Contrast media use in patients with chronic kidney disease undergoing coronary angiography: A systematic review and meta-analysis of randomized trials

Effectiveness of edaravone in preventing contrast-induced nephropathy in high-risk patients undergoing coronary angiography: A randomized, double-blind trial

Contrast-induced nephropathy (CIN) is a serious complication that occurs subsequent to the administration of contrast media for therapeutic angiographic interventions. As of present, no effective therapy exists to prevent its occurrence. This single-center double-blind randomized controlled trial aimed to evaluate the effect of edaravone, an antioxidant, in a group of high-risk patients undergoing coronary angiography. Ninety eligible patients with chronic kidney disease Stages 3-4 were randomly assigned to either the control group (n = 45) or the intervention group (n = 45). In the intervention group, one dosage of edaravone (60 mg) in 1 L of normal saline was infused via a peripheral vein 1 h prior to femoral artery-directed coronary angiography. Patients in the control group received an equal amount of infusion in their last hour before angiography. Both groups received intravenous hydration with 0.9% sodium 1 mL/kg/h starting 12 h before and continuing for 24 h after angiography. The primary outcome measure was the onset of CIN, defined as a 25% increase in serum creatinine levels 120 h after administration of contrast media. The occurrence of CIN was observed in 5.5% (n = 5) of the studied population: 2.2% of patients in the intervention group (n = 1) and 8.9% of controls (n = 4). However, this difference was not statistically significant. Administration of a single dosage of edaravone 1 h prior to infusion of contrast media led to a reduction in the incidence of CIN. Further investigations, employing larger sample sizes, are warranted to gain a comprehensive understanding of its efficacy.

Acute Kidney Injury After Percutaneous Coronary Intervention Guided by Intravascular Ultrasound

Purpose We investigated the impact of intravascular ultrasound guidance on reducing the incidence of contrast-induced acute kidney injury (CI-AKI) in patients undergoing percutaneous coronary intervention (PCI). Methods Ninety-nine patients were enrolled in this prospective cohort who were not randomly assigned to angiography-guided percutaneous coronary intervention or intravascular ultrasound-guided percutaneous coronary intervention. The patients were hospitalized at the Vietnam National Heart Institute - Bach Mai Hospital between 2019 and 2020. Acute kidney injury incidence during hospitalization was the primary endpoint. Results A total of 99 patients were divided into two groups: the intravascular ultrasound-guided group (33 participants) and the angiography-guided group (66 participants). The mean ± SD contrast volume of each group was 95.2 ± 37.1 mL and 133.0 ± 36.0 mL for the ultrasound-guided and angiography-guided groups, with P < 0.0001. Intravascular imaging-guided percutaneous coronary intervention (IVUS-guided PCI) was associated with reduced acute kidney injury incidence during hospitalization: 0.0% vs. 12.12% and P = 0.049. Conclusions Intravascular ultrasound is a safe imaging tool that guides percutaneous coronary intervention and significantly reduces the rate of acute kidney injury compared to angiography alone. Patients who have a high chance of experiencing acute kidney injury benefit from using intravascular ultrasound.

Intra-arterial PRRT with Lu-177 DOTATATE in Liver-dominant Metastatic Neuroendocrine Tumors: Early Assessment of Efficacy and Toxicity

Purpose

We proposed to administer Lu-177-DOTATATE in intra-arterial (IA) mode for higher first-pass localization to somatostatin receptors, higher residence time in liver metastases, and more radiation to tumor. This study aimed at assessing early hematological, renal and hepatotoxicity; and objective response to IA peptide receptor radionuclide therapy (PRRT).

Materials and Methods

Fourteen patients (4 females and 10 males) were prospectively assessed. 5/14 patients underwent 2 cycles, whereas 3/14 underwent 3 cycles, and 6/14 received 1 cycle of IA PRRT. 200 mCi of Lu-177-DOTATATE was administered in 15-20 min by IA route under angiographic guidance. Patients were asked to follow-up at 4 and 8 weeks with hematological, liver, and renal functional parameters, and Ga-68 DOTATATE positron emission tomography/computed tomography (PET/CT) after 8 weeks. Response was assessed using RECIST 1.1 and EORTC PET criteria.

