Development of contrast-induced nephropathy in subarachnoid hemorrhage: a single center perspective

Influence of Perioperative Three-Dimensional Computed Tomography (CT) Angiography and Surgical Clipping for Unruptured Cerebral Aneurysms on Renal Function in Patients with Chronic Kidney Disease

BACKROUND

Surgical clipping is a valuable treatment option for unruptured intracranial aneurysms in patients with chronic kidney disease (CKD). However, the comprehensive impact of clipping and perioperative three-dimensional computed tomography angiography (3D-CTA) on renal function remains unclear. This study aimed to evaluate the effects of perioperative 3D-CTA and surgical clipping on renal function in patients with CKD.

METHODS

We retrospectively analyzed 529 patients who underwent surgical clipping and perioperative 3D-CTA. An estimated glomerular filtration rate (eGFR) < 60 was defined as CKD. Patients were stratified according to their renal function (group 1: eGFR ≥60, group 2: 45 ≤ eGFR <60, group 3: 30 ≤ eGFR <45, group 4: eGFR <30 ml/min/1.73 m2), and eGFR was assessed preoperatively and 1 week and several months postoperatively.

RESULTS

Of the 529 patients, 442 did not have CKD and 87 had CKD. Hypertension, hyperlipidemia, and hyperuricemia were significantly more common in those with CKD. After the surgery and perioperative series of 3D-CTA, renal function deterioration was not observed in any group, whether in the acute or chronic postoperative period. Notably, eGFR significantly increased in groups 2 (66.7 ± 10.1, P < 0.01) and 3 (48.9 ± 9.2, P = 0.02) 1 week postoperatively, despite the CKD.

CONCLUSIONS

Surgical clipping of unruptured intracranial aneurysms and perioperative 3D-CTA with normal-dose contrast media did not impair renal function in patients with CKD. These results could be valuable in determining treatment strategies for those with CKD and intracranial aneurysms.

Acute kidney injury in neurocritical patients: a retrospective cohort study

BACKGROUND /OBJECTIVE

Acute kidney injury (AKI) is a significant complication in critical care units (CCU). Non-neurological complications such as AKI are an independent predictor of poor clinical outcomes, with an increase in morbidity and mortality, financial costs, and worse functional recovery. This work aims to estimate the incidence of AKI and evaluate the risk factors and complications of AKI in neurocritical patients hospitalized in the CCU.

METHODS

A retrospective cohort study was conducted. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed in regard to the incidence, risk factors, and outcomes of AKI.

RESULTS

The study population comprised 213 neurocritical patients. The incidence of AKI was 23.5%, with 58% KDIGO 1 and 2% requiring renal replacement therapy. AKI was an independent predictor of prolonged use of mechanical ventilation, cerebral edema, and mortality. Cerebral edema [OR 4.40 (95% CI 1.98-9.75) p < 0.001] and a change in chloride levels greater than 4 mmol/L at 48 h (OR 2.44 (95% CI 1.10-5.37) p = 0.027) were risk factors for developing AKI in the first 14 days of hospitalization.

CONCLUSION

There is a high incidence of AKI in neurocritical patients; it is associated with worse clinical outcomes regardless of the CCU admission etiology or AKI severity.

Early Acute Kidney Injury in Patients with Non-Traumatic Subarachnoid Hemorrhage who Undergo Catheter Angiography: Incidence, Associated Risk Factors and Impact on Outcome

OBJECTIVES

After subarachnoid hemorrhage (SAH), potential renal insults are numerous but the burden of early acute kidney injury (AKI) is unclear. We determined its incidence, rate of persistence, risk factors, and impact on patients' outcomes.

MATERIALS AND METHODS

Patients with non-traumatic SAH were retrospectively included if they underwent catheter angiography within the 48 h after their admission to the intensive care unit. Early AKI was defined according to Kidney Disease Improving Global Outcome (KDIGO) criteria, analyzed from the time of catheter angiography. Early AKI was considered as persistent if the KDIGO stage did not decrease between the 48th and the 60th hour.

RESULTS

Among 499 consecutive patients, early AKI (mostly oliguria) occurred in 132 (26%): stage 1, 2 and 3 in 72 (14%), 44 (9%), and 16 (3%) patients, respectively. It persisted in 36% of cases. Early AKI occurred more likely when SAH was severe or renal function was impaired at hospital admission: adjusted odds ratio of 2.76 [95% 1.77-4.30] and 3.32 [1.17-9.46], respectively. ICU and hospital lengths of stay were longer in patients who developed early AKI than in patients who did not: 16 [9-29] versus 12 [4-24] days (p = 0.0003) and 21 [14-43] versus 16 [11-32] days (p = 0.007), respectively. There was an independent link between early AKI and renal outcome (n = 274 in the model) but not with hospital mortality (n = 453).

