Contrast-induced nephropathy: pharmacology, pathophysiology and prevention

Assessing the Predictive Value of Different Nutritional Indexes for Contrast-Associated Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

The link between malnutrition and poor prognosis in cardiovascular disease has been established but the association between malnutrition and contrast-associated acute kidney injury (CA-AKI), a common complication of coronary procedures, remains poorly understood. In this study we investigated the predictive value of 3 nutritional indexes for CA-AKI in patients undergoing percutaneous coronary intervention (PCI).Methods and Results: The study included a total of 6,049 consecutive patients undergoing PCI between May 2012 and September 2020, among whom 352 (5.8%) developed CA-AKI. We used the Controlling Nutritional Status (CONUT) score, the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI) to assess the association between malnutrition risk and CA-AKI after PCI. Multivariate logistic regression analysis revealed that malnutrition, as identified by GNRI and PNI, was significantly associated with a higher risk of CA-AKI (moderate-severe malnutrition in GNRI: odds ratio [OR]=1.92, [95% confidence interval (CI), 1.27-2.85]; malnutrition in PNI: OR=1.87, [95% CI, 1.39-2.50]), whereas the CONUT score did not demonstrate a significant difference (P>0.05). Furthermore, GNRI (∆AUC=0.115, P<0.001) and PNI (∆AUC=0.101, P<0.001) exhibited superior predictive ability than the CONUT score for CA-AKI and significantly improved reclassification and discrimination in the fully adjusted model.

CONCLUSIONS

Malnutrition, especially identified by the GNRI and PNI, was associated with a higher risk of CA-AKI after PCI. GNRI and PNI performed better than the CONUT score in predicting CA-AKI.

Efficacy of Trimetazidine in the Prevention of Contrast-Induced Nephropathy in Patients Undergoing Contrast Coronary Intervention: A Systematic Review and Meta-Analysis (PRISMA)

Objective: The present systematic review assessed the efficacy of peri-procedurally administered trimetazidine in the prevention of contrast-induced nephropathy (CIN) in patients undergoing coronary interventions with contrast agents. Methods: We performed a systematic literature review of articles published in PubMed and Google Scholar by 7 December 2023 and included articles from the last 15 years that evaluated the efficacy of trimetazidine in preventing CIN in cardiac patients undergoing coronary intervention. Results: After title/abstract and full-text screening, this systematic review included 9 randomized controlled trials (N = 2158 patients) with two groups: Trimetazidine (60-70 mg/day 24 to 48 h before and up to 72 h after the procedure) with hydration and the control group with only hydration. A total of 234/2158 patients developed CIN (Incidence rate [IR], 10.8%) as per the CIN definition of the Contrast Media Safety Committee of the European Society of Urogenital Radiology. The incidence of CIN in the trimetazidine vs. control group was 6.4% (69/1083) vs. 15.4% (165/1075), and the odds ratio (95% CI) was 0.3753 (0.279-0.504). Conclusions: In conclusion, the trimetazidine group had a lower incidence of CIN. Trimetazidine offers a reno-protective effect and helps in reducing the CIN incidence in patients undergoing cardiac intervention. Peri-procedure administration of trimetazidine significantly decreases the risk of CIN in patients despite comorbidities.

Safety of Administering Intravenous CT Contrast Agents Repeatedly or Using Both CT and MRI Contrast Agents on the Same Day: An Animal Study

OBJECTIVE

To investigate molecular and functional consequences of additional exposures to iodine- or gadolinium-based contrast agents within 24 hours from the initial intravenous administration of iodine-based contrast agents through an animal study.

MATERIALS AND METHODS

Fifty-six Sprague-Dawley male rats were equally divided into eight groups: negative control, positive control (PC) with single-dose administration of CT contrast agent, and additional administration of either CT or MR contrast agents 2, 4, or 24 hours from initial CT contrast agent injection. A 12 µL/g of iodinated contrast agent or a 0.47 µL/g of gadolinium-based contrast agent were injected into the tail vein. Serum levels of blood urea nitrogen, creatinine, cystatin C (Cys C), and malondialdehyde (MDA) were measured. mRNA and protein levels of kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated.

RESULTS

Levels of serum creatinine (SCr) were significantly higher in repeated CT contrast agent injection groups than in PC (0.21 ± 0.02 mg/dL for PC; 0.40 ± 0.02, 0.34 ± 0.03, and 0.41 ± 0.10 mg/dL for 2-, 4-, and 24-hour interval groups, respectively; P < 0.001). There was no significant difference in the average Cys C and MDA levels between PC and repeated CT contrast agent injection groups (Cys C, P = 0.256-0.362; MDA, P > 0.99). Additional doses of MR contrast agent did not make significant changes compared to PC in SCr (P > 0.99), Cys C (P = 0.262), and MDA (P = 0.139-0.771) levels. mRNA and protein levels of KIM-1 and NGAL were not significantly different among additional CT or MR contrast agent groups (P > 0.05).

CONCLUSION

A sufficient time interval, probably more than 24 hours, between repeated contrast-enhanced CT examinations may be necessary to avoid deterioration in renal function. However, conducting contrast-enhanced MRI on the same day as contrast-enhanced CT may not induce clinically significant kidney injury.

Preventive effect and mechanism of compound Danshen dripping pills on contrast-induced nephropathy after percutaneous coronary interventional

Background

Contrast-induced nephropathy (CIN) is one of the most common complications after coronary stent implantation due to the extensive development of coronary catheterization technology. Compound Danshen dripping pills (CDDP) are clinically used as cardiovascular drugs, relieving systemic inflammatory response. Previous studies have observed that CDDP can decrease CIN incidence after coronary stent implantation with uncertain effectiveness.

Methods

We conducted a prospective, randomized, single-center, single-blind, controlled trial. We enrolled patients 18 years and older with unstable angina pectoris and NSTEMI who underwent PCI at the Tianjin Chest Hospital between November 1, 2021, and November 31, 2022, and followed for 30 days. Patients were randomized to CDDP and hydration therapy (10 capsules three times/day; N = 411) or hydration only (N = 411). The primary outcome was the contrast nephropathy incidence, defined as an elevation in serum creatinine by more than 25% or 44 μmol/L from baseline within 48-72 h of contrast exposure. Secondary outcomes included major adverse cardiovascular events post-surgery and during follow-up.

Results

After 48 h of operation, the two groups had statistical significance in Scr and BUN values (80.0 ± 12.59 vs. 84.43 ± 13.49, P < 0.05; 6.22 ± 1.01 vs. 6.40 ± 0.93, P < 0.05). The difference in Scr in 72 h between the two groups was statistically significant (76.42 ± 10.92 vs. 79.06 ± 11.58, P < 0.05). The CIN incidence was significantly lower in the CDDP group than in the hydration group. The CIN risk was significantly elevated in patients with LVEF <50%, contrast volume ≥160 ml, and hypertension, after 48 and 72 h of operation. The serum inflammation index levels NGAL, TNF-α, oxidative stress indexes SOD, and MDA significantly differed between the two groups. However, there was no significant difference in serum apoptosis indexes Bax, Bcl-2, and Casepase-9.

Conclusions

CDDP pre-treatment could prevent contrast-induced nephropathy. Inflammatory response and oxidative stress could be significant in the CDDP mechanism.

Intravenous versus oral hydration to reduce the risk of postcontrast acute kidney injury after intravenous contrast-enhanced CT in patients with severe chronic kidney disease (ENRICH): a study protocol for a single-centre, parallel-group, open-labelled non-inferiority randomised controlled trial in Denmark

INTRODUCTION

Contrast-enhanced CT (CECT) is widely used for diagnostic purposes. The use of contrast medium carries a risk for postcontrast acute kidney injury (PC-AKI), especially in patients with AKI or chronic kidney disease (CKD). Current guidelines recommend prophylactic intravenous hydration to prevent PC-AKI in high-risk patients. Oral hydration is non-inferior to intravenous hydration in patients with moderate CKD, but it has not been evaluated in high-risk patients.

