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Nijssen EC, Nelemans PJ, Wildberger JE. Letter to the Editor: "Effects of intravenous hydration in preventing post-contrast acute kidney injury in patients with eGFR < 30 mL/min/1.73 m 2". Eur Radiol 2024; 34:2641-2643. [PMID: 37815604 DOI: 10.1007/s00330-023-10291-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/14/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Estelle C Nijssen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Patricia J Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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Ravn EJ, Hasific S, Thomassen M, Hjortebjerg R, Bach Laursen K, Diederichsen A, Bistrup C, Øvrehus KA. Intravenous versus oral hydration to reduce the risk of postcontrast acute kidney injury after intravenous contrast-enhanced CT in patients with severe chronic kidney disease (ENRICH): a study protocol for a single-centre, parallel-group, open-labelled non-inferiority randomised controlled trial in Denmark. BMJ Open 2023; 13:e074057. [PMID: 37699636 PMCID: PMC10503331 DOI: 10.1136/bmjopen-2023-074057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Contrast-enhanced CT (CECT) is widely used for diagnostic purposes. The use of contrast medium carries a risk for postcontrast acute kidney injury (PC-AKI), especially in patients with AKI or chronic kidney disease (CKD). Current guidelines recommend prophylactic intravenous hydration to prevent PC-AKI in high-risk patients. Oral hydration is non-inferior to intravenous hydration in patients with moderate CKD, but it has not been evaluated in high-risk patients. METHODS AND ANALYSIS The ENRICH trial will enrol 254 patients with estimated glomerular filtration rate ≤30 mL/min/1.73 m2 undergoing intravenous CECT, who are block randomised (2-4-2) with stratification for CKD stage, diabetes status, and indication for referral to prophylactic treatment with oral or intravenous hydration. PC-AKI is defined as an absolute increase in SCr of >0.3 mg/dL or >1.5 from baseline at 2-5 days. Renal function will also be evaluated <90 days, <7 days and 1-3 days before intravenous CECT, and 25-40 days after intravenous CECT. Secondary outcomes include dialysis, renal adverse events, hospitalisation due to hydration-related or contrast-related sequelae, and all-cause mortality ≤30 days postcontrast. Pre- and postcontrast plasma and urinary biomarkers will be evaluated for diagnostic and prognostic accuracy of the primary and secondary outcomes. ETHICS AND DISSEMINATION Oral hydration is patient-friendly and less costly compared with intravenous hydration. If oral hydration is non-inferior to intravenous hydration in high-risk patients, it could be implemented as new hydration strategy, which will facilitate the clinical diagnosing of elective patients with severe CKD without unnecessary resource utilisation. The protocol is approved by the Regional Scientific Ethical Committee for Southern Denmark (S-20210126), and the Data Protection Agency (21/66779). The study is conducted in accordance with the Declaration of Helsinki. Positive as well as negative findings will be reported in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05283512.
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Affiliation(s)
| | - Selma Hasific
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Mads Thomassen
- Clinical Genetics, University of Southern Denmark, Odense, Denmark
| | | | | | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Bistrup
- Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
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Zanardo M, Cozzi A, Cardani R, Renna LV, Pomati F, Asmundo L, Di Leo G, Sardanelli F. Reducing contrast agent residuals in hospital wastewater: the GREENWATER study protocol. Eur Radiol Exp 2023; 7:27. [PMID: 37142839 PMCID: PMC10160294 DOI: 10.1186/s41747-023-00337-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/09/2023] [Indexed: 05/06/2023] Open
Abstract
The potential enviromental impact of iodinated (ICAs) and gadolinium-based contrast agents (GBCAs) have recently come under scrutiny, considering the current nonselective wastewater treatment. However, their rapid excretion after intravenous administration could allow their potential recovery by targeting hospital sewage. The GREENWATER study aims to appraise the effective quantities of ICAs and GBCAs retrievable from patients' urine collected after computed tomography (CT) and magnetic resonance imaging (MRI) exams, selecting ICA/GBCA per-patient urinary excretion and patients' acceptance rate as study endpoints. Within a prospective, observational, single-centre, 1-year framework, we will enrol outpatients aged ≥ 18 years, scheduled to perform contrast-enhanced CT or MRI, willing to collect post-examination urine in dedicated canisters by prolonging their hospital stay to 1 h after injection. Collected urine will be processed and partially stored in the institutional biobank. Patient-based analysis will be performed for the first 100 CT and 100 MRI patients, and then, all analyses will be conducted on the pooled urinary sample. Quantification of urinary iodine and gadolinium will be performed with spectroscopy after oxidative digestion. The evaluation of the acceptance rate will assess the "environmental awareness" of patients and will aid to model how procedures to reduce ICA/GBCA enviromental impact could be adapted in different settings. Key points • Enviromental impact of iodinated and gadolinium-based contrast agents represents a growing point of attention.• Current wastewater treatment is unable to retrieve and recycle contrast agents.• Prolonging hospital stay may allow contrast agents retrieval from patients' urine.• The GREENWATER study will assess the effectively retrievable contrast agents' quantities.• The enrolment acceptance rate will allow to evaluate patients' "green sensitivity".