CONCLUSIONS

One quarter of our population developed early AKI, mostly oliguria. It persisted beyond the 48th hour in one third of cases. The associated risk factors we identified were non-modifiable.

Acute kidney injury after aneurysmal subarachnoid hemorrhage and its effect on patient outcome: an exploratory analysis

OBJECTIVE

Acute kidney injury (AKI) is associated with death in critically ill patients, but this complication has not been well characterized after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of this study was to determine the incidence of AKI after aSAH and to identify risk factors for renal dysfunction. Secondary objectives were to examine what effect AKI has on patient mortality and functional outcome at 12 weeks post-aSAH.

METHODS

The authors performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data set (clinical trial registration no.: NCT00111085, https://clinicaltrials.gov). The primary outcome of interest was the development of AKI, which was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Secondary outcomes of interest were death and a modified Rankin Scale score greater than 2 at 12 weeks post-aSAH. Propensity score matching was used to assess for a significant treatment effect related to clazosentan administration and AKI. Univariate analysis, locally weighted scatterplot smoothing (LOWESS) curves, and stepwise logistic regression models were used to evaluate for associations between baseline or disease-related characteristics and study outcomes.

RESULTS

One hundred fifty-six (38%) of the 413 patients enrolled in the CONSCIOUS-1 trial developed AKI during their ICU stay. A history of hypertension (p < 0.001) and the number of nephrotoxic medications administered (p = 0.029) were independent predictors of AKI on multivariate analysis. AKI was an independent predictor of death (p = 0.028) but not a poor functional outcome (p = 0.21) on multivariate testing. Unresolved renal dysfunction was the strongest independent predictor of death in this cohort (p < 0.001).

CONCLUSIONS

AKI is a common complication following aSAH. Patients with premorbid hypertension and those treated with nephrotoxic medications may be at greater risk for renal dysfunction. AKI appears to confer an increased probability of death after aSAH.

Contrast-induced nephropathy: A dilemma between loss of neurons or nephrons in the setting of endovascular treatment of acute ischemic stroke

PURPOSE

The aim is to report the incidence and risk factors of contrast-induced nephropathy after the use of iodine-based contrast for the endovascular treatment of acute ischemic stroke.

METHODS

Data from patients who underwent neuroendovascular procedures in a center over a period of 22 months were analysed retrospectively. Contrast-induced nephropathy was determined by an increase in serum creatinine level of >25% of baseline or an absolute increase in serum creatinine level of at least 44 µmol/L (0.50 mg/dL) occurring after intravascular administration of contrast media without alternative explanation. The primary outcome measure of this study was the presence of contrast-induced nephropathy in these treated patients. Continuous data were presented as mean ± standard deviation, and categorical data as frequencies or percentages. The comparison was made using Student's t-test or Fisher's test. Logistic regression was performed to find independent contrast-induced nephropathy predictors. All statistical analyses were performed using Microsoft Excel. A p value of less than 0.05 was considered statistically significant.

RESULTS

One hundred and eighty-nine patients undergoing endovascular treatment for acute ischemic stroke. Twenty cases of the total cohort (n = 189) presented contrast-induced nephropathy (10.58%). Only diabetes and creatinine levels between 1.3 and 2.5 mg/dL were associated with contrast-induced nephropathy. No patient was treated with dialysis.

CONCLUSION

Contrast-induced nephropathy is a relatively common complication after endovascular treatment of acute ischemic stroke and is associated with worse outcome in patients with this condition. However, there is no increase in the frequency of hemodialysis after the use of iodinated contrast medium.

Contrast Media-Induced Nephropathy in Patients with Unruptured Cerebral Aneurysm After Coiling Endovascular Treatment

BACKGROUND

The endovascular coiling procedure to treat cerebral aneurysms using contrast media has become more popular. However, studies of the incidence of, and risk factors for, contrast media-induced nephropathy (CIN) after coiling procedures have been limited. Thus, we evaluated the incidence and risk factors for CIN in patients who had undergone cerebral aneurysmal coiling procedures.

