Epidemiology and prognostic implications of contrast-induced nephropathy

Machine learning algorithms using the inflammatory prognostic index for contrast-induced nephropathy in NSTEMI patients

Aim: Inflammatory prognostic index (IPI), has been shown to be related with poor outcomes in cancer patients. We aimed to investigate the predictive role of IPI for contrast-induced nephropathy (CIN) development in non-ST segment elevation myocardial infarction patients using a nomogram and performing machine learning (ML) algorithms.Materials & methods: A total of 178 patients with CIN (+) and 1511 with CIN (-) were included.Results: CIN (+) patients had higher IPI levels, and IPI was independently associated with CIN. A risk prediction nomogram including IPI had a higher predictive ability and good calibration. Naive Bayes and k-nearest neighbors were the best ML algorithms for the prediction of CIN patients.Conclusion: IPI might be used as an easily obtainable marker for CIN prediction using ML algorithms.

The High-Sensitivity C-Reactive Protein to High-Density Lipoprotein Cholesterol Ratio and the Risk of Contrast-Induced Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention

Background

The high-sensitivity C-reactive protein to high-density lipoprotein cholesterol ratio (CHR) is a novel biomarker associated with coronary artery disease (CAD) risk. This study aimed to analyze the relationship between CHR and contrast-induced acute kidney injury (CI-AKI).

Methods

This retrospective cross-sectional research included 10,917 individuals who underwent PCI. CI-AKI was diagnosed using the Kidney Disease: Improving Global Outcomes (KIDIGO) standard. Univariate and multivariable logistic regression analyses were conducted to examine the association between CHR and CI-AKI, followed by a receiver operating characteristic (ROC) curve of participants to assess the clinical diagnostic performance of CHR on CI-AKI.

Results

A total of 1037 patients (9.50%) developed CI-AKI after PCI. The age of individuals averaged 64.1 ± 11.1 years old, with 2511 females (23.0%). A multivariate logistic regression study revealed that higher CHR levels were linked to higher CI-AKI incidence rates ([Q4 vs. Q1]: odds ratio (OR) = 1.89, 95% confidence interval (CI) [1.42 to 2.54], p < 0.001). A restricted cubic spline analysis revealed a linear association between CHR and CI-AKI. ROC analysis indicated that CHR was an excellent predictor of CI-AKI (area under ROC curve = 0.606, 95% CI [0.588 to 0.624]).

Conclusions

A high CHR level is strongly associated with increased CI-AKI incidence, suggesting that CHR may be an independent risk factor for CI-AKI.

Clinical Trial registration

NCT05050877. https://clinicaltrials.gov/study/NCT05050877?tab=results.

Differential Incidence of Contrast-Associated Acute Kidney Injury: Comparing Intravenous and Intraarterial Contrast Administration

PURPOSE OF THE REVIEW

Contrast-associated acute kidney injury (CA-AKI) remains a significant concern in diagnostic and invasive procedures, particularly in the context of iodinated contrast material administration. The traditional definition of CA-AKI, based on serum creatinine elevation following contrast exposure, may not accurately capture its multifactorial nature.

RECENT FINDINGS

Studies have provided new insights into the differential incidence of CA-AKI between intravenous and intraarterial contrast administration, emphasizing the importance of tailored preventative strategies for high-risk procedures. This higher risk may arise from two proposed mechanisms: one implicating free radical formation leading to cytotoxicity and apoptosis in renal cells and another suggesting that contrast media alter renal hemodynamics, particularly in the outer medulla, by constricting the vasa recta and reducing medullary flow. Advances in technology and patient care, including contemporary use of low-osmolar contrast agents and hydration protocols, mitigate CA-AKI risk. Diagnostic and invasive procedures should not be avoided solely due to concerns about renal dysfunction if the patient is likely to benefit clinically.

Evaluation of Emerging Predictors for Contrast-Induced Nephropathy in High-Risk Patients Undergoing Percutaneous Coronary Intervention

OBJECTIVE

The objective of this study is to investigate the occurrence and factors that influence the development of contrast-induced nephropathy (CIN) in high-risk patients undergoing angioplasty and to evaluate the effectiveness of the Mehran risk score in predicting CIN among this patient population.

MATERIALS AND METHOD

This prospective, observational study enrolled patients undergoing elective coronary angiography or a percutaneous coronary intervention (PCI) procedure. The patients were stratified into four risk groups based on the Mehran risk score, a validated tool for predicting the risk of CIN. Univariate and multivariate analyses were conducted to evaluate the risk factors associated with the development of CIN. A p-value of <0.05 was considered to indicate statistical significance.

RESULTS

During the study period, a total of 55 high-risk patients underwent PCI. The incidence of CIN was 25.5% (n=14). Univariate and multivariate analyses revealed that age >75 years and estimated glomerular filtration rate (eGFR) <60 (p<0.05) were independently associated with a significantly increased risk of developing CIN. A considerable proportion of patients (23; 41.8%) in the study were categorized as having an intermediate risk for CIN based on the Mehran risk score.

CONCLUSION

This study observed a high incidence of CIN and encourages the use of predictive tools like the Mehran risk score to assess the risk of CIN occurrence, with age over 70 years and eGFR less than 60 emerging as significant.

Impact of white blood cell count on the development of contrast-induced acute kidney injury in patients receiving percutaneous coronary intervention

This study aimed to investigate the efficacy of a pre-procedural white blood cell (WBC) count in the prediction of contrast-induced acute kidney injury (CI-AKI) risk in coronary artery disease patients receiving a percutaneous coronary intervention (PCI). This observational study comprises a sample of 1,013 coronary artery disease patients (including ACS and stable angina) receiving PCI, gathered from September 2015 to July 2017. CI-AKI incidence in the study population was 4.8% (49/1013). Patients in the CI-AKI group had significantly higher WBC counts than those in the non-CI-AKI group (10.41 ± 5.37 vs. 8.09 ± 3.10, p = 0.004). Logistic analysis showed that WBC count (odds ratio [OR]: 1.12, 95% CI [1.03-1.21], P = 0.006) was a significant and independent predictor of CI-AKI risk in patients receiving PCI, Receiver-operating characteristic (ROC) curve analysis found that pre-procedural WBC count ≥11.03*109/L was the optimal cut-off value in the prediction of CI-AKI risk with a sensitivity of 41.0% and a specificity of 86.5%. Patients with CI-AKI had a significantly worse 1-year survival rate than patients without CI-AKI (91.8% vs. 97.6%, P = 0.012). In summary, increased pre-procedural WBC count is associated with an increased risk of developing CI-AKI in patients receiving PCI.

Adverse reactions after intravascular iodinated contrast media administration and their management

Endovascular interventions and diagnostic examinations using iodinated contrast media (ICM) are standard of care in current vascular medicine. Although ICM use is generally considered safe, it may be associated with adverse reactions, vary from minor disturbances to rare, but severe life-threatening complications. This position paper of European Society of Vascular Medicine integrates current knowledge and summarizes the key information related to the use of intravascular ICM, serving as recommendation on prevention and management of acute, late, and very late adverse reactions. It should help the health professionals in all fields of vascular medicine to make decisions in daily practice for safe use of contrast media.

Burden and Risk Factors of Contrast-Associated Acute Kidney Injury in Hospitalized Zambian Children: A Prospective Cohort Study at the University Teaching Hospitals

Background

Contrast-associated acute kidney injury (CAAKI) is defined as acute kidney injury (AKI) occurring within 72 hours of administration of contrast media (CM) and is linked to adverse outcomes including longer hospital stay, increased hospital mortality, and a higher risk of chronic kidney disease in later life. Risk factors for the development of CAAKI in the Zambian pediatric population have not been well studied.

Objectives

The objective of this study was to assess the burden of CAAKI, ascertain its risk factors, and describe short-term outcomes in hospitalized children at the University Teaching Hospitals (UTH) undergoing contrast-enhanced radiological investigations.

