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Timal RJ, Kooiman J, Sijpkens YWJ, de Vries JPPM, Verberk-Jonkers IJAM, Brulez HFH, van Buren M, van der Molen AJ, Cannegieter SC, Putter H, van den Hout WB, Jukema JW, Rabelink TJ, Huisman MV. Effect of No Prehydration vs Sodium Bicarbonate Prehydration Prior to Contrast-Enhanced Computed Tomography in the Prevention of Postcontrast Acute Kidney Injury in Adults With Chronic Kidney Disease: The Kompas Randomized Clinical Trial. JAMA Intern Med 2020; 180:533-541. [PMID: 32065601 PMCID: PMC7042862 DOI: 10.1001/jamainternmed.2019.7428] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Prevention of postcontrast acute kidney injury in patients with stage 3 chronic kidney disease (CKD) by means of prehydration has been standard care for years. However, evidence for the need for prehydration in this group is limited. OBJECTIVE To assess the renal safety of omitting prophylactic prehydration prior to iodine-based contrast media administration in patients with stage 3 CKD. DESIGN, SETTING, AND PARTICIPANTS The Kompas trial was a multicenter, noninferiority, randomized clinical trial conducted at 6 hospitals in the Netherlands in which 523 patients with stage 3 CKD were randomized in a 1:1 ratio to receive no prehydration or prehydration with 250 mL of 1.4% sodium bicarbonate administered in a 1-hour infusion before undergoing elective contrast-enhanced computed tomography from April 2013 through September 2016. Final follow-up was completed in September 2017. Data were analyzed from January 2018 to June 2019. INTERVENTIONS In total, 262 patients were allocated to the no prehydration group and 261 were allocated to receive prehydration. Analysis on the primary end point was available in 505 patients (96.6%). MAIN OUTCOMES AND MEASURES The primary end point was the mean relative increase in serum creatinine level 2 to 5 days after contrast administration compared with baseline (noninferiority margin of less than 10% increase in serum creatinine level). Secondary outcomes included the incidence of postcontrast acute kidney injury 2 to 5 days after contrast administration, mean relative increase in creatinine level 7 to 14 days after contrast administration, incidences of acute heart failure and renal failure requiring dialysis, and health care costs. RESULTS Of 554 patients randomized, 523 were included in the intention-to-treat analysis. The median (interquartile range) age was 74 (67-79) years; 336 (64.2%) were men and 187 (35.8%) were women. The mean (SD) relative increase in creatinine level 2 to 5 days after contrast administration compared with baseline was 3.0% (10.5) in the no prehydration group vs 3.5% (10.3) in the prehydration group (mean difference, 0.5; 95% CI, -1.3 to 2.3; P < .001 for noninferiority). Postcontrast acute kidney injury occurred in 11 patients (2.1%), including 7 of 262 (2.7%) in the no prehydration group and 4 of 261 (1.5%) in the prehydration group, which resulted in a relative risk of 1.7 (95% CI, 0.5-5.9; P = .36). None of the patients required dialysis or developed acute heart failure. Subgroup analyses showed no evidence of statistical interactions between treatment arms and predefined subgroups. Mean hydration costs were €119 (US $143.94) per patient in the prehydration group compared with €0 (US $0) in the no prehydration group (P < .001). Other health care costs were similar. CONCLUSIONS AND RELEVANCE Among patients with stage 3 CKD undergoing contrast-enhanced computed tomography, withholding prehydration did not compromise patient safety. The findings of this study support the option of not giving prehydration as a safe and cost-efficient measure. TRIAL REGISTRATION Netherlands Trial Register Identifier: NTR3764.
