Prevention of contrast-induced nephropathy by adequate hydration combined with isosorbide dinitrate for patients with renal insufficiency and congestive heart failure

Inorganic nitrate benefits contrast-induced nephropathy after coronary angiography for acute coronary syndromes: the NITRATE-CIN trial

BACKGROUND AND AIMS

Contrast-induced nephropathy (CIN), also known as contrast-associated acute kidney injury (CA-AKI) underlies a significant proportion of the morbidity and mortality following coronary angiographic procedures in high-risk patients and remains a significant unmet need. In pre-clinical studies inorganic nitrate, which is chemically reduced in vivo to nitric oxide, is renoprotective but this observation is yet to be translated clinically. In this study, the efficacy of inorganic nitrate in the prevention of CIN in high-risk patients presenting with acute coronary syndromes (ACS) is reported.

METHODS

NITRATE-CIN is a double-blind, randomized, single-centre, placebo-controlled trial assessing efficacy of inorganic nitrate in CIN prevention in at-risk patients presenting with ACS. Patients were randomized 1:1 to once daily potassium nitrate (12 mmol) or placebo (potassium chloride) capsules for 5 days. The primary endpoint was CIN (KDIGO criteria). Secondary outcomes included kidney function [estimated glomerular filtration rate (eGFR)] at 3 months, rates of procedural myocardial infarction, and major adverse cardiac events (MACE) at 12 months. This study is registered with ClinicalTrials.gov: NCT03627130.

RESULTS

Over 3 years, 640 patients were randomized with a median follow-up of 1.0 years, 319 received inorganic nitrate with 321 received placebo. The mean age of trial participants was 71.0 years, with 73.3% male and 75.2% Caucasian; 45.9% had diabetes, 56.0% had chronic kidney disease (eGFR <60 mL/min) and the mean Mehran score of the population was 10. Inorganic nitrate treatment significantly reduced CIN rates (9.1%) vs. placebo (30.5%, P < .001). This difference persisted after adjustment for baseline creatinine and diabetes status (odds ratio 0.21, 95% confidence interval 0.13-0.34). Secondary outcomes were improved with inorganic nitrate, with lower rates of procedural myocardial infarction (2.7% vs. 12.5%, P = .003), improved 3-month renal function (between-group change in eGFR 5.17, 95% CI 2.94-7.39) and reduced 1-year MACE (9.1% vs. 18.1%, P = .001) vs. placebo.

CONCLUSIONS

In patients at risk of renal injury undergoing coronary angiography for ACS, a short (5 day) course of once-daily inorganic nitrate reduced CIN, improved kidney outcomes at 3 months, and MACE events at 1 year compared to placebo.

Effect of hydration therapy and nursing intervention on preventing contrast-induced nephropathy after interventional treatment of lower extremity arteriosclerosis obliterans

BACKGROUND

Endoluminal interventions have become one of the main options for the treatment of arteriosclerosis obliterans (ASO).

OBJECTIVE

To explore the effect of hydration therapy and nursing intervention on the prevention of contrast-induced nephropathy (CIN) after interventional treatment of lower extremity ASO.

METHODS

A convenience sampling method was used to select 94 patients who received ASO treatment in our hospital from March 2019 to May 2021 as the study subjects. All patients underwent endovascular interventional therapy and were randomly divided into two groups by the random number table method, with odd numbers entering the observation group (n= 47) and even numbers entering the control group (n= 47). The control group received routine nursing intervention, while the observation group underwent hydration therapy and had a corresponding nursing intervention scheme. The clinical efficacy of the two groups and the incidence of contrast-induced nephropathy after interventional therapy were compared, and an evaluation of satisfaction within the two groups was performed via a questionnaire.

RESULTS

The total effective rate of patients in the observation group was higher after hydration treatment (97.87% vs 87.23%, p< 0.05). The blood urea nitrogen, creatinine, and β2 microglobulin levels in the observation group were significantly lower than those in the control group after the intervention (p< 0.05). Patients in the observation group had higher nursing satisfaction after using preventive measures of hydration therapy combined with nursing interventions (100% vs 89.36%, p< 0.05).