METHODS AND ANALYSIS

The ENRICH trial will enrol 254 patients with estimated glomerular filtration rate ≤30 mL/min/1.73 m2 undergoing intravenous CECT, who are block randomised (2-4-2) with stratification for CKD stage, diabetes status, and indication for referral to prophylactic treatment with oral or intravenous hydration. PC-AKI is defined as an absolute increase in SCr of >0.3 mg/dL or >1.5 from baseline at 2-5 days. Renal function will also be evaluated <90 days, <7 days and 1-3 days before intravenous CECT, and 25-40 days after intravenous CECT. Secondary outcomes include dialysis, renal adverse events, hospitalisation due to hydration-related or contrast-related sequelae, and all-cause mortality ≤30 days postcontrast. Pre- and postcontrast plasma and urinary biomarkers will be evaluated for diagnostic and prognostic accuracy of the primary and secondary outcomes.

ETHICS AND DISSEMINATION

Oral hydration is patient-friendly and less costly compared with intravenous hydration. If oral hydration is non-inferior to intravenous hydration in high-risk patients, it could be implemented as new hydration strategy, which will facilitate the clinical diagnosing of elective patients with severe CKD without unnecessary resource utilisation. The protocol is approved by the Regional Scientific Ethical Committee for Southern Denmark (S-20210126), and the Data Protection Agency (21/66779). The study is conducted in accordance with the Declaration of Helsinki. Positive as well as negative findings will be reported in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05283512.

Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review

ABSTRACT

Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

Gamma glutamyl transferase as a biomarker to predict contrast-induced nephropathy among patients with acute coronary syndrome undergoing coronary interventions: a meta-analysis

The third most frequent reason for hospitalized acute kidney injury is contrast-induced nephropathy (CIN). Percutaneous coronary intervention (PCI) and coronary angiography (CAG) are two interventions that can result in CIN. In this study, we sought to determine how well gamma-glutamyl transferase (GGT) can predict CIN following CAG and PCI.

METHOD

Two researchers searched through PubMed, Scopus, and Web of Science in November 2022 to find articles that examined GGT levels in CIN patients following PCI or CAG. To rate the quality of the studies, the Joanna Briggs Institute Critical Appraisal Checklist was employed. The Cochran test and I2 statistics were utilized to assess study heterogeneity. To calculate the number of participants required to reject the null hypothesis, power analysis was used. We evaluated the epidemiologic strength of the results using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The authors used Comprehensive Meta-analysis Version 3 to summarize the results.

RESULTS

GGT was shown to be considerably greater in patients with CIN according to the meta-analysis's findings (odds ratio: 3.21, 95% CI: 1.26-8.15, P=0.014); nevertheless, the findings were accompanied by significant heterogeneity (I2=91.93%, P<0.001). Although the relationship between CIN and GGT was power full regarding power analysis (1- β =1, number of effect sizes=4, the average number per group=336), very low quality of evidence was observed regarding GRADE criteria.

CONCLUSIONS

These results suggest the GGT level may be a predictor of contrast-induced nephropathy in patients having cardiac catheterization; however, more research is required to prove the epidemiological validity.

Contrast media-induced nephropathy in Tunisia: prospective case-control study with cardio-nephrological monitoring

Introduction

vascular opacification using iodinated contrast media (ICM) is often the primary diagnostic and therapeutic approach. However, the risk of post-injection nephrotoxicity of ICM is significantly higher in patients with underlying nephropathy. This study aimed to determine the incidence of Contrast Media Induced Nephropathy (CMIN) and identify predictive factors for its occurrence in patients from a cardiology department.

Methods

our prospective study involved 158 patients who underwent coronary angiography or angioplasty at the cardiology department between December 2017 and May 2018. Two types of ICM were used in our study: Iopromide and Iohexol. All patients received either physiological serum (9‰) or bicarbonate serum (14‰) intravenously for hydration. We defined impaired renal function as an increase in creatinine ranging from 10 to 26 µmol/L, while CMIN was defined as an increase in serum creatinine exceeding 26.5 µmol/L. We investigated the factors associated with CMIN using logistic regression analysis.

Results

the mean age of our patients was 60 ± 11 years (range: 29-82), with a predominance of men 63.9% (n=101). The most common cardiovascular risk factors were tobacco (36.1%, n = 57), diabetes (48.1%, n =76), hypertension (55%, n = 87). Pre-procedural creatinine averaged 81.1 ± 47.3 µmol / L with extremes ranging from 39 to 600 µmol / L. The median Mehran risk score was 3.2 (range: 0- 15). The interventional cardiology act consisted of coronary angiography in 86.2% (n=136) of cases, coronary angioplasty in 2.5% (n=4) of cases. We used iohexol and iopromide in 57.6% (n=91) and 42.4% (n=67) of cases, respectively. The overall incidence of CMIN was 9.5% (n=9). The multivariable regression analysis identified 4 risk factors independently linked to the occurrence of CMIN which were Pre-existing renal failure (OR: 6.05, 95%CI [1.23-29.62], p = 0.026), anemia (OR: 0.043, CI [1.03-8.96], p = 0.043), the toxic dose of PC (OR: 4.7, CI [1.28-17.7], p=0.02), and at a Mehran score = 11 (OR: 3.7, CI [0.88-15.6], p=0.036).

Conclusion

the most effective approach for CMIN is prevention, which focuses on addressing modifiable risk factors to minimize the risk especially in patients with pre-existing renal failure.

Comparison of image quality of two versions of deep-learning image reconstruction algorithm on a rapid kV-switching CT: a phantom study

BACKGROUND

To assess the impact of the new version of a deep learning (DL) spectral reconstruction on image quality of virtual monoenergetic images (VMIs) for contrast-enhanced abdominal computed tomography in the rapid kV-switching platform.

METHODS

Two phantoms were scanned with a rapid kV-switching CT using abdomen-pelvic CT examination parameters at dose of 12.6 mGy. Images were reconstructed using two versions of DL spectral reconstruction algorithms (DLSR V1 and V2) for three reconstruction levels. The noise power spectrum (NSP) and task-based transfer function at 50% (TTF₅₀) were computed at 40/50/60/70 keV. A detectability index (d') was calculated for enhanced lesions at low iodine concentrations: 2, 1, and 0.5 mg/mL.

RESULTS

The noise magnitude was significantly lower with DLSR V2 compared to DLSR V1 for energy levels between 40 and 60 keV by -36.5% ± 1.4% (mean ± standard deviation) for the standard level. The average NPS frequencies increased significantly with DLSR V2 by 23.7% ± 4.2% for the standard level. The highest difference in TTF₅₀ was observed at the mild level with a significant increase of 61.7% ± 11.8% over 40-60 keV energy with DLSR V2. The d' values were significantly higher for DLSR V2 versus DLSR V1.

CONCLUSIONS

The DLSR V2 improves image quality and detectability of low iodine concentrations in VMIs compared to DLSR V1. This suggests a great potential of DLSR V2 to reduce iodined contrast doses.

Preoperative Fasting Blood Glucose Levels and the Risk of Contrast-Induced Nephropathy in Patients With Diabetes and Pre-diabetes Undergoing Coronary Arteriography or Percutaneous Coronary Intervention: A Cross-Sectional Study

Diabetes mellitus is an independent risk factor for contrast-induced nephropathy (CIN) in patients undergoing coronary arteriography/percutaneous coronary intervention (CAG/PCI). We evaluated whether preoperative fasting blood glucose (FBG) levels in diabetic and pre-diabetic patients who underwent CAG/PCI influenced the occurrence of CIN. From June 1, 2020, to February 28, 2021, 687 patients were divided into five groups based on their preoperative FBG levels. Blood samples were collected at admission and at 48 hours and 72 hours after the procedure to determine serum creatinine levels. The P value for trend was used to analyze the trend between preoperative FBG levels and the increased risk of CIN. Univariable and multivariable logistic regression analysis were used to exclude the influence of confounding factors, and some high-risk confounders were selected for subgroup analysis. The results of our cross-sectional study show that elevated preoperative FBG levels are independently associated with the risk of CIN in diabetic and pre-diabetic patients undergoing CAG/PCI. Furthermore, the incidence of CIN gradually increases with the rise in preoperative FBG levels. Patients with elevated preoperative FBG at admission should be carefully monitored and more active measures should be taken to prevent CIN.

The Role of RIPC in Preventing Organ Damage, Inflammation, and Oxidative Stress during Lower Limb DSA: A Randomised Controlled Trial

Objective

Diagnostic digital subtraction angiography (DSA) and DSA with percutaneous transluminal angioplasty (DSA-PTA) are common procedures for diagnosing and treating symptomatic lower extremity arterial disease (LEAD). However, organ damage following DSA and DSA-PTA is often underrecognised and hence undiagnosed. To reduce the risk induced by invasive procedures in symptomatic LEAD patients, the method of remote ischemic preconditioning (RIPC) has been suggested. The aim of the current study was to assess the effect of RIPC intervention on the organ damage markers profile, oxidative stress, and inflammation biomarkers in LEAD patients undergoing DSA and DSA-PTA procedure.