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Affiliation(s)
- Rohit J Timal
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith Kooiman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.,Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Yvo W J Sijpkens
- Department of Internal Medicine, Haaglanden Medisch Centrum Bronovo, The Hague, the Netherlands
| | - Jean-Paul P M de Vries
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,Department of Vascular Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Harald F H Brulez
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Aart J van der Molen
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ton J Rabelink
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Noce A, Marrone G, Rovella V, Busca A, Gola C, Ferrannini M, Di Daniele N. Fenoldopam Mesylate: A Narrative Review of Its Use in Acute Kidney Injury. Curr Pharm Biotechnol 2019; 20:366-375. [PMID: 31038062 PMCID: PMC6751352 DOI: 10.2174/1389201020666190417124711] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/04/2019] [Accepted: 04/08/2019] [Indexed: 01/11/2023]
Abstract
Background: Fenoldopam mesylate is a selective agonist of DA-1 receptors. It is currently used for the in-hospital treatment of severe hypertension. DA-1 receptors have high density in renal pa-renchyma and for this reason, a possible reno-protective role of Fenoldopam mesylate was investigated. Methods: We examined all studies regarding the role of Fenoldopam mesylate in Acute Kidney Injury (AKI); particularly, those involving post-surgical patients, intensive care unit patients and contrast-induced nephropathy. Results: Fenoldopam mesylate was found to be effective in reducing the onset of postoperative AKI, when used before the development of the kidney damage. Positive results were also obtained in the management of intensive care unit patients with AKI, although the clinical studies investigated were few and conducted on small samples. Conclusion: Conflicting results were achieved in contrast-induced nephropathy.
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Affiliation(s)
- Annalisa Noce
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
| | - Giulia Marrone
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy.,PhD School of Applied Medical-Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Valentina Rovella
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
| | - Andrea Busca
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
| | - Caterina Gola
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
| | - Michele Ferrannini
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
| | - Nicola Di Daniele
- Department of Systems Medicine, Internal Medicine-Center of Hypertension and Nephrology Unit, Tor Vergata University, Rome, Italy
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Ahmed K, McVeigh T, Cerneviciute R, Mohamed S, Tubassam M, Karim M, Walsh S. Effectiveness of contrast-associated acute kidney injury prevention methods; a systematic review and network meta-analysis. BMC Nephrol 2018; 19:323. [PMID: 30424723 PMCID: PMC6234687 DOI: 10.1186/s12882-018-1113-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 10/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Different methods to prevent contrast-associated acute kidney injury (CA-AKI) have been proposed in recent years. We performed a mixed treatment comparison to evaluate and rank suggested interventions. METHODS A comprehensive Systematic review and a Bayesian network meta-analysis of randomised controlled trials was completed. Results were tabulated and graphically represented using a network diagram; forest plots and league tables were shown to rank treatments by the surface under the cumulative ranking curve (SUCRA). A stacked bar chart rankogram was generated. We performed main analysis with 200 RCTs and three analyses according to contrast media and high or normal baseline renal profile that includes 173, 112 & 60 RCTs respectively. RESULTS We have included 200 trials with 42,273 patients and 44 interventions. The primary outcome was CI-AKI, defined as ≥25% relative increase or ≥ 0.5 mg/dl increase from baseline creatinine one to 5 days post contrast exposure. The top ranked interventions through different analyses were Allopurinol, Prostaglandin E1 (PGE1) & Oxygen (0.9647, 0.7809 & 0.7527 in the main analysis). Comparatively, reference treatment intravenous hydration was ranked lower but better than Placebo (0.3124 VS 0.2694 in the main analysis). CONCLUSION Multiple CA-AKI preventive interventions have been tested in RCTs. This network evaluates data for all the explored options. The results suggest that some options (particularly allopurinol, PGE1 & Oxygen) deserve further evaluation in a larger well-designed RCTs.