Methods

This was a prospective observational study of in-patients undergoing contrast-enhanced radiological procedures, between September 2020 and September 2021. The participants were recruited from the Children's Hospital, the Cancer Diseases Hospital, and the Pediatric Surgical Ward at the University Teaching Hospital in Lusaka, Zambia. The primary outcome variable was occurrence of AKI at 48 hours post CM administration. We used 2 criteria to define CAAKI in our study-the European Society of Urogenital Radiology (ESUR) and the Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria. Multivariable logistic regression models were formulated to assess for risk factors of CAAKI.

Results

Of the 201 enrolled participants, 123 (61.2%) were male and the median age of the participants was 5 years (interquartile range [IQR] = 3-10). The mean hemoglobin was 103 g/L (standard deviation [SD] = 26), median creatinine was 30.9 µmol/l (IQR = 22.6-43), and the glomerular filtration rate (GFR) was 102.5 mL/min/1.73 m2 (IQR = 76.2-129.4). Forty-six (22.9%) developed CAAKI using the ESUR compared with 4.5% (9/201) using the KDIGO criteria. Independent risk factors of CAAKI were receiving a higher dose of CM (adjusted odds ratio [aOR] = 2.54; 95% confidence interval [CI] = [1.12-5.74]), prematurity (aOR = 4.6; 95% CI = [1.05-16.7]), and a higher eGFR (aOR= 1.01; 95% CI = [1.01-1.02]). Females had higher odds of CAAKI (aOR = 2.48; 95% CI = [1.18-5.18]) when compared with males. One CAAKI participant (2.2%) died; none of the participants who developed CAAKI and survived required dialysis and most of them (90%) were discharged before day 7. Day 7 eGFR results had returned to or near baseline values for those whose creatinine results were available.

Conclusions

Using the ESUR criteria, a significant proportion (22.9%) of children undergoing contrast-enhanced computed tomography (CT) scans at the UTH developed CAAKI. In contrast, using the KDIGO criteria only 4.5% had CAAKI. Being born as a preterm baby, being female, having a higher eGFR at baseline, and receiving a higher dose of CM were found to be independent risk factors for CAAKI development in Zambian children. Most of the cases of CAAKI in children were transient and of little clinical significance as only a minority of patients developing CAAKI required kidney replacement therapy and all resolved by day 7 post administration of CM.

Different effects of medications for hypertension on renal function between patients with and without diabetes mellitus undergoing percutaneous coronary intervention: a retrospective single-center cohort study

BACKGROUND

Diabetes mellitus (DM) and hypertension are well-known atherosclerosis risk factors. Furthermore, renal dysfunction is a crucial risk factor for patients with coronary artery disease (CAD), and managing renal function in these patients is complicated because of comorbid conditions and potential side effects during treatment. Therefore, this study aimed to investigate the effect of medications for hypertension on renal function after percutaneous coronary intervention (PCI) between patients with and without DM with statins.

METHODS

In 297 consecutive patients undergoing PCI for stable angina pectoris, cystatin C (CysC) was evaluated at baseline and 9 months after PCI, and the percent change in CysC (%CysC) was calculated. The association of worsening renal function (WRF: %CysC ≥ 0) and baseline characteristics, including medications, was assessed.

RESULTS

Among 297 hypertensive patients with statins, 196 and 101 were with and without DM, respectively. Angiotensin-converting enzyme inhibitor (ACEI), angiotensin II receptor blocker, and β-blocker were prescribed in 56 (29%), 82 (42%), and 91 (46%) patients in the DM group, and 20 (20%), 52 (51%), and 52 (51%) in the non-DM group, respectively. The patients with WRF after PCI were 100 (51%) and 59 (58%) in the DM and non-DM groups (p = 0.261). Additionally, the %CysC had no significant differences between groups [median: 0%, interquartile range (IQR): -7.9% to 8.5% vs. median: 1.1%, IQR: -6.6% to 9.6%, p = 0.521]. Multivariate logistic analysis for WRF using relevant factors from univariate analysis showed that only β-blocker [odds ratio (OR): 2.76, 95% confidence interval (CI): 1.03-7.90, p = 0.048] was independently associated with WRF in the DM group whereas ACEI (OR: 0.07, 95% CI: 0.01-0.47, p = 0.012) was negatively correlated with WRF in the non-DM group.

CONCLUSION

The β-blocker was the independent risk factor for WRF in patients with DM in the late phase after PCI for stable angina pectoris, while the use of ACEI had a renoprotective effect in patients without DM.

Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions

In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.

Contrast-Associated Acute Kidney Injury: Definitions, Epidemiology, Pathophysiology, and Implications

Acute kidney injury (AKI) is a common occurrence after contrast media administration. Hemodynamic changes, direct tubular injury, and reactive oxygen species are the proposed mechanisms involved in AKI. However, in most scenarios, it is not possible to establish causality despite extensive clinical evaluation, therefore, contrast-associated AKI (CA-AKI) has become a widely accepted term to define AKI postcontrast. CA-AKI is associated with worse clinical outcomes including cardiovascular events and mortality; however, discussions are ongoing whether CA-AKI is a marker of an increased risk of adverse outcomes or a mediator of such outcomes.

Clinical Outcomes of Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Interventions with a Novel Dynamic Coronary Roadmap System

Dynamic coronary roadmap (DCR) is a novel technology that creates a real-time overlay of the coronary arteries in percutaneous coronary intervention (PCI) and has the potential to reduce the contrast volume. However, the efficacy of DCR in terms of clinical outcomes in patients with chronic kidney disease (CKD) remains to be fully elucidated.This single center retrospective study enrolled 275 patients with CKD who underwent PCI, and divided them into a DCR group (n = 124) and Non-DCR group (n = 151). Propensity score matching was performed to minimize the differences in baseline characteristics in 113 patient pairs. The primary endpoint was a composite outcome of all-cause death, hospitalization for heart failure, nonfatal myocardial infarction, or the introductory rate of dialysis within 2 years. The secondary endpoints were contrast medium volume, the incidence of contrast-induced acute kidney injury (CI-AKI), and the introductory rate of dialysis within 2 years.Although there was no significant difference in the success rate (DCR group: 99.1% versus Non-DCR group: 98.2%; P = 0.561), contrast volume (92.20 mL versus 115.97 mL; P = 0.002) was significantly lower in the DCR group. CI-AKI incidence was 0.9% versus 6.2% in the DCR and Non-DCR groups, respectively (P = 0.031). The composite outcome defined as primary endpoint occurred in 10 patients in the DCR group and 20 patients in the Non-DCR group (8.8% versus 17.7%; P = 0.049).From the perspective of acute and long-term clinical outcomes, DCR use may be effective for patients with CKD.

Key Considerations regarding the Renal Risks of Iodinated Contrast Media: The Nephrologist's Role

BACKGROUND

The administration of iodinated contrast medium during diagnostic and therapeutic procedures has always been associated with the fear of causing acute kidney injury (AKI) or an exacerbation of chronic kidney disease. This has led, on the one hand, to the deterrence, when possible, of the use of contrast medium (preferring other imaging methods with the risk of loss of diagnostic power), and on the other hand, to the trialling of multiple prophylaxis protocols in an attempt to reduce the risk of kidney injury.

SUMMARY

A literature review on contrast-induced (CI)-AKI risk mitigation strategies was performed, focussing on the recognition of individual risk factors and on the most recent evidence regarding prophylaxis.

KEY MESSAGES

Nephrologists can contribute significantly in the CI-AKI context, from the early stages of the decision-making process to stratifying patients by risk, individualising prophylaxis measures based on the risk profile, and ensuring appropriate evaluation of kidney function and damage post-procedure to improve care.

Erythrocyte parameters, anemia conditions, and sex differences are associated with the incidence of contrast-associated acute kidney injury after coronary angiography

Objective

Contrast-associated acute kidney injury (CA-AKI) is a critical complication when applying contrast medium, and the risk factors of CA-AKI have not been fully clarified. This study aimed to explore the relationships of CA-AKI with erythrocyte parameters, anemia conditions, and sex differences in patients after coronary angiography (CAG).

