Strategies Preventing Contrast-Induced Nephropathy After Coronary Angiography: A Comprehensive Meta-Analysis and Systematic Review of 125 Randomized Controlled Trials

Alpha-lipoic acid: A promising pharmacotherapy seen through the lens of kidney diseases

Kidney diseases have rapidly increased in prevalence over the past few decades, and have now become a major global public health concern. This has put economic burden on the public healthcare system and causing significant morbidity and mortality worldwide. Unfortunately, drugs currently in use for the management of kidney diseases have long-term major adverse effects that negatively impact the quality of life of these patients, hence making these drugs a "necessary evil". In recent times, antioxidant therapy has been explored as a potential pharmacological avenue for treatment of kidney diseases, and could offer a better therapeutic option with less adverse effect profile. One of such antioxidants is alpha-lipoic acid (ALA), a sulphur-containing multifunctional antioxidant that is endogenously produced by lipoic acid synthase in the mitochondria of many tissues, including the kidney. Burgeoning evidence indicates that ALA is showing clinical promise in the treatment and pharmacological management of many kidney diseases through its antioxidant and other therapeutic properties by activating several protective mechanisms while inhibiting deleterious signaling pathways. In this review, we present ALA as a potent naturally occurring antioxidant, its mitochondrial biosynthesis and pharmacological properties. In addition, we also discuss within the limit of present literature, ALA and its underlying molecular mechanisms implicated in experimental and clinical treatment of various kidney conditions, and thus, may offer nephrologists an additional and/or alternative avenue in the pharmacological management and treatment of kidney diseases while giving hope to these patients.

Vitamin E for the Prevention of Contrast-Induced Nephropathy: A Systematic Review and Meta-Analysis

Contrast-induced nephropathy (CIN) is a serious condition that may develop in patients undergoing diagnostic radiologic procedures. Several treatments have been assessed to prevent CIN development. This study aims to assess the efficacy and safety of vitamin E in the prevention of CIN compared to intravenous (IV) saline hydration. The literature search included MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, the Web of Science, ProQuest, and Scopus for articles published until May 11, 2024, without language or time limits. The outcomes included the incidence of CIN, new-onset dialysis, and death (primary), as well as the change in serum creatinine and glomerular filtration rate (GFR) (secondary). Numerical and dichotomous outcomes were presented as standardized mean difference (SMD) and risk ratio (RR), respectively, with 95% confidence intervals (CI). Six clinical trials were included. Vitamin E was administered orally in varying doses, but one study used IV infusion. Vitamin E decreased the risk of developing CIN by 59% (n=5; pooled RR: 0.41; 95% CI: 0.25, 0.65; P<0.001) compared to IV hydration. None of the patients required renal replacement therapy. One patient on vitamin E died due to the occurrence of acute coronary syndrome. Vitamin E is a promising effective prophylaxis against CIN. However, the number of included studies and their sample sizes are small. The studies showed several limitations. There is a need for further high-quality clinical trials to ascertain the effectiveness of vitamin E compared to IV hydration and to compare vitamin E to other therapies, such as N-acetyl cysteine.

Association Between Remnant Cholesterol and Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography and/or Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) is an acute renal complication that can occur after the use of iodinated contrast media. Remnant cholesterol (RC) is one of the markers of atherosclerotic cardiovascular disease risk. We evaluated the impact of RC on CIN and clinical outcomes after coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). Consecutive patients (n = 3332) undergoing CAG and/or PCI were assessed in this retrospective study. Patients were divided into four groups based on baseline RC levels. In the quartile analysis, RC were associated with a higher risk of CIN, especially when RC ≤0.20 or ≥0.38 mmol/L (P < .05). However, after adjustment, the association of RC with CIN was not significant. There was a significant correlation between RC and repeated revascularization in patients undergoing PCI (P < .001) and driven primarily by the highest quartile level. After adjustment, this remained statistically significant (adjusted odds ratio (aOR) 4.06; 95% CI 2.10-7.87; P < .001). This is the first large study to show a possible association between RC and the risk of CIN after CAG and/or PCI; however, this finding was not further confirmed after adjustment. The complex clinical risk profile of patients, rather than RC itself, may contribute to the risk of CIN in this high-risk subgroup.

Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions

In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.

The triglyceride-glucose index and contrast-induced nephropathy in non-ST elevation myocardial infarction patients undergoing percutaneous coronary intervention

The triglyceride glucose (TyG) index is an indicator of insulin resistance and associated with increased risk of diabetes mellitus and cardiovascular events. Our study investigates the correlation between TyG index and contrast induced nephropathy (CIN) in non-diabetic patients with non-ST elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI). 350 non-diabetic NSTEMI patients (183, 52.3% male) undergoing PCI were retrospectively enrolled. The enrolled cohort was divided into 2 groups based on the calculated TyG index, namely values < 8.65 or higher. CIN was defined as an increase in serum creatinine > 25% or 0.5 mg/dL from baseline in the first 48 to 72 hours after PCI. A total of 56 (16%) cases of CIN were diagnosed. In contrast to patients with lower TyG indexes, patients with higher TyG indexes (≥8.65) had a higher frequency of CIN, 9.5%. versus 20.8% respectively (P .004). Patients with CIN also had higher TyG indexes (8.74 ± 0.12 vs 8.67 ± 0.11, P < .001). In addition, TyG index, age, and glomerular filtration rate were identified as independent risk factors for CIN in logistic regression model (OR: 2.5 CI: 1.3-4.6, P .006, OR: 1.0 CI: 1.0-1.1, P < .001, OR: 1.0 KI: 1.03-1.06, P .025). In the ROC analysis, the area under the curve predictive of CIN was 0.666 (P < .001, 95% [CI] 0.58-0.75) with a cutoff value of 8.69 (sensitivity 71,4%, specificity 55.1%) TyG index. Higher TyG indexes are associated with an increased risk of CIN in non-diabetic patients with NSTEMI.

Contrast-induced acute kidney injury and its contemporary prevention

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Fluid administration strategies for the prevention of contrast-associated acute kidney injury

PURPOSE OF REVIEW

The known timing of contrast media exposure in patients identified as high-risk for contrast-associated acute kidney injury (CA-AKI) enables the use of strategies to prevent this complication of intravascular contrast media exposure. Although multiple preventive strategies have been proposed, periprocedural fluid administration remains as the primary preventive strategy. This is a critical review of the current evidence evaluating a variety of fluid administration strategies in CA-AKI.

RECENT FINDINGS

Fluid administration strategies to prevent CA-AKI include comparisons of intravenous (i.v.) to no fluid administration, different fluid solutions, duration of fluid administration, oral hydration, left ventricular end diastolic-pressure guided fluid administration and forced diuresis techniques.

SUMMARY

Despite an abundance of fluid administration trials, it is difficult to make definitive recommendations about preventive fluid administration strategies due to low scientific quality of published studies. The literature supports use of i.v. compared with no fluid administration, especially in high-risk patients undergoing intra-arterial contrast media exposure. Use of isotonic saline is recommended over 0.45% saline or isotonic sodium bicarbonate. Logistical considerations support shortened over longer i.v. fluid administration strategies, despite an absence of evidence of equivalent efficacy. Current literature does not support oral hydration for high-risk patients. The use of tailored fluid administration in heart failure patients and forced diuresis with matching fluid administration are promising new fluid administration strategies.

Efficacy of brain natriuretic peptide vs. nicorandil in preventing contrast-induced nephropathy: a network meta-analysis