Methods

The RIPC intervention was performed by inflating a standard blood pressure cuff on the patient's upper arm to 200 mmHg for 5 minutes four times with 5-minute perfusion between each cycle. The sham intervention was performed similarly, but the cuff was inflated to 20 mmHg. Changes in the cardiac and renal damage biomarkers' profile, oxidative stress, and inflammation biomarkers were recorded before and 24 hours after DSA or DSA-PTA.

Results

A total of 111 (RIPC 54, sham 57) patients with symptomatic LEAD scheduled for endovascular procedure were randomised, and 102 patients (RIPC 47, sham 55) completed the study protocol. RIPC significantly limited the increase of adiponectine levels after DSA and DSA-PTA, compared to sham intervention (p = 0.020), but CK-MB levels were markedly lower in the sham group (p = 0.047) after procedure. There was no significant difference between the RIPC and the sham group in mean changes in hs-troponin-T (p = 0.25), NT-proBNP (p = 0.24), creatinine (p = 0.76), eGFR (p = 0.61), urea (p = 0.95), beta-2-microglobuline (p = 0.34), or cystatine C (p = 0.24) levels.

Conclusion

In this controlled clinical study, RIPC failed to improve the profile of renal and cardiac biomarkers in patients with LEAD periprocedurally. RIPC significantly limits the rise in adiponectin levels and may influence the decrease of CK-MB levels 24 hours after endovascular procedure.

Trimetazidine an emerging paradigm in renal therapeutics: Preclinical and clinical insights

Trimetazidine (TMZ) is a well-known anti-ischemic agent used for the treatment of angina pectoris. In the past decades, the efficacy of this drug has been tested in a wide range of kidney injuries, including drug-induced nephrotoxicity (DIN), radio-contrast agent-induced nephropathy, and surgically induced renal ischemic injury. TMZhas renoprotective effects by attenuating oxidative stress, inflammatory cytokine release, maintaining oxygen and energy balance. Moreover, TMZ administration prevented kidney graft rejection in the porcine model by suppressing the infiltration of mononuclear cells, preserving mitochondrial functions, and maintaining Ca+ homeostasis. In DIN and diabetic kidney diseases,TMZ treatment prevents renal injury by inactivating immune cells, attenuating renal fibrosis, inflammation, apoptosis, and histological abnormalities. Interestingly, the clinical therapeutic efficacy of TMZ has also been documented in pre-existing kidney disease patients undergoing contrast exposure for diagnostic intervention. However, the mechanistic insights into the TMZ mediated renoprotective effects in other forms of renal injuries, including type-2 diabetes, drug-induced nephrotoxicity, and hypertension-induced chronic kidney diseases, remain uninvestigated and incomplete. Moreover, the clinical utility of TMZ as a renoprotective agent in radio-contrast-induced nephrotoxicity needs to be tested in a large patient population. Nevertheless, the available pieces of evidence suggest that TMZ is a promising and emerging renal therapy for the treatment and management of kidney diseases of variable etiologies. This review discusses the various pre-clinical and clinical findings and provides mechanistic insights into the TMZ mediated beneficial effects in various kidney diseases.

Novel nanoliposomes alleviate contrast-induced acute kidney injury in New Zealand rabbits by mediating inflammatory response

Background

The purpose of the research was to investigate the preventive effect of nanoliposomes on contrast-induced nephropathy (CIN) in New Zealand rabbits and to provide a theoretical basis for clinically effective prevention and treatment of CIN and the development of new contrast agents.

Methods

A total of 48 New Zealand rabbits were divided into four groups randomly, there were 12 rabbits in eacj group: (I) control group; (II) contrast group; (III) hydration prevention group; and (IV) nanoliposome group. The changes of serum creatinine (SCr) and blood urea nitrogen (BUN) were messured before and after injection of iopromide. Enzyme-linked immunosorbent assay (ELISA) was used to detect inflammatory and oxidative stress indexes, including neutrophil gelatinase-associated lipoprotein (NGAL), tumor necrosis factor-α (TNF-α), superoxide dismutase (SOD), and malondialdehyde (MDA). Twenty-four hours after injection of the contrast medium, the rabbits were killed and the pathological changes were observed under an electron microscope.

Results

There were statistical significances in sCr and BUN values among the four groups at both 8 hours and 24 hours after injection of the contrast medium. Serum NGAL and TNF-α levels were also significantly different among the four groups (P<0.05) 24 hours after injection of the contrast medium. The incidence rate of CIN in each group was statistically significant. Nanoliposomes had obvious advantages over hydration prevention in NGAL and TNF-α levels.

Conclusions

Nanoliposomes can prevent the occurrence of CIN and reduce the damage of contrast agent to the kidney by reducing inflammatory reaction.

Novel Nanoliposomes Alleviate Contrast-Induced Nephropathy by Mediating Apoptosis Response in New Zealand Rabbits

The aim of this study was to test the preventive effects of nano liposomes against contrast-induced nephropathy (CIN) in New Zealand rabbits. Sixty New Zealand rabbits were randomly divided into four groups, with 15 rabbits in each group: control group, contrast group, hydration group and nano liposome group. Serum creatinine (Scr) and Blood Urea Nitrogen (BUN) were measured before and after injection of the contrast agent iopromide. Oxidative stress markers, such as superoxide dismutase (SOD) and malondialdehyde (MDA), and apoptosis markers, such as Bcl2-Associated X (Bax) and B-cell lymphoma-2 (Bcl-2), were measured by enzyme-linked immunosorbent assay (ELISA). Rabbits were killed 24 h after injection of the contrast medium and both kidneys were removed. Real-time Polymerase Chain Reaction (RT-PCR) and Western blot assays were performed in kidney tissue. Pathological changes were analyzed under the optical and electron microscope. Compared with the hydration group, the nano liposome group showed improved protection of renal function, with significantly different Scr and BUN levels, incidence of CIN, apoptosis index, RT-PCR and Western blot protein expression patterns. Under the optical and electron microscope, the renal injury in the nano liposome group was less than in the hydration group. However, based on SOD and MDA, there was no significant difference in oxidative stress when compared with the hydration group. Apoptosis is an important mechanism in CIN. Nano liposomes can prevent the occurrence of CIN by decreasing apoptosis, reducing damage to the kidney by the contrast agent.

Prognostic significance of malnutrition scores in elderly patients for the prediction of contrast-induced acute kidney injury

BACKGROUND

Malnutrition reflects the general condition of a patient including physical condition, protein turnover, and immune competence. Contrast-induced acute kidney injury (CI-AKI) is a disorder that adversely affects the prognosis of older adults. In our study, we aimed to show the relationship between CI-AKI and malnutrition status in elderly patients over 65 years of age with chronic coronary artery disease (CAD).

METHODS

Study enrolled 360 consecutive patients with coronary angiography performed because of chronic coronary artery disease. Patients pre-procedural and post-procedural blood samples were taken and prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and geriatric nutritional risk index (GNRI) malnutrition scores were calculated.

RESULTS

The median age of the patients included in the study was 69 (67-72, IQR) and CI-AKI was seen in 91 (25.2%) patients. Univariate regression analysis showed that age, diabetes mellitus, baseline creatinine, body weight-adapted contrast agent, haemoglobin, left ventricular ejection fraction, CONUT score, PNI score, and GNRI score were independent predictors of CI-AKI. In model 1, increase in CONUT score (2 to 5) (OR: 3.21 (2.11-4.88), in model 2, increase in PNI score (37.4 to 45) (OR: 0.34, (0.24-0.49)), and in model 3, increase in GNRI score (89.5 to 103.8) (OR: 0.55, (0.38-0.81)) were independently associated with the presence of CI-AKI. PNI showed better results than other models in discriminating the predictable capability for CI-AKI.

CONCLUSION

Malnutrition assessment of elderly patients before performing diagnostic or interventional coronary procedures could help clinicians to identify patients with elevated risk for CI-AKI.

