A Bayesian network meta-analysis of preventive strategies for contrast-induced nephropathy after cardiac catheterization

Lipid-Lowering Efficacy of Combination Therapy With Moderate-Intensity Statin and Ezetimibe Versus High-Intensity Statin Monotherapy: A Randomized, Open-Label, Non-Inferiority Trial From Korea

Objective

This phase IV, multicenter, randomized controlled, open-label, and parallel clinical trial aimed to compare the efficacy and safety of ezetimibe and moderate intensity rosuvastatin combination therapy to that of high intensity rosuvastatin monotherapy in patients with atherosclerotic cardiovascular disease (ASCVD).

Methods

This study enrolled patients with ASCVD and after a four-week screening period, patients were randomly assigned to receive either rosuvastatin and ezetimibe (RE 10/10 group) or high-intensity rosuvastatin (R20 group) only in a 1:1 ratio. The primary outcome was the difference in the percent change in the mean low-density lipoprotein cholesterol (LDL-C) level from baseline to 12 weeks between two groups after treatment.

Results

The study found that after 12 and 24 weeks of treatment, the RE10/10 group had a greater reduction in LDL-C level compared to the R20 group (-22.9±2.6% vs. -15.6 ± 2.5% [p=0.041] and -24.2±2.5% vs. -12.9±2.4% [p=0.001] at 12 and 24 weeks, respectively). Moreover, a greater number of patients achieved the target LDL-C level of ≤70 mg/dL after the treatment period in the combination group (74.6% vs. 59.9% [p=0.012] and 76.2% vs. 50.8% [p<0.001] at 12 and 24 weeks, respectively). Importantly, there were no significant differences in the occurrence of overall adverse events and adverse drug reactions between two groups.

Conclusion

Moderate-intensity rosuvastatin and ezetimibe combination therapy had better efficacy in lowering LDL-C levels without increasing adverse effects in patients with ASCVD than high-intensity rosuvastatin monotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03494270.

Use of Prophylactic High-Dose Statin Therapy to Reduce Contrast-Induced Acute Kidney Injury in Adults Undergoing Acute Coronary Angiography: Evaluation of a Practice Change

BACKGROUND

Development of contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity, mortality, hospital length of stay, and overall health care costs.

OBJECTIVES

The purpose of this project was to evaluate a clinical practice change-the addition of high-dose statin therapy to standard renal protection measures-in adults undergoing acute cardiac catheterization procedures and assessing its effect on CI-AKI.

METHOD

The evaluation was a pretest/posttest descriptive design. Adult patients undergoing acute cardiac catheterization procedures were evaluated for the rate of CI-AKI before (10 months preimplementation, N = 283) and after (10 months postimplementation, N = 286) a recent practice change that added high-dose statin therapy (within 24 hours of dye exposure) to a standard renal protection bundle (intravenous fluids, maximum dye calculations, and avoidance of nephrotoxic medications). Outcomes included the rate of CI-AKI, stage of acute kidney injury, need for new hemodialysis, discharge disposition (alive or died in the hospital), and hospital length of stay.

RESULTS

Patients in the postintervention group that received renal protection bundle with high-dose statin had significantly lower incidence of CI-AKI (10.1% pre vs 3.2% post; P < .001). There were no significant differences in hospital length of stay, need for new hemodialysis, or mortality. Administration of high-dose statin within 24 hours of the cardiac catheterization procedure improved significantly (19.4% pre vs 74.1% post; P < .001). Adherence to all 5 components of the renal bundle improved post intervention (17% pre vs 73.4% post; P < .001).

DISCUSSION

The addition of a high-dose statin in addition to existing renal protective measures in patients with acute cardiac procedures is associated with a decreased incidence of CI-AKI.

Endogenous and Exogenous Antioxidants as Agents Preventing the Negative Effects of Contrast Media (Contrast-Induced Nephropathy)

The use of conventional contrast media for diagnostic purposes (in particular, Gd-containing and iodinated agents) causes a large number of complications, the most common of which is contrast-induced nephropathy. It has been shown that after exposure to contrast agents, oxidative stress often occurs in patients, especially in people suffering from various diseases. Antioxidants in the human body can diminish the pathological consequences of the use of contrast media by suppressing oxidative stress. This review considers the research studies on the role of antioxidants in preventing the negative consequences of the use of contrast agents in diagnostics (mainly contrast-induced nephropathy) and the clinical trials of different antioxidant drugs against contrast-induced nephropathy. Composite antioxidant/contrast systems as theranostic agents are also considered.

