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Griffiths RI, Bhave A, McGovern AM, Hargens LM, Solid CA, Amin AP. Clinical and economic outcomes of assigning percutaneous coronary intervention patients to contrast-sparing strategies based on the predicted risk of contrast-induced acute kidney injury. J Med Econ 2024; 27:663-670. [PMID: 38632967 DOI: 10.1080/13696998.2024.2334180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Contrast-sparing strategies have been developed for percutaneous coronary intervention (PCI) patients at increased risk of contrast-induced acute kidney injury (CI-AKI), and numerous CI-AKI risk prediction models have been created. However, the potential clinical and economic consequences of using predicted CI-AKI risk thresholds for assigning patients to contrast-sparing regimens have not been evaluated. We estimated the clinical and economic consequences of alternative CI-AKI risk thresholds for assigning Medicare PCI patients to contrast-sparing strategies. METHODS Medicare data were used to identify inpatient PCI from January 2017 to June 2021. A prediction model was developed to assign each patient a predicted probability of CI-AKI. Multivariable modeling was used to assign each patient two marginal predicted values for each of several clinical and economic outcomes based on (1) their underlying clinical and procedural characteristics plus their true CI-AKI status in the data and (2) their characteristics plus their counterfactual CI-AKI status. Specifically, CI-AKI patients above the predicted risk threshold for contrast-sparing were reassigned their no CI-AKI (counterfactual) outcomes. Expected event rates, resource use, and costs were estimated before and after those CI-AKI patients were reassigned their counterfactual outcomes. This entailed bootstrapped sampling of the full cohort. RESULTS Of the 542,813 patients in the study cohort, 5,802 (1.1%) had CI-AKI. The area under the receiver operating characteristic curve for the prediction model was 0.81. At a predicted risk threshold for CI-AKI of >2%, approximately 18.0% of PCI patients were assigned to contrast-sparing strategies, resulting in (/100,000 PCI patients) 121 fewer deaths, 58 fewer myocardial infarction readmissions, 4,303 fewer PCI hospital days, $11.3 million PCI cost savings, and $25.8 million total one-year cost savings, versus no contrast-sparing strategies. LIMITATIONS Claims data may not fully capture disease burden and are subject to inherent limitations such as coding inaccuracies. Further, the dataset used reflects only individuals with fee-for-service Medicare, and the results may not be generalizable to Medicare Advantage or other patient populations. CONCLUSIONS Assignment to contrast-sparing regimens at a predicted risk threshold close to the underlying incidence of CI-AKI is projected to result in significant clinical and economic benefits.
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Affiliation(s)
| | | | | | | | | | - Amit P Amin
- Rush College of Medicine, Rush University Medical Center, Chicago, IL, USA
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Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, Lin Y, Sokolowski A, Hoss A, Heinen Y, Schulze V, Icks A, Jung C, Kelm M, Wolff G. National Cardiovascular Data Registry-Acute Kidney Injury (NCDR) vs. Mehran risk models for prediction of contrast-induced nephropathy and need for dialysis after coronary angiography in a German patient cohort. J Nephrol 2021; 34:1491-1500. [PMID: 34363595 PMCID: PMC8494719 DOI: 10.1007/s40620-021-01124-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) is a major adverse event in patients undergoing coronary angiography. The Mehran risk model is the gold-standard for CIN risk prediction. However, its performance in comparison to more contemporary National Cardiovascular Data Registry-Acute Kidney Injury (NCDR-AKI) risk models remains unknown. We aimed to compare both in this study. METHODS AND RESULTS Predictions of Mehran and NCDR-AKI risk models and clinical events of CIN and need for dialysis were assessed in a total of 2067 patients undergoing coronary angiography with or without percutaneous coronary intervention. Risk models were compared regarding discrimination (receiver operating characteristic analysis), net reclassification improvement (NRI) and calibration (graphical and statistical analysis). The NCDR risk model showed superior risk discrimination for predicting CIN (NCDR c-index 0.75, 95% CI 0.72-0.78; vs. Mehran c-index 0.69, 95% CI 0.66-0.72, p < 0.01), and continuous NRI (0.22; 95% CI 0.12-0.32; p < 0.01) compared to the Mehran model. The NCDR risk model tended to underestimate the risk of CIN, while the Mehran model was more evenly calibrated. For the prediction of need for dialysis, NCDR-AKI-D also discriminated risk better (c-index 0.85, 95% CI 0.79-0.91; vs. Mehran c-index 0.75, 95% CI 0.66-0.84; pNCDRvsMehran < 0.01), but continuous NRI showed no benefit and calibration analysis revealed an underestimation of dialysis risk. CONCLUSION In German patients undergoing coronary angiography, the modern NCDR risk model for predicting contrast-induced nephropathy showed superior discrimination compared to the GRACE model while showing less accurate calibration. Results for the outcome 'need for dialysis' were equivocal.
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Affiliation(s)
- Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lucin Kosejian
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Julia Quade
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jennifer Tröstler
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Selina Bader
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Sokolowski
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Hoss
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Yvonne Heinen
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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Zhang F, Lu Z, Wang F. Advances in the pathogenesis and prevention of contrast-induced nephropathy. Life Sci 2020; 259:118379. [PMID: 32890604 DOI: 10.1016/j.lfs.2020.118379] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/18/2020] [Accepted: 08/31/2020] [Indexed: 12/11/2022]
Abstract
With the increasing application of medical imaging contrast materials, contrast-induced nephropathy has become one of the leading causes of iatrogenic renal insufficiency. The underlying mechanism is associated with renal medullary hypoxia, direct toxicity of contrast agents, oxidative stress, apoptosis, immune/inflammation and epigenetic regulation in contrast-induced nephropathy. Up to date, there is no effective therapy for contrast-induced nephropathy, and thus risk predication and effective preventive strategies are keys to reduce the occurrence of contrast-induced nephropathy. It was found that the proper use of contrast medium, personalized hydration, and high-dose statins may reduce the occurrence of contrast-induced nephropathy, while antioxidants have not shown significant therapeutic benefits. Additionally, the role of remote ischemia preconditioning and vasodilators in the prevention of contrast-induced nephropathy needs further study. This review aims to discuss the incidence, pathogenesis, risk prediction, and preventive strategies for contrast-induced nephropathy.