Neuroimaging Considerations in Patients with Chronic Kidney Disease

Chronic Kidney Disease is a common medical condition that frequently overlaps with neurologic disease. Neuroimaging can be a useful tool to aid in the diagnoses of neurologic illness, including those that result from renal impairment. Some neuroimaging studies also have the potential to lead to adverse effects on the kidneys necessitating a thoughtful approach to selection of imaging modalities. In particular, multimodal imaging is becoming increasingly common in patients presenting with symptoms of acute stroke, a population that may be at higher risk for renal complications. This article will summarize the neuroimaging manifestations of conditions with shared renal and neurologic involvement and highlight considerations regarding the use of contrast media, nephrogenic systemic fibrosis, and metformin-associated lactic acidosis.

Glycosylated hemoglobin levels and the risk for contrast-induced nephropathy in diabetic patients undergoing coronary arteriography/percutaneous coronary intervention

Backgrounds

Diabetes mellitus is an independent risk factor for Contrast-induced nephropathy (CIN) in patients undergoing Coronary arteriography (CAG)/percutaneous coronary intervention (PCI). Glycosylated hemoglobin (HbA1c) is the gold standard to measure blood glucose control, which has important clinical significance for evaluating blood glucose control in diabetic patients in the past 3 months. This study aimed to assess whether preoperative HbA1c levels in diabetic patients who received CAG/PCI impacted the occurrence of postoperative CIN.

Methods

We reviewed the incidence of preoperative HbA1c and postoperative CIN in 670 patients with CAG/PCI from January 1, 2020 to October 30, 2020 and divided the preoperative HbA1c levels into 5 groups. Blood samples were collected at admission, 48 h and 72 h after operation to measure the Scr value of patients. Categorical variables were compared using a chi-square test, and continuous variables were compared using an analysis of variance. Fisher’s exact test was used to compare the percentages when the expected frequency was less than 5. Univariable and multivariable logistic regression analysis was used to exclude the influence of confounding factors, and P for trend was used to analyze the trend between HbA1c levels and the increased risk of CIN.

Results

Patients with elevated HbA1c had higher BMI, FBG, and LDL-C, and they were more often on therapy with hypoglycemic agents, Insulin and PCI. They also had higher basal, 48 h and 72 h Scr. The incidence of CIN in the 5 groups of patients were: 9.8, 11.9, 15.2, 25.3, 48.1%. (p < 0.0001) The multivariate analysis confirmed that in the main high-risk subgroup, patients with elevated HbA1C levels (≥8.8%) had a higher risk of CIN disease. Trend test showed the change of OR (1.000,1.248,1.553,2.625,5.829).

Conclusions

Studies have shown that in diabetic patients undergoing CAG/PCI, elevated HbA1c is independently associated with the risk of CIN, and when HbA1c > 9.5%, the incidence of CIN trends increase. Therefore, we should attach great importance to patients with elevated HbA1c at admission and take more active measures to prevent CIN.

Kidney Injury Molecule-1 Is Associated with Contrast-Induced Nephropathy in Elderly Patients with Non-STEMI

BACKGROUND

Contrast-induced nephropathy (CIN) is associated with an increased risk of major adverse cardiovascular events (MACE), and the association between CIN and oxidative mechanisms is well documented.

OBJECTIVE

This study aimed to evaluate the relationship between serum levels of kidney injury molecule-1 (KIM-1) and CIN in elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS

This study included a total of 758 patients with NSTEMI, who underwent percutaneous coronary intervention (PCI); 15 developed CIN after PCI, and another 104 were the control group, matched for age > 65 years. Baseline to 48-to-72-hour laboratory values and clinical outcomes were recorded. Patients were followed during one year. P values of < 0.05 were considered significant.

RESULTS

CIN was observed in 12.60% of the patients. Serum KIM-1 was significantly higher in the CIN group than in the non-CIN group (14.02 [9.53 - 19.90] vs. 5.41 [3.41 - 9.03], p < 0.001). The Mehran score was significantly higher in the CIN group than in the non-CIN group (14 [5 - 22] vs. 5 [2 - 7], p = 0.001). MACE were significantly higher in the CIN group than in the non-CIN group (7 [46.70%] vs. 12 [11.50%], p = 0.001). Multivariate logistic regression analysis showed that baseline KIM-1 level (OR = 1.652, 95% CI: 1.20 - 2.27, p = 0.002) and Mehran score (OR = 1.457, 95% CI: 1.01 - 2.08, p = 0.039) were independent predictors of CIN in elderly patients with NSTEMI.

CONCLUSION

Baseline serum KIM-1 concentration and Mehran score are independent predictors of CIN in elderly patients with NSTEMI. Additionally, all-cause mortality, cardiovascular death, myocardial reinfarction, stroke, and MACE were significantly higher in the CIN group at one-year follow-up. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0).

Contrast-Induced Nephropathy: A Review of Mechanisms and Risks

Radiological procedures utilizing intravenous iodinated contrast agents are being widely utilized for both therapeutic and diagnostic purposes. This has resulted in an increasing incidence of procedure-related, contrast-induced nephropathy (CIN). CIN is commonly defined as a decline in kidney function occurring in a narrow time window after administration of iodinated contrast agents. Although self-limiting in most cases, CIN carries a risk of more permanent renal insufficiency, dialysis, and death. It remains a common and serious complication among at-risk patients after exposure of contrast agents. Therefore, it is important to identify patients who are at risk during early stages to implement preventative strategies to decrease the incidence of CIN. Minimizing the amount of contrast administered and providing adequate hydration are the cornerstones of an effective preventative approach. This review focuses on the basic concepts of CIN and summarizes the current understanding of its pathophysiology. In addition, it provides practical recommendations with respect to CIN prevention and management.

Can sodium fluorescein cause contrast-induced nephropathy?

BACKGROUND

Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury (AKI), and can be diagnosed when the etiology of AKI is unclear other than via a contrast agent. Fluorescent angiography (FAG) with fluorescein sodium dye is generally considered to be safe for patients with kidney diseases. However, it remains unresolved whether or not FAG can induce CIN.

METHODS

Patients from two tertiary hospitals who underwent FAG and had serum creatinine results within 4 weeks before FAG and 3 days after FAG between 2001 and 2017 were retrieved. Cases with concurrent iodinated contrast imaging or undergoing dialysis were excluded from the analysis. CIN was defined by two criteria: CIN criteria as >0.5 mg/dL or >25% increase in serum creatinine (sCr) level within 3 days after FAG, and contrast-induced acute kidney injury (CIAKI) criteria as ≥0.3 mg/dL increase within 2 days or ≥50% increase within 7 days after FAG.

RESULTS

A total of 979 patients were screened, and we found 124 patients with AKI after FAG. After excluding 32 patients with clear causes of AKI other than FAG, the incidence rates of CIN were 7.3% by CIN criteria and 6.4% by CIAKI criteria. CIN incidence had a U-shaped distribution according to chronic kidney disease (CKD) stages in CIN criteria, while linear association between CIN incidence and CKD stages were found in CIAKI criteria. Kaplan-Meier curves showed the CIN group was significantly associated with end-stage renal disease (ESRD) progression (log-rank P < 0.001, in both CIN criteria and CIAKI criteria), and adjusted hazard ratios by multivariable Cox regression were 2.23 [95% confidence interval (CI) 1.468-3.378] in CIN criteria and 2.17 (95% CI 1.462-3.232) in CIAKI criteria.

CONCLUSIONS

According to CIN and CIAKI criteria, FAG may cause CIN and appeared to be a possible risk factor for ESRD progression. However, CIN or CIAKI criteria themselves may overestimate AKI and require meticulous attention to the interpretation of results.

A Novel Risk Assessment Model Using Urinary System Contrast Blush Grading to Predict Contrast-Induced Acute Kidney Injury in Low-Risk Profile Patients

Contrast-induced acute kidney injury (CI-AKI) can occur after coronary interventions despite protective measures. We evaluated the effect of urinary system contrast blush grading for predicting post-procedure CI-AKI in 486 patients with chronic coronary artery disease. Patient characteristics and blood samples were collected. Urinary system contrast blush grade was recorded during the coronary angiography and interventions. Post-procedure third to fourth day blood samples were collected for diagnosis of CI-AKI. The median age of the patients was 61 years (53-70, interquartile range), and 194 (39.9%) participants were female. Contrast-induced acute kidney injury occurred in 78 (16%) patients. By comparing full and reduced models with the likelihood ratio test, it was observed that in the reduced model, factors such as age, diabetes mellitus, body weight-adapted contrast media (CM), hemoglobin, and urinary system blush were associated with CI-AKI presence. The probability of CI-AKI presence increased slightly from grade 0 to 1 blush, but it increased sharply grade from 1 to 2 blush. According to our results, an increase in body weight-adapted CM and urinary blush grading were the main predictors of CI-AKI. These findings suggest that when body weight-adapted CM ratio exceeds 3.5 mL/kg and urinary contrast blush reaches grade 2, the patients should be followed up more carefully for the development of CI-AKI.