Methods

In this retrospective study, 4,269 patients who underwent CAG were enrolled. CA-AKI was defined as an increase in plasma creatinine of at least 0.5 mg/dl (44 μmol/L) or 25% within 72 h after exposure to the contrast medium. Three erythrocyte parameters, including hemoglobin, hematocrit, and red blood cell (RBC) count, were collected on admission. Logistic regression analyses were used to examine the associations of sex differences and erythrocyte parameters with CA-AKI in the overall population, restricted cubic splines to visualize these associations flexibly. Moreover, stratified and sensitivity analyses were conducted to assess the robustness of the findings.

Results

Overall, the mean (± standard deviations) age of patients was 67.05 ± 10.77 years, and 759 subjects (17.8%) developed CA-AKI. The results showed L-shaped relationships between erythrocyte parameters and CA-AKI incidence in each model (all P < 0.001). The incidence of CA-AKI was positively associated with the severity of anemia, while it showed no significant differences among the types of anemia. Moreover, female patients undergoing CAG had a higher risk of CA-AKI than male patients. Mediation analysis verified that erythrocyte parameters exerted an indirect effect on the sex differences of CA-AKI incidences.

Conclusion

In conclusion, females, perioperative anemia conditions, and lower erythrocyte parameters (hemoglobin, hematocrit, and RBC count) were verified as risk factors of CA-AKI in patients undergoing CAG. Furthermore, lower erythrocyte parameters among females exerted indirect effects on the sex differences in CA-AKI incidence.

Different hydration methods for the prevention of contrast-induced nephropathy in patients with elective percutaneous coronary intervention: a retrospective study

BACKGROUND

Hydration is currently the main measure to prevent contrast-induced nephropathy (CIN). We aimed to compare the preventive effect of preprocedure and postprocedure hydration on CIN in patients with coronary heart disease undergoing elective percutaneous coronary intervention (PCI).

METHODS

A retrospective study included 198 cases of postprocedure hydration and 396 cases of preprocedure hydration using propensity score matching. The incidence of CIN 48 h after PCI and adverse events within 30 days after contrast media exposure were compared between the two groups. Logistic regression analysis was used to analyse the risk factors for CIN.

RESULTS

The incidence of CIN in the postprocedure hydration group was 3.54%, while that in the preprocedure hydration group was 4.8%. There was no significant difference between the two groups (p = 0.478). Multivariate logistic regression analysis showed that diabetes mellitus, baseline BNP and cystatin C levels, and contrast agent dosage were independent risk factors for CIN. There was no significant difference in the incidence of major adverse events between the two groups (3.03% vs. 2.02%, p = 0.830).

CONCLUSIONS

Postprocedure hydration is equally effective compared to preoperative hydration in the prevention of CIN in patients with coronary heart disease undergoing elective PCI.

Neutrophil gelatinase-associated lipocalin monitoring reveals persistent subclinical kidney injury following intraarterial administration of iodinated contrast agents

Clinically overt contrast-induced nephropathy (CIN) is one of the most feared complications in patients exposed to iodinated contrast media and has been extensively studied over the years. Meanwhile, the incidence and evolution of subclinical contrast-induced kidney injury remain elusive. With the continuous increase in the number of patients that are repeatedly exposed to contrast media, elucidating these issues is of critical importance. Accordingly, we aimed to evaluate the incidence and the evolution of clinical and subclinical kidney injury in patients exposed to contrast media. A total of 178 patients who underwent elective percutaneous angioplasty procedures were evaluated prospectively. Serum creatinine and neutrophil gelatinase-associated lipocalin (NGAL) levels were evaluated pre-procedurally, 48 h and 1 month after administration of contrast media. The evolution of creatinine and NGAL levels was analyzed at the three time points, and the potential predictors of contrast-induced clinical and subclinical renal injury were evaluated. Clinically overt CIN occurred in 10 (5.6%) patients. Baseline serum creatinine and the volume of contrast media were the only independent predictors of CIN and in all 10 patients creatinine levels returned to baseline by 1 month (p = 0.32). Subclinical contrast-induced kidney injury was much more common, affecting 32 (17.9%) patients, was only predicted by the baseline serum creatinine, and persisted in 53.1% of patients after 1 month. This study showed that whereas clinically overt CIN is rather rare and regressive, subclinical contrast-induced kidney injury is considerably more frequent, affecting almost 18% of patients that receive intraarterial contrast media. More importantly, subclinical kidney injury persisted after 1 month in more than 50% of the initially affected patients, who may thus be at increased risk for further renal impairment, particularly if exposed to nephrotoxic agents or repeated administration of contrast media.

When Prevention is Truly Better than Cure: Contrast-Associated Acute Kidney Injury in Percutaneous Coronary Intervention

Contrast-associated acute kidney injury (CA-AKI) is a fairly frequent complication of cardiovascular angiography and percutaneous coronary intervention (PCI). The risk is significantly higher in patients with advanced chronic kidney disease (CKD). Prevention is the only option for avoiding the significant morbidity and mortality associated with CA-AKI. This review provides a concise and clinically directed appraisal of the latest pre-procedural and peri-procedural strategies to minimize the risk of CA-AKI in all patients undergoing PCI. By broadly implementing these evidence-based care bundles, we can dramatically improve outcomes in this vulnerable patient population.

Incidence of Contrast-Associated Acute Kidney Injury in Renal-Competent COVID-19 Patients Undergoing Computed Chest Angiography

PURPOSE

COVID-19 infection poses a significant risk of both renal injury and pulmonary embolism, producing a clinical challenge, as the criterion standard examination for pulmonary embolism, computed tomography angiography (CTA), requires the use of nephrotoxic iodinated contrast agents.Our investigation evaluated whether symptomatic COVID-19-positive patients without laboratory evidence of renal impairment are at increased risk for developing contrast-associated acute kidney injury (CA-AKI).

METHOD

All COVID-19-positive patients undergoing noncontrast chest computed tomography and CTA at an apex tertiary medical center between March 1 and December 10, 2020, were retrospectively evaluated. A total of 258 renal-competent (estimated glomerular filtration rate >30) patients with baseline and 48- to 72-hour postexamination creatinine measurements were identified and analyzed for incidence of acute kidney injury (AKI) meeting the criteria for CA-AKI.

RESULTS

Twenty-five of 191 patients undergoing CTA (13.1%) and 9 of the 67 undergoing noncontrast computed tomography (13.4%) experienced creatinine increases meeting the criteria for CA-AKI. Univariate and multivariate analyses accounting for known AKI risk factors revealed no correlation between iodinated contrast administration and the incidence AKI meeting the criteria for CA-AKI (univariable odds ratio, 0.97 [95% confidence interval, 0.43-2.20]; multivariable odds ratio, 0.97 [95% confidence interval, 0.40-2.36]).

CONCLUSIONS

Renal-competent COVID-19 patients undergoing chest CTA may not have an increased risk of AKI. Additional studies are needed to confirm this preliminary finding.

Relationship between contrast-induced nephropathy and long-term mortality after percutaneous coronary intervention in patients with chronic coronary total occlusion

OBJECTIVE:

Intervention in chronic total occlusion lesions involves long procedure time, a serious contrast load, and complex procedures. In this study, we aimed to investigate mortality rate of patients who had procedural coronary angiography done for chronic total occlusion lesions in coronary angiography series and who developed contrast-induced nephropathy.

METHODS:

A total of 218 patients with chronic total occlusion lesion in at least one coronary artery, from three different medical centers, who underwent procedural coronary angiography were recruited for the study. Patient population was divided into two groups: those who developed contrast-induced nephropathy and those who did not. Mortality due to all causes was investigated between both groups throughout a 100-month follow-up.