This study aimed to conduct a network meta-analysis (NMA) to compare the efficacy of brain natriuretic peptide (BNP) vs nicorandil for preventing contrast-induced nephropathy (CIN). Databases of Pubmed, Cochrane, Embase, Web of Science were searched by keywords for eligible studies of randomized controlled trials investigating different agents (BNP, nicorandil, nitroglycerin, intravenous saline) for preventing CIN. The outcomes included a change in serum creatinine level at 48 h and the incidence of CIN after percutaneous coronary intervention (PCI) or coronary angiography (CAG). A total of 13 studies with 3,462 patients were included. Compared with intravenous saline alone, except for nitroglycerin (odds ratio [OR]: 1.02, 95% CI [0.36-2.88]), the other drugs significantly reduced the CIN incidence with OR of 0.35 (95% CI [0.24-0.51]) for BNP, 0.52 (0.29, 0.94) for usual-dose nicorandil, 0.28 (0.19, 0.43) for double-dose nicorandil. BNP and double-dose nicorandil significantly decreased the change of serum creatinine (SCr) levels with mean difference (MD) of -6.98, (-10.01, -3.95) for BNP, -8.78, (-11.63, -5.93) for double-dose nicorandil. No significant differences were observed in the change of SCr levels for nitroglycerin (-4.97, [-11.46, 1.52]) and usual-dose nicorandil (-2.32, [-5.52, 0.89]) compared with intravenous saline alone. For double-dose nicorandil, the CIN incidence and the change of SCr level in group of 4-5 days treatment course were more than group of less than or equal to 24 h treatment course (OR of 1.48, [0.63-3.46] and MD of 2.48, [-1.96, 6.91]). In conclusion, BNP and double-dose nicorandil can have effects on preventing the incidence of CIN and double-dose nicorandil performed better than BNP. In double-dose nicorandil groups, a course of less than or equal to 24 h before and after procedure performed with better efficacy than a course of 4-5 days.

Meta-analysis of intravascular volume expansion strategies to prevent contrast-associated acute kidney injury following invasive angiography

OBJECTIVE

To perform a detailed analysis of published data regarding intravascular volume expansion to prevent contrast-associated acute kidney injury (CA-AKI) and to determine if an ideal dose of IV fluids can be recommended.

BACKGROUND

Administration of contrast media during invasive angiography is associated with CA-AKI. Intravascular volume expansion is the most effective intervention to prevent CA-AKI, yet evidenced based protocols are lacking.

METHODS

Literature review and meta-analysis of randomized controlled trials (RCT) of patients receiving IV volume expansion as prophylaxis for CA-AKI was performed. Normal saline, Lactated Ringer's and sodium bicarbonate were included. The primary outcome was incidence of CA-AKI.

RESULTS

37 RCTs studying 12,166 patients were included. Mean age was 67 ± 5 years, 70% of the patients were male. 68% had chronic kidney disease, 41% diabetes, and 30% heart failure. The incidence of CA-AKI was 9.5% (95% CI: 8-12%). IV expansion versus no volume administration was associated with a lower risk of CA-AKI (RR:0.62; 95% CI: 0.49-0.77, p < .001). Intensive IV volume expansion was associated with a reduced risk of CA-AKI(RR: 0.66; 95%CI: 0.52-0.85, p < .01). The intensive IV volume expansion arm received significantly more fluids than the standard protocols: 1,574(1,123 - 1,913) ml versus 849(558-1,067) ml (p = .03) without significant difference in the duration of infusion (median of 12 vs. 17 hr, p = .1) or pulmonary edema (1.7% vs 1.3%, p = .7).

CONCLUSIONS

Despite high variability in protocols used, IV volume expansion is effective in preventing CA-AKI. Intensive IVF expansion (median 1.6 L over 17 hr) was associated with decreased risk of CA-AKI.

Contrast-induced nephropathy in non-cardiac vascular procedures, a narrative review: Part 1

Contrast-induced nephropathy (CIN) is an important complication of iodinated contrast medium (CM) administration, which is associated with both short- and long-term adverse outcomes (e.g., cardiorenal events, longer hospital stay, and mortality). CIN has been mainly studied in relation to cardiac procedures, but it can also occur following non-cardiac vascular interventions. This is Part 1 of a narrative review summarizing the available literature on CIN after non-cardiac vascular diagnostic or therapeutic procedures for aortic aneurysm and carotid stenosis. We discuss the definition, pathophysiology, incidence, risk factors, biomarkers, and consequences of CIN in these settings, as well as preventive strategies and alternatives to limit iodinated CM use. Physicians and vascular surgeons should be aware of CM-related adverse events and the potential strategies to avoid them. Clearly, more research in this important field is required.