Trimetazidine reduces contrast-induced nephropathy in patients with renal insufficiency undergoing coronary angiography and angioplasty: A systematic review and meta-analysis (PRISMA)

OBJECTIVES

This systematic review and meta-analysis assesses the utility of trimetazidine (TMZ) to prevent contrast induced nephropathy (CIN) in patients with renal insufficiency undergoing coronary angiography and angioplasty.

MATERIALS AND METHODS

This meta-analysis was formulated and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of databases was conducted by 2 researchers independently for clinical trials, comparing hydration plus TMZ vs conventional hydration alone for prevention of CIN through January 2020. All patients had renal insufficiency (defined as GFR < 89 ml/minute/1.73 m2) and the outcome of interest was the incidence of contrast induced acute kidney injury. The odds ratio (OR) was estimated with 95% confidence interval (CI). Heterogeneity was reported with the I2 statistic, using a fixed-effects model, and >50% of I2 was considered to be statistically significant.

RESULTS

Eleven studies, 1611 patients, met the inclusion/exclusion criteria: 797 patients comprised the TMZ plus hydration group and the remaining 814 patients comprised the control (hydration only) group. Heterogeneity was low I2 = 0%, P = .84, and the heterogeneity of each study was also low. The incidence of CIN in the TMZ plus hydration group was 6.6% (53/797), while the incidence of CIN in the control (hydration only) group was 20% (165/814). Pooled analysis of all studies showed TMZ reduced incidence of CIN compared to saline hydration alone (OR risk 0.30, 95% CI 0.21, 0.42, P < .0001).

CONCLUSION

TMZ added to hydration reduces CIN in renal insufficiency patients undergoing coronary angiography.

Drug-Induced Acute Kidney Injury: A Study from the French Medical Administrative and the French National Pharmacovigilance Databases Using Capture-Recapture Method

BACKGROUND

Acute kidney injury (AKI) is a public health concern. Among the pathological situations leading to AKI, drugs are preventable factors but are still under-notified. We aimed to provide an overview of drug-induced AKI (DIAKI) using pharmacovigilance and medical administrative databases Methods: A query of the PMSI database (French Medical Information System Program) of adult inpatient hospital stays between 1 January 2017 and 31 December 2018 was performed using ICD-10 (International Classification of Diseases 10th revision) codes to identify AKI cases which were reviewed by a nephrologist and a pharmacovigilance expert to identify DIAKI cases. In parallel, DIAKIs notified in the French Pharmacovigilance Database (FPVDB) were collected. A capture-recapture method was performed to estimate the total number of DIAKIs.

RESULTS

The estimated total number of DIAKIs was 521 (95%CI 480; 563), representing 20.0% of all AKIs. The notification was at a rate of 12.9% (95%CI 10.0; 15.8). According to the KDIGO classification, 50.2% of the DIAKI cases were stage 1 and 49.8% stage 2 and 3. The mortality rate was 11.1% and 9.6% required hemodialysis.

CONCLUSION

This study showed that drugs are involved in a significant proportion of patients developing AKI during a hospital stay and emphasizes the severity of DIAKI cases.

Preventing contrast-induced nephropathy (CIN) with herbal medicines: A review

OBJECTIVES

Currently, the use of iodinated contrast media in diagnostic imaging has been increased in clinical medicine. Contrast-induced nephropathy (CIN) is an important adverse effect of contrast media injection. According to the significant role of oxidative stress in the pathophysiology of CIN, different herbal antioxidants have been used for the prevention of nephropathy in different studies. In this review, we discussed the preventive effects of herbal medicine and natural products against CIN.

METHODS

We searched the electronic databases or search engines including PubMed, Scopus, ISI, Google Scholar with search terms such as "Contrast-induced nephropathy" and "Herbal medicine," "Contrast acute kidney injury" AND "natural products" and similar headings such as plant and extract.

RESULTS

Known medicinal plants and active ingredients such as green tea, ginger, garlic, silymarin, curcumin, resveratrol, and thymoquinone have been examined for prophylactic effects or treatment of contrast media nephropathy.

CONCLUSION

Herbal medicines have promising effects in the laboratory-based studies for the prevention and/or treatment of CIN. However, more practical and completed clinical trials are needed to investigate the clinical benefits of natural products against CIN.

MicroRNAs as Biomarkers and Therapeutic Targets in Inflammation- and Ischemia-Reperfusion-Related Acute Renal Injury

Acute kidney injury (AKI), caused mainly by ischemia-reperfusion, sepsis, or nephrotoxins (such as contrast medium), is identified by an abrupt decline in kidney function and is associated with high morbidity and mortality. Despite decades of efforts, the pathogenesis of AKI remains poorly understood, and effective therapies are lacking. MicroRNAs (miRNAs) are small noncoding RNAs that regulate gene expression at the posttranscriptional level to control cell differentiation, development, and homeostasis. Additionally, extracellular miRNAs might mediate cell-cell communication during various physiological and pathological processes. Recently, mounting evidence indicates that miRNAs play a role in the pathogenesis of AKI. Moreover, emerging research suggests that because of their remarkable stability in body fluids, microRNAs can potentially serve as novel diagnostic biomarkers of AKI. Of note, our previous finding that miR-494 is rapidly elevated in urine but not in serum provides insight into the ultimate role of urine miRNAs in AKI. Additionally, exosomal miRNAs derived from stem cells, known as the stem cell secretome, might be a potential innovative therapeutic strategy for AKI. This review aims to provide new data obtained in this field of research. It is hoped that new studies on this topic will not only generate new insights into the pathophysiology of urine miRNAs in AKI but also might lead to the precise management of this fatal disease.

Trimetazidine can prevent the occurrence of contrast-induced nephropathy after percutaneous coronary intervention in elderly patients with renal insufficiency

BACKGROUND

Contrast-induced nephropathy (CIN) has become a common cause of hospital-acquired acute kidney injury in elderly patients. Trimetazidine (TMZ) is a type of anti-ischemic drug developed in recent years, which can reduce the incidence of CIN. This study aimed to evaluate the efficacy of TMZ in the prevention of contrast-induced nephropathy in elderly patients with renal insufficiency undergoing percutaneous coronary intervention (PCI) and to explore the mechanism of action.

METHODS

A total of 310 elderly patients with renal insufficiency undergoing elective PCI were enrolled and randomly assigned to a control group (n = 155, hydration only) and a TMZ group (n = 155, 20 mg thrice daily orally 24 hours before and 72 hours after PCI). The primary endpoint of the study was the incidence of CIN, which was defined as an increase of 25% or more, or an absolute increase of 0.5 mg/dL or more in serum creatinine from baseline value, at 48 to 72 hours following the exposure to contrast media (CM).

RESULTS

The incidence of CIN was significantly lower in the TMZ group than that in the control group (3.2% vs. 9.7%, p = 0.021). There was no difference regarding the incidence of major adverse events during hospitalization between the TMZ group and control group (1.9% vs. 2.6%, p = 1.000). Binary logistic regression results showed that TMZ was protective factors of CIN (OR = 0.274; 95% CI: 0.089-0.847; p = 0.025).

CONCLUSION

Therefore, we came to the conclusion that prophylactic administration of TMZ can prevent the occurrence of CIN in elderly patients with renal insufficiency undergoing PCI and has a certain protective effect on the renal function of patients. According to the experimental results and the mechanism of TMZ on cardiomyocytes, we speculate that TMZ increases kidney glucose metabolism, reduces fatty acid oxidation, and also has a protective effect on kidney free radical damage and ischemia-reperfusion injury.

Biomarkers in the prediction of contrast media induced nephropathy - the BITCOIN study

Background

Subjects with chronic kidney disease are at increased risk for contrast-induced acute kidney injury (CI-AKI). Risk stratification is traditionally based on glomerular filtration rate (GFR) and proteinuria. The present trial examines, whether tubular and inflammatory biomarkers are able to identify subjects at increased risk as well.