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Affiliation(s)
- Moreno Zanardo
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
| | - Andrea Cozzi
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Rosanna Cardani
- Biobank BioCor, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | - Luigi Asmundo
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Di Leo
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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4
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Long-term safety of withholding standard prophylaxis in patients with moderate chronic kidney disease. Eur Radiol 2022; 33:627-632. [PMID: 35763097 DOI: 10.1007/s00330-022-08959-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/29/2022] [Accepted: 06/08/2022] [Indexed: 11/04/2022]
Abstract
In the latest ESUR contrast media guidelines, standard prophylaxis is no longer recommended for patients with moderate chronic kidney disease (CKD). In the absence of solid evidence, guideline updates are often based on indirect evidence and expert opinion. Likewise, evidence supporting the withdrawal of standard prophylaxis in moderate CKD patients was scarce and mostly indirect, but did include one randomised controlled trial evaluating guideline-recommended standard prophylactic intravenous hydration against a group receiving no prophylaxis (A MAastricht Contrast-Induced Nephropathy Guideline (AMACING) trial). Since then, benefits of the updated guideline recommendation for patient and hospital burden have been numerated and were shown to be substantial. The current special report provides data on long-term safety from the AMACING randomised controlled trial. KEY POINTS: • In the latest version of ESUR clinical practice guidelines for safe use of contrast media, standard prophylaxis is no longer recommended for patients with moderate chronic kidney disease. • Benefits of this change in recommendations for patient and hospital burden have been numerated. The current report provides data on long-term safety from the AMACING randomised controlled trial. • No disadvantage of withholding prophylaxis could be discerned. Results suggest that, in this population, underlying disease is more relevant for survival and prognosis than contrast administration itself.
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Initial Experience Using Digital Variance Angiography in Context of Prostatic Artery Embolization in Comparison with Digital Subtraction Angiography. Acad Radiol 2022; 30:689-697. [PMID: 35688786 DOI: 10.1016/j.acra.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES In previous clinical studies digital variance angiography (DVA) provided higher contrast-to-noise ratio (CNR) and better image quality in lower extremity angiography than digital subtraction angiography (DSA). Our aim was to investigate whether DVA has similar quality reserve in prostatic artery embolization (PAE). The secondary aim was to explore the potential advantages of the color-coded DVA (ccDVA) technology in PAE. MATERIAL AND METHODS This retrospective study evaluated 108 angiographic acquisitions from 30 patients (mean ± SD age 68.0 ± 8.9, range 41-87) undergoing PAE between May and October 2020. DSA and DVA images were generated from the same unsubtracted acquisition, and their CNR was calculated. Visual evaluation of DVA and DSA image quality was performed by four experienced interventional radiologists in a randomized, blinded manner. The diagnostic value of DSA and ccDVA images was also evaluated using clinically relevant criteria (visibility of small [< 2.5 mm] and large arteries [> 2.5 mm], feeding arteries and tissue blush) in a paired comparison. Data were analysed by the Wilcoxon signed rank test or the binomial test, the interrater agreement was determined by the Kendall W or Fleiss Kappa analysis. RESULTS DVA provided 4.11 times higher median CNR than DSA (IQR: 1.72). The visual score of DVA images (4.40 ± 0.05) was significantly higher than that of DSA (3.39 ± 0.07, p < 0.001). The Kendall W analysis showed moderate but significant agreement (WDVA = 0.38, WDSA = 0.53). The preference of ccDVA images was significantly higher in all criteria (63-89%) with an interrater agreement of 58-79%. The Fleiss Kappa range was 0.02-0.18, significant in all criteria except large vessels. CONCLUSION Our data show that DVA provides higher CNR and better image quality in PAE. This quality reserve might be used for dose management (reduction of radiation dose and contrast agent volume), and ccDVA technology has also a high potential to assist PAE interventions in the future.
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Pein U, Fritz A, Markau S, Wohlgemuth WA, Girndt M. [Contrast media use in kidney disease - clinical practice recommendations]. Dtsch Med Wochenschr 2021; 146:1489-1495. [PMID: 34741294 DOI: 10.1055/a-1640-4503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Contrast media use in patients with renal disease regularly ensures discussions in everyday clinical practice. Both X-ray and MRI contrast media are predominantly eliminated by the kidneys and therefore closely linked to kidney function. Risk stratification prior to contrast media use in patients with pre-existing renal dysfunction should be based on eGFR-determination. Patients with an eGFR ≥ 30 ml/min require an individual risk assessment. In patients with advanced renal insufficiency ensuring euvolemia is crucial. Currently, there is no evidence for any other preventive approach. Therefore, no further specific procedures preventing contrast-associated kidney injury are recommended. Timing of contrast media injection and dialysis sessions in patients with end stage renal disease is necessary only after MRI contrast media use. Independently, acute kidney injury requires a patient individual decision.