[ESUR recommendations on the use of contrast media: Practice survey, review and commentary by CJN, FIRN and SFNDT]

Contrast media administration is classically considered to cause or worsen kidney failure. Recent data may moderate this assertion. The European Society of Urogenital Radiology recently published guidelines re-evaluating the precautions before administering contrast media. The present work evaluates the practice of French nephrologists, and provides a commentary on these recommendations based on an updated review of the literature. We conducted survey among French nephrologists, using an electronic questionnaire distributed by the Société Francophone de Néphrologie, Dialyse et Transplantation, the French Intensive care Renal Network and the Club des Jeunes Néphrologues. 266 responses were collected. The European Society of Urogenital Radiology guidelines are poorly known among the panel of nephrologists. Their practices differ from the guidelines by the more frequent and earlier implementation of measures to prevent renal failure post contrast media. In accordance with the guidelines, hydration is prescribed as a first-line preventive measure, mainly with saline and bicarbonate. Inhibitors of the renin-angiotensin-aldosterone system are frequently discontinued before an injection of contrast media, contrary to what is recommended. In conclusion, the European Society of Urogenital Radiology guidelines, which the working group endorses, but which are still too little known and applied in clinical nephrology in France, prompt nephrologists to lift some of the restrictions on the use of PCI as well as on the continuation of ARS inhibitors before injecting PCI.

Kidney and contrast media: Common viewpoint of the French Nephrology societies (SFNDT, FIRN, CJN) and the French Radiological Society (SFR) following ESUR guidelines

Contrast medium administration is classically considered to cause or worsen kidney failure, but recent data may moderate this assertion. The European Society of Urogenital Radiology recently published guidelines re-evaluating the precautions before administering contrast media. Kidney injury does not constitute a contra-indication to the administration of iodinated contrast medium, as long as the benefit-risk ratio justifies it. Intravenous hydration with 0.9% NaCl or 1.4% sodium bicarbonate is the only validated measure for the prevention of post-iodine contrast nephropathy. This is necessary for intravenous or intra-arterial administration of iodinated contrast agent without first renal pass when the glomerular filtration rate is less than 30mL/min/1.73m², for intra-arterial administration of iodinated contrast agent with first renal passage when the glomerular filtration rate is less than 45mL/min/1.73m², or in patients with acute renal failure. The use of iodinated contrast medium should allow the carrying out of relevant examinations based on an analysis of the benefit-risk ratio and the implementation of measures to prevent toxicity when necessary.

A High Triglyceride-Glucose Index Is Associated With Contrast-Induced Acute Kidney Injury in Chinese Patients With Type 2 Diabetes Mellitus

Background and Objectives

Triglyceride-glucose (TyG) is an emerging vital indicator of insulin resistance and is associated with increased risk of T2DM and cardiovascular events. We aimed to explore the TyG index and contrast-induced acute kidney injury (CI-AKI) in patients with type 2 diabetes who underwent coronary angiology.

Methods

This study enrolled 928 patients with suspected coronary artery disease who underwent coronary angiology or percutaneous coronary intervention in Zhongda hospital. Patient data were divided into quartiles according to the TyG index: group 1: TyG ≤ 8.62; group 2: 8.629.45. CI-AKI was diagnosed according to the KIDIGO criteria. Demographic data, hematological parameters, coronary angiology data, and medications were all recorded. We calculated the TyG index using the following formula: ln [fasting TG (mg/dL)×FPG (mg/dL)/2].

Results

Patients who developed CI-AKI exhibited significantly higher TyG index levels compared to patients who did not develop CI-AKI. The incidence of CI-AKI sharply increased with increasing TyG. Univariate and multivariate analysis identified TyG as an independent risk factor for CI-AKI. The AUC of the ROC curve was as high as 0.728 when the value of TyG was 8.88. The corresponding sensitivity was as high as 94.9%. Adding the variable TyG to the model for predicting CI-AKI risk further increased the predictive value of the model from 80.4% to 82%.