Contrast-induced acute kidney injury and its contemporary prevention

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Evaluation of Crocin Effect on Contrast-Induced Nephropathy Following Coronary Angiography or Angioplasty: A Randomized Controlled Trial

Contrast-induced nephropathy (CIN) is the third cause of hospital-acquired acute kidney injury. The CIN prophylactic strategies adopted to date, although not highly efficient, are mostly based on antioxidant activity and hydration therapy. This study was designed and conducted to evaluate crocin’s efficacy in the prevention of CIN in chronic kidney disease (CKD) patients undergoing coronary angiography/angioplasty. In this randomized clinical trial, a total of 110 eligible CKD stage 3 patients requiring contrast agent administration for coronary angiography/angioplasty were enrolled and randomly assigned to either crocin (n = 57) or control (n = 53) group. The patients in both groups received standard hydration therapy; nevertheless, in the crocin group, the patients were also orally administered three consecutive oral doses of 30 mg crocin tablets 1 day before up to 1 day after contrast media (CM) exposure. The primary endpoint was CIN incidence defined as an increase in serum creatinine (SrCr) level by ≥ 0.3 mg/dL or any change in urinary neutrophil gelatinase-associated lipocalin (NGAL) from the baseline within 48 hours of CM exposure. During 4 months, 130 patients were recruited. The mean age of the patients was 65.62 ± 9.05 years, and the majority of them were male (64.54%). The SrCr in the crocin group did not significantly increase within 48 hours of angiography/angioplasty. The changes in the urinary NGAL level were not significant in both groups. The CIN incidence was significantly lower in the crocin group than in the control group (1.75% and 13.2%; P = 0.028). Crocin administration plays an important nephron-protective role in the prevention of CIN.

[Effect of half-dose fluorescein sodium contrast agent on liver and kidney functions in patients with mild to moderate chronic kidney disease: a retrospective cohort study]

OBJECTIVE

To observe the effect of half-dose fluorescein sodium (FINa) contrast agent on liver and kidney functions in patients with mild to moderate (stage 1 to 3) chronic kidney disease (CKD) and the incidence of contrast-induced nephropathy (CIN).

METHODS

Seventy-seven patients (including 50 male and 27 female patients with an mean age of 53.5±9.6 years) with CKD with normal renal function or mild to moderate abnormalities underwent fundus fluorescein angiography (FFG) examination with half-dose FINa. Liver function, blood creatinine (Scr), blood urea nitrogen (BUN), urine β2 microglobulin (β2-MG), and glomerular filtration rate (eGFR) of the patients were measured within 3 days before intravenous injection of the contrast agent and at 1, 3, 7, and 30±1 days after the operation to analyze the effect of the contrast agent on renal function.

RESULTS

Among the 77 patients, CIN occurred only in one case with an incidence rate of 1.30%. BUN, urine β2- MG, or rapid microalbumin/creatinine did not vary significantly after FFA in these patients. Scr levels showed no significant increments at 1 day and 7 days after FFA, but increased significantly at 3 days (24.6±2.3; P < 0.01) and 30 days (16.0±21.7; P < 0.05). Urine NAG enzymes and urinary osmolality were significantly reduced at 1, 3, 7, and 30 days after FFA (P < 0.01). The eGFR decreased significantly to 10.23±0.62 at 3 days after FAG and became normal at 7 days. Urine albumin level decreased significantly at 1, 3, 7, and 30 days after FFA (P < 0.01). Blood β2-MGFAG level increased significantly at 3 days after FFA (0.314± 0.121; P < 0.01), but decreased to 0.134±0.143 at 7 days (P < 0.05). The level transaminase decreased significantly at 3 and 7 days after FFA (P < 0.01).

CONCLUSION

Half-dose of FINa has no significant effect on liver function and has only minimal effect on kidney function in patients with mild to moderate CKD, and FFA with half-dose FINa can therefore be safely performed in these patients.

De-escalation of antiplatelets after percutaneous coronary intervention: a Bayesian network meta-analysis of various de-escalation strategies

AIMS

To compare early de-escalation of dual antiplatelet therapy (DAPT) (1-3 months) to monotherapy with either P2Y12 inhibitor or aspirin vs. 12 months DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

METHODS AND RESULTS

Electronic databases of Medline, Embase, and Cochrane library were searched through February 2020 to identify randomized controlled trials. A Bayesian network meta-analysis was conducted with random effects model. The main endpoints of interest were cardiovascular mortality and total bleeding events. Among seven trials (35 821 patients), 52.6% patients were presented with acute coronary syndrome. A total of 3359 patients and 14 530 patients were de-escalated to aspirin and P2Y12 inhibitor monotherapy, respectively. At a median follow-up of 12 months, compared with 12 months of DAPT, there was no significant difference in cardiovascular mortality between 1-month DAPT followed by P2Y12 inhibitor monotherapy [hazard ratio (HR) 0.84 (95% credible interval 0.29-2.43)], 3 months of DAPT followed by P2Y12 inhibitor monotherapy [HR 0.74 (0.39-1.46)], or 3 months of DAPT [HR 1.00 (0.54-1.86)] followed by aspirin monotherapy. Except for de-escalation of DAPT to aspirin monotherapy after 3 months [HR 0.75 (0.43-1.20)], de-escalation to P2Y12 inhibitor monotherapy after 1 month [HR 0.28 (0.10-0.83)], or 3 months [HR 0.57 (0.33-0.98)] were associated with significant decrease in total bleeding events. There were no significant differences in terms of ischaemic endpoints among different DAPT strategies.

CONCLUSION

Early de-escalation of DAPT (1-3 months) to monotherapy with a P2Y12 inhibitor instead of aspirin might be a safer and equally effective approach compared with 12 months of DAPT in patients with PCI and DES.