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Affiliation(s)
- Ulrich Pein
- Universitätsklinik und Poliklinik für Innere Medizin II, Universitätsklinikum Halle (Saale)
| | - Annekathrin Fritz
- Universitätsklinik und Poliklinik für Innere Medizin II, Universitätsklinikum Halle (Saale)
| | - Silke Markau
- Universitätsklinik und Poliklinik für Innere Medizin II, Universitätsklinikum Halle (Saale)
| | - Walter A Wohlgemuth
- Department für Strahlenmedizin, Universitätsklinik und Poliklinik für Radiologie, Universitätsklinikum Halle (Saale)
| | - Matthias Girndt
- Universitätsklinik und Poliklinik für Innere Medizin II, Universitätsklinikum Halle (Saale)
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Liu X, Zhang P, Zhang J, Zhang X, Yang S, Fu N. The Preventive Effect of Alprostadil on the Contrast-Induced Nephropathy of Coronary Heart Disease Treated by Percutaneous Coronary Intervention in Moderate and High-Risk Population Stratified by Mehran Score. Angiology 2021; 73:33-41. [PMID: 34098771 DOI: 10.1177/00033197211015540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Mehran risk score (MRS) was used to classify patients with coronary heart disease and evaluate the preventive effect of alprostadil on contrast-induced nephropathy (CIN) after percutaneous coronary intervention. The patients (n = 1146) were randomized into an alprostadil and control group and then divided into 3 groups on the basis of the MRS: low-risk, moderate-risk, and high-risk groups. The primary end point was the occurrence of CIN (alprostadil + hydration vs simple hydration treatment); secondary end points included serum creatinine, blood urea nitrogen, creatinine clearance rate, cystatin C, interleukin-6, C-reactive protein, proteinuria, and differences in the incidence of major adverse events. In the low-risk, moderate-risk, and high-risk groups, the incidence of CIN in the control and alprostadil group was 2.9 versus 2.6% (P = .832), 11.4 versus 4.9% (P = .030), 19.1 versus 7.7% (P = .041), respectively. Multivariate logistic regression analysis showed that alprostadil treatment was a favorable protective factor for moderate-risk and high-risk CIN patients (OR = 0.343, 95% CI: 0.124-0.951, P = .040). Alprostadil can be used as a preventive treatment for moderate- and high-risk CIN patients classified by the MRS. The reduction of CIN by alprostadil may be related to an anti-inflammatory effect.
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Affiliation(s)
- Xiaogang Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Peng Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jing Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Xue Zhang
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Shicheng Yang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Naikuan Fu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
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Acute Kidney Injury After Radiocontrast-Enhanced Computerized Tomography in Hospitalized Patients With Advanced Renal Failure: A Propensity-Score-Matching Analysis. Invest Radiol 2021; 55:677-687. [PMID: 32101881 DOI: 10.1097/rli.0000000000000659] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The overall risk of postcontrast acute kidney injury (PC-AKI) after computerized tomography (CT) is negligible, likely because of the small volume of injected iodinated contrast media required. However, the safety of contrast media-enhanced CT in patients with advanced renal functional impairment, an established major risk factor for PC-AKI, is unknown. MATERIALS AND METHODS This is a retrospective study using large data analysis of hospitalized patients at a single center. Adults undergoing CT or magnetic resonance imaging were included in the study and were stratified by estimated glomerular filtration rate (eGFR) (≤30 or >30 mL/min/1.73 m) and by either contrast-enhanced or nonenhanced imaging. Only patients with serial determination of creatinine before and after imaging were included. Demographic, clinical, and laboratory data between groups were analyzed and compared using univariate analysis, propensity score matching, and multivariate logistic regression analysis. RESULTS A total of 22,319 imaging studies were included. Patients with an eGFR of 30 mL/min/1.73 m or lower undergoing contrast-enhanced CT (n = 403) had an increased risk to develop PC-AKI than did similar patients undergoing enhanced or nonenhanced magnetic resonance imaging (n = 96) or nonenhanced CT (n = 1576) or patients undergoing contrast-enhanced CT with a preprocedural eGFR higher than 30 mL/min/1.73 m (n = 9173). These findings remained robust after propensity matching for demographic, procedural, and clinical parameters. Multivariate regression analysis of all patients undergoing CT with preimaging eGFR of 30 mL/min or lower (n = 1979) revealed that iodine-based contrast enhancement increased the likelihood of post-CT AKI by 51% (confidence interval, 1.23-2.05). CONCLUSION Although radiocontrast-enhanced CT is considered safe in most hospitalized patients and in ambulatory settings, the risk of PC-AKI remains significant among inpatients with substantial preimaging renal functional impairment. Caution is warranted using iodine-based enhanced CT in hospitalized patients with an eGFR of 30 mL/min/1.73 m or lower.
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Latus J, Schwenger V, Schlieper G, Reinecke H, Hoyer J, Persson PB, Remppis BA, Mahfoud F. [Contrast medium-induced acute kidney injury-Consensus paper of the working group "Heart and Kidney" of the German Cardiac Society and the German Society of Nephrology]. Internist (Berl) 2020; 62:111-120. [PMID: 33349899 DOI: 10.1007/s00108-020-00938-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This consensus paper summarizes the expert consensus and recommendations of the working group "Heart and Kidney" of the German Cardiac Society (DGK) and the German Society of Nephrology (DGfN) on contrast medium-induced acute kidney injury. Potentially nephrotoxic contrast agents containing iodine are frequently used in interventional medicine and for computer tomography diagnostics. Acute kidney injury occurs in approximately 8-17% of patients exposed to contrast media. The risk factors and underlying pathophysiology are discussed and recommendations for the prophylaxis and treatment of contrast medium-induced acute nephropathy are presented.
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Affiliation(s)
- J Latus
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum der Landeshauptstadt Stuttgart, Stuttgart, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum der Landeshauptstadt Stuttgart, Stuttgart, Deutschland
| | - G Schlieper
- Zentrum für Nieren‑, Hochdruck- und Stoffwechselerkrankungen, Hannover, Deutschland
| | - H Reinecke
- Klinik für Kardiologie I: Koronare Herzkrankheit, Herzinsuffizienz und Angiologie, Universitätsklinik Münster, Münster, Deutschland
| | - J Hoyer
- Klinik für Innere Medizin, Nephrologie und Internistische Intensivmedizin, Universitätsklinikum Marburg, Marburg, Deutschland
| | - P B Persson
- Institute of Physiology, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - B A Remppis
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Deutschland
| | - F Mahfoud
- Klinik für Innere Medizin III, Kardiologie und Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, IMED, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland.