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Affiliation(s)
- Khalid Ahmed
- Lambe Institute for Translational Research, Discipline of Surgery National University of Ireland, Galway, Republic of Ireland. .,Department of Vascular surgery, Galway University Hospital, Galway, Republic of Ireland.
| | - Terri McVeigh
- Lambe Institute for Translational Research, Discipline of Surgery National University of Ireland, Galway, Republic of Ireland
| | - Raminta Cerneviciute
- Lambe Institute for Translational Research, Discipline of Surgery National University of Ireland, Galway, Republic of Ireland
| | - Sara Mohamed
- Lambe Institute for Translational Research, Discipline of Surgery National University of Ireland, Galway, Republic of Ireland
| | - Mohammad Tubassam
- Department of Vascular surgery, Galway University Hospital, Galway, Republic of Ireland
| | - Mohammad Karim
- School of Population and Public Health, University of British Columbia, Scientist / Biostatistician, Centre for Health Evaluation and Outcome Sciences (CHEOS), St. Paul's Hospital, Vancouver, Canada
| | - Stewart Walsh
- Lambe Institute for Translational Research, Discipline of Surgery National University of Ireland, Galway, Republic of Ireland.,Department of Vascular surgery, Galway University Hospital, Galway, Republic of Ireland.,HRB Clinical Research Facility Galway, Galway, Republic of Ireland
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4
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Kooiman J, de Vries JPPM, Van der Heyden J, Sijpkens YWJ, van Dijkman PRM, Wever JJ, van Overhagen H, Vahl AC, Aarts N, Verberk-Jonkers IJAM, Brulez HFH, Hamming JF, van der Molen AJ, Cannegieter SC, Putter H, van den Hout WB, Kilicsoy I, Rabelink TJ, Huisman MV. Randomized trial of one-hour sodium bicarbonate vs standard periprocedural saline hydration in chronic kidney disease patients undergoing cardiovascular contrast procedures. PLoS One 2018; 13:e0189372. [PMID: 29420536 PMCID: PMC5805164 DOI: 10.1371/journal.pone.0189372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 11/22/2017] [Indexed: 02/08/2023] Open
Abstract
Background Guidelines advise periprocedural saline hydration for prevention of contrast induced-acute kidney injury (CI-AKI). We analysed whether 1-hour sodium bicarbonate hydration administered solely prior to intra-arterial contrast exposure is non-inferior to standard periprocedural saline hydration in chronic kidney disease (CKD) patients undergoing elective cardiovascular diagnostic or interventional contrast procedures. Methods We performed an open-label multicentre non-inferiority trial between 2011–2014. Patients were randomized to 1 hour pre-procedure sodium bicarbonate hydration (250 ml 1.4%, N = 168) or 4–12 hours saline hydration (1000 ml 0.9%, N = 165) prior to and following contrast administration (2000 ml of saline total). Primary outcome was the relative serum creatinine increase (%) 48–96 hours post contrast exposure. Secondary outcomes were: incidence of CI-AKI (serum creatinine increase>25% or >44μmol/L), recovery of renal function, the need for dialysis, and hospital costs within two months follow-up. Results Mean relative creatinine increase was 3.1% (95%CI 0.9 to 5.2%) in the bicarbonate and 1.1% (95%CI -1.2 to 3.5%) in the saline arm, mean difference 1.9% (95%CI -1.2 to 5.1%, p-non-inferiority <0.001). CI-AKI occurred in 11 (6.7%) patients randomized to sodium bicarbonate and 12 (7.5%) to saline (p = 0.79). Renal function did not fully recover in 40.0% and 44.4% of CI-AKI patients, respectively (p = 0.84). No patient required dialysis. Mean costs for preventive hydration and clinical preparation for the contrast procedure were $1158 for sodium bicarbonate vs. $1561 for saline (p < 0.001). Conclusion Short hydration with sodium bicarbonate prior to elective cardiovascular diagnostic or therapeutic contrast procedures is non-inferior to standard periprocedural saline hydration in CKD patients with respect to renal safety and results in considerable healthcare savings. Trial registration Netherlands Trial Register (http://www.trialregister.nl/trialreg/index.asp), Nr NTR2699
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Affiliation(s)
- Judith Kooiman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | | | - Jan Van der Heyden
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Yvo W. J. Sijpkens
- Department of Internal Medicine, Bronovo Hospital, The Hague, the Netherlands
| | | | - Jan J. Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hans van Overhagen
- Department of Radiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Antonie C. Vahl