RESULTS:

Mean age of patients with incidence of contrast-induced nephropathy was 66.7±11.8, and 23.8% of them were comprised by female. We found a significantly higher mortality in long-term follow-up in the patient group with contrast-induced nephropathy (42.9 vs. 57.1%, p=<0.001). According to Kaplan-Meier analysis performed additionally, survival during follow-up was significantly shorter in this group and, in logistic regression analysis, it was an independent predictor of mortality (OR 11.78; 95%CI 3.38–40.9).

CONCLUSION:

We identified that the development of contrast-induced nephropathy is associated with long-term mortality. It might be possible to reduce adverse events with prophylactic approaches before the procedure and close follow-up of such patients after the procedure.

Safety considerations related to intravenous contrast agents in pediatric imaging

Intravenous contrast media are used in MRI, CT and US studies for anatomical evaluation and lesion characterization. Safety is always of paramount importance when administering any contrast media to children, and it is important for radiologists and ordering providers to be knowledgeable of the safety profiles and potential adverse events that can occur. This manuscript reviews the frequency and types of adverse events associated with intravenous contrast agents reported in the pediatric literature. Overall, intravenous contrast agents are very safe to use in children. However, familiarity with how to treat and prevent these uncommon events is crucial in preventing poor outcomes. In addition, an understanding of gadolinium deposition in tissues can help facilitate conversations with concerned physicians and parents. This review provides a concise yet comprehensive reference for radiologists and ordering providers on intravenous contrast safety considerations in the pediatric patient.

Feasibility of an ultra-low dose contrast media protocol for coronary CT angiography

AIM

To evaluate the feasibility of an ultra-low volume contrast media (CM) protocol for coronary computed tomography angiography (CTA).

MATERIALS AND METHODS

In total, 214 patients receiving coronary CTA were enrolled prospectively and divided into group A (n=107) receiving a conventional dose of CM and group B (n=107) receiving an ultra-low dose. CT values of the right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCX) were measured and radiation doses recorded. The image quality was compared between the groups. Changes in renal function indices and proteinuria before, 24, and 72 hours after coronary CTA among those with chronic kidney disease (CKD) were also assessed.

RESULTS

There were significant differences in CT values and radiation doses between groups A and B. In group A, the average RCA, LAD, and LCX CT values were 412.5 ± 79.2, 423.5 ± 73.7, and 422.0 ± 88.1 HU, respectively. In group B, the average RCA, LAD, and LCX CT values were 275.2 ± 16.2, 277.8 ± 16.4, and 278.9 ± 16.5 HU, respectively. The radiation dose in the ultra-low protocol recipients (118.70 ± 18.52 mGy·cm) was significantly lower than that used in conventional coronary CTA (131.75 ± 20.96 mGy·cm). The image quality of group B was comparable to that of group A, satisfying the diagnostic requirement. In patients with mild CKD, there were no significant differences in renal functions after coronary CTA.

CONCLUSION

An ultra-low CM protocol was established for coronary CTA, providing comparable image quality and diagnostic yields but significantly lower radiation dose compared with a conventional protocol. This new protocol might be applicable to patients with mild CKD.

Impact of impaired renal function on outcomes of chronic total occlusion undergoing revascularization: a systemic review and meta-analysis

PURPOSE

Patients with chronic kidney disease (CKD) have an associated burden of coronary artery disease, including chronic total occlusions (CTO). It is unclear how the presence of CKD affects the outcomes of CTO revascularization. Previous reviews have not taken into account all relevant published studies that examined the association of CKD with outcomes of CTO revascularization.

METHODS

A systematic search was conducted using PubMed, Scopus, and Google Scholar databases for studies investigating patients with or without CKD who also had coronary chronic total occlusion undergoing revascularization procedures Statistical analysis was performed using STATA software. Effect sizes were reported as pooled relative risk (RR).

RESULTS

A total of 13 studies were included. CKD patients showed elevated risk of in-hospital mortality (RR 4.25, 95% CI 2.64, 6.82) and mortality at latest follow-up (RR 3.24, 95% CI 2.56, 4.11), elevated risk of major cardio or cerebrovascular events (RR 1.65, 95% CI 1.38, 1.98), major bleeding (RR 2.85, 95% CI 1.96, 4.13), and contrast-induced acute kidney injury (RR 3.06, 95% CI 1.70, 5.52). CKD patients also showed lower chances of technical success (RR 0.95, 95% CI 0.91, 1.00).

CONCLUSIONS

The presence of CKD increases the risk of mortality, complications and adversely affects the success of CTO revascularization. Patients with CKD undergoing revascularization should have their kidney function comprehensively evaluated and these patients should be carefully monitored.

Evaluating the Effectiveness of Pretreatment With Intravenous Fluid in Reducing the Risk of Developing Contrast-Induced Nephropathy: A Systematic Review and Meta-Analysis

Contrast media administration to patients during cardiac events increases the risk of developing contrast-induced nephropathy (CIN). CIN is among some complications usually associated with the percutaneous coronary intervention and may result in acute renal failure. Several risk factors are associated with CIN. These risk factors include; age (elderly patients), pre-existing renal impairment, diabetes mellitus, and the use of high osmolar contrast media. Studies have shown that several measures such as using low osmolar contrast media, N-acetylcysteine, intravenous sodium bicarbonate, and hydration through oral or intravenous fluid administration play a significant role in CIN incidence reduction. Hydration using intravenous fluid, especially saline solution, has been critical in preventing CIN. Prehydration using the intravenous fluid before contrast media administration is vital.

A systematic literature search with meta-analysis for relevant and original articles was carried out from 2000 to 2022 on databases such as PubMed, Cochrane Library, Google Scholar, ScienceDirect, Web of Science, and Embase. The search on the databases was based on various keywords related to intravenous fluid and CIN. The studies that met the inclusion criteria were critically analyzed, and data such as study design, interventions, participants, and outcomes of the research were retrieved.

Out of the 784 results yielded during the initial search, ten articles met the eligibility criteria and were included in the study. The data analysis obtained from the included studies showed that pretreatment using intravenous fluid has conflicting results. Some studies showed that hydrating patients using intravenous fluid before contrast media administration significantly reduces the risk of CIN. In contrast, others claimed that intravenous fluid has minimal impact on preventing CIN.

Despite the different investigations conducted on CIN, it remains insufficiently understood. From the analysis, most of the studies support that intravenous fluid administration decreases the occurrence of CIN in patients that receive contrast media. The analysis also has established that oral hydration is similar to intravenous fluid administration in reducing CIN incidence.

Contrast-Associated Acute Kidney Injury

Contrast-associated acute kidney injury (CA-AKI) is an impairment of renal function, which occurs within days of intravascular administration of iodinated contrast media. Taking into account that minimally invasive cardiac interventions are becoming increasingly popular, compared to traditional surgery, given their impact on prognosis and costs, CA-AKI remains a subject of increasing interest for patients and physicians. This review summarizes the epidemiology and risk stratification, diagnostic criteria, pathophysiology and clinical implications of CA-AKI, providing evidence for the most studied preventive strategies.

Admission electrolyte and osmotic pressure levels are associated with the incidence of contrast-associated acute kidney injury

This retrospective study aimed to explore the relationships between electrolytes and osmotic pressure homeostasis with contrast-associated acute kidney injury (CA-AKI) risk in patients with percutaneous coronary intervention or coronary angiography. We totally enrolled 4386 hospitalized patients, who were categorized into five groups based on the predetermined cutoff values of electrolytes and osmotic pressure. CA-AKI was defined as an increase in serum creatine by 0.5 mg/dL (44.2 mol/L) or a 25% increase of the highest level post-operation compared to baseline. Multivariable logistic analysis was used to examine the association of CA-AKI incidence with electrolytes and osmotic pressure levels. Piecewise linear regression models and restricted cubic spline analysis were further utilized to determine the nonlinear relationship. The results showed U-shaped relationships between sodium, chloride, magnesium, and osmotic pressure levels and CA-AKI incidence. The lowest incidence was observed in the categories of 139–141.9 mmol/L, 107.0–109.9 mmol/L, 0.91–1.07 mmol/L, and 290.0–299.9 mOsm/kg, respectively. J-shaped associations were observed for potassium and phosphate levels and CA-AKI incidence, with the lowest incidence in the categories of 3.50–4.09 mmol/L and 0.96–1.28 mmol/L, respectively. A negative correlation was observed between calcium level and CA-AKI incidence, with the lowest CA-AKI risk in the category of ≥ 2.58 mmol/L. In conclusion, abnormally higher or lower sodium, chloride, magnesium, phosphate, and osmotic pressure levels on admission were associated with increased risks of CA-AKI. While for potassium and calcium, the status of hyperkalemia and hypocalcemia on admission showed more susceptibility for CA-AKI.