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Nijssen EC, Rennenberg R, Nelemans P, van Ommen V, Wildberger JE. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. ROFO-FORTSCHR RONTG 2020; 193:151-159. [PMID: 33327033 DOI: 10.1055/a-1248-9178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite tremendous improvement in molecular properties over the last century, intravascular injection of iodinated contrast material may still have systemic and hemodynamic consequences. Patients with pre-existing renal insufficiency may be at risk for acute kidney injury, which may be associated with an increased risk of the need for dialysis and mortality in the long term. Many questions as to the physiological pathways, optimal definition, and incidence of contrast-induced acute kidney injury remain open. These uncertainties are reflected in the changing landscape of this field in terms of nomenclature, research, and clinical practice. METHODS Clinical practice guidelines for the prevention of post-contrast acute kidney injury all recommend giving prophylaxis in the form of intravenous hydration to high-risk patients. Solid evidence for this strategy is lacking. This article gives an overview of the changing landscape of post-contrast acute kidney injury and prophylactic intravenous hydration, with the aim of supporting informed decision-making in clinical practice. RESULTS Recent data have caused a shift in guideline recommendations: 90 % of patients formerly considered high-risk for contrast-induced acute kidney injury no longer qualify for prophylaxis. The remaining high-risk patients, with severe chronic kidney disease, represent a vulnerable population for whom intravenous hydration may provide some benefits but also carries risk. CONCLUSION Intravenous hydration may benefit 'new' high-risk patients. However, it also confers risk. A dual approach to screening patients will help avoid this risk in clinical practice. KEY POINTS · Intravenous hydration is the cornerstone for preventing contrast-induced acute kidney injury. · Solid evidence is lacking; recent data caused a shift in guideline recommendations. · Intravenous hydration may benefit 'new' high-risk patients with severe chronic kidney disease; however, it also confers risk. · A dual approach to screening patients will help avoid this risk in clinical practice. CITATION FORMAT · Nijssen E, Rennenberg R, Nelemans P et al. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. Fortschr Röntgenstr 2021; 193: 151 - 159.
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Affiliation(s)
- Estelle Claire Nijssen
- Radiology & Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Roger Rennenberg
- Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Patty Nelemans
- Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Vincent van Ommen
- Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Joachim E Wildberger
- Radiology & Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
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11
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Óriás VI, Szöllősi D, Gyánó M, Veres DS, Nardai S, Csobay-Novák C, Nemes B, Kiss JP, Szigeti K, Osváth S, Sótonyi P, Ruzsa Z. Initial evidence of a 50% reduction of contrast media using digital variance angiography in endovascular carotid interventions. Eur J Radiol Open 2020; 7:100288. [PMID: 33294499 PMCID: PMC7683322 DOI: 10.1016/j.ejro.2020.100288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Digital Variance Angiography (DVA) is a novel medical image processing method. DVA provides better image quality than Digital Subtraction Angiography (DSA). The quality reserve of DVA allows the reduction of contrast agents in angiography.
Purpose In previous clinical studies Digital Variance Angiography (DVA) provided higher signal-to-noise ratio (SNR) and better image quality than Digital Subtraction Angiography (DSA). Our aim was to investigate whether this quality reserve of DVA provides an opportunity for the reduction of iodinated contrast media (ICM) in carotid X-ray angiography (CXA). Method Our prospective study enrolled 26 patients (67.0 ± 8.1 years) undergoing carotid percutaneous transluminal angioplasty. The SNR of DSA and DVA image pairs obtained by a standard (100 %, 6 mL ICM) or a low-dose (50 %, 3 mL ICM) protocol were compared. Visual evaluation of all images was performed by five specialists using a 5-grade rating scale. The quality of DSA100 and DVA50 videos was also compared. Results DVA provided more than two-fold SNR, the median SNRDVA/SNRDSA ratio was 2.06 (100 %) and 2.25 (50 %). In the visual evaluation, the DVA100 score (3.73 ± 0.06) was significantly higher than the DSA100 score (3.52 ± 0.07, Wilcoxon p < 0.001), and the DVA50 score (3.64 ± 0.13) was also significantly higher than the DSA50 score (3.01 ± 0.17, Wilcoxon p < 0.001). While the low-dose protocol significantly decreased the DSA score (Mann-Whitney p < 0.01, DSA100 vs DSA50), it had no effect on the DVA score (DVA100 vs DVA50). There was no statistical difference between the DSA100 and DVA50 scores. Evaluators preferred the diagnostic value of DVA50 to DSA100 videos in 61% of comparisons, the interrater agreement was 69 % (Fleiss’ kappa 0.35, p < 0.001) Conclusions Our data show that DVA allows a substantial (50 %) ICM reduction in CXA without affecting the quality and diagnostic value of angiograms.