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Nico Aarts
- Department of Radiology, Bronovo Hospital, The Hague, the Netherlands
| | | | - Harald F. H. Brulez
- Department of Nephrology, St. Lucas Andreas Hospital, Amsterdam, the Netherlands
| | - Jaap F. Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilbert B. van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Inci Kilicsoy
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ton J. Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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5
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Wong G, Lee E, Irwin M. Contrast induced nephropathy in vascular surgery. Br J Anaesth 2016; 117:ii63-ii73. [DOI: 10.1093/bja/aew213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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6
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Leow KS, Wu YW, Tan CH. Renal-related adverse effects of intravenous contrast media in computed tomography. Singapore Med J 2015; 56:186-93. [PMID: 25917468 DOI: 10.11622/smedj.2015057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Renal-related adverse effects of intravascular contrast media (CM) include contrast-induced nephropathy in computed tomography and angiography. While large retrospective studies have been published, the exact pathogenesis of this condition is still unknown. We review the main international guidelines, including the American College of Radiology white paper and the guidelines of European Society of Urogenital Radiology, Royal College of Radiologists and Canadian Association of Radiologists, as well as their references, regarding this subject. We present a simplified, concise approach to renal-related adverse effects of CM, taking into consideration the basis for each recommendation in these published guidelines. This will allow the reader to better understand the rationale behind appropriate patient preparation for cross-sectional imaging.
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Affiliation(s)
- Kheng Song Leow
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433.
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7
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Abstract
Contrast medium-induced acute kidney injury (CI-AKI) is a predominant cause of hospital-acquired renal insufficiency. With an increasing number of contrast medium-enhanced radiological procedures being performed in a rapidly increasing ageing population in the Western world, it is imperative that more attention is given to understand the aetiology of CI-AKI to devise novel diagnostic methods and to formulate effective prophylactic and therapeutic regimens to reduce its incidence and its associated morbidity and mortality. This article presents high-yield information on the above-mentioned aspects of CI-AKI, primarily based on results of randomised controlled trials, meta-analyses, systematic reviews and international consensus guidelines.
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Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ammara Usman
- University Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan R. Boyle
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul D. Hayes
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard J. Solomon
- University of Vermont College of Medicine, Division of Nephrology, Fletcher Allen Health Care, Burlington, Vt., USA
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8
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9
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Naeem M, McEnteggart GE, Murphy TP, Prince E, Ahn S, Soares G. Fenoldopam for the prevention of contrast-induced nephropathy (CIN)-do we need more trials? A meta-analysis. Clin Imaging 2015; 39:759-64. [PMID: 25709111 DOI: 10.1016/j.clinimag.2015.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/13/2015] [Accepted: 02/03/2015] [Indexed: 11/27/2022]
Abstract
We conducted a pooled analysis of clinical trials comparing intravenous Fenoldopam (FP) with Saline/Placebo/N-acetyl cysteine (NAC) for the prevention of contrast-induced nephropathy (CIN). Five studies were eligible. Quantitative analyses were done with Review Manager (RevMan version 5.2.). A total of 85 out of 353 patients in Fenoldopam group while 73 among 366 in the control group were affected due to CIN. The risk ratio for the development of CIN in the Fenoldopam group was 1.19 compared to the control group. This was not statistically significant. Fenoldopam is no better than Placebo/Saline or NAC in preventing CIN, but more studies are required.