Results

Safety: 2/14 patients had high total and direct bilirubin, which reverted to normal after IA PRRT. Three patients had low albumin, which improved after 1 cycle. Nine patients showed no worsening of liver function. Two patients showed Grade 1 hematotoxicity which reverted to normal. Five patients showed high creatinine, but preserved glomerular filtration rate and EC clearance. On follow-up at 8 weeks, serum creatinine reverted to normal. Efficacy: In five patients who underwent 2 cycles of IA PRRT, 3 showed partial response (PR) on RECIST 1.1 and partial metabolic response (PMR) on EORTC criteria, whereas 2 showed stable disease (SD). In patients who underwent 3 cycles, 1 showed SD, whereas other patient showed PMR on DOTANOC PET/CT, with PR in size. Among the remaining seven patients, 5 showed PMR, whereas the other 2 showed SD. Thus 9/14 patients showed PR, whereas 5 showed SD on metabolic and size criteria.

Conclusions

IA PRRT is a safe and efficacious approach for the treatment of liver dominant metastatic neuroendocrine tumors.

Prevention of Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury has varying definitions, but in general, increased serum creatinine level by ≥ 0.3 mg/dL (26.5 µmol/L) or 1.5x of baseline value or urine output <0.5 mL/kg/h within 1-7 days after contrast media (CM) administration can be considered as CIN. CIN is one of the most common complications and is associated with increased mortality in patients undergoing percutaneous coronary intervention (PCI). Thus, risk stratification for CIN should be made and preventive strategies should be employed in which the intensity of the approach must be tailored to patient's risk profile. In all patients, adequate hydration is required, nephrotoxic medications should be discontinued, and pre-procedural high-intensity statin is recommended. In patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, IV hydration should be started 12 hours pre-procedure up until 12-24 hours after the procedure. Remote ischemic preconditioning may be performed pre-procedurally. Radial first approach for vascular access is recommended. During the procedure, low or iso-osmolar CM should be used and its volume should be limited to eGFR x 3.7. In patients at high risk for CIN, additional contrast-sparing strategies may be applied, such as using a contrast reduction system, 5 Fr catheter with no sideholes, CM dilution, limiting test injection, confirming placement using guidewire, use of stent enhancing imaging technology, using metallic/software roadmap to guide PCI, use of IVUS or dextran-based OCT, and coronary aspiration. A more advanced hydration technique based on central venous pressure, left ventricular end-diastolic pressure, or using furosemide-matched hydration, might be considered.

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.

Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury

Iodinated contrast media (ICM) is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after ICM administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. This revised guidance document was developed by a multidisciplinary CAR Working Group of radiologists and nephrologists, and summarizes changes in practice related to contrast administration, screening, and risk stratification since the last guideline. It reviews the scientific evidence for contrast associated AKI and provides consensus-based recommendations for its prevention and management in the Canadian healthcare context. This article is a joint publication in the Canadian Association of Radiologists Journal and Canadian Journal of Kidney Health and Disease, intended to inform both communities of practice.

Canadian Association of Radiologists Guidance on Contrast-Associated Acute Kidney Injury

Purpose

Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations.

Information sources

Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada.

Methods

The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations.

Key Findings

The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration.

Limitations

We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment.

Implications

Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.

A Simple Nomogram to Predict Contrast-Induced Acute Kidney Injury in Patients with Congestive Heart Failure Undergoing Coronary Angiography

Background

Patients with congestive heart failure (CHF) are vulnerable to contrast-induced kidney injury (CI-AKI), but few prediction models are currently available. Therefore, we aimed to establish a simple nomogram for CI-AKI risk assessment for patients with CHF undergoing coronary angiography.

Methods

A total of 1876 consecutive patients with CHF (defined as New York Heart Association functional class II-IV or Killip class II-IV) were enrolled and randomly (2:1) assigned to a development cohort and a validation cohort. The endpoint was CI-AKI defined as serum creatinine elevation of ≥0.3 mg/dL or 50% from baseline within the first 48–72 hours following the procedure. Predictors for the simple nomogram were selected by multivariable logistic regression with a stepwise approach. The discriminative power was assessed using the area under the receiver operating characteristic (ROC) curve and was compared with the classic Mehran score in the validation cohort. Calibration was assessed using the Hosmer–Lemeshow test and 1000 bootstrap samples.