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Affiliation(s)
- Viktor I Óriás
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Bács-Kiskun County Hospital, 6000, Nyíri út 38, Kecskemét, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Dávid Szöllősi
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Marcell Gyánó
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Dániel S Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Sándor Nardai
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Csaba Csobay-Novák
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Balázs Nemes
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - János P Kiss
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary
| | - Krisztián Szigeti
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Szabolcs Osváth
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Péter Sótonyi
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Zoltán Ruzsa
- Bács-Kiskun County Hospital, 6000, Nyíri út 38, Kecskemét, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
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12
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Porta C, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Małyszko J. KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancer. Kidney Int 2020; 98:1108-1119. [PMID: 33126977 DOI: 10.1016/j.kint.2020.06.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022]
Abstract
The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.
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Affiliation(s)
- Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland.
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Zhang X, Zhang P, Yang S, Li W, Men X, Fu N. Preventive effect of trimetazidine on contrast-induced nephropathy undergoing percutaneous coronary intervention in elderly moderate and high risk diabetics stratified by mehran score. Perfusion 2020; 36:491-500. [PMID: 32838661 DOI: 10.1177/0267659120952057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this research was to use the Mehran risk score to classify elderly diabetics with coronary heart disease to assess the preventive effect of trimetazidine on contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) in different risk population. METHODS An uncompromised of 760 elderly diabetics that went through PCI were included in this research. The patients were first divided into three groups in the light of MRS: low-risk, moderate-risk, and high-risk group, then randomized into trimetazidine group and the control group respectively. The first endpoint was the amount of CIN, which is described as a rise in serum creatinine levels by ⩾44.2 μmol/L or ⩾25% ratio within 48 or 72 hours after medication. Second endpoint included differences in creatinine clearance rate (CrCl), blood urea nitrogen (BUN), serum creatinine (Scr), cystatin-C (Cys-C), and the incidence of major adverse events after administration. RESULTS In the three groups, the incidence of CIN in trimetazidine and control group was 5.0% versus 4.9%(χ2 = 0.005, p > 0.05), 8.0% versus 18.0% (χ2 = 7.685, p < 0.05), 10.4% versus 27.1% (χ2 = 4.376, p < 0.05), respectively. The multivariable logistic regression result demonstrated that trimetazidine intervention was a profitable element of CIN in moderate and high-risk groups (OR = 0.294, 95% CI 0.094-0.920, p = 0.035). CONCLUSION Our study confirmed that trimetazidine can be considered for preventive treatment of CIN occurrence in elderly diabetics with moderate and high-risk population, while there is no obvious advantage compared with hydration therapy in low-risk patients.
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Affiliation(s)
- Xue Zhang
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Peng Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Shicheng Yang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Wenyuan Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Xiuzhen Men
- Department of Catheter lab, Dongying Second People's Hospital, Shandong,China
| | - Naikuan Fu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
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Corbett M, Duarte A, Llewellyn A, Altunkaya J, Harden M, Harris M, Walker S, Palmer S, Dias S, Soares M. Point-of-care creatinine tests to assess kidney function for outpatients requiring contrast-enhanced CT imaging: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-248. [PMID: 32840478 PMCID: PMC7475798 DOI: 10.3310/hta24390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with low estimated glomerular filtration rates may be at higher risk of post-contrast acute kidney injury following contrast-enhanced computed tomography imaging. Point-of-care devices allow rapid measurement of estimated glomerular filtration rates for patients referred without a recent estimated glomerular filtration rate result. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of point-of-care creatinine tests for outpatients without a recent estimated glomerular filtration rate measurement who need contrast-enhanced computed tomography imaging. METHODS Three systematic reviews of test accuracy, implementation and clinical outcomes, and economic analyses were carried out. Bibliographic databases were searched from inception to November 2018. Studies comparing the accuracy of point-of-care creatinine tests with laboratory reference tests to assess kidney function in adults in a non-emergency setting and studies reporting implementation and clinical outcomes were included. Risk of bias of diagnostic accuracy studies was assessed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Probabilities of individuals having their estimated glomerular filtration rates correctly classified were estimated within a Bayesian framework and pooled using a fixed-effects model. A de novo probabilistic decision tree cohort model was developed to characterise the decision problem from an NHS and a Personal Social Services perspective. A range of alternative point-of-care testing approaches were considered. Scenario analyses were conducted. RESULTS Fifty-four studies were included in the clinical reviews. Twelve studies reported diagnostic accuracy for estimated glomerular filtration rates; half were rated as being at low risk of bias, but there were applicability concerns for most. i-STAT (Abbott Point of Care, Inc., Princeton, NJ, USA) and ABL (Radiometer Ltd, Crawley, UK) devices had higher probabilities of correctly classifying individuals in the same estimated glomerular filtration rate categories as the reference laboratory test than StatSensor® devices (Nova Biomedical, Runcorn, UK). There was limited evidence for epoc® (Siemens Healthineers AG, Erlangen, Germany) and Piccolo Xpress® (Abaxis, Inc., Union City, CA, USA) devices and no studies of DRI-CHEM NX 500 (Fujifilm Corporation, Tokyo, Japan). The review of implementation and clinical outcomes included six studies showing practice variation in the management decisions