In-hospital outcomes of patients with chronic kidney disease undergoing percutaneous coronary intervention for chronic total occlusion: a systematic review and meta-analysis

BACKGROUND

The relative safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in patients with chronic kidney disease (CKD) have not been well defined. We performed a systematic review and meta-analysis of observational studies to assess in-hospital outcomes in this population.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to April 2020 for all clinical trials and observational studies. Five observational studies with a total of 6769 patients met our inclusion criteria. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR <60 ml/min/1.73m2 in CKD group and ≥ 60 ml/min/1.73m2 in non-CKD group). The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury, coronary injury (perforation, dissection or tamponade), stroke and procedural success. Mantel-Haenszel random-effects model was used to calculate the odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

In-hospital mortality was significantly higher among patients with CKD undergoing PCI for CTO (OR: 5.16, 95% CI: 2.60-10.26, P < 0.00001). Acute kidney injury (OR: 2.54, 95% CI: 1.89-3.40, P < 0.00001) and major bleeding (OR: 2.58, 95% CI: 1.20-5.54, P < 0.01) were also more common in the CKD group. No significant difference was observed in the occurrence of stroke (OR: 2.36, 95% CI: 0.74-7.54, P < 0.15) or coronary injury (OR: 1.38, 95% CI: 0.98-1.93, P < 0.06) between the two groups. Non-CKD patients had a higher likelihood of procedural success compared to CKD patients (OR: 0.66, 95% CI: 0.57-0.77, P < 0.00001).

CONCLUSION

Patients with CKD undergoing PCI for CTO have a significantly higher risk of in-hospital mortality, acute kidney injury and major bleeding when compared to non-CKD patients. They also have a lower procedural success rate.

Predictive value of aspartate aminotransferase-to-alanine aminotransferase ratio for contrast-associated acute kidney injury in patients undergoing elective percutaneous coronary intervention

BACKGROUND

Pre-procedure liver insufficiency has been demonstrated as a poor prognostic factor after percutaneous coronary intervention (PCI). Recent research discovered that the aspartate aminotransferase-to-alanine aminotransferase ratio (De-Ritis ratio) reflects the severity of liver insufficiency and was associated with adverse outcomes. We aim to evaluate the predictive value of the De-Ritis ratio for contrast-associated acute kidney injury (CA-AKI) and long-term mortality in patients undergoing elective PCI.

METHODS

We retrospectively enrolled 5780 consenting patients undergoing elective PCI between January 2012 and December 2018. CA-AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥50% within 48 h after the administration of contrast media.

RESULTS

The incidence of CA-AKI was 6.3% (n = 363). The De-Ritis ratio >1.30 was identified as the best cut-off value for CA-AKI prediction. The De-Ritis ratio showed an area under the curve (AUC) of 0.636 [95% confidence interval (CI): 0.605-0.667] in predicting CA-AKI, which was significantly greater than alanine aminotransferase (p<0.001) and aspartate aminotransferase (p = 0.012) alone. Furthermore, compared to currently recognized liver function assessment tools, the predictive value of the De-Ritis ratio on CA-AKI was similar to the MELD score (AUC: 0.636 vs 0.626, p = 0.631) and higher than the MELD-XI score (AUC: 0.636 vs 0.561, p<0.001). Multivariate logistic analysis showed that the De-Ritis ratio >1.30 was independently associated with CA-AKI (odds ratio=1.551, 95% CI: 1.185-2.030, p = 0.001). The addition of the De-Ritis ratio to the fully adjusted logistic regression model has significant incremental effects on the risk prediction for CA-AKI with a continuous net reclassification improvement of 0.395 (p<0.001) and an integrated discrimination improvement of 0.005 (p = 0.018). Additionally, the De-Ritis ratio >1.30 was significantly associated with long-term mortality (hazard ratio=1.285, 95% CI: 1.007-1.641, p = 0.044).

CONCLUSIONS

The De-Ritis ratio was an independent risk factor for CA-AKI and long-term mortality in patients undergoing elective PCI.

Incidence, Predictors and Outcomes of Contrast Induced Nephropathy in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background:

Contrast induced nephropathy (CIN) is considered one of the most common causes of hospital acquired renal failure and severely affects morbidity and mortality. Our objective was to investigate incidence, predictors and outcomes of CIN in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

Methods:

The study was conducted on 550 patients with STEMI subjected to PPCI. Patients were classified into two groups according to the occurrence of CIN; group I (Patients without CIN) and group II (Patients with CIN). The two groups were assessed for the clinical outcomes including mortality and major adverse cardiac events (MACE).

Results:

Incidence of CIN was 10.6%, multivariate regression analysis identified the independent predictors of CIN including; age > 60 years OR 6.083 (CI95% 3.143–11.77, P = 0.001), presence of diabetes mellitus OR 2.491 (CI95% 1.327–4.675, P = 0.005), non-steroidal anti-inflammatory drugs (NSAIDs) use OR 2.708 (CI95% 1.393–5.263, P = 0.003), the volume of contrast agent >200 ml OR 6.543 (CI95% 3.382–12.65, P = 0.001) and cardiogenic shock OR 4.514 (CI95% 1.738–11.72, P = 0.002). Mortality was higher in group II than group I (11.9% vs. 4.4% respectively, P = 0.015). The incidence of MACE were higher in group II than group I (heart failure; 18.6% vs. 7.3%, cardiac arrest; 8.5% vs. 2.8% and cardiogenic shock; 16.9% vs. 6.9% with P. value = 0.003, 0.024, 0.007 respectively).

Conclusion:

Contrast induced nephropathy was associated with increased morbidity and mortality. The independent predictors of CIN were advanced age, diabetes mellitus, NSAIDs use, the volume of contrast agent >200 ml and cardiogenic shock.

The Definition of "Acute Kidney Injury" Following Percutaneous Coronary Intervention and Cardiovascular Outcomes

Acute kidney injury (AKI) is a complication of percutaneous coronary intervention (PCI), known to increase rates of adverse medical events. We aimed to identify the optimal definition of AKI in predicting adverse cardiovascular outcomes and mortality post PCI. From a large registry of patients undergoing PCI between 2006-2018 (n = 25,690) at our medical center, consecutive patients were assessed for the presence of AKI according to four different definitions: a relative elevation of ≥25% or ≥50%; or an absolute elevation of ≥0.3 mg/dL or ≥0.5 mg/dL in serum creatinine at 48 hours post PCI. We assessed the calculated rates of AKI according to the different definitions. The discriminant capacity for 30-day and 1-year mortality and MACE (MACE: all-cause death, myocardial infarction, target-vessel revascularization and coronary artery bypass graft surgery) of each definition was calculated using ROC curves and AUCs. Data of 15,153 patients was available for the final analysis. Rates of AKI were 12.1%, 3.2%, 8.1% and 3.9% according to the four definitions, respectively. The discriminant capacity of adverse outcomes was highest among those defined as AKI according to the third definition - an absolute elevation of ≥0.3 mg/dL in serum creatinine with an AUC of 0.82 (95% CI 0.80-0.84) for 30-day mortality (P value = 0.036) and an AUC of 0.78 (CI 0.76-0.79) for 30-day MACE. In conclusion, an absolute elevation of ≥ 0.3 mg/dL in serum creatinine 48 hours post PCI predicts overall mortality and MACE most accurately.