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Affiliation(s)
- Muhammad Naeem
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Gregory E McEnteggart
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Timothy P Murphy
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Ethan Prince
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Sun Ahn
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Gregory Soares
- Vascular Disease Research Center, Division of Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
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10
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Firouzi A, Maadani M, Kiani R, Shakerian F, Sanati HR, Zahedmehr A, Nabavi S, Heidarali M. Intravenous magnesium sulfate: new method in prevention of contrast-induced nephropathy in primary percutaneous coronary intervention. Int Urol Nephrol 2014; 47:521-5. [PMID: 25475196 DOI: 10.1007/s11255-014-0890-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 10/28/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Contrast-induced acute kidney injury (CI-AKI) is an adverse consequence of percutaneous coronary interventions which results in significant morbidity and mortality and adds to the costs of diagnostic and interventional cardiology procedures. Various pathophysiological mechanisms have been proposed for CI-AKI and various agents tested for its prevention. There is currently a general agreement that adequate pre-procedural hydration constitutes the cornerstone of prevention, yet there are reports of the use of some other agents with various efficacies. We prospectively tested IV magnesium sulfate (Mg) for CI-AKI prevention. METHOD AND DESIGN This study is a prospective, randomized, open-labeled, single-center clinical trial. We randomly assigned 122 consecutive patients to two groups. The first group was the control group with routine treatment (n = 64), and second group was the study group with routine treatment plus IV magnesium sulfate 1 g just before the procedure (n = 62). Serum creatinine was measured before the procedure and 2 days after the procedure. The primary end point was the occurrence of CI-AKI within 48 h. CI-AKI was defined as 0.5 mg/dl or more increase in serum creatinine or 25% or more increase above baseline serum creatinine. There was no difference in definition if both of these parameters were present. RESULTS The control and study groups were comparable in the overall predicted risk of CI-AKI. Also, the type and volume of the contrast were not significantly different between the two groups. Following angioplasty, CI-AKI occurred in 17 (26.6%) patients in the control group and nine (14.5%) patients in the study group; there was a significant reduction in CI-AKI in the study group (P = 0.01). Additionally, there was no mortality or a need for hemodialysis in either group. CONCLUSION In primary PCI patients, the prophylactic use of intravenous Mg can be recommended to be added to traditional hydration for CI-AKI prevention.
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Affiliation(s)
- Ata Firouzi
- Department of Interventional Cardiology, Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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11
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Kooiman J, Sijpkens YWJ, van Buren M, Groeneveld JHM, Ramai SRS, van der Molen AJ, Aarts NJM, van Rooden CJ, Cannegieter SC, Putter H, Rabelink TJ, Huisman MV. Randomised trial of no hydration vs. sodium bicarbonate hydration in patients with chronic kidney disease undergoing acute computed tomography-pulmonary angiography. J Thromb Haemost 2014; 12:1658-66. [PMID: 25142085 DOI: 10.1111/jth.12701] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/09/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hydration to prevent contrast-induced acute kidney injury (CI-AKI) induces a diagnostic delay when performing computed tomography-pulmonary angiography (CTPA) in patients suspected of having acute pulmonary embolism. AIM To analyze whether withholding hydration is non-inferior to sodium bicarbonate hydration before CTPA in patients with chronic kidney disease (CKD). METHODS We performed an open-label multicenter randomized trial between 2009 and 2013. One hundred thirty-nine CKD patients were randomized, of whom 138 were included in the intention-to-treat population: 67 were randomized to withholding hydration and 71 were randomized to 1-h 250 mL 1.4% sodium bicarbonate hydration before CTPA. Primary outcome was the increase in serum creatinine 48-96 h after CTPA. Secondary outcomes were the incidence of CI-AKI (creatinine increase > 25%/> 0.5 mg dL(-1) ), recovery of renal function, and the need for dialysis within 2 months after CTPA. Withholding hydration was considered non-inferior if the mean relative creatinine increase was ≤ 15% compared with sodium bicarbonate. RESULTS Mean relative creatinine increase was -0.14% (interquartile range -15.1% to 12.0%) for withholding hydration and -0.32% (interquartile range -9.7% to 10.1%) for sodium bicarbonate (mean difference 0.19%, 95% confidence interval -5.88% to 6.25%, P-value non-inferiority < 0.001). CI-AKI occurred in 11 patients (8.1%): 6 (9.2%) were randomized to withholding hydration and 5 (7.1%) to sodium bicarbonate (relative risk 1.29, 95% confidence interval 0.41-4.03). Renal function recovered in 80.0% of CI-AKI patients within each group (relative risk 1.00, 95% confidence interval 0.54-1.86). None of the CI-AKI patients developed a need for dialysis. CONCLUSION Our results suggest that preventive hydration could be safely withheld in CKD patients undergoing CTPA for suspected acute pulmonary embolism. This will facilitate management of these patients and prevents delay in diagnosis as well as unnecessary start of anticoagulant treatment while receiving volume expansion.