CONCLUSION

Hydration therapy and nursing intervention can effectively prevent CIN after interventional treatment of lower extremity ASO. After interventional therapy, patients had better clinical outcomes, lower biochemical indexes and improved satisfaction evaluations. The therapy is worthy of clinical promotion and application.

Does intravenous contrast medium administration result in altered renal biomarkers? A study in clinically stable cats with and without azotemia

OBJECTIVES

The aim of this study was to determine the prevalence of post-contrast acute kidney injury or comparable side effects on kidney function in cats receiving the non-ionic, iodinated agent ioversol and/or paramagnetic agent gadoteric acid.

METHODS

Fifty-two animals were divided into four groups on the basis of contrast medium administration for imaging: ioversol (n = 27), gadoteric acid (n = 12), dual contrast media (n = 4) or control, which received an infusion of isotone intravenous fluids only during anaesthesia (n = 9). Blood and urine samples were obtained three times after contrast administration and compared with values obtained prior to administration of the contrast medium. Creatinine (<1.60 mg/dl), symmetric dimethylarginine (SDMA; ⩽14 μg/dl), urine protein:creatinine ratio (UPC; <0.2) and critical differences for creatinine (<0.3 mg/dl) and SDMA (<5.98 μg/dl) were measured.

RESULTS

No significant short-term effects on mean creatinine, SDMA and UPC measurements were seen. Borderline proteinuria (UPC, 0.2-0.4) was detected in 11.4% of cases after contrast media administration. A UPC of more than 0.2 in five cases indicated that contrast media may affect kidney function, leading to (transient) proteinuria.

CONCLUSIONS AND RELEVANCE

This study found no side effect on renal function following the administration of ioversol or gadoteric acid, provided patients were adequately hydrated. However, the clinical relevance of proteinuria in some cats needs to be evaluated in future studies.

Exploring the relationship between post-contrast acute kidney injury and different baseline creatinine standards: A retrospective cohort study

OBJECTIVE

According to previous studies, the incidence of post-contrast acute kidney injury(PC-AKI) in diabetic is far higher than that in the general population. Therefore, we explored the relationship between the incidence of PC-AKI and different baseline serum creatinine (SCr) levels, and determined the relationship between PC-AKI and different types of contrast media (CMs), different doses of CM, and different examination methods in this specific population.

MATERIALS AND METHODS

Patients with diabetes in whom CM was used between 2010 and 2020 at our institution were included. Participants were identified according to the following three schemes: Scheme 1 (n=5911), SCr was detected before and within 72 h after using CM; Scheme 2 (n=2385), SCr was detected within 24 h before and within 24-72 h after using CM; and Scheme 3 (n=81), SCr was detected within 24 h before and within 0-24, 24-48, and 48-72 h after using CM. The incidence of PC-AKI with different types of CM, incidence of PC-AKI on digital subtraction angiography (DSA) and enhanced computed tomography (CT), proportion of PC-AKI with different doses of CM, and baseline SCr at different stages of PC-AKI were compared. Multivariate logistic regression analysis was used to explore risk factors for PC-AKI.

RESULTS

A total of 29,081 patients were included in this study. The incidence of PC-AKI in Scheme 3 (22.22%) was higher than those in Schemes 1 (6.19%) and 2 (7.71%). The incidence of PC-AKI on DSA was higher than that on enhanced CT (8.30% vs. 5.80%; P<0.05). The incidence of PC-AKI in the increased-dose CM group was higher than that in the non-increased-dose CM group (7.9% vs. 5.7%; P<0.01). Moreover, there were differences in baseline SCr values at different stages of PC-AKI (P<0.01). Multivariate logistic regression analysis showed that hypertension, chronic kidney disease, heart failure, peripheral vascular disease, metformin, diuretics, and CM dose were risk factors for PC-AKI.