Methods

We performed a prospective study in 490 patients undergoing coronary angiography. An increase of serum creatinine concentration ≥ 0.3 mg/dl from baseline to day 2–3 was defined as primary endpoint (CI-AKI). Urinary neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and calprotectin were assessed < 24h before coronary angiography. Prognostic accuracy was assessed by receiver operating characteristics (ROC) calculations.

Results

30 (6.1%) patients suffered from CI-AKI (27 AKIN stage I, 3 AKIN stage II, 0 AKIN stage III). Those subjects who developed CI-AKI had 3.1 fold higher baseline urinary NGAL/creatinine ratios than those without CI-AKI (60.8 [IQR 18.7–93.1] μg/mg vs. 19.9 [IQR 12.3–38.9] μg/mg, p = 0.001). In those subjects without clinically overt CKD (eGFR > 60 ml/min, urinary albumin creatinine ratio <30 mg/g), the NGAL/creatinine ratio was 2.6 higher in CI-AKI vs. no CI-AKI (47.8 [IQR 11.8–75.3] vs. 18.6 [IQR 11.7–36.3] μg/mg). No significant differences were obtained for KIM-1 and calprotectin (p>0.05 each). ROC analyses revealed an area under the curve (AUC) of 0.68 (95% CI 0.60–0.81) for NGAL/creatinine. An NGAL/creatinine ratio < 56.4 μg/mg has a negative predictive value of 96.5%.

Conclusions

The present study is the largest investigation on the use of urinary biomarkers for CI-AKI risk stratification so far. It shows that NGAL provides prognostic information beyond the glomerular biomarkers eGFR and proteinuria.

The Role of MicroRNA in Contrast-Induced Nephropathy: A Scoping Review and Meta-Analysis

Objective

Early diagnosis of contrast-induced nephropathy (CIN) remains crucial for successful treatment; unfortunately, the widely used serum creatinine is elevated only in the late stage of CIN. The circulating microRNAs (miRNAs) are stable biomarker that might be useful. The aim of this scoping review and meta-analysis is to assess the role of miRNAs in CIN.

Methods

We performed a systematic literature search on topics that assess the role of miRNAs in CIN from several electronic databases.

Results

There were 6 preclinical studies and 2 of them validated their findings in human. Only miR-30a, miR-30c, miR-30e, and miR-188 have been validated in human models. Meta-analysis showed that increase in miR-30a expression was associated with higher incidence of CIN (OR 4.48 [1.52, 13.26],  p = 0.007; I²: 94%, p < 0.001). An increase in miR-30e expression was associated with higher incidence of CIN (OR 2.34 [1.70, 3.20], p < 0.001; I²: 0%, p = 0.76). There is an indication that miR-188 is associated with contrast-induced apoptosis and might potentially be a drug target in the future.

Conclusion

This study highlighted the importance of certain miRNAs in CIN pathophysiology. Future researches should explore on the prognostic and therapeutic implication of miRNA in CIN.

Pathophysiology of Contrast-Induced Acute Kidney Injury (CIAKI)

Contrast-induced acute kidney injury (CIAKI) is a severe complication associated with the use of iodinated contrast media (CM); a sudden but potentially reversible fall in glomerular filtration rate (GFR) typically occurring 48-72 hours after CM administration. Principal risk factors related with the presentation of CIAKI are preexisting chronic kidney disease and diabetes mellitus. Studies on CIAKI present considerable complexity because of differences in CM type and dose, controversies in definition and baseline comorbidities. Despite that, it should be noted that CIAKI poses a serious health problem because it is a very common cause of hospitalacquired AKI, linked to increased morbidity and mortality and utilizing growing healthcare resources. The pathogenesis of CIAKI is heterogeneous and, thus, is incompletely understood. Three basic mechanisms appear to simultaneously occur for CIAKI development: Renal vasoconstriction and medullary hypoxia, tubular cell toxicity and reactive oxygen species formation. The relative contribution of each one of these mechanisms is unknown but they ultimately lead to epithelial and endothelial cell apoptosis and GFR reduction. Further research is needed in order to better clarify CIAKI pathophysiology and accordingly introduce effective preventive and therapeutic strategies.

Nicorandil Reduces the Incidence of Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography/Intervention - Systematic Review and Meta-Analysis of Randomized Controlled Trials Including GRADE Qualification

BACKGROUND

Contrast-induced nephropathy (CIN) is associated with increased mortality and morbidity in patients undergoing coronary angiography (CAG) and percutaneous coronary intervention (PCI). We aimed to assess the latest evidence on the effect of nicorandil on the incidence of CIN in patients undergoing CAG/PCI.

METHODS

We performed a comprehensive search on topics that assessed nicorandil and CIN in CAG/PCI patients from inception up until November 2019 through several electronic databases.

RESULTS

There were a total of 1532 subjects from 7 randomized controlled trials. Nicorandil was associated with decrease CIN incidence (OR 0.31 [0.20, 0.46], p < 0.001; I²: 0%). Funnel plot was asymmetrical, indicating the risk of publication bias. Oral administration (OR 0.29 [0.18, 0.46], p < 0.001; I²: 0%) has a greater efficacy compared to intravenous route (OR 0.40 [0.17, 0.93], p < 0.001; I²: 73%). Pooled analysis of adjusted OR revealed that nicorandil reduced CIN incidence independent to other factors in the respective studies (OR 0.34 [0.16, 0.74], p = 0.006, I²: 75%). Protection against CIN (OR 0.37 [0.22, 0.61], p < 0.001; I²: 22%) was also demonstrated in renal dysfunction subgroup, pooled adjusted OR showed that the effect is independent (OR 0.30 [0.10, 0.90], p = 0.03, I²: 86%). GRADE assessment showed moderate level of certainty for the CIN reducing effect of nicorandil in both unadjusted and adjusted models with an absolute reduction of 85 per 1000 and 87 per 1000. Harbord test showed no evidence of small-study effects (p = 0.866).

CONCLUSION

Nicorandil is associated with a lower risk of CIN in patients undergoing CAG/PCI with a moderate level of certainty.

Efficacy of nicorandil on the prevention of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention

OBJECTIVES

The purpose of this study was to explore the effect of nicorandil on the incidence of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention.

METHODS

This study randomized 300 patients undergoing percutaneous coronary intervention to receive conventional treatment in the control group (hydration only; n = 150) vs. nicorandil therapy (nicorandil 10 mg three times daily plus hydration; n = 150). The primary endpoint was the incidence of contrast-induced nephropathy, defined as rise in serum creatinine ≥44.2 μmol/L or >25% above baseline within 72 hours after exposure to contrast administered during percutaneous coronary intervention. Secondary endpoints included differences in post-percutaneous coronary intervention serum creatinine, blood urea nitrogen, creatinine clearance rate, cystatin-C, and occurrence of major adverse events.

RESULTS

Contrast-induced nephropathy incidence was 3.3% (5/150) in the nicorandil group vs. 10.7% (16/150) in the control group (P < 0.05). At 48 and 72 hours after contrast administration, cystatin-C levels were significantly lower and creatinine clearance rate were significantly higher with nicroandil therapy compared to conventional treatment (all P values <0.05). No statistical difference was observed in the incidence of major post-procedure side effect events in hospital and fourteen days of follow-up period between the nicorandil group and control group (3.3% vs. 4.0%, P > 0.05).

CONCLUSION

Compared to conventional treatment, oral nicorandil therapy was associated with less contrast-induced nephropathy and improved renal function following contrast administration during percutaneous coronary intervention.