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Affiliation(s)
- J Kooiman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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12
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Kooiman J, Sijpkens YW, de Vries JPP, Brulez HF, Hamming JF, van der Molen AJ, Aarts NJ, Cannegieter SC, Putter H, Swarts R, van den Hout WB, Rabelink TJ, Huisman MV. A randomized comparison of 1-h sodium bicarbonate hydration versus standard peri-procedural saline hydration in patients with chronic kidney disease undergoing intravenous contrast-enhanced computerized tomography. Nephrol Dial Transplant 2014; 29:1029-36. [DOI: 10.1093/ndt/gfu025] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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13
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Pharmacological strategies to prevent contrast-induced acute kidney injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:236930. [PMID: 24719848 PMCID: PMC3955653 DOI: 10.1155/2014/236930] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 01/03/2014] [Accepted: 01/07/2014] [Indexed: 02/01/2023]
Abstract
Contrast-induced acute kidney injury (CI-AKI) is the most common iatrogenic cause of acute kidney injury after intravenous contrast media administration. In general, the incidence of CI-AKI is low in patients with normal renal function. However, the rate is remarkably elevated in patients with preexisting chronic kidney disease, diabetes mellitus, old age, high volume of contrast agent, congestive heart failure, hypotension, anemia, use of nephrotoxic drug, and volume depletion. Consequently, CI-AKI particularly in high risk patients contributes to extended hospitalizations and increases long-term morbidity and mortality. The pathogenesis of CI-AKI involves at least three mechanisms; contrast agents induce renal vasoconstriction, increase of oxygen free radicals through oxidative stress, and direct tubular toxicity. Several strategies to prevent CI-AKI have been evaluated in experimental studies and clinical trials. At present, intravascular volume expansion with either isotonic saline or sodium bicarbonate solutions has provided more consistent positive results and was recommended in the prevention of CI-AKI. However, the proportion of patients with risk still develops CI-AKI. This review critically evaluated the current evidence for pharmacological strategies to prevent CI-AKI in patients with a risk of developing CI-AKI.
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Peppard WJ, Peppard SR, Somberg L. Optimizing drug therapy in the surgical intensive care unit. Surg Clin North Am 2013; 92:1573-620. [PMID: 23153885 DOI: 10.1016/j.suc.2012.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article provides a review of commonly prescribed medications in the surgical ICU, focusing on sedatives, antipsychotics, neuromuscular blocking agents, cardiovascular agents, anticoagulants, and antibiotics. A brief overview of pharmacology is followed by practical considerations to aid prescribers in selecting the best therapy within a given category of drugs to optimize patient outcomes.