METHODS

We retrospectively reviewed the electric medical records of 380 patients who had undergone cerebral aneurysmal coiling treatment under general anesthesia. CIN was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or a relative increase (≥25%) in the baseline serum creatinine value at 48-72 hours after exposure to a contrast agent.

RESULTS

Elective cerebral aneurysmal coiling procedures were performed in 230 patients. Of the 230 patients, CIN developed in 13 (5.6%). The presence of diabetes mellitus (30.8% vs. 9.7%; P = 0.040) and patient age >75 years (30.8% vs. 6.5%; P = 0.012) were risk factors for CIN.

CONCLUSIONS

Our study has demonstrated that the incidence of CIN in patients undergoing elective cerebral aneurysmal coiling procedures is ∼6.0%. We also identified underlying diabetes mellitus and advanced age (≥75 years) as potential risk factors.

Incidence, Risk Factors, and Outcome of Acute Kidney Injury in Neurocritical Care

PURPOSE

Acute kidney injury (AKI) is a severe complication in medical and surgical intensive care units accounting for a high morbidity and mortality. Incidence, risk factors, and prognostic impact of this deleterious condition are well established in this setting. Data concerning the neurocritically ill patients is scarce. Therefore, aim of this study was to determine the incidence of AKI and elucidate risk factors in this special population.

METHODS

Patients admitted to a specialized neurocritical care unit between 2005 and 2011 with a length of stay above 48 hours were analyzed retrospectively for incidence, cause, and outcome of AKI (AKI Network-stage ≥2).

RESULTS

The study population comprised 681 neurocritically ill patients from a mixed neurosurgical and neurological intensive care unit. The prevalence of chronic kidney disease (CKD) was 8.4% (57/681). Overall incidence of AKI was 11.6% with 36 (45.6%) patients developing dialysis-requiring AKI. Sepsis was the main cause of AKI in nearly 50% of patients. Acute kidney injury and renal replacement therapy are independent predictors of worse outcome (hazard ratio [HR]: 3.704; 95% confidence interval [CI]: 1.867-7.350; P < .001; and HR: 2.848; CI: 1.301-6.325; P = .009). Chronic kidney disease was the strongest independent risk factor (odds ratio: 12.473; CI: 5.944-26.172; P < .001), whereas surgical intervention or contrast agents were not associated with AKI.

CONCLUSIONS

Acute kidney injury in neurocritical care has a high incidence and is a crucial risk factor for mortality independently of the underlying neurocritical condition. Sepsis is the main cause of AKI in this setting. Therefore, careful prevention of infectious complications and considering CKD in treatment decisions may lower the incidence of AKI and hereby improve outcome in neurocritical care.

Contrast-Induced Acute Kidney Injury after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage

PURPOSE

Contrast-induced acute kidney injury (CI-AKI) is associated with poor outcomes after percutaneous coronary intervention. However, CI-AKI has rarely been evaluated within the neurovascular field. The aim of this study was to investigate the incidence and clinical implication of CI-AKI after coil embolization in patients with an aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Between January 2005 and March 2016, 192 patients who underwent coil embolization were enrolled in this study. CI-AKI was defined as an increase from baseline serum creatinine concentration of >25% or >0.5 mg/dL within 72 hours after coil embolization. A poor clinical outcome was defined as a score of ≥3 on the modified Rankin Scale at one-year post-treatment.

RESULTS

A total of 16 patients (8.3%) died as a result of medical problems within one year. CI-AKI was identified in 14 patients (7.3%). Prominent risk factors for one-year mortality included CI-AKI [odds ratio (OR): 16.856; 95% confidence interval (CI): 3.437-82.664] and an initial Glasgow Coma Scale (GCS) score ≤8 (OR: 5.565; 95% CI: 1.703-18.184). A poor clinical outcome was associated with old age (≥65 years) (OR: 7.921; 95% CI: 2.977-21.076), CI-AKI (OR: 11.281; 95% CI: 2.138-59.525), an initial GCS score ≤8 (OR 31.02; 95% CI, 10.669-90.187), and a ruptured aneurysm (p=0.016, OR: 4.278) in posterior circulation.

CONCLUSION

CI-AKI seems to be an independent predictor of the overall outcomes of aSAH after endovascular treatment.

Proteinuria as an independent risk factor for contrast-induced acute kidney injury and mortality in patients with stroke undergoing cerebral angiography

BACKGROUND

The correlation between proteinuria and contrast-induced acute kidney injury (CI-AKI) in patients with cerebrovascular disease is still unknown.