Efficacy of Oral Nicorandil to Prevent Contrast-Induced Nephropathy in Patients with Chronic Renal Dysfunction Undergoing an Elective Coronary Procedure

Objectives: This prospective, randomized study was to investigate the role of nicorandil in the prevention of contrast-induced nephropathy (CIN) in patients with chronic renal dysfunction undergoing an elective coronary procedure. Methods: A total of 252 eligible patients were enrolled in this study and allocated into the control group (n = 125) or nicorandil group (n = 127). Both groups received the standard hydration treatment, and patients in the nicorandil group were orally administrated 10 mg of nicorandil (t.i.d.) beginning 2 days before and continuing for 2 days after an elective coronary procedure. Serum creatinine (SCr) and cystatin C (CysC) were measured at 24 h before and 24, 48, and 72 h after the procedure. The occurrences of CIN and adverse events within 1 year were recorded. Results: The nicorandil group had relatively lower SCr and CysC levels and a higher eGFR at 24 and 48 h after the procedure than the control group (p < 0.05). The incidence of CIN was significantly decreased in the nicorandil group compared to the control group. The multivariate logistic regression model revealed that nicorandil treatment was an independent protective factor for CIN (OR 0.669, 95% CI 0.522–0.857, p = 0.001). The multivariate COX proportional hazard model showed that nicorandil treatment was an independent protective predictor for adverse events (HR 0.881, 95% CI 0.781–0.993, p = 0.037). Conclusions: Nicorandil could exhibit a protective effect against CIN in patients with chronic renal dysfunction undergoing an elective coronary procedure and reduce the adverse events within 1 year after the procedure, which is superior to hydration treatment only.

Is it possible to prevent contrast-induced nephropathy with dexpanthenol?

PURPOSE

Contrast-induced nephropathy (CIN) is one of the side effects of diagnostic procedures. Oxidative stress plays an important role in CIN's pathophysiology. Dexpanthenol (Dexp) is a substance with antioxidant efficacy. We investigated the likely protective effects of dexpanthenol for CIN.

METHODS

Twenty-four Sprague-Dawley rats were divided randomly into four groups of 6 rats; control (group 1), Dexp (group 2), CIN (group 3) and Dexp + CIN (group 4). All rats were restricted of water moderately to facilitate of nephrotoxicity. Dexp was administered into the intraperitoneally at a dose of 500 mg/kg for 5 days in groups 2 and 4. The same amount of saline was applied via intraperitoneally to group 1 and 3. In CIN and Dexp + CIN groups, L-NAME (10 mg/kg), tenoxicam (0.5 mg/kg) and sodium amidotrizoate (10 ml/kg) were administered on the 4th day via the tail vein for CIN. All rats were euthanized on the 6th day and samples for biochemical and pathological evaluations were collected.

RESULTS

When the Dexp + CIN group and the CIN group were compared, it was found to be provide a significant decline at the level of acute tubular injury and necrosis in kidney biopsies by dexp. Furthermore Dexp significantly reduced the serum cystatin C (Cys-C) levels, not serum creatinine. There was no statistically significant difference between the groups in total oxidant and antioxidant levels.

CONCLUSIONS

Dexpanthenol did not have significant effect on oxidative stress of acute kidney injury on this rat model. However, it has ameliorated serum Cys-C levels and histopathological findings of CIN.

Preventive Effects of Nicorandil Against Contrast-Induced Nephropathy in Patients With Moderate Renal Insufficiency Undergoing Percutaneous Coronary Intervention

We investigated the preventive effect of nicorandil on contrast-induced nephropathy (CIN) in patients with moderate renal insufficiency undergoing percutaneous coronary intervention (PCI). A total of 250 patients with a creatinine clearance (crCl) ≤60 mL/min undergoing PCI were randomly assigned to either a nicorandil group (nicorandil 10 mg 3 times/d and hydration; n = 125) or a control group (hydration only; n = 125). The first end point was the incidence of CIN defined as an increase in serum creatinine (Scr) levels by ≥0.5 mg/dL or ≥25% within 72 hours after exposure to the contrast medium. The secondary end points were (1) changes in Scr, blood urea nitrogen, and crCl and (2) the incidence of major adverse events during hospitalization. The incidence of CIN was 1.6% (2/125) in the nicorandil group and 9.6% (12/125) in the control group ( P = .011). There was no obvious difference in the incidence of major adverse events during hospitalization between the nicorandil and the control group (4.0% vs 4.8%, P = 1.000). Multivariate logistic regression analysis showed that nicorandil was a protective factor for CIN (odds ratios = 0.126, 95% confidence interval: −19.996 to −0.932, P = .012). Prophylactic administration of nicorandil may prevent against CIN in patients with moderate renal insufficiency undergoing PCI.

Calculated Serum Osmolality, Acute Kidney Injury, and Relationship to Mortality after Percutaneous Coronary Intervention

BACKGROUND

Data on the associations between serum osmolality (sOsmo) and acute kidney injury (AKI) as well as short- and long-term mortality in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) are limited.

OBJECTIVES

To investigate the association between sOsmo and development of AKI and clinical outcomes in patients undergoing PCI.

METHODS

We investigated 1,927 consecutive patients undergoing PCI from the registry of a single center. Patients were divided into quartiles according to sOsmo at admission (Q1-Q4). sOsmo was calculated using the following equation: (1.86 × serum sodium [mmol/L]) + (glucose [mg/dL] / 18) + (blood urea nitrogen [mg/dL] / 2.8) + 9. The primary endpoint was AKI, per Kidney Disease: Improving Global Outcomes (KDIGO) definition. The secondary endpoints were 30-day and 1-year all-cause mortality.

RESULTS

Patients with the highest sOsmo (Q4) were older and more likely female, with significantly more cardiovascular risk factors and comorbidities compared to those with lower sOsmo (Q1-Q3). Incidence of AKI was highest in Q4 and lowest in Q2. In the multivariate logistic regression model, high sOsmo independently predicted the development of AKI (OR 2.00, 95% CI 1.26-3.19, p = 0.003). Patients with Q4 had a higher risk of 1-year mortality compared to patients with Q2 (HR 2.11, 95% CI 1.10-4.15; p = 0.031), but not after adding AKI to the multivariate model (HR 1.71, 95% CI 0.87-3.39; p = 0.12).

CONCLUSION

sOsmo is a valid and easily obtainable predictor of AKI after PCI. High sOsmo is associated with increased risk of AKI and 1-year mortality in patients undergoing PCI. Further research is warranted to clarify whether the use of an sOsmo-directed hydration protocol might reduce the incidence of AKI in patients undergoing PCI.

Pharmacology, Part 5: CT and MRI Contrast Media

Pharmacology principles provide key understanding that underpins the clinical and research roles of nuclear medicine practitioners. The scope of practice of the nuclear medicine technologist demands knowledge and understanding of indications, contraindications, warnings, precautions, proper use, drug interactions, and adverse reactions for each medication to be used. This article is part of a series that aims to enhance understanding of pharmacologic principles relevant to nuclear medicine. This article will build on the introductory concepts, terminology, and principles of pharmacology explored in the first 2 articles in the series. Specifically, this article will focus on the pharmacologic principles and adverse reactions associated with iodinated and gadolinium contrast media used in CT and MRI, respectively.

Acute, in-Hospital Outcome of Percutaneous Coronary Intervention for In-Stent Chronic Total Occlusion

BACKGROUND

Percutaneous coronary intervention (PCI) of total chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of in-stent CTO (IS-CTO) is associated with inferior success rates. This present study aims to comparatively evaluate the acute outcome of patients with IS-CTO and de novo CTO.

METHODS

Between 2012 and 2018 we included 600 patients. Antegrade and retrograde CTO-PCI techniques were used and the primary endpoint was a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction.

RESULTS

IS-CTO predominantly occurred in the right coronary artery (71.2%). The success (p = 0.495) and complication rates (p = 0.255) were independent of the target vessel. The lesion lengths of IS-CTO were longer than in de-novo CTO (40 mm vs. 30 mm, statistical trend p = 0.081) alongside with the implanted stent lengths (76 mm vs. 63 mm, statistical trend p = 0.070) and their diameter (3.5 mm vs. 3.0 mm, p < 0.001). We determined that procedural and fluoroscopy time were longer in patients with IS-CTO (115.0 min vs. 93.0 min, p = 0.018 and 40.0 min vs. 30.0 min, p = 0.040) and that in this group of patients the amount of contrast medium was higher (250 ml vs. 200 ml, p = 0.015). Overall success rates were comparable between the two group of patients (87.9% vs. 84.4%, p = 0.586). In-hospital, acute procedural complications regarding the composite safety were rare and showed no statistically significant difference (3.0% vs. 5.6%; p = 0.563).

CONCLUSIONS

Recanalization of in-stent CTO lesions go along with long procedural and high fluoroscopy times as well as an increased amount of contrast medium. Compared to de novo CTO they can be performed safe in experienced hands with similar success rates.

Assessment of radiation dose and iodine load reduction in head-neck CT angiography using two scan protocols with wide-detector

OBJECTIVE

To compare image quality, radiation dose, and iodine intake of head-neck CT angiography (CTA) acquired by wide-detector with the gemstone spectral imaging (GSI) combination with low iodine intake or routine scan protocol.