Results

The incidence of CI-AKI was 9.06% (170) in the total sample, 8.64% (n = 109) in the development cohort, and 9.92% (n = 61) in the validation cohort (P=0.367). The simple nomogram including four predictors (age, intra-aortic balloon pump, acute myocardial infarction, and chronic kidney disease) demonstrated a similar predictive power as the Mehran score (area under the curve: 0.80 vs. 0.75, P=0.061), as well as a well-fitted calibration curve.

Conclusions

The present simple nomogram including four predictors is a simple and reliable tool to identify CHF patients at risk of CI-AKI, whereas further external validations are needed.

Development and verification of a predictive nomogram to evaluate the risk of complicating ventricular tachyarrhythmia after acute myocardial infarction during hospitalization: A retrospective analysis

PURPOSE

The purpose of this study was to establish a nomogram to predict the risk of complicating ventricular tachyarrhythmia (VTA) in patients with acute myocardial infarction (AMI) during hospitalization and to verify the accuracy of the model.

CLINICAL INFORMATION AND METHOD

The authors enrolled the information of 503 patients who were diagnosed as AMI from January 2017 to December 2019. The cohort was randomly divided into a training set and a testing set at a ratio of 70%:30%. A total of 13 clinical indicators were screened by the least absolute shrinkage and selection operator (LASSO) regression and Boruta arithmetic independently in order to figure out the optimal feature variables. Multivariable logistic regression analysis was applied to establish the prediction model represented by a nomogram incorporating the selected feature variables. The performance of the nomogram was assessed by discrimination, calibration and clinical usefulness. C-Statistics with the area under the receiver operating characteristic curve (AUC), calibration curve and decision curve analysis were used to evaluate the identification ability, calibration and clinical practicability respectively. The prediction model was verified on the testing set to ensure its accuracy.

RESULTS

Five feature variables as percutaneous coronary intervention (PCI) timing after hospitalization, ejection fraction (EF), high-sensitive troponin T (hsTnT) score, infection and estimated glomerular filtration rate (eGFR) were selected by both LASSO regression and Boruta arithmetic. C-statistics with AUC was 0.764 (95% confidence interval: 0.690-0.838) in the training set while a slight increasing to 0.804 (95% confidence interval: 0.673-0.935) in the testing set. Calibration curve illustrated that the predicted and actually diagnosis of VTA probabilities were satisfactory on both training set and testing validation. Decision curve analysis indicated that the nomogram can be used in clinical settings as it has a threshold of between 4% to 90% along with a net benefit.

CONCLUSION

The nomogram with five variables is practical to clinicians in estimating the risk of complicating VTA after AMI during hospitalization.

Nomogram for contrast-induced acute kidney injury in patients with chronic kidney disease undergoing coronary angiography in China: a cohort study

OBJECTIVES

To establish a nomogram for contrast-induced acute kidney injury (CI-AKI) risk assessment among patients with chronic kidney disease (CKD) undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI).

DESIGN

Prospective observational cohort study.

SETTING

Southern China.

INTERVENTIONS

None.

PARTICIPANTS

643 consecutive patients with CKD (defined as estimated glomerular filtration rate calculated by Modification of Diet in Renal Disease formula <60 mL/min/1.73 mm2) were enrolled.

OUTCOME MEASURES

The end point was CI-AKI defined as serum creatinine elevation ≥0.5 mg/dL or 25% from baseline within the first 48-72 hours following contrast exposure.Predictors of CI-AKI were selected by multivariable logistic regression and stepwise approach. A nomogram based on these predictors was constructed and compared with the classic Mehran Score. For validation, a bootstrap method (1000 times) was performed.

RESULTS

The nomogram including age, weight, heart rate, hypotension, PCI and β-blocker demonstrated a better predictive value than the classic Mehran Score (area under the curve: 0.78 vs 0.71, p=0.024), as well as a well-fitted calibration curve (χ2=12.146, p=0.145). Validation through the bootstrap method (1000 times) also indicated a good discriminative power (adjusted C-statistic: 0.76).