CONCLUSION

The incidence of PC-AKI increased significantly with increasing time requirement and frequency of SCr detection. Moreover, before using CM, we should control the blood pressure and heart failure, stop using metformin and diuretics, and use CMs at the minimum dose to avoid PC-AKI.

Risk factors of contrast-induced nephropathy after percutaneous coronary intervention: a retrospective analysis

Objective

Contrast-induced nephropathy (CIN) is a serious complication in patients with acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). This study aimed to analyze the potential risk factors for CIN in patients undergoing PCI.

Methods

Patients with ACS who underwent PCI treatment from January 2017 to January 2020 were selected. The patients’ characteristics and medical information were collected and compared.

Results

A total of 1331 patients undergoing PCI were included. The incidence of CIN was 15.33%. Logistic regression analyses showed that a left ventricular ejection fraction ≤45% (odds ratio [OR] 4.18, 95% confidence interval [CI] 1.10–7.36), serum creatinine levels ≤60 μmol/L (OR 3.03, 95% CI 1.21–5.57), age ≥65 years (OR 2.75, 95% CI 1.32–4.60), log N-terminal pro-B-type natriuretic peptide levels ≥2.5 pg/mL (OR 2.31, 95% CI 1.18–5.13), uric acid levels ≥350 μmol/L (OR 2.29, 95% CI 1.04–5.30), emergency percutaneous intervention (OR 1.35, 95% CI 0.34–3.12), and triglyceride levels ≤1.30 mmol/L (OR 1.10, 95% CI 0.01–2.27) were independent risk factors for CIN in patients who underwent PCI.

Conclusions

Early prevention is required to reduce the occurrence of CIN in patients who undergo PCI and have risk factors for CIN.

Prevention of Contrast-Induced Nephropathy by Inferior Vena Cava Ultrasonography-Guided Hydration in Chronic Heart Failure Patients

INTRODUCTION

Contrast-induced nephropathy (CIN) is a common complication resulting from the administration of contrast media. This study was designed to determine whether inferior vena cava (IVC) ultrasonography (IVCU)-guided hydration can reduce the risk of CIN in chronic heart failure patients undergoing coronary angiography or coronary angiography with percutaneous coronary intervention compared with standard hydration.

METHODS

This prospective clinical trial enrolled 207 chronic heart failure patients from February 2016 to November 2017, who were randomly assigned to either the IVCU-guided hydration group (n = 104) or the routine hydration group (n = 103). In the IVCU-guided group, the hydration infusion rate was set according to the IVC diameter determined by IVCU, while the control group received intravenous infusion of 0.9% saline at 0.5 mL/(kg·h). Serum Cr was measured before and 48-72 h after the procedure. All patients were followed up for 18 months. The incidence of nephropathy and major adverse cardiovascular or cerebrovascular events (MACCEs) was also compared between the 2 groups.

RESULTS

Statistically significant difference between the 2 groups regarding the occurrence of CIN was observed (12.5 vs. 29.1%, p = 0.004). The hydration volume of the IVCU-guided group was significantly higher than that of the routine group (p < 0.001). In addition, patients receiving IVCU-guided hydration had significantly lower risk of developing MACCEs than patients in the control group during the 18-month follow-up (14.4 vs. 27.2%, p = 0.027).

CONCLUSION

Our findings support that IVCU-guided hydration is superior to standard hydration in prevention of CIN and may substantially reduce longtime composite major adverse events.