METHODS

Three hundred patients who had head-neck CTA were enrolled and divided into three groups according to their BMI values: group A (18.5 kg/m2 ≦ BMI <24.9 kg/m2), group B (24.9 kg/m2 ≦ BMI <29.9 kg/m2) and group C (29.9 kg/m2 ≦ BMI ≦ 34.9 kg/m2) with 100 patients in each group. Patients in each group were randomly divided into two subgroups (n = 50) namely, A1, A2, B1, B2, C1 and C2. The patients in subgroups A1, B1 and C1 underwent GSI with low iodine intake (270 mgI/ml, 50 ml) and combined with the ASiR-V algorithm. Other patients underwent three dimensional (3D) smart mA modulation with routine iodine intake (350 mgI/ml, 60 ml). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of all images were calculated after angiography. Images were then subjectively assessed using a 5-point scale. CT dose index of volume and dose-length product (DLP) was converted to the effective dose (ED) and then compared.

RESULTS

The mean CT values, SNR, CNR and subjective image quality in subgroups A2, B2 and C2 are significantly lower than in subgroups A1, B1, and C1 (P < 0.01), respectively. The ED values in subgroup A1, B1, and C1 are 55.18%, 61.89%, and 69.64% lower than those in A2, B2, and C2, respectively (P < 0.01). The total iodine intakes in subgroups A1, B1, and C1 are 35.72% lower than those in subgroups A2, B2, and C2.

CONCLUSIONS

The gemstone spectral imaging with monochromatic images at 53-57 keV combined with ASiR-V algorithm allows significant reduction in iodine load and radiation dose in head-neck CT angiography than those yielded in routine scan protocol. It also enhances signal intensity of head-neck CTA and maintains image quality.

Maximum allowable contrast dose and prevention of acute kidney injury following cardiovascular procedures

PURPOSE OF REVIEW

Contrast-induced acute kidney injury (CI-AKI) is a serious complication. Although nonmodifiable and modifiable risk factors have been thoroughly characterized, the utility of the maximal allowable contrast dose (MACD) has not received adequate attention. The focus of this review is to provide a critical appraisal of this modifiable risk factor.

RECENT FINDINGS

Several retrospective and prospective cohort studies have demonstrated that the incidence of CI-AKI among patients receiving contrast media in volumes exceeding the MACD is consistently higher compared with those who do not exceed the MACD (an average of 24 vs. 6%). Furthermore, the MACD is independent predictor of CI-AKI and other adverse events. A two-step algorithm incorporating the determination of the MACD and the contrast volume to eGFR ratio prior to a planned cardiovascular procedure is a sound approach to minimize contrast volume and prevent CI-AKI.

SUMMARY

Prevention of CI-AKI must remain a clinical priority. Intraprocedural preventive measures should include a priori calculation of the MACD and contrast volume to eGFR ratio to limit contrast volume. Other measures may include the adoption of the transradial approach, the use of automated contrast injectors and small catheters to limit contrast volume, the use of low-osmolar contrast agents, and if necessary the use of staged procedures. We call for the system-wide implementation of evidence-based care bundles to prevent CI-AKI.

Association of prealbumin levels with contrast-induced acute kidney injury in elderly patients with elective percutaneous coronary intervention

Purpose

Inflammatory factors play a critical role in contrast-induced acute kidney injury (CI-AKI). Prealbumin, a nutritional and inflammatory indicator, is a well-established predictor of short- and long-term outcomes in numerous clinical conditions. The current study investigated the association of pre-procedural prealbumin levels with CI-AKI and long-term outcomes in geriatric patients after elective percutaneous coronary intervention (PCI).

Patients and methods

A total of 558 patients aged≥75 years, who underwent elective PCI between January 2012 and December 2015, were selected for the current study. Pre-procedural prealbumin levels were measured before PCI. Multivariable logistic regression and Cox proportional hazard regression analyses were performed to identify the independent risk factors for CI-AKI and long-term mortality.

Results

Out of 558 patients, 54 developed CI-AKI. The optimal cutoff value of prealbumin for detecting CI-AKI was 185.5 mg/L with 62.7% sensitivity and 70.4% specificity based on the receiver operating characteristic analysis (C-statistic=0.710; 95% confidence interval [CI] 0.673–0.751). Multivariable analysis demonstrated that prealbumin≤185.5 mg/L was significantly associated with CI-AKI (odds ratio [OR] 0.397; 95% CI 0.195–0.808; P=0.011). Cox regression analysis demonstrated that prealbumin≤185.5 mg/L was associated with long-term mortality (adjusted hazard ratio [HR] 0.525; 95% CI 0.289–0.952; P=0.034) during the follow-up.

Conclusion

Pre-procedural levels of prealbumin were independently associated with an increased risk of CI-AKI and long-term mortality in elderly patients undergoing elective PCI.

Contrast media-induced nephropathy: how has Italy contributed in the past 30 years? A systematic review

Background and objective

The use of contrast media in Italy has exponentially increased in the past 3 decades. However, it is unknown whether there has been an increase in clinical research evaluating the risks associated with contrast media usage, especially regarding contrast-induced nephropathy. To fill this gap in knowledge, we performed a systematic review.

Study eligibility criteria

Meta-analyses, observational studies, and clinical trials assessing contrast media-induced nephropathy as the safety outcome, in which at least one author was affiliated with an Italian university/health care structure, were eligble.

Data sources

Ovid MEDLINE, Ovid Embase, Cochrane Methodology Register, and Web of Science were screened.

Participants

Men and women exposed to contrast media.

Results

In total, 60 original articles were retrieved with an incremental trend between 1990 and 2017. Cohort studies were the most common study design represented. In total, 45 of 60 (75.0%) studies were monocenter studies and 41 of 60 (68.3%) received no funding. In all, 91.7% of studies disclosed no conflicts of interest and 81.7% had no external collaboration. Most of the studies provided a level of evidence of III-2 (32/60; 53.3%) and II (23/60; 38.3%). In total, 50 of 60 studies (83.3%) were published in a scientific journal ranked in the first quartile of their subject area.

Conclusion

There was an increased number of studies evaluating contrast-induced nephropathy in Italy during the last three decades. These studies covered procedures to prevent contrast-induced nephropathy or aimed to identify risk factors, biomarkers, and scores, and their related prognosis.

Assessing renal changes after remote ischemic preconditioning (RIPC) of the upper extremity using BOLD imaging at 3T

OBJECTIVE

Acute kidney injury (AKI) is an important risk factor for a number of adverse outcomes including end-stage renal disease and cardiovascular morbidity and mortality. Whilst many clinical situations that can induce AKI are known-e.g. drug toxicity, contrast agent exposure or ischemia during surgery-targeted preventive or therapeutic measures are still lacking. As to renoprotective strategies, remote ischemic preconditioning (RIPC) is one of the most promising novel approaches and has been examined by a number of clinical trials. The aim of this study was to use blood oxygenation level-dependent (BOLD) MRI as a surrogate parameter to assess the effect of RIPC in healthy volunteers.

MATERIALS AND METHODS

In this IRB-approved, prospective study, 40 healthy volunteers were stratified with 20 undergoing an RIPC procedure (i.e. RIPC group) with a transient ischemia of the right arm, and 20 undergoing a sham procedure. Before and after the procedure, both kidneys of all participants were scanned using a 12-echo mGRE sequence for functional BOLD imaging at 3T. For each volunteer, 180 ROIs were placed in the cortex and the medulla of the kidneys. Ultimately, R2* values, which have an inverse correlation with the oxygenation level of tissue, were averaged for the RIPC and control groups.

RESULTS

Following intervention, mean R2* values significantly decreased in the RIPC group in both the cortex (18.6 ± 2.3 vs. 17.5 ± 1.7 Hz; p = 0.0047) and medulla (34 ± 5.2 vs. 32.2 ± 4.2 Hz; p = 0.0001). However, no significant differences were observed in the control group.

CONCLUSION

RIPC can be non-invasively assessed in healthy volunteers using BOLD MRI at 3T, demonstrating a higher oxygen content in kidney tissue. This study presents a first-in-man trial establishing a quantifiable readout of RIPC and its effects on kidney physiology. BOLD measurements may advance clinical trials in further evaluating RIPC for future clinical care.