CONCLUSIONS

With fewer predictors and higher discriminative power, the present nomogram may be a simple and reliable tool to identify patients with CKD at risk of CI-AKI, whereas further external validations are needed.

Meta-analysis of effect of renin-angiotensin-aldosterone system blockers on contrast-induced nephropathy

Background:

The purpose of this study was to systematically evaluate the effect of renin–angiotensin–aldosterone system blockers on the incidence of contrast-induced nephropathy in patients undergoing coronary angiography or percutaneous coronary intervention.

Methods:

A systematic literature search of several databases was conducted to identify studies that met the inclusion criteria. A total of 12 studies with 14 trials that performed studies on a total of 4864 patients (2484 treated with renin–angiotensin–aldosterone system blockers and 2380 in the control group) were included. The primary endpoint was the overall incidence of contrast-induced nephropathy. Analyses were performed with STATA version 12.0.

Results:

The overall contrast-induced nephropathy incidence in renin–angiotensin–aldosterone system blocker and control groups was 10.43% and 6.81%, respectively. The pooled relative risk of contrast-induced nephropathy incidence was 1.22 (95% confidence interval: 0.81–1.84) in the renin–angiotensin–aldosterone system blocker group. An increased risk of developing contrast-induced nephropathy in the renin–angiotensin–aldosterone system blocker group was observed among older people, non-Asians, chronic users, and studies with larger sample size, and the pooled RRs and 95% confidence intervals were 2.02 (1.21–3.36), 2.30 (1.41–3.76), 1.69 (1.10–2.59) and 1.83 (1.28–2.63), respectively.

Conclusions:

Intervention with renin–angiotensin–aldosterone system blockers was associated with an increased risk of contrast-induced nephropathy among non-Asians, chronic users, older people, and studies with larger sample size. Large clinical trials with strict inclusion criteria are needed to confirm our results and to evaluate the effect further.

Role of serum cystatin C in the prediction of contrast-induced nephropathy after intra-arterial interventions

Background

The diagnosis of contrast-induced nephropathy (CIN) is usually based on changes in serum creatinine (sCr). However, sCr has poor sensitivity as a biomarker of kidney injury. The aim of this study was to investigate the usefulness of serum cystatin C (sCysC) to predict CIN after intra-arterial interventions.

Methods

A total of 360 consecutive patients underwent intra-arterial procedures using digital subtraction angiography. SCr, sCysC, and estimated glomerular filtration rate were measured at 1 to 2 days before and at 48, 72 h, and 7 days after the procedure.

Results

Thirty-one patients (8.61%) developed CIN. Receiver operating characteristic (ROC) curve analysis showed that pre-operative sCysC levels had good discriminatory power (area under the curve [AUC] = 0.634; 95% confidence interval [CI] = 0.526–0.743) for evaluating the risk of CIN after an endovascular procedure, with a sensitivity of 53.33% and specificity of 73.70%. ROC analysis showed that sCysC at 48 h after contrast medium administration was predictive of CIN after an endovascular procedure (AUC = 0.735; 95% CI = 0.647–0.822) with satisfactory sensitivity of 74.20% and specificity of 63.90%. Diabetes mellitus was an independent risk factor for CIN (odds ratio = 2.778; 95% CI = 1.045–7.382; P = 0.040).

Conclusions

SCysC is an appropriate biomarker to predict the occurrence of CIN. Baseline sCysC before an intervention is useful to obtain a preliminary estimate of the risk of CIN. A 48-h cut-off value of sCysC of 0.99 mg/L after an endovascular procedure may help to rule out patients at lower risk of CIN.

Practical guide to prevention of contrast-induced acute kidney injury after percutaneous coronary intervention

Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.

Remote ischemic preconditioning reduces the incidence of contrast-induced nephropathy in patients undergoing coronary angiography/intervention: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

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

METHODS

We performed a comprehensive search on topics assessing RIPC and CIN in CAG/PCI patients from inception up until July 2019 through several electronic databases.