Safe Limits of Contrast Media for Contrast-Induced Nephropathy: A Multicenter Prospective Cohort Study

Background: The safe level of contrast media volume (CV) is an important modifiable risk factor for contrast-induced nephropathy (CIN). The safe limit of CV remains unclear and is limited to single-center studies. Our objective was to determine the association between the ratio of contrast volume-to-glomerular filtration (CV/GFR) and CIN in patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI). Methods: We assessed the association between CV/GFR and the risk of CIN in 4,254 patients undergoing CAG or PCI from the year 2013 to 2016 and enrolled in the REICIN (REduction of rIsk for Contrast-Induced Nephropathy), a prospective, multicenter, observational cohort study. CV/GFR was calculated at the five primary GFR equation. Results: Sixty-nine (1.7%) patients with a median contrast volume-to-chronic kidney disease epidemiology collaboration (CV/CKD-EPI) ratio of 2.16 (1.30-3.93) have suffered from CIN. The CV/CKD-EPI demonstrated the best performance of model fit, discrimination (area under curve = 0.736), calibration, reclassification, and equation conciseness (1 variable). The CV/CKD-EPI ≥1.78 was the statistical significance associated with CIN [adjusted odds ratio, 4.64 (2.84-7.56); p < 0.001]. Furthermore, similar results were found in the subgroup analyses. Conclusions: The CV/CKD-EPI showed the best performance in patients undergoing CAG or PCI. CV/CKD-EPI ≥1.78 could be a more reliable and convenient predictor of CIN. Intraprocedural preventive measures should include a priori calculation of CV/GFR to limit contrast volume.

Contrast-induced nephropathy in a patient with type 2 diabetes and coronary artery disease: a case report

Contrast-induced nephropathy (CIN) is the impairment of kidney function defined as a serum creatinine increase of 25% or 44 µmol/L compared with baseline, usually occurring 24 to 48 hours after the use of intravenous contrast. Important risk factors for CIN include female sex, advanced age (>65 years), type 2 diabetes (T2D), kidney disease, advanced heart failure, and intravascular volume depletion. We herein present a male patient with T2D, moderately reduced renal function, no albuminuria, and a positive echocardiography stress test. He underwent percutaneous coronary intervention (PCI), and two drug-eluting stents (in the left anterior descending coronary artery) and three bare-metal stents (in the right coronary artery) were implanted. Despite adequate rehydration (0.9% intravenous NaCl with 8.4% sodium bicarbonate) before and after the procedures, he developed irreversible kidney injury after coronary angiography and PCI. This case report demonstrates the unpredictable clinical course of CIN. Patients with T2D are at high risk for the occurrence of CIN, so careful clinical assessment is recommended with global renal functional reserve evaluation.

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 acute kidney injury]

The nephrotoxicity of iodinated contrast agent/media is defined by acute renal failure occurring within 48 to 72 hours after injection of iodized contrast product, in the absence of other etiology. The risk factors for contrast agent renal injury must systematically be sought before the exam. The presence of risk factors, including the existence of a renal failure defined by a creatinine clearance (eGFR) of less than 60 mL/min/1.73 m², requires to take prevention measures including hydration. If eGFR is less than 30 mL/min/1.73 m², the advice of a nephrologist is necessary.

Incidence, Predictors, and Outcomes of Acute Kidney Injury in Patients Undergoing Transcatheter Aortic Valve Replacement: Insights From the Society of Thoracic Surgeons/American College of Cardiology National Cardiovascular Data Registry-Transcatheter Valve Therapy Registry

[Figure: see text].

High-Dose Atorvastatin Raises Threshold of Contrast-Induced Nephropathy in Diabetic Patients Undergoing Elective Coronary Intervention: A Randomized Controlled Study

Background. Contrast-induced nephropathy (CIN) is a significant complication of angiographic procedures resulting from injection of iodinated contrast media (CM). Patients with diabetes mellitus (DM) are at the highest risk of CIN. Statins have recently been proposed for protection against CIN due to their antioxidant and anti-inflammatory properties. Aim of Work. To investigate the potential benefit of acute pretreatment with high-dose atorvastatin (80 mg) in reduction of the incidence of CIN in diabetic patients indicated for elective coronary intervention. Patients and Methods. 200 diabetic patients with indication for coronary intervention were enrolled in the study. 100 patients will be randomly assigned to receive atorvastatin (80 mg) just before coronary intervention (statin group) and 100 patients received placebo (control group). CIN was defined as a rise of serum creatinine of more than 25% or ≥0.5 mg/dl (44 μmol/l) from baseline within 48 hours of the angiography. After the procedure, Thrombolysis in Myocardial Infarction (TIMI) flow of the culprit vessel was reported, as well as the volume of used contrast media and time of X-ray exposure. Results. Our study reported a CIN incidence of 12, 18, and 6% among the whole study, placebo, and statin groups, respectively, $P$ value of 0.001. Among the placebo group, CIN is likely to develop after a 13.5-minute X-ray exposure time with a specificity of 73.2% and sensitivity of 77.8%, area under the curve (AUC) of 0.879 (CI: 0.798–0.960), and $P$ value of 0.001, while in the statin group, CIN is likely to develop after 14.5-minute X-ray exposure time with a specificity of 74.5% and sensitivity of 83.3%, AUC of 0.818 (CI: 0.727–0.910), and P value of 0.009. In the placebo group, CIN is likely to develop after injection of 145 ml of contrast media with a specificity of 75.6% and sensitivity of 77.8%, AUC of 0.855 (CI: 0.757–0.952), and $P$ value of 0.001, while in the statin group, CIN is likely to develop after injection of 165 ml of contrast media with a specificity of 84% and sensitivity of 83.3%, AUC of 0.878 (CI: 0.811–0.944), and $P$ value of 0.002. Conclusions. Acute pretreatment with high-dose atorvastatin can effectively protect against CIN and was associated with a marked decrease in the prevalence of CIN in diabetic patients undergoing coronary interventions. Moreover, pretreatment with high-dose atorvastatin raises the threshold of X-ray exposure time and the amount of contrast media beyond which CIN is likely to develop. The trial is registered with NCT04375787.

Impact of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers on Renal Function in Chronic Kidney Disease Patients Undergoing Coronary Angiography

Background: Cardiac catheterizations and coronary angiography are minimally invasive methods for studying the heart and the coronary arteries, using iodinated radiocontrast agents which can cause acute kidney injury (AKI). Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) are widely used due to their well-established benefit in coronary artery disease and renal protection in diabetes mellitus. Renin-angiotensin-aldosterone system inhibitors can induce AKI in some patients.

Method: This study analyzed the effect of radiocontrast media used for coronary angiography on renal function in patients with chronic kidney disease (CKD) stages 2-5 who also took ACE inhibitors/ARB medications. Information was collected from the electronic medical records of 116 cases to determine changes in serum creatinine following angiography. 

Result: The average age of patients was 65.2 ± 12.3 years. There were 89 men (76.7%) and 27 women (23.3%). Six patients had documented ACE inhibitor discontinuation, and one patient had documented ARB discontinuation prior to their procedures. Based on the criteria of an increase in serum creatinine (SCr) by ≥0.3 mg/dl within 48 hours, 19 cases (16.4%) had AKI. Based on the criteria of increasing in SCr to ≥ 1.5 times baseline, AKI developed in 2 cases (1.7%) on day 1, 4 cases (3.5%) on day 2, and 7 cases (6.0%) on day 3 after coronary angiography.

Conclusion: This study suggests that the continuation of ACE inhibitors/ARB does not appear to have any important effect or association with changes in renal function, within one-month post angiography in patients with CKD stages 2-5.

Could sST2 Predict Contrast-Induced Nephropathy in ST-Segment Elevation Myocardial Infarction?

Background and Aim

One of the most worrying complications of primary percutaneous coronary interventions is contrast-induced nephropathy (CIN) that is associated with increased mortality and morbidity in myocardial infarction. In this study, we questioned whether soluble suppression of tumorigenesis-2 (sST2), which has thought to play a role in inflammatory processes, cardiac remodeling, and fibrosis could give an idea about the development of CIN in ST-elevation myocardial infarction (STEMI) patients.