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Affiliation(s)
- William J Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI 53226, USA
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Firouzi A, Eshraghi A, Shakerian F, Sanati HR, Salehi N, Zahedmehr A, Kiani R, Madani M, Pedarzadeh A. Efficacy of pentoxifylline in prevention of contrast-induced nephropathy in angioplasty patients. Int Urol Nephrol 2011; 44:1145-9. [PMID: 21898040 DOI: 10.1007/s11255-011-0053-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 08/20/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) is an adverse consequence of contrast media use that results in significant morbidity and mortality and adds significant costs to diagnostic and interventional cardiology procedures. Various pathophysiological mechanisms have been proposed for CIN and various agents have been tested for its prevention. There is currently a general agreement that adequate pre-procedure hydration constitutes the cornerstone of prevention, yet there are reports of the use of some other agents with various efficacies. We prospectively tested pentoxifylline (PTX), an antioxidant, anti-inflammatory drug, for CIN prevention in patients undergoing coronary angioplasty. MATERIALS AND METHODS In this prospective, randomized, single-blind, single-center clinical trial, 286 consecutive patients were randomly assigned to the control group (n = 146), with routine treatment and no PTX, or the study group (n = 140), with routine treatment and PTX, 400 mg/tid from 24 h before to 24 h after coronary angioplasty. Serum creatinine was measured before and 2 days after the procedure. The primary end point was the occurrence of CIN within 48 h. RESULTS The control and PTX groups were comparable in the overall predicted risk of CIN. Also, the type and volume of the contrast agent were not significantly different between the two groups. Following angioplasty, CIN occurred in 20 (13.69%) patients in the control group and in 12 (8.5%) patients in the study group; the difference was not statistically significant (P = 0.17). Additionally, there was no mortality and need for hemodialysis in either group. CONCLUSION In angioplasty patients, the prophylactic oral use of PTX could be recommended for CIN prevention, although no statistically significant protective effect was documented.
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Affiliation(s)
- Ata Firouzi
- Department of Cardiology, Shahid Rajaie Cardiovascular Medical and Research Hospital, P. O. Box: 13185-1678 Tehran, Iran
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Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 2011; 21:2527-41. [PMID: 21866433 DOI: 10.1007/s00330-011-2225-0] [Citation(s) in RCA: 630] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 06/15/2011] [Accepted: 06/30/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE The Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) has updated its 1999 guidelines on contrast medium-induced nephropathy (CIN). AREAS COVERED Topics reviewed include the definition of CIN, the choice of contrast medium, the prophylactic measures used to reduce the incidence of CIN, and the management of patients receiving metformin. Key Points • Definition, risk factors and prevention of contrast medium induced nephropathy are reviewed. • CIN risk is lower with intravenous than intra-arterial iodinated contrast medium. • eGFR of 45 ml/min/1.73 m (2) is CIN risk threshold for intravenous contrast medium. • Hydration with either saline or sodium bicarbonate reduces CIN incidence. • Patients with eGFR ≥ 60 ml/min/1.73 m (2) receiving contrast medium can continue metformin normally.
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17
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Akyuz S, Ergelen M, Ergelen R, Uyarel H. Contrast-induced nephropathy: a contemporary and simplified review. Interv Cardiol 2010. [DOI: 10.2217/ica.10.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 1. Am J Health Syst Pharm 2009; 66:1343-52. [DOI: 10.2146/ajhp080348.p1] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Denise Rhoney
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - W. Frank Peacock
- Institute of Emergency Medicine, The Cleveland Clinic Foundation, Cleveland, OH
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Abstract
Approximately 72 million people in the US experience hypertension. Worldwide, hypertension may affect as many as 1 billion people and be responsible for approximately 7.1 million deaths per year. It is estimated that approximately 1% of patients with hypertension will, at some point, develop a hypertensive crisis. Hypertensive crises are further defined as either hypertensive emergencies or urgencies, depending on the degree of blood pressure elevation and presence of end-organ damage. Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e. hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent, while severe hypertension without acute end-organ damage (i.e. hypertensive urgency) is usually treated with oral antihypertensive agents. The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure. The appropriate therapeutic approach of each patient will depend on their clinical presentation. Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents. Rapid-acting intravenous antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine and sodium nitroprusside. Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages to other available agents in the management of hypertensive crises. Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided. Similarly, nifedipine, nitroglycerin and hydralazine should not to be considered first-line therapies in the management of hypertensive crises because these agents are associated with significant toxicities and/or adverse effects.