when a point-of-care device indicated an abnormal estimated glomerular filtration rate. The review of cost-effectiveness evidence identified no relevant studies. The de novo decision model that was developed included a total of 14 strategies. Owing to limited data, the model included only i-STAT, ABL800 FLEX and StatSensor. In the base-case analysis, the cost-effective strategy appeared to be a three-step testing sequence involving initially screening all individuals for risk factors, point-of-care testing for those individuals with at least one risk factor, and including a final confirmatory laboratory test for individuals with a point-of-care-positive test result. Within this testing approach, the specific point-of-care device with the highest net benefit was i-STAT, although differences in net benefit with StatSensor were very small. LIMITATIONS There was insufficient evidence for patients with estimated glomerular filtration rates < 30 ml/minute/1.73 m2, and on the full potential health impact of delayed or rescheduled computed tomography scans or the use of alternative imaging modalities. CONCLUSIONS A three-step testing sequence combining a risk factor questionnaire with a point-of-care test and confirmatory laboratory testing appears to be a cost-effective use of NHS resources compared with current practice. The risk of contrast causing acute kidney injury to patients with an estimated glomerular filtration rate of < 30 ml/minute/1.73 m2 is uncertain. Cost-effectiveness of point-of-care testing appears largely driven by the potential of point-of-care tests to minimise delays within the current computed tomography pathway. FUTURE WORK Studies evaluating the impact of risk-stratifying questionnaires on workflow outcomes in computed tomography patients without recent estimated glomerular filtration rate results are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42018115818. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 39. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Mark Corbett
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Ana Duarte
- Centre for Health Economics (CHE), University of York, York, UK
| | - Alexis Llewellyn
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - James Altunkaya
- Centre for Health Economics (CHE), University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Martine Harris
- Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Wakefield, UK
| | - Simon Walker
- Centre for Health Economics (CHE), University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics (CHE), University of York, York, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Marta Soares
- Centre for Health Economics (CHE), University of York, York, UK
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Initial Operating Room Experience with Digital Variance Angiography in Carbon Dioxide-Assisted Lower Limb Interventions: A Pilot Study. Cardiovasc Intervent Radiol 2020; 43:1226-1231. [PMID: 32476034 PMCID: PMC7369257 DOI: 10.1007/s00270-020-02530-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/15/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE In retrospective clinical studies digital variance angiography (DVA) provided higher contrast-to-noise ratio and better image quality than digital subtraction angiography (DSA). Our aim was to verify the clinical usefulness and benefits of DVA in carbon dioxide (CO2)-assisted lower limb interventions. MATERIALS AND METHODS A workstation running the DVA software was integrated into a Siemens Artis Zee with Pure angiography system, and this new image processing technology was used in four patients (3 male, 1 female, age: 76.2 ± 4.2 years) with peripheral artery disease (PAD, Rutherford 2-3) and impaired renal function (average eGFR 25.5 ± 11.2 ml/min/1.73 m2). The DSA and DVA images of 46 CO2-assisted runs were visually evaluated by five experts in single-image evaluation using a 5-grade Likert scale and in paired comparisons. RESULTS DVA images received significantly higher score (3.84 ± 0.10) than DSA images (3.31 ± 0.10, p < 0.001). Raters preferred DVA images in terms of diagnostic value and usefulness for therapeutic decisions in 85.2% and 83.9% of all comparisons, respectively. These benefits were achieved at lower frame rates (1-3 FPS) than usually recommended for CO2 angiography (4-6 FPS). No adverse events were recorded during or after the procedures. CONCLUSIONS Our initial experience shows that DVA might facilitate the correct diagnostic and therapeutic decisions, and potentially help to reduce radiation exposure in lower limb CO2 angiography. Although the dose management capabilities of DVA have to be validated in further clinical studies, this technology might be a useful new tool in the operating room and contributes to the safety and efficacy of CO2-enhanced endovascular interventions. LEVEL OF EVIDENCE Level IV.
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Use of Contrast Medium Volume to Guide Prophylactic Hydration to Prevent Acute Kidney Injury After Contrast Administration: A Meta-Analysis. AJR Am J Roentgenol 2020; 215:15-24. [PMID: 32348183 DOI: 10.2214/ajr.19.22325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE. The purpose of this study was to determine whether contrast medium volume and method of administration and baseline estimated glomerular filtration rate influence the efficacy of prophylactic hydration for prevention of acute kidney injury after contrast administration. MATERIALS AND METHODS. An online search of PubMed conducted on August 25, 2017, produced a total of 697 studies. After the reports were reviewed, nine were included in this study. The extracted data on all patients in these studies were separated into a group that received prophylactic hydration and a group that did not. The following three parameters were used for subgroup analysis: contrast medium volume, contrast administration method, and baseline estimated glomerular filtration rate. The t test was performed, and study-level odds ratios with 95% CIs and p values were calculated. Tests of heterogeneity were conducted. RESULTS. When the volume of contrast agent administered exceeded 100 mL, hydration was beneficial in the prevention of contrast-induced acute kidney injury (odds ratio, 0.546). If the volume was less than 100 mL, hydration had no efficacy in preventing contrast-induced acute kidney injury (odds ratio, 0.917). Administration route and baseline estimated glomerular filtration rate exerted no effect on the efficacy of prophylactic hydration. CONCLUSION. For patients who receive less than 100 mL of contrast medium, the prevalent practice for contrast-enhanced CT studies, prophylactic hydration may not be necessary, regardless of the estimated glomerular filtration rate or route of contrast administration. For patients undergoing procedures requiring administration of large volumes of contrast medium, however, hydration is recommended to prevent contrast-induced acute kidney injury.
