Contrast Volume/Raw eGFR Ratio for Predicting Contrast-Induced Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention for Myocardial Infarction

Risk factors for acute renal injury caused by contrast media after percutaneous coronary intervention and coronary angiography: A protocol for systematic review and meta-analysis

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) caused by contrast medium is one of the common complications of percutaneous coronary intervention (PCI)/coronary angiography (CAG). Early identification of the risk factors of CI-AKI in patients with PCI/CAG and help clinical staff to prevent and intervene as soon as possible is very important to improve the clinical outcome of patients. Although domestic and foreign scholars have studied and summarized the risk factors of CI-AKI in PCI/CAG, the conclusions are not the same. Therefore, in this study, meta-analysis was used to summarize the risk factors of CI-AKI in patients with PCI/CAG, and to explore the characteristics of high-risk groups of CI-AKI, to provide reference for early identification and prevention of clinical doctors and nurses.

METHODS

We will search related literature of PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database. Eligible studies will be screened based on inclusion criteria, and data extraction, risk of bias assessment, publication bias assessment, subgroup analysis, and quality assessment will be performed. Review Manager version 5.3 software will be used for data analysis. Each process is independently conducted by 2 researchers, and if there is any objection, it will be submitted to the third researcher for resolution.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSIONS

The results of this analysis can be used to generate a risk prediction model and provide an intervention strategy for the occurrence of CI-AKI in PCI/CAG.

Renal function-adjusted contrast medium volume is a major risk factor in the occurrence of acute kidney injury after endovascular aneurysm repair

Acute kidney injury (AKI) is a complication that can occur during endovascular aneurysm repair (EVAR), increasing postoperative mortality and disease-related death. We therefore evaluated the incidence of AKI after elective EVAR, as well as related factors affecting AKI occurrence, investigating the volume of contrast medium (CV)/estimated glomerular filtration rate (eGFR) ratio as a predictive factor.We retrospectively reviewed the data of patients who underwent EVAR for infrarenal abdominal aorta aneurysm at a single center between April 2011 and December 2018. AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria. We evaluated the occurrence of AKI within the first 7 days postoperatively, comparing serum creatinine levels, eGFR, CV, CV/eGFR ratio, fluid input and output, and morbidity between the AKI and no-AKI groups.The data of 147 patients were analyzed, of which 131 (89.1%) were males (mean age: 72.10±7.40 years); the incidence of AKI was 4.1% (6/147 patients). The mean dose of contrast agents used was greater in the AKI group than in the no-AKI group (249.17 ± 83.21 mL vs 179.43 ± 84.32 mL, respectively; P = .05). The baseline eGFR was 42.69 ± 22.08 mL/kg/1.73 m2 in the AKI group and 77.96 ± 18.92 mL/kg/1.73 m2 in the no-AKI group (P = .001). The CV/eGFR ratio was significantly higher in the AKI group (8.21 ± 6.13 vs 2.46 ± 1.44; P = 0.003). Baseline eGFR (odds ratio [OR] = 0.922, P = .001) and the CV/eGFR ratio (OR = 2.049, P = .008) were observed to be factors related to the occurrence of AKI in the logistic regression analysis for patients' characteristics, operation-related factors, and renal outcomes. In the receiver operating characteristic curve analysis, the area under the curve of the CV/eGFR ratio was 0.856, indicating the greatest influence. A CV/eGFR ratio cutoff value of 3.84 was considered the most appropriate, with an 83.3% sensitivity and 83.0% specificity.The CV/eGFR ratio, rather than the absolute amount of contrast agents, was associated with the development of AKI after EVAR. The CV/eGFR ratio could be used as a possible indicator to limit the amount of contrast media required for the procedure.