RESULTS

There were a total of 1,925 subjects from 14 randomized controlled trials. Remote ischemic preconditioning was associated with reduced CIN incidence in patients undergoing CAG/PCI (OR 0.41 [0.30, 0.55], p < .001; I² : 22%). The nephroprotective effect was also demonstrated in those at moderate-high risk for CIN subgroup (OR 0.41 [0.29, 0.58], p < .001; I² : 26%) and PCI-only subgroup (OR 0.41 [0.29, 0.58], p < .001; I² : 0%). Time from RIPC to CAG/PCI has similar effectiveness among ≤45, ≤60, and ≤120 min. Mortality, rehospitalization, hemodialysis, and major adverse events were lower in the RIPC group (OR 0.50 [0.33, 0.76], p = .001; I² : 0%). Grading of recommendations assessment, development and evaluation (GRADE) assessment showed that RIPC has high evidence certainty for reducing CIN in patients undergoing PCI/CAG, moderate-high risk subgroup, and PCI-only subgroup with absolute reduction of 97 per 1,000, 129 per 1,000, and 121 per 1,000, respectively. Harbord test showed no evidence for the presence of small-study effects (p = .157).

CONCLUSIONS

Remote ischemic preconditioning is an effective procedure to reduce the risk of CIN and should be considered in patients with moderate-high risk at developing CIN.

Increased urinary adiponectin level is associated with contrast-induced nephropathy in patients undergoing elective percutaneous coronary intervention

Background

Contrast-induced nephropathy (CIN) is one of major and serious complications in patients undergoing percutaneous coronary intervention (PCI). It is unknown whether increased urinary adiponectin (UAPN), a sensitive marker for early renal function impairment, is associated with an increased risk of CIN. Therefore, we prospectively investigate the association of UAPN with CIN.

Methods

We prospectively enrolled 208 patients who were undergoing elective PCI. The baseline UAPN was assessed prior to PCI. The ROC analysis was used to evaluate the predictive value of UAPN for CIN. Multivariate logistic regression analysis was performed to analyze the independent risk factors for CIN.

Results

Of 208 patients, CIN occurred in 19 patients (9.13%), and 6 of them (2.88%) required dialysis. Patients with CIN had a higher UAPN level than those without CIN (17.15 ± 12.36 vs. 10.29 ± 3.04 ng/ml, P < 0.01). ROC analysis showed that the optimal cutoff value of UAPN for predicting CIN was 12.24 ng/ml with 68.42% sensitivity and 76.72% specificity (AUC = 0.7204; 95% CI, 0.582–0.859; 푃< 0.01). Multivariate analysis demonstrated that UAPN (OR, 5.071; 95% CI,1.711–15.028; P < 0.01) and serum creatinine (Scr) > 124 μmol/L (OR, 4.210; 95% CI, 1.297–13.669; P < 0.01) were independently associated with CIN.

Conclusions

Our present study showed that a higher baseline UAPN (≥12.24 ng/ml) level was significantly associated with an increased risk for developing CIN post PCI.

Current Radiographic Iodinated Contrast Agents

Millions of radiologic examinations requiring the use of iodinated contrast are performed yearly in North America. Triiodobenzoic acid, the contrast agent molecule currently in use, is a benzene ring covalently bonded to the 3 iodine atoms. Iodinated contrast media can be divided in 4 categories: ionic monomers, ionic dimers, nonionic monomer, and nonionic dimers. Currently, second- and third-generation nonionic low-osmolar and iso-osmolar contrast media are used in clinical practice. The search for a safer and more effective iodinated contrast agents remains an ongoing challenge and important research topic.

Intravenous Contrast: Friend or Foe? A Review on Contrast-Induced Nephropathy

Intravenous iodinated contrast is used in many contrasted imaging studies ranging from computed tomography to angiography. The risks of contrast-induced nephropathy (CIN) and its incidence have not been clearly defined. Most iodinated contrast media used today are hypertonic compared with serum osmolality and pose biological risks. However, the risk of CIN in the general population may be overestimated. Confounding risk factors may contribute to acute kidney injury other than attributable risk of contrast exposure. In high-risk populations such as in those with CKD, CIN risk may be higher and thus caution should be exerted with contrast exposure. The volumes of contrast should be minimized as much as possible and hemodynamic status should be optimized before contrast administration.