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Nijssen EC, Nelemans PJ, Rennenberg RJ, van der Molen AJ, van Ommen GV, Wildberger JE. Impact on clinical practice of updated guidelines on iodinated contrast material: CINART. Eur Radiol 2020; 30:4005-4013. [PMID: 32107605 PMCID: PMC7305084 DOI: 10.1007/s00330-020-06719-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
Objective Guidelines on safe use of iodinated contrast material recommend intravenous prophylactic hydration to prevent post-contrast adverse (renal) effects. Recently, guidelines have been updated and standard prophylaxis is no longer recommended for the majority of patients. The current study aims to evaluate the consequences for clinical practice of the updated guidelines in terms of complications, hospitalisations, and costs. Methods The Contrast-Induced Nephropathy After Reduction of the prophylaxis Threshold (CINART) project is a retrospective observational study. All elective procedures with intravascular iodinated contrast administration at Maastricht University Medical Centre (UMC+) in patients aged > 18 years, formerly eligible for prophylaxis (eGFR 30–44 ml/min/1.73 m2 or eGFR 45–59 ml/min/1.73 m2 in combination with diabetes or > 1 predefined risk factor), and currently eligible for prophylaxis (eGFR < 30 ml/min/1.73 m2) were included. Data were used to calculate relative reductions in complications, hospitalisations, and costs associated with standard prophylactic intravenous hydration. CINART is registered with Clinicaltrials.gov: NCT03227835. Results Between July 1, 2017, and July 1, 2018, 1992 elective procedures with intravascular iodinated contrast in patients formerly and currently eligible for prophylaxis were identified: 1808 in patients formerly eligible for prophylaxis and 184 in patients currently eligible for prophylaxis. At Maastricht UMC+, guideline updates led to large relative reductions in numbers of complications of prophylaxis (e.g. symptomatic heart failure; − 89%), extra hospitalisations (− 93%), and costs (− 91%). Conclusion Guideline updates have had a demonstrable impact on daily clinical practice benefiting patient, hospital, and health care budgets. Clinical practice varies between institutions and countries; therefore, a local estimation model is provided with which local impact on costs, hospitalisations, and complications can be calculated. Key Points • Clinical practice guidelines recommend prophylactic intravenous hydration to prevent post-contrast adverse outcomes such as contrast-induced acute kidney injury. • Clinical practice guidelines have recently been updated, and standard prophylaxis is no longer recommended for the majority of patients. • The guideline updates have a large impact on daily clinical practice: relative reductions at Maastricht UMC+ were − 89% prophylaxis complications, − 93% hospitalisations, and − 91% costs, and similar reductions are expected for Dutch and adherent European medical centres. Electronic supplementary material The online version of this article (10.1007/s00330-020-06719-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E C Nijssen
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - P J Nelemans
- Department of Epidemiology, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - R J Rennenberg
- Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - A J van der Molen
- Department of Radiology, Leiden University Medical Centre, Postal zone C-2S, 2333 ZA, Leiden, The Netherlands
| | - G V van Ommen
- Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - J E Wildberger
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
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Abstract
OBJECTIVES Our aim was to investigate the feasibility of digital variance angiography (DVA) in lower extremity CO2 angiography and to compare the quantitative and qualitative performance of the new image processing technique with that of the current reference standard digital subtraction angiography (DSA). MATERIALS AND METHODS This prospective study enrolled 24 patients (mean age ± SD, 65.5 ± 9.2 years; 14 males, 65.1 ± 7.5 years; 10 females, 66.1 ± 11.6 years) undergoing lower-limb CO2 angiography between December 2017 and April 2018 at 2 clinical centers: The Heart and Vascular Center (HVC) of Semmelweis University, Budapest (7 patients), and the Bács-Kiskun County Hospital (BKCH) in Kecskemét (17 patients). The interventional protocol was similar at both sites, but the image acquisition instruments and protocols were different, which allowed us to investigate DVA in different settings. For comparison, the signal-to-noise ratio (SNR) of DSA and DVA images were calculated. The visual quality of DSA and DVA images were compared by independent clinical specialists using an online questionnaire. Interrater agreement was characterized by percent agreement and Fleiss kappa. The specialists also evaluated in a random and blinded manner the individual DSA and DVA images on a 5-grade scale ranging from poor (1) to outstanding (5) image quality, and the mean ± standard error of mean (SEM) was calculated. RESULTS A total of 4912 regions of interest were carefully selected in 110 image pairs to determine the SNRs. The ratio of SNRDVA/SNRDSA was calculated. At HVC, it ranged between 2.58 and 4.16 in the anatomical regions (abdominal, iliac, femoral, popliteal, crural, talar), and the overall median value was 3.53, whereas at BKCH the range was 2.71 to 4.92 and the overall median value was 4.52. During the visual evaluation, 120 DSA and DVA image pairs were compared. At HVC in 78%, although at BKCH in 90% of comparisons, it was judged that DVA provided higher quality images. The interrater agreement was 88% (P < 0.001) and 90% (P < 0.01), respectively. DVA images received consistently higher individual rating than DSA images, regardless of the research site and anatomical region. At HVC, the overall DSA and DVA scores (mean ± SEM) were 2.75 ± 0.12 and 3.23 ± 0.16, respectively (P < 0.05), whereas at BKCH these values were 2.49 ± 0.10 and 3.03 ± 0.09, respectively (P < 0.001). CONCLUSIONS These data show that lower-limb CO2 angiography DVA, regardless of the image acquisition instruments and protocols, produces higher SNR and significantly better image quality than DSA; therefore this new image processing technique might help the widespread use of CO2 as a safer contrast agent in clinical practice.