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Affiliation(s)
- Joseph Varon
- The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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20
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Gonzales DA, Norsworthy KJ, Kern SJ, Banks S, Sieving PC, Star RA, Natanson C, Danner RL. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med 2007; 5:32. [PMID: 18001477 PMCID: PMC2200657 DOI: 10.1186/1741-7015-5-32] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 11/14/2007] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Meta-analyses of N-acetylcysteine (NAC) for preventing contrast-induced nephrotoxicity (CIN) have led to disparate conclusions. Here we examine and attempt to resolve the heterogeneity evident among these trials. METHODS Two reviewers independently extracted and graded the data. Limiting studies to randomized, controlled trials with adequate outcome data yielded 22 reports with 2746 patients. RESULTS Significant heterogeneity was detected among these trials (I2 = 37%; p = 0.04). Meta-regression analysis failed to identify significant sources of heterogeneity. A modified L'Abbé plot that substituted groupwise changes in serum creatinine for nephrotoxicity rates, followed by model-based, unsupervised clustering resolved trials into two distinct, significantly different (p < 0.0001) and homogeneous populations (I2 = 0 and p > 0.5, for both). Cluster 1 studies (n = 18; 2445 patients) showed no benefit (relative risk (RR) = 0.87; 95% confidence interval (CI) 0.68-1.12, p = 0.28), while cluster 2 studies (n = 4; 301 patients) indicated that NAC was highly beneficial (RR = 0.15; 95% CI 0.07-0.33, p < 0.0001). Benefit in cluster 2 was unexpectedly associated with NAC-induced decreases in creatinine from baseline (p = 0.07). Cluster 2 studies were relatively early, small and of lower quality compared with cluster 1 studies (p = 0.01 for the three factors combined). Dialysis use across all studies (five control, eight treatment; p = 0.42) did not suggest that NAC is beneficial. CONCLUSION This meta-analysis does not support the efficacy of NAC to prevent CIN.
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Affiliation(s)
- Denise A Gonzales
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kelly J Norsworthy
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Steven J Kern
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Steve Banks
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Pamela C Sieving
- National Institutes of Health Library, National Institutes of Health, Bethesda, MD, USA
| | - Robert A Star
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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21
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Abstract
Hypertension affects > 65 million people in the United States and is one of the leading causes of death. One to two percent of patients with hypertension have acute elevations of BP that require urgent medical treatment. Depending on the degree of BP elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. A hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting IV antihypertensive agent. Severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents. This article reviews definitions, current concepts, common misconceptions, and pitfalls in the diagnosis and management of patients with acutely elevated BP as well as special clinical situations in which BP must be controlled.
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Affiliation(s)
- Paul E Marik
- Department of Pulmonary and Critical Care, Thomas Jefferson University, Philadelphia, PA USA.
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Abstract
Contrast-induced nephropathy (CIN) is a well-known complication of therapeutic and diagnostic procedures requiring contrast administration and accounts for 10 to 12% of acute renal failure in hospitalized patients. Although the incidence of this complication is relatively low, its consequences can be catastrophic. The development of CIN is associated with increased hospital length of stay, an increased requirement for acute dialysis, and an increased risk of death. Preexisting renal dysfunction, age, diabetes, congestive heart failure, and volume of administered contrast are all associated with a risk of developing CIN. Despite a large number of clinical trials that have evaluated prophylaxis strategies for CIN, only the use of hemofiltration and N-acetylcysteine (NAC) in specific subgroups of patients have been shown to reduce dialysis requirement and mortality in patients undergoing angiographic procedures. In this review we will discuss the epidemiology and the risk factors for CIN and the evidence for commonly employed prophylaxis strategies, and we will provide general recommendations with respect to CIN prevention and management.
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Affiliation(s)
- Mohammed Al-Ghonaim
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
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