OBJECTIVE

To determine whether proteinuria is a risk factor for CI-AKI and death in patients with stroke undergoing cerebral angiography.

METHODS

Data from 2015 patients with stroke undergoing cerebral angiography between January 2009 and December 2013 were retrospectively collected. Clinical parameters were obtained from the hospital's computerized database. All variables were analyzed by univariate analysis and multivariate logistic regression analysis.

RESULTS

CI-AKI was seen in 85 patients (4.2%). After adjustment for potential confounding risk factors, patients with proteinuria had a fivefold higher risk of CI-AKI than patients without proteinuria (OR=5.74; 95% CI 2.23 to 14.83; p<0.001). Other independent risk factors for CI-AKI were estimated glomerular filtration rate <60 mL/min/1.73 m2, anemia, and a high National Institute of Health Stroke Scale score. Proteinuria did not increase in-hospital mortality (OR=1.25; 95% CI 0.49 to 3.17; p=0.639) but did increase 1-year mortality (HR=2.30, 95% CI 1.55 to 3.41, p<0.001).

CONCLUSIONS

Proteinuria is an independent risk factor for CI-AKI and 1-year mortality in patients with stroke undergoing cerebral angiography. More attention should be paid to the development of CI-AKI in patients with stroke with proteinuria.

Relationship Between the Urine Flow Rate and Risk of Contrast-Induced Nephropathy After Emergent Percutaneous Coronary Intervention

A low urine flow rate is a marker of acute kidney injury. However, it is unclear whether a high urine flow rate is associated with a reduced risk of contrast-induced nephropathy (CIN) in high-risk patients. We conducted this study to evaluate the predictive value of the urine flow rate for the risk of CIN following emergent percutaneous coronary intervention (PCI). We prospectively examined 308 patients undergoing emergent PCI who provided consent. The predictive value of the 24-hour postprocedural urine flow rate, adjusted by weight (UR/W, mL/kg/h) and divided into quartiles, for the risk of CIN was assessed using multivariate logistic regression analysis. The cumulative incidence of CIN was 24.4%. In particular, CIN was observed in 29.5%, 19.5%, 16.7%, and 32.0% of cases in the UR/W quartile (Q)-1 (≤0.94  mL/kg/h), Q2 (0.94-1.30  mL/kg/h), Q3 (1.30-1.71  mL/kg/h), and Q4 (≥1.71  mL/kg/h), respectively. Moreover, in-hospital death was noted in 7.7%, 3.9%, 5.1%, and 5.3% of patients in Q1, Q2, Q3, and Q4, respectively. After adjusting for potential confounding predictors, multivariate analysis indicated that compared with the moderate urine flow rate quartiles (Q2 + Q3), a high urine flow rate (Q4) (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27-5.68; P = 0.010) and low urine flow rate (Q1) (OR, 2.23; 95% CI, 1.03-4.82; P = 0.041) were significantly associated with an increased risk of CIN. Moreover, a moderate urine flow rate (0.94-1.71  mL/kg/h) was significantly associated with a decreased risk of mortality. Our data suggest that higher and lower urine flow rates were significantly associated with an increased risk of CIN after emergent PCI, and a moderate urine flow rate (0.94-1.71  mL/kg/h) may be associated with a decreased risk of CIN with a good long-term prognosis after emergent PCI.

Incidence and risk of developing contrast-induced acute kidney injury following intravascular contrast administration in elderly patients

Background

The purpose of this meta-analysis was to evaluate the epidemiology of contrast-induced acute kidney injury (CI-AKI) in the elderly.

Methods

A literature review was undertaken to determine the incidence of CI-AKI in individuals receiving intravascular contrast medium in the hospital setting.

Results

Twenty-two studies with 186,455 patients were identified. The pooled incidence of CI-AKI was 13.6% in 67,831 patients older than 65 years of age (95% confidence interval [CI] 10.1–18.2, I²=0.496). The pooled odds ratio of CI-AKI in the elderly was 2.55 (95% CI 1.85–3.52, I²=0.34). The high incidence of CI-AKI in the elderly was consistent across different administration route subgroups (intracoronary contrast medium group, 15.5% [95% CI 10.3–22.6]; intravenous contrast medium group, 12.4% [95% CI 8.0–18.8]).

Conclusion

Elderly patients are at greater risk for developing CI-AKI.