Patients and Methods

This study is a cross-sectional observational study and includes 357 consecutive STEMI patients. Demographic features, medical history, laboratory parameters, and procedural characteristics were compared according to CIN's development. The multivariate logistic regression analysis was selected to detect independent risk factors of CIN.

Results

In the study, 81 patients (22.7%) who developed CIN were identified. The concentration of sST2 in CIN (+) group was higher than that of CIN (-) group (40.6±21.0 ng/mL vs 31.5±13.0 ng/L, p<0.001). Independent predictors of CIN development were diabetes mellitus (OR, 2.059; 95% CI, 1.093-3.879; p=0.025), eGFR (OR, 0.983; 95% CI, 0.972-0.995; p=0.006), lower systolic blood pressure (OR, 0.976; 95% CI, 0.960-0.993; p=0.006), total procedure time (OR, 1.030; 95% CI, 1.011-1.049; p=0.002), and sST2 (OR, 1.101; 95% CI; 1.046-1.160; p<0.001). Besides, the risk of developing CIN in the high sST2 group is 3.06 times higher than the low group sST2 group regardless of other risk factors.

Conclusion

sST2 levels on admission in STEMI patients are useful in predicting CIN development.

Correlation of the Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR) with Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Interventions

Introduction

Contrast-induced acute nephropathy (CIN) in patients undergoing percutaneous coronary intervention (PCI) in the setting of acute coronary syndromes (ACS) is associated with adverse outcomes, including longer hospitalization and short and long-term mortality. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are inflammatory markers that have been validated separately in prior studies as a predictor of CIN in patients with ACS who undergo a left heart catheterization. Our study aims to further investigate the role of NLR and PLR together as markers for predicting CIN in patients with ACS. 

Methods

A retrospective chart review was performed on a total of 1,577 patients aged 18 - 90 who presented with ACS and underwent PCI between January 2011 to December 2015 at the Florida Hospital Orlando. Cut-off values used for a high PLR and NLR were PLR > 128 and NLR > 2.6. CIN was defined as an increased serum creatinine level by ≥ 0.5 mg/dL, or ≥ 25%, over the baseline value within 72 hours after contrast agent administration. Patients with end-stage renal disease (ESRD) were excluded. 

Results

Of the 1,577 patients included in the study, 213 (13.51%) patients had CIN. On multivariate logistic regression analysis, high NLR showed an independent association with an elevated risk of CIN (OR 2.03, 95% CI: 1.403 - 3.176, P < 0.001). High PLR did not correlate with CIN (OR 0.831, 95% CI: 0.569 - 1.214, P = 0.339). 

Conclusion

Elevated NLR is an independent predictor of CIN in patients with acute myocardial infarction (AMI) and may be used to improve on current risk prediction models. 

Preventive Effect of Pretreatment with Pitavastatin on Contrast-Induced Nephropathy in Patients with Renal Dysfunction Undergoing Coronary Procedure: PRINCIPLE-II Randomized Clinical Trial

This study aimed to evaluate the efficacy of pitavastatin pretreatment on contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) after a coronary procedure. This was a prospective, randomized, double-blinded, placebo-controlled, multicenter clinical trial. All consecutive 70 patients with CKD (eGFR < 60 mL/min/1.73 m²) were enrolled and randomized into two groups. Group I consisted of patients who were treated with statins (pitavastatin 4 mg/day) for seven days before and three days after the procedure (n = 37, 52.9%), and group II consisted of patients who were treated with a placebo (n = 33, 47.1%). The primary endpoint was the incidence of CIN, and the secondary endpoints were the change in serum creatinine (∆sCr) level and estimated glomerular filtration rate (∆eGFR) after the procedure. The mean age of the patients (males, 74%) was 70.4 ± 9.0 years. After the coronary procedure, the incidence of CIN was lower in group I than in group II, but the difference was not significant (5.4% vs. 9.1%, p = 0.661). The maximal ∆sCr was lower and the maximal ∆eGFR was higher in group I than in group II, but the difference was not significant (-0.11 ± 0.53 mg/dL and -0.04 ± 0.33 mg/dL, p = 0.678; 4.3 ± 11.2 mL/min/1.73 m² and -2.9 ± 20.4 mL/min/1.73 m², p = 0.161, respectively). This study showed the possibility of a clinical benefit of pretreatment with a high dose of pitavastatin for the prevention of CIN in patients with CKD after coronary procedure (ClinicalTrials.gov Identifier: NCT01871792).

Temporal trends of acute kidney injury in patients undergoing percutaneous coronary intervention over a span of 12 years

BACKGROUND

AKI is a known complication of PCI and is associated with higher rates of adverse events. We assessed temporal trends in rates of AKI, factors associated with risk of AKI and prognosis.

METHODS

From a prospective registry of patients undergoing PCI at two hospitals of the Rabin Medical Center, 15,153 consecutive patients were assessed at two time periods: 2006-2012 and 2012-2018. AKI was defined as either a relative elevation of ≥25% in serum creatinine or an absolute elevation of ≥0.5 mg/dl in serum creatinine at 48 h post PCI.

RESULTS

Data for 7913 patients from 2006 to 2012 and 7240 during 2012-2018 was available for analysis. Mean age was 65.0 ± 11.9y and 66.0 ± 12.3y (p < 0.001) and baseline creatinine was 1.08 ± 0.87 mg/dl and 1.15 ± 0.97 mg/dl, respectively (p < 0.001). Rates of AKI were 11.1% in the early and 7.3% in the late period (p < 0.001). Following adjustment, risk of AKI was lower in the late period (OR- 0.72; 95% CI 0.61-0.85, p < 0.001). AKI was associated with increased MACE (HR 1.62; 95% CI 1.44-1.82, p < 0.001 for the early period and HR 2.11; 95% CI 1.80-2.46, P < 0.001 for the late period) and death (HR 1.86; 95% CI 1.64-2.11, p < 0.001; HR 2.4; 95% CI 2.02-2.86; p < 0.001) in both time periods.

CONCLUSIONS

Over time, there was an improvement in the rates of post-PCI AKI. Increased adverse outcomes were evident at both periods. Further research is warranted, to further reduce peri-procedural AKI which is associated with impaired prognosis.

The Value of d-Dimer Level in Predicting Contrast-Induced Acute Kidney Injury in Patients With Acute ST-Segment Elevation Myocardial Infarction After PCI

Contrast-induced acute kidney injury (CI-AKI) is a serious complication of percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Early identification of high-risk patients has an essential role in preventing CI-AKI. This study was designed to evaluate the predictive value of d-dimer, a marker of thrombosis and hypercoagulable state, for CI-AKI and prognosis in patients with STEMI. We included 400 patients with STEMI who underwent PCI. The patients were subdivided into 4 groups according to d-dimer level using the 4-quantile method. Contrast-induced acute kidney injury occurred in 66 (16.5%) patients. The incidence of CI-AKI in the highest quartile of the d-dimer groups (29.0%) was higher than that in the other 3 groups. Multivariable logistic regression showed that a low d-dimer level was significantly associated with a decreased risk of CI-AKI independent of confounding factors, with an odds ratio (OR) of 0.487 (95% CI: 0.178-0.931, P = 0.041) for those in the first quartile compared with those in the highest quartile. Age (OR: 1.047, 95% CI: 1.003-1.092), diabetes mellitus (OR: 5.896, 95% CI: 2.496-13.927), anemia (OR: 3.488, 95% CI: 1.308-9.306), and total bilirubin (OR: 0.946, 95% CI: 0.904-0.992) were independent predictors of CI-AKI. The incidence of major adverse cardiovascular and cerebral events and all-cause mortality within 30 days, 6 months, and 1 year after PCI in the highest quartile of the d-dimer groups were higher than those in the other 3 groups. In conclusion, increasing d-dimer levels were independently associated with the incidence of CI-AKI and adverse outcomes in patients with STEMI after PCI.

