controlled trials (RCT) was done in PubMed, Embase, Ovid MEDLINE and the Cochrane Central Register of Controlled Trials in November 2012. The quality of each study was assessed with the Cochrane Collaboration Tools. An I-square ≥ 25% was chosen as the cut-off point for heterogeneity exploration. The search produced 29 trials. Statins reduced the 0-30 days' risk of myocardial infarction: risk ratio (RR) 0.48 (95%CI 0.38, 0.61); I-square 13.2%; p<0.001; number needed-to-treat 17 (14, 24). There were no statistical differences at 0-30 days for stroke RR 0.70 (0.25, 1.95), acute renal insufficiency RR 0.54 (0.26, 1.12) or reoperation RR 1.10 (0.51, 2.38). There was a trend for a reduced mortality at 1 year RR 0.26 (0.06, 1.02); I-square 0%; p = 0.053. The hospital length of stay was slightly decreased with atorvastatin: standardized mean difference (SMD) -0.27 (-0.39, -0.14), p<0.001; fluvastatin SMD -0.95 (-1.56, -0.34), p = 0.002; and rosuvastatin SMD -0.69 (-0.98, -0.40), p<0.001 but not with simvastatin SMD -0.04 (-0.41, 0.48).

CONCLUSIONS

Adding a statin before a high risk cardiac procedure reduces the 0-30 days' risk of myocardial infarction.

Statin treatment before percutaneous cononary intervention

Treatment with 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) improves short-and-long term prognosis in high-risk patients with stable coronary artery disease and in those with acute coronary syndrome and their use is strongly recommended for secondary prevention. Moreover, recent data suggest that statin pre-treatment is associated with a better short- and long-term outcome in patients undergoing percutaneous coronary intervention. Current guidelines for coronary revascularization recommend the use of high-dose of statins before percutaneous coronary intervention to reduce the risk of periprocedural myocardial infarction in statin naïve patients (class IIa A) and in those on chronic statin therapy (class IIa B). However, the beneficial clinical effects elicited by statins in patients undergoing coronary angioplasty may arise not only from a cardiac protection against periprocedural myocardial injury but also from a renal protection against acute kidney injury caused by iodinated contrast media. Actually, statins exert multiple non-lipid lowering (pleiotropic) effects, including improved endothelial function, reduced inflammatory and immuno-modulatory processes, oxidative stress and platelet adhesion, that may contribute to both cardio- and nephro-protection even in the short-term.

Role of statins in coronary artery disease

Statins have been known to significantly reduce cardiovascular events in patients with cardiovascular disease. This review was undertaken to examine the current evidence for the effect of statins in patients with coronary artery disease. Further research is needed to clarify questions concerning the optimal timing, dosage, and type of statin therapy as well as the problems associated with adverse effects.

Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction

PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.

Impact of a high loading dose of atorvastatin on contrast-induced acute kidney injury

BACKGROUND

The role of statins in the prevention of contrast-induced acute kidney injury (CIAKI) is controversial.

METHODS AND RESULTS

First, we investigated the in vivo effects of atorvastatin on CIAKI. Patients with chronic kidney disease enrolled in the Novel Approaches for Preventing or Limiting Events (NAPLES) II trial were randomly assigned to (1) the atorvastatin group (80 mg within 24 hours before contrast media [CM] exposure; n=202) or (2) the control group (n=208). All patients received a high dose of N-acetylcysteine and sodium bicarbonate solution. Second, we investigated the in vitro effects of atorvastatin pretreatment on CM-mediated modifications of intracellular pathways leading to apoptosis or survival in renal tubular cells. CIAKI (ie, an increase >10% of serum cystatin C concentration within 24 hours after CM exposure) occurred in 9 of 202 patients in the atorvastatin group (4.5%) and in 37 of 208 patients in the control group (17.8%) (P=0.005; odds ratio=0.22; 95% confidence interval, 0.07-0.69). CIAKI rate was lower in the atorvastatin group in both diabetics and nondiabetics and in patients with moderate chronic kidney disease (estimated glomerular filtration rate, 31-60 mL/min per 1.73 m(2)). In the in vitro model, pretreatment with atorvastatin (1) prevented CM-induced renal cell apoptosis by reducing stress kinases activation and (2) restored the survival signals (mediated by Akt and ERK pathways).

CONCLUSIONS

A single high loading dose of atorvastatin administered within 24 hours before CM exposure is effective in reducing the rate of CIAKI. This beneficial effect is observed only in patients at low to medium risk.