Renal protective effect of sodium ferulate on pulmonary hypertension patients undergoing computed tomography pulmonary angiography

This study aimed to explore the correlation of sodium ferulate and the renal protective effect on computed tomography pulmonary angiography in patients suffering from pulmonary hypertension. This prospective study enrolled 92 consecutive patients with pulmonary hypertension diagnosed by echocardiography, and all included patients underwent computed tomography pulmonary angiography after admission. The participants were randomized, divided into sodium ferulate group (n = 49) and control group (n = 43), of which patients in the sodium ferulate group received intravenous sodium ferulate 3.0 g per day from 12 h before computed tomography pulmonary angiography examination to 72 h after that, and patients in the control group were provided with routine treatment. Renal function was assessed by measuring serum creatinine, estimated glomerular filtration rate, Cystatin-C as well as 24 h, 48 h, and 72 h after computed tomography pulmonary angiography, followed by the calculation of the incidence of contrast-induced nephropathy for contrast-induced nephropathy and non-contrast-induced nephropathy grouping. Besides, renal resistive index was determined via Doppler ultrasound examination before, after 1 h and 24 h after computed tomography pulmonary angiography. There were no significant differences between the two groups in serum creatinine at baseline and 24 h after computed tomography pulmonary angiography (P > 0.05, respectively), but at 48 h and 72 h, it was lower in the sodium ferulate group (P < 0.05). There were no significant differences of estimated glomerular filtration rate between the two groups (P > 0.05). The level of Cystatin-C at 48 h and 72 h after computed tomography pulmonary angiography was lower than in the sodium ferulate group (P < 0.05). Contrast-induced nephropathy was identified in nine patients (9.78%). Sodium ferulate was associated with a decline in the incidence of contrast-induced nephropathy (4.08 vs. 16.28 %, P < 0.05). Compared to patients with contrast-induced nephropathy, lower renal resistive index were observed at 1 h and 24 h after computed tomography pulmonary angiography in patients without contrast-induced nephropathy (P < 0.05). Infusion of sodium ferulate before and after computed tomography pulmonary angiography was associated with a decline in incidence of contrast-induced nephropathy.

Contrast Nephropathy Associated with Percutaneous Coronary Angiography and Intervention

Contrast nephropathy (CN) is acute kidney injury (AKI) that occurs within 24 to 72 hours of iodinated contrast medium (ICM) administration. Mechanisms of CN include hyperviscosity, free radical formation, and renal medullary oxygen supply/demand mismatch. Although risk factors for CN have been identified, it remains uncertain whether ICM causes or is simply associated with AKI. The cornerstones of CN prevention are using low-osmolal ICM, intravenous hydration, and statins, especially in patients with chronic kidney disease. With appropriate CN risk mitigation, coronary angiography and intervention should not be routinely withheld from patients with acute coronary syndromes.

Prevention of contrast-induced nephropathy by adequate hydration combined with isosorbide dinitrate for patients with renal insufficiency and congestive heart failure

BACKGROUND

Adequate hydration remains the mainstay of contrast-induced nephropathy prevention, and nitrates could reduce cardiac preload.

HYPOTHESIS

This study aimed to explore the adequate hydration with nitrates for patients with chronic kidney disease (CKD) and congestive heart failure (CHF) to reduce the risk of contrast-induced nephropathy (CIN) and at the same time avoid the acute heart failure.

METHODS

Three hundred and ninty-four consecutive patients with CKD and CHF undergoing coronary procedures were randomized to either adequate hydration with nitrates (n = 196) or to routine hydration (control group; n = 198). The adequate hydration group received continuous intravenous infusion of isosorbide dinitrate combined with intravenous infusion of isotonic saline at a rate of 1.5 mL/kg/h during perioperative period. The definition of CIN was a 25% or 0.5 mg/dL rise in serum creatinine over baseline. This trial is registered with www.clinicaltrials.gov, number NCT02718521.

RESULTS

Baseline characteristics were well-matched between the two groups. CIN occurred less frequently in adequate hydration group than the control group (12.8% vs 21.2%; P = 0.018). The incidence of acute heart failure did not differ between the two groups (8 [4.08%] vs 6[3.03%]; P = 0.599). Cumulative major adverse events (death, myocardial infarction, stoke, hospitalization for acute heart failure) during the 90-day follow-up were lower in the adequate hydration with nitrates group (P = 0.002).

CONCLUSIONS

Adequate hydration with nitrates can safely and effectively reduce the risk of CIN in patients with CKD and CHF.