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Negligible Risk of Acute Renal Failure Among Hospitalized Patients After Contrast-Enhanced Imaging With Iodinated Versus Gadolinium-Based Agents. Invest Radiol 2019; 54:312-318. [PMID: 30480553 DOI: 10.1097/rli.0000000000000534] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The potential adverse renal outcome among patients undergoing iodine-based contrast-enhanced computerized tomography (CT) has been questioned recently, given the caution undertaken in patients' selection, hydration protocols, and the low radiocontrast volume, used with advanced imaging equipment. MATERIALS AND METHODS This study is a retrospective assessment of renal outcome in 12,580 hospitalized patients undergoing contrast-enhanced CT, compared with 754 patients subjected to gadolinium-based magnetic resonance imaging, with subsequent propensity matching for clinical characteristics and potential risk factors. RESULTS The risk of postcontrast acute kidney injury (PC-AKI) was found to be negligible as compared with patients undergoing enhanced magnetic resonance imaging studies, before and after propensity matching (8% vs 7.3% rate of AKI in the nonmatched iodine-based contrast agents [IBCAs] and gadolinium-based contrast agents [GBCAs], respectively, P = 0.3, and 7% in the matched IBCA group, P = 0.9), including comparisons among subgroups with well-defined risk factors such as chronic renal failure, diabetes, older age, and hypertension. However, lower systolic blood pressure before imaging was associated with higher risk to develop PC-AKI after IBCA administration but not with GBCA (for systolic blood pressure lower than 110 mm Hg, odds ratio for AKI after IBCA was 1.49; 95% confidence interval, 1.16-1.88, and after GBCA; odds ratio, 0.12; 95% confidence interval, 0.003-0.73). CONCLUSIONS With the current precautions undertaken, the real-life risk of PC-AKI among inpatients undergoing CT is insignificant. Possible reasons for the diverse impact of blood pressure on the propensity to develop acute kidney failure after iodine-based but not gadolinium-based enhancement imaging are discussed.
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Cunha-Silva H, Arcos-Martinez MJ. Cathodic stripping voltammetric determination of iodide using disposable sensors. Talanta 2019; 199:262-269. [DOI: 10.1016/j.talanta.2019.02.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 02/07/2023]
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Nijssen EC, Nelemans PJ, Rennenberg RJ, van Ommen V, Wildberger JE. Prophylactic Intravenous Hydration to Protect Renal Function From Intravascular Iodinated Contrast Material (AMACING): Long-term Results of a Prospective, Randomised, Controlled Trial. EClinicalMedicine 2018; 4-5:109-116. [PMID: 31193613 PMCID: PMC6537536 DOI: 10.1016/j.eclinm.2018.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/28/2018] [Accepted: 10/25/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of A MAastricht Contrast-Induced Nephropathy Guideline (AMACING) trial was to evaluate non-inferiority of no prophylaxis compared to guideline-recommended prophylaxis in preventing contrast induced nephropathy (CIN), and to explore the effect on long-term post-contrast adverse outcomes. The current paper presents the long-term results. METHODS AMACING is a single-centre, randomised, parallel-group, open-label, phase 3, non-inferiority trial in patients with estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m2 combined with risk factors, undergoing elective procedures requiring intravenous or intra-arterial iodinated contrast material. Exclusion criteria were eGFR < 30 mL/min/1.73 m2, dialysis, no referral for prophylaxis. The outcomes dialysis, mortality, and change in renal function at 1 year post-contrast were secondary outcomes of the trial. Subgroup analyses were performed based on pre-defined stratification risk factors. AMACING is registered with ClinicalTrials.gov: NCT02106234. FINDINGS From 28,803 referrals, 1120 at-risk patients were identified. 660 consecutive patients agreed to participate and were randomly assigned (1:1) to no prophylaxis (n = 332) or standard prophylactic intravenous hydration (n = 328). Dialysis and mortality data were available for all patients. At 365 days post-contrast dialysis was recorded in two no prophylaxis (2/332, 0.60%), and two prophylaxis patients (2/328, 0.61%; p = 0.9909); mortality was recorded for 36/332 (10.84%) no prophylaxis, and 32/328 (9.76%) prophylaxis patients (p = 0.6490). The hazard ratio was 1.118 (no prophylaxis vs prophylaxis) for one-year risk of death (95% CI: 0.695 to 1.801, p = 0.6449). The differences in long-term changes in serum creatinine were small between groups, and gave no indication of a disadvantage for the no-prophylaxis group. INTERPRETATION Assuming optimal contrast administration, not giving prophylaxis to elective patients with eGFR 30-59 mL/min/1.73 m2 is safe, even in the long-term. FUNDING Stichting de Weijerhorst.
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Affiliation(s)
- Estelle C. Nijssen
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, 6202 AZ Maastricht, the Netherlands
| | - Patty J. Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, 6202 AZ Maastricht, the Netherlands
| | - Roger J. Rennenberg
- Department of Internal Medicine, Maastricht University Medical Centre, 6202 AZ Maastricht, the Netherlands
| | - Vincent van Ommen
- Department of Cardiology, Maastricht University Medical Centre, 6202 AZ Maastricht, the Netherlands
| | - Joachim E. Wildberger
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, 6202 AZ Maastricht, the Netherlands
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