Contrast-Induced Acute Kidney Injury: An Update

Contrast-induced acute kidney injury (CI-AKI) is defined as an abrupt deterioration in renal function associated with the administration of iodinated contrast media. This type of acute kidney injury is frequently encountered as a complication of percutaneous coronary intervention (PCI) and is associated with adverse short- and long-term outcomes including mainly mortality, cardiovascular morbidity and prolongation of hospitalization. The incidence of CI-AKI after PCI ranges from 2 to 20 % according to baseline kidney function. It may also range according to the clinical setting, being higher after emergency PCI. The primary manifestation is a small decline in kidney function, occurring 1 to 3 days after the procedure. Kidney function usually returns to preexisting levels within 7 days. Incidence of acute renal failure requiring dialysis following PCI is rare (<1 %). The present article aims to review up-to-date published data concerning diagnosis, definition, epidemiology and prognosis of this novel in-hospital epidemic.

A New Preprocedure Risk Score for Predicting Contrast-Induced Acute Kidney Injury

BACKGROUND

Most of the risk models for predicting contrast-induced acute kidney injury (CI-AKI) are available for only postcontrast exposure prediction; however, prediction before the procedure is more valuable in practice. This study aimed to develop a risk scoring system based on preprocedural characteristics for early prediction of CI-AKI in patients after coronary angiography or percutaneous coronary intervention (PCI).

METHODS

We prospectively recruited 1777 consecutive patients who were randomized in an approximate 3:2 ratio to create a development data set (n = 1076) and a validation data set (n = 701). A risk score model based on preprocedural risk factors was developed using stepwise logistic regression. Validation was performed by bootstrap and split-sample methods.

RESULTS

The occurrence of CI-AKI was 5.97% (106 of 1777), 5.95% (64 of 1076), and 5.99% (42 of 701) in the overall, developmental, and validation data sets, respectively. The risk score was developed with 5 prognostic factors (age, serum creatinine levels, N-terminal pro b-type natriuretic peptide levels, high-sensitivity C-reactive protein, and primary PCI), ranged from 0-36, and was well calibrated (Hosmer-Lemeshow χ² = 4.162; P = 0.842). Good discrimination was obtained both in the developmental and validation data sets (C-statistic, 0.809 and 0.798, respectively). The risk score was highly and positively associated with CI-AKI (P for trend < 0.001) in-hospital and long-term outcomes.

CONCLUSIONS

The novel risk score model we developed is a simple and accurate tool for early/preprocedural prediction of CI-AKI in patients undergoing coronary angiography or PCI. This tool allows assessment of the risk of CI-AKI before contrast exposure, allowing for timely initiation of appropriate preventive measures.

Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair

OBJECTIVE

The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors.

METHODS

All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction.

RESULTS

This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P < .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction.

CONCLUSIONS

Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.

Outcomes of Endovascular Aortic Aneurysm Repair in Kidney Transplant Recipients: Results From a National Quality Initiative

Contrast-induced nephropathy after endovascular aortic aneurysm repair (EVAR) in kidney transplant recipients (KTRs) can have devastating consequences. The Vascular Quality Initiative (VQI) database was queried to select all KTRs who underwent EVAR between January 2003 and December 2014. Our primary outcome was renal dysfunction, defined as acute kidney injury (AKI; elevation of serum creatinine >0.5 mg/dL from baseline) or new postoperative hemodialysis requirement. Within the EVAR VQI dataset, 40 patients were KTRs (40 of 17 213, or 0.2%). Renal dysfunction occurred in five of 40 patients in the KTR group in comparison to 779 of 17 173 patients in the nontransplanted group (12.5% versus 4.5%, p < 0.01). Emergent EVAR was required in 2 (5%) patients, one of whom required dialysis after surgery and subsequently died. One-year survival after EVAR was similar in the two groups (92.9% versus 93.1%, p = 0.73). KTRs who developed renal dysfunction had significantly lower preoperative estimated glomerular filtration rates (eGFRs) (29.5 versus 54.7, p = 0.007) and a significantly higher iodine:eGFR ratio (0.78 versus 0.39, p = 0.02) despite receiving a similar volume of contrast (70.0 versus 68.8, p = 0.97). Renal dysfunction is 3 times more frequent in KTRs treated with EVAR, though overall survival did not differ between the groups. Decreased preoperative eGFR and a higher iodine:eGFR ratio are associated with postoperative renal dysfunction.