Conclusions

High TyG is closely associated with increased incidence of CI-AKI, demonstrating that TyG is an independent risk factor for CI-AKI. TyG has potentially predictive value for CI-AKI and may play a crucial role in risk stratification in clinical practice.

Effect of Calcium Dobesilate in Preventing Contrast-Induced Nephropathy in Patients with Diabetes and Chronic Kidney Disease

OBJECTIVES

This study assessed the protective effect of calcium dobesilate against contrast-induced nephropathy (CIN) after coronary angiography (CAG) or percutaneous coronary intervention (PCI) in patients with diabetes and chronic kidney disease (CKD).

METHODS

A total of 130 patients with diabetes and CKD estimated glomerular filtration rate: 30-90 mL/min/1.73m2 were enrolled and included in the analysis. They were divided into experimental (n=65) and control groups (n=65). Patients in the experimental group were administered oral calcium dobesilate (500 mg) three times daily for 2 days before and 3 days after the procedure. The serum creatinine (SCr), cystatin C (Cys C), and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured before and after the procedure.

RESULTS

The mean SCr level at 24h after the procedure was found to be significantly lower in the experimental group than in the control group (79.1±19.6 μmol/L vs. 87.0±19.3 μmol/L, p=0.023). However, the Cys C and NGAL levels were not significantly different between the two groups at all measurement time points (all p>0.05). The incidence of CIN defined by the SCr level was significantly lower in the experimental group than in the control group (3 [4.6%] vs. 13 [20.0%], p=0.017). However, the incidence of CIN defined by the Cys C level was not statistically different between the two groups (7 [10.8%] vs. 7 [10.8%], p=1.000).

CONCLUSIONS

This study revealed that calcium dobesilate has no preventive effect against CIN in patients with diabetes and CKD.

Contrast-associated acute kidney injury: An update of risk factors, risk factor scores, and preventive measures

As lifespans lengthen, age-related diseases such as cardiovascular disease and diabetes are becoming more prevalent. Correspondingly, the use of contrast agents for medical imaging is also becoming more common, and there is increasing awareness of contrast-associated acute kidney injury (CA-AKI). There is no specific treatment for CA-AKI, and clinicians currently focus on prevention, interventions that alter its pathogenesis, and identification of risk factors. Although the incidence of CA-AKI is low in the general population, the risk of CA-AKI can reach 20% to 30% in patients with multiple risk factors. Many models have been applied in the clinic to assess the risk factors for CA-AKI, enable identification of high-risk groups, and improve clinical management. Hypotonic or isotonic contrast media are recommended to prevent CA-AKI in high-risk patients. Patients with risk factors should avoid using contrast media multiple times within a short period of time. All nephrotoxic drugs should be stopped at least 24 h before the administration of contrast media in high-risk populations, and adequate hydration is recommended for all patients. This review summarizes the pathophysiology of CA-AKI and the progress in diagnosis and differential diagnosis; updates the risk factors and risk factor scoring systems; reviews the latest advances related to prevention and treatment; discusses current problems in epidemiological studies; and highlights the importance of identifying high-risk subjects to control modifiable risk factors and use of a rating scale to estimate the risk and implement appropriate prevention strategies.

Impact of Geriatric Nutritional Index in Contrast-Induced Nephropathy Developed in Patients with Non-ST Segment Elevation Myocardial Infarction who Underwent Percutaneous Coronary Intervention

Objective:

Geriatric nutritional risk index (GNRI) is a useful tool to determine the nutritional status of patients. Any study has not evaluated the impact of GNRI in development of contrast- induced nephropathy (CIN) after percutaneous coronary intervention (PCI). We aimed to evaluate whether GNRI could predict CIN after PCI.

Method:

A total of 1116 patients with non-ST elevation myocardial infarction (non-STEMI) that underwent PCI were enrolled to the present study. The GNRI was calculated using a previously reported formula: GNRI=14.89 × albumin (g/dL) + 41.7 × body weight (kg)/ideal body weight (kg). CIN was defined as an increase in serum creatinine level of ≥0.5 mg/dL or ≥25% above baseline within 72 hours after the PCI procedure. The patients were categorized into two groups as CIN (+) and CIN (-).