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Affiliation(s)
- Fangfei Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Zeyuan Lu
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Feng Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China.
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Takahashi EA, Kallmes DF, Mara KC, Harmsen WS, Misra S. Nephrotoxicity of gadolinium-based contrast in the setting of renal artery intervention: retrospective analysis with 10-year follow-up. ACTA ACUST UNITED AC 2019; 24:378-384. [PMID: 30406762 DOI: 10.5152/dir.2018.18172] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE We aimed to determine the incidence rate and potential risk factors for postcontrast acute kidney injury (PC-AKI) as well as the long-term clinical implications on dialysis and mortality in patients with chronic kidney disease (CKD) who underwent renal artery stent placement exclusively with gadolinium-based contrast agents. METHODS This retrospective study reviewed 412 patients with CKD who underwent renal artery stent placement. Sixty-eight patients underwent intervention exclusively with gadolinium-based contrast agents and were analyzed. Criteria for PC-AKI included either an absolute serum creatinine increase >0.3 mg/dL or percentage increase in serum creatinine >50% within 48 hours of intervention. Logistic regression analysis was performed to identify risk factors for PC-AKI. The cumulative proportion of patients who died or went on to hemodialysis was determined using Kaplan-Meier survival analysis. RESULTS The incidence of PC-AKI was 14.7%. The rate of AKI decreased for every 1 unit increase in glomerular filtration rate ( GFR, odds ratio [OR]=0.91, P = 0.047). Prehydration was associated with a lower PC-AKI rate (OR=0.17; P = 0.015). Acute kidney injury after intervention was associated with an increased rate of dialysis (Hazard ratio [HR]=4.51, P = 0.002) and mortality (HR=2.52; P = 0.027). CONCLUSION Gadolinium-based contrast agents are potentially nephrotoxic when used for endovascular intervention in patients with CKD. The risk of PC-AKI increased with lower GFR and decreased with prehydration. Dialysis and mortality risk were increased in patients who developed PC-AKI.
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Affiliation(s)
| | | | - Kristin C Mara
- Department of Clinical Statistics, Mayo Clinic, Minnesota, USA
| | - William S Harmsen
- Department of Radiology, Mayo Clinic, Department of Clinical Statistics, Mayo Clinic, Minnesota, USA
| | - Sanjay Misra
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, Minnesota, USA
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Li Y, Liu H, Peng W, Song Z. Nicorandil improves clinical outcomes in patients with stable angina pectoris requiring PCI: a systematic review and meta-analysis of 14 randomized trials. Expert Rev Clin Pharmacol 2018; 11:855-865. [PMID: 30079778 DOI: 10.1080/17512433.2018.1508342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Yiliang Li
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
- Clinical Medicine, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Hai Liu
- Third Department of Cardiac Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Peng
- Department of Cardiology, The Central Hospital of Loudi Affiliated to the University of South China, Loudi, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
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Di Serafino L, Turturo M, Lanzone S, Marano M, Scognamiglio G, Trimarco B, Cirillo P, Esposito G, D'Agostino C. Comparison of the Effect of Dual-Axis Rotational Coronary Angiography Versus Conventional Coronary Angiography on Frequency of Acute Kidney Injury, X-Ray Exposure Time, and Quantity of Contrast Medium Injected. Am J Cardiol 2018. [PMID: 29519544 DOI: 10.1016/j.amjcard.2018.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Dual-axis rotational coronary angiography (DARCA) has already been shown to reduce both the amount of contrast medium and radiation exposure compared with conventional coronary angiography (CCA). However, a clinical benefit of such imaging modality has never been demonstrated. The aim of this study was to evaluate the efficacy of DARCA to prevent acute kidney injury (AKI) compared with CCA. Consecutive patients who underwent coronary angiography were enrolled to DARCA (n = 80) or CCA (n = 80). Patients presenting with ST-segment elevation myocardial infarction or previously underwent coronary artery bypass graft were excluded. The 2 groups were homogeneous in terms of both clinical and procedural characteristics. Total x-ray time and total amount of contrast medium were significantly lower in the DARCA group compared with the CCA group (x-ray time 3.2 minutes [1.8 to 7.0] vs 5.1 minutes [2.6 to 9.9], p = 0.002; contrast medium amount 40 ml [31 to 116] vs 80 ml [50 to 150], p <0.001). AKI more often occurred in the CCA group compared with the DARCA group (16 [20%] vs 4 [5%], p = 0.007). Moreover, in patients presenting with acute coronary syndrome (ACS) or who underwent percutaneous coronary intervention (PCI), AKI more often occurred in the CCA group compared with the DARCA group (ACS patients, 6 [29%] vs 2 [6%], p = 0.04, and PCI patients, 11 [33%] vs 0 [0%], p <0.001). In addition, in patients with high pretest probability of coronary artery disease, AKI more often occurred in the CCA group compared with the DARCA group (11 [55%] vs 2 [6%], p <0.001). In conclusion, DARCA significantly reduces both x-ray exposure and amount of contrast medium usage, thereby reducing the occurrence of AKI compared with CCA.
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