Effects of the radiocontrast agent iodixanol on endothelial cell morphology and function

Iodinated radiocontrast media (RCM) are usually well tolerated, but their large and increasing use renders their toxicity a relevant problem, especially in high risk patients. The aim of the study was to investigate the possible toxic or activating effects of iodixanol on endothelial cells (EC) and the putative in vitro protective action of N-acetylcysteine and rosuvastatin. Morphology, oxidative status, redistribution of heat-shock protein 60 and secretion of proinflammatory products were studied in cultured human EC through confocal microscopy, immunofluorescence and immuno-enzymatic methods. EC reacted to iodixanol with shrinking and bulging, increase in intracellular oxidation and translocation of Heat Shock Protein 60 to the cell membrane. The secretion of proinflammatory products was strongly stimulated by sequential incubation of EC with iodixanol and TNFα (p<0.00001 for all tested molecules, namely TNFα, IL-8, sVCAM-1, MCP-1, and IL-6). N-acetylcysteine prevented morphologic and oxidative derangements, and significantly reduced proinflammatory product secretion (P range<0.0001 to<0.00001 for TNFα, VCAM-1, MCP-1, and IL-6); rosuvastatin inhibited morphology and oxidative modifications only. Our data help clarifying the mechanisms of early and late toxicity of RCM and support the use of anti-oxidant and anti-inflammatory agents for optimization of radiological procedures in high risk patients.

Beneficial effects of high-dose atorvastatin pretreatment on renal function in patients with acute ST-segment elevation myocardial infarction undergoing emergency percutaneous coronary intervention

OBJECTIVES

To investigate whether preprocedural high-dose atorvastatin decreases the incidence of contrast-induced nephropathy (CIN) and protects the renal function after emergency percutaneous coronary intervention (PCI).

METHODS

Statin-naive patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing emergency PCI (n = 161) randomly received atorvastatin (80 mg, n = 78, ATOR group) or placebo [n = 83, control (CON) group] followed by long-term atorvastatin (40 mg/day). The primary end point was incidence of CIN.

RESULTS

In the ATOR group, 2.6% of the patients developed CIN versus 15.7% in the CON group (p = 0.01). In the ATOR group, postprocedural serum creatinine was significantly lower (93.4 ± 17.1 vs. 112.6 ± 23.3 µmol/l at 48 h and 84.2 ± 14.2 vs. 95.3 ± 17.7 µmol/l at 72 h, both p < 0.0001) and in the CON group, peak serum cystatin C was lower (0.51 ± 0.14 vs. 0.61 ± 0.13 mg/l, p < 0.0001). Atorvastatin pretreatment was independently associated with a decreased risk of CIN (OR 0.084, 95% CI 0.015-0.462, p = 0.004). The proportion of alanine aminotransferase > 3 × upper limit of the normal value within 1 month was 3.85 versus 1.20% (ATOR vs. CON group, p = 0.57).

CONCLUSION

Preprocedural high-dose atorvastatin prevents CIN and protects the renal function in patients with acute STEMI undergoing emergency PCI.

Efficacy of short-term high-dose statin in preventing contrast-induced nephropathy: a meta-analysis of seven randomized controlled trials

Background

A few studies focused on statin therapy as specific prophylactic measures of contrast-induced nephropathy have been published with conflicting results. In this meta-analysis of randomized controlled trials, we aimed to assess the effectiveness of shor-term high-dose statin treatment for the prevention of CIN and clinical outcomes and re-evaluate of the potential benefits of statin therapy.

Methods

We searched PubMed, OVID, EMBASE, Web of science and the Cochrane Central Register of Controlled Trials databases for randomized controlled trials comparing short-term high-dose statin treatment versus low-dose statin treatment or placebo for preventing CIN. Our outcome measures were the risk of CIN within 2–5 days after contrast administration and need for dialysis.

Results

Seven randomized controlled trials with a total of 1,399 patients were identified and analyzed. The overall results based on fixed-effect model showed that the use of short-term high-dose statin treatment was associated with a significant reduction in risk of CIN (RR = 0.51, 95% CI 0.34–0.76, p = 0.001; I² = 0%). The incidence of acute renal failure requiring dialysis was not significant different after the use of statin (RR = 0.33, 95% CI 0.05–2.10, p = 0.24; I² = 0%). The use of statin was not associated with a significant decrease in the plasma C-reactive protein level (SMD −0.64, 95% CI: −1.57 to 0.29, P = 0.18, I² = 97%).

Conclusions

Although this meta-analysis supports the use of statin to reduce the incidence of CIN, it must be considered in the context of variable patient demographics. Only a limited recommendation can be made in favour of the use of statin based on current data. Considering the limitations of included studies, a large, well designed trial that incorporates the evaluation of clinically relevant outcomes in participants with different underlying risks of CIN is required to more adequately assess the role for statin in CIN prevention.