Results:

The mean age of the CIN (+) group was significantly higher than the CIN (–) group (64.8±10.67 vs. 60.5±10.61 years; p<0.001). The mean values of height, weight, and body mass index were significanlty lower in CIN (+) group than CIN (-) group (p<0.001, for all). The mean of GNRI was significantly lower in the CIN (+) group than the CIN (-) group (101.4±8.7 vs. 112.1±12.9; p<0.001). Serum albumin level was significantly lower in the CIN (+) group (3.71±0.52 g/dL vs. 3.94±0.53 g/dL; p<0.001). Left ventricular ejection fraction (LVEF) was significantly lower in the CIN (+) group (50.7%±9.07 vs. 54.3%±7.20; p<0.001).

Conclusion:

In this study, GNRI, serum albumin level, BMI, and LVEF were independent predictors of CIN. Moreover, GNRI was better than both serum albumin level and BMI in predicting development of CIN.

Residual SYNTAX Score Is Associated With Contrast-Induced Nephropathy in Patients With Non-ST Segment Elevation Myocardial Infarction With Preserved LVEF

The purpose of this study is to investigate the relation between residual SYNTAX score (rSS) and contrast-induced nephropathy (CIN) development in patients with non-ST segment elevation myocardial infarction (NSTEMI) with normal or near-to-normal left ventricular ejection fraction (LVEF) who underwent percutaneous coronary intervention (PCI). A total of 306 patients who underwent PCI with NSTEMI were included in our study. SYNTAX scores were calculated for the periods before and after PCI. Patients were divided into 2 groups as developed CIN following PCI (CIN +) and patients did not (CIN -). Fifty-four (17.6%) of patients who were included in the study developed CIN. Age (P = .001) and rSS (P = .002) were significantly higher and LVEF was lower (P = .034) in the CIN (+) group. Age (P = .031, odds ratio [OR]: 1.031, 95% CI, 1.003-1.059) and rSS (P = .04, OR: 1.036, 95% CI, 1.002-1.071) were independent predictors for CIN. In receiver operating characteristic analyses, when the cutoff value of rSS was taken as 3.5, it determined CIN with 79% sensitivity and 65% specificity. Contrast-induced nephropathy may develop more frequently in patients with increased rSS value. The rSS may be useful to follow-up these patients for CIN development.

Non-Invasive Imaging for Evaluating Cardiovascular Involvement in Patients with Primary and Lupus Nephritis

Background:

Evidence suggests that proteinuric diseases, such as primary or secondary glomerulonephritis, increase cardiovascular risk, but few studies confirmed this association.

Methods:

This is a cross-sectional, observational study on 32 patients, 17 with Primary Glomerulonephritis (PG) and 15 with Lupus Glomerulonephritis (LG). The control group consisted of 32 healthy individuals. Intima-media thickness (IMT) of the left common carotid artery, carotid bifurcation and internal carotid artery was measured by ultrasound. Left ventricular myocardial deformation was assessed by the use of the Global Circumferential Strain (GCS) and the Global Longitudinal Strain (GLS) following 2-Dimensional (2D) echocardiography in all participants.

Results:

Patients with glomerulonephritis in both groups showed significantly lower GLS compared with controls (p=0.0005). There was also a significant difference in common carotid IMT values between the LG and GP group (0.45±0.09 vs. 0.58±0.17 mm, respectively; p=0.01), but there was no difference with the control group. In patient group (n=32), a significantly positive correlation was observed between C-reactive protein and proteinuria (r=0.98; p<0.0001), whereas negative correlations were found between common carotid IMT and creatinine clearance (r=-0.97; p<0.0001) and between carotid bifurcation IMT and phosphate levels (r=-0.97; p<0.0001)

Conclusion:

Subclinical systolic myocardial dysfunction is present early in the course of glomerular disease. The use of 2D GLS revealed that LG and PG patients with no cardiovascular symptoms or history and a preserved left ventricle ejection fraction on conventional echocardiography had subclinical reduction in LV global longitudinