Effect of Angiotensin-Converting Enzyme Inhibitors in Contrast-Induced Nephropathy: A Meta-Analysis

Angiotensin-Converting Enzyme Inhibitors and Contrast-Associated Acute Kidney Injury After Coronary Angiography and Intervention

Contrast-associated acute kidney injury has multiple definitions, but is generally described as worsening renal function after administration of iodinated contrast media. It is associated with high in-hospital mortality and poor long-term survival. Furthermore, patients undergoing coronary angiography commonly have comorbidities such as hypertension or congestive heart failure, which are often treated with renin-angiotensin-aldosterone system-blocking agents such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Trials assessing the effects of these renin-angiotensin-aldosterone system-blocking agents on the subsequent development of contrast-associated acute kidney injury have shown conflicting data, suggesting both beneficial and harmful effects. Therefore, there are no clear guidelines on whether clinicians should discontinue renin-angiotensin-aldosterone system-blocking agents peri-procedurally. In this article, we review the data from trials assessing the effects of peri-procedural renin-angiotensin system-blocking agent use in patients undergoing coronary and peripheral angiography and intervention. Future studies will likely focus on the extent of damage or potential benefit of these agents on renal function, cardiac function, as well as morbidity and mortality. Currently, there is insufficient evidence to recommend discontinuation of angiotensin-converting enzyme inhibitors prior to coronary angiography.

Impact of RAAS Blockers on Contrast-Induced Nephropathy in Patients With Renal Insufficiency: A Meta-Analysis

The effect of renin-angiotensin-aldosterone system (RAAS) blockers [angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers] on Contrast-induced nephropathy (CIN) is unclear in patients with renal insufficiency. Thus, we conduct a meta-analysis to evaluate the association between the administration of RAAS blockers and CIN in patients with renal insufficiency. We searched PubMed, EMBASE, and Cochrane Library for relevant studies published before September 2019. The primary outcome was the incidence of CIN, and the secondary outcome was the changes in serum creatinine (SCr) from baseline to postprocedure (ΔSCr). Pooled odds ratio (OR) or weighted mean difference (WMD) with their 95% confidence interval (CIs) for the CIN incidence, ΔSCr were used to calculate original data. A total of 8 studies were included in the meta-analysis. Compared with controls, ACEI/angiotensin receptor blocker increased the risk of CIN (OR = 1.61, 95% CI 1.14-2.28, I = 30%; P = 0.007), whereas this association was not significant in Chinese patients (OR = 1.07, 95% CI 0.65-1.77, I = 19%, P = 0.79). The total weighted mean differences of the ΔSCr were 0.06 mg/dL (95% CI: 0.01-0.11, I = 82%; P = 0.03). Administration of RAAS blockers in patients with renal insufficiency was associated with a significantly higher incidence of CIN, whereas it did not show a significant effect on Chinese patients.

Intensity of hydration changes the role of renin-angiotensin-aldosterone system blockers in contrast-induced nephropathy risk after coronary catheterisation in patients with chronic kidney disease

Objective:

This study evaluated the potential effect of hydration intensity on the role of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) on contrast-induced nephropathy in patients with renal insufficiency.

Methods:

All eligible patients were included and stratified according to hydration intensity defined as saline hydration volume to body weight tertiles: <10.21 mL/kg, 10.21 to <17.86 mL/kg, and ⩾17.86 mL/kg.

Results:

In total, 84 (6.7%) of 1254 patients developed contrast-induced nephropathy: 6.2% in the ACEI/ARB group versus 10.8% in the non-ACEI/ARB group (P=0.029), with an adjusted odds ratio (OR) of 0.89 (95% confidence interval (CI) 0.46–1.73, P=0.735). The incidence of contrast-induced nephropathy was lower in the ACEI/ARB group than in the non-ACEI/ARB group in the second tertile (P=0.031), while not significantly different in the first (P=0.701) and third (P=0.254) tertiles. ACEIs/ARBs were independently associated with a lower contrast-induced nephropathy risk (OR 0.26, 95% CI 0.09–0.74, P=0.012) and long-term all-cause death (hazard ratio 0.461, 95% CI 0.282–0.755, P=0.002) only in the second hydration volume to body weight tertile.

Conclusion:

The effects of ACEIs/ARBs on contrast-induced nephropathy risk vary according to saline hydration intensity in chronic kidney disease patients, and may further reduce contrast-induced nephropathy risk in patients administered moderate saline hydration.

Contrast-induced acute kidney injury: A review of practical points

Contrast-induced acute kidney injury (CI-AKI) is one of the most common causes of AKI in clinical practice. CI-AKI has been found to be strongly associated with morbidity and mortality of the patients. Furthermore, CI-AKI may not be always reversible and it may be associated with the development of chronic kidney disease. Pathophysiology of CI-AKI is not exactly understood and there is no consensus on the preventive strategies. CI-AKI is an active research area thus clinicians should be updated periodically about this topic. In this review, we aimed to discuss the indications of contrast-enhanced imaging, types of contrast media and their impact on nephrotoxicity, major pathophysiological mechanisms, risk factors and preventive strategies of CI-AKI and alternative non-contrast-enhanced imaging methods.