Brain Natriuretic Peptide for Predicting Contrast-Induced Acute Kidney Injury in Patients with Acute Coronary Syndrome Undergoing Coronary Angiography: A Systematic Review and Meta-Analysis

Objective

To assess the diagnostic value of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) for contrast-induced acute kidney injury (CI-AKI) in patients with acute coronary syndrome (ACS) undergoing coronary angiography.

Background

ACS remains a major cause of death worldwide. Patients with ACS undergoing coronary angiography are more likely to develop CI-AKI, which correlates highly with poor clinical outcomes. Early diagnosis of CI-AKI remains a challenge. Many recent studies have suggested that BNP or NT-proBNP may be a useful biomarker for the early diagnosis of CI-AKI.

Methods

We searched databases (PubMed, EMBASE, and Cochrane Library) to identify eligible studies. Two authors independently screened the studies and extracted data. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria to assess the methodological quality of the included studies and STATA to perform all statistical analyses.

Results

Nine studies including 2832 patients were identified. The pooled sensitivity of 0.73 (95% CI 0.65–0.79), specificity of 0.79 (95% CI 0.70–0.85), and area under the summary receiver operating characteristic curve of 0.81 (95% CI 0.77–0.84) suggested that BNP or NT-proBNP had a good diagnostic value for CI-AKI in patients with ACS undergoing coronary angiography.

Conclusions

Our findings suggest that BNP or NT-proBNP may be an effective predictive marker for CI-AKI. However, additional high-quality studies are required to find the optimal cutoff value and the diagnostic value of BNP or NT-proBNP in combination with other biomarkers.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Predictive value of combining the level of fibrinogen and antithrombin III for contrast-induced nephropathy in coronary artery disease patients undergoing percutaneous coronary intervention

Contrast-induced nephropathy (CIN) is a common adverse event in the diagnosis and treatment of coronary intervention. The current study investigated the predictive effect of preoperative fibrinogen (FIB) combined with antithrombin III (AT-III) on CIN following percutaneous coronary intervention (PCI). A total of 394 patients who underwent PCI between October 2018 and May 2019 were selected for the present study. Pre-procedural FIB levels and AT-III activity were measured before PCI. CIN was defined as a 0.5 mg/dl or 25% increase in serum creatinine levels 48 to 72 h after exposure to a radiocontrast agent. Patients were classified into CIN and non-CIN groups. CIN occurred in 48 (12.2%) patients. The serum FIB levels were significantly higher in patients who developed CIN compared with those who did not develop CIN. In addition, AT-III levels ≤89.5% were associated with higher rates of CIN. Logistical regression analysis showed that high FIB, and low AT-III and albumin levels were high-risk factors associated with CIN. For FIB, the area under the receiver operating characteristic curve (AUC) for predicting CIN was 0.653. The optimal cut-off value was 3.48 g/l with a sensitivity of 45.8% and a specificity of 79.7% [95% confidence interval (CI): 0.603-0.701; P=0.0002)]. For AT-III, the AUC was 0.711, and the optimal cut-off value was 89.5%, with a sensitivity of 81.3% and specificity of 58.2% (95% CI: 0.659-0.758; P<0.0001). When combining FIB and AT-III, the AUC was 0.747. The optimal cut-off value was 0.090424, with a diagnostic sensitivity of 93.8% and specificity of 46.6% (95% CI: 0.697-0.792; P<0.0001). The results showed that FIB combined with AT-III resulted in improved predictive accuracy of CIN (FIB vs. AT-III, AUC=0.653 vs. 0.711, P=0.292; FIB vs. FIB + AT-III, AUC=0.653 vs. 0.747, P=0.012; AT-III vs. FIB + AT-III, AUC=0.711 vs. 0.747, P=0.138). Pre-procedural levels of FIB, AT-III and albumin were independently associated with an increased risk of CIN. Furthermore, the results suggested that the combination of FIB and AT-III was a better predictor of CIN after PCI.

Predictive Value of Fibrinogen-to-Albumin Ratio for Post-Contrast Acute Kidney Injury in Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND Post-contrast acute kidney injury (PC-AKI) is a contributor to adverse outcomes after percutaneous coronary intervention (PCI). This study aimed to investigate whether fibrinogen-to-albumin ratio (FAR), a novel inflammation-based risk index, can predict the occurrence of PC-AKI in patients undergoing elective PCI. MATERIAL AND METHODS We retrospectively enrolled 291 patients who underwent elective PCI from June 2017 to June 2019. PC-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL (≥26.5 μmol/L), or ≥1.5 times baseline within 48 to 72 hours after PCI. The area under the receiver-operating characteristic curve (AUC), continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to make comparison for PC-AKI prediction. RESULTS PC-AKI occurred in 43 patients (14.8%). FAR showed an AUC of 0.691 (95% confidence interval: 0.64-0.74; P<0.001) in predicting PC-AKI. In stepwise multivariable logistic regression, FAR was independently associated with the occurrence of PC-AKI along with hypertension, diabetes, hemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction. FAR significantly improved PC-AKI prediction over Mehran risk score in the continuous NRI and IDI, but not AUC. CONCLUSIONS FAR is independently associated with the occurrence of PC-AKI, and can significantly improve PC-AKI prediction over Mehran risk score in patients undergoing elective PCI.

Contrast Administration to the Deceased Kidney Donor Has No Impact on Post-Transplant Outcomes

BACKGROUND

Contrast-induced acute kidney injury may occur in patients undergoing imaging studies. This study reviews all deceased kidney donors at a single center during a 15-y period to determine if donor contrast exposure results in contrast-induced acute kidney injury in the donor or is associated with worse outcomes in the transplant recipient.

METHODS

Donor and recipient renal functions were recorded, including donor serum creatinine and recipient delayed graft function, creatinine clearance at 1 y, and early and late graft survival. Donor contrast exposure was recorded as the number of preprocurement contrasted studies.

RESULTS

Donor and recipient records were available for 1394 transplants (88%). There were 51% of donors who received any contrasted study (38%, one study; 12%, two studies, and 1%, three studies). Donor contrast exposure was not associated with significant differences in preprocurement serum creatinine levels. Post-transplant, donor contrast exposure was associated with risk of neither delayed graft function (4% for all) nor early kidney graft loss. Creatinine clearance at 1 y was equivalent. Five-year Cox regression demonstrated higher graft survival for contrast-exposed grafts (P = 0.03).

CONCLUSIONS

There is no negative effect of donor contrast administration on early and late kidney graft function. These findings included donor kidneys exposed to as many as three contrasted studies.

Renin-angiotensin-aldosterone system blockade is associated with higher risk of contrast-induced acute kidney injury in patients with diabetes

As the incidence of diabetes and cardiovascular comorbidities continues to rise, driven by increased prevalence of obesity and an aging population, so does the demand for percutaneous coronary intervention (PCI) to restore cardiac blood flow. Renin-angiotensin-aldosterone system (RAAS) inhibitors are commonly prescribed to hypertensive diabetic patients to prevent diabetic nephropathy. However, evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of contrast-induced acute kidney injury (CIAKI) following coronary angiography (CAG) and PCI. We therefore conducted a retrospective, multicenter study applying the propensity score matching method to evaluate the impact of RAAS inhibition on CIAKI in diabetic patients undergoing CAG/PCI. Among 2240 subjects that met the inclusion criteria, 704 patients in the ACEIs/ARBs group were successfully matched to eligible control patients. The incidence of CIAKI (serum creatinine increase ≥0.5 mg/dl or ≥25% from baseline within 72 h post-CAG/PCI) was significantly higher in the ACEIs/ARBs group than in the control group (26.6% vs. 16.2%, P<0.001). However, control patients showed increased risk of overall adverse cardiovascular events (4.1% vs. 1.8% for ACEIs/ARBs; P=0.016). These data indicate that RAAS inhibition increases the risk of CIAKI in diabetic patients, but confers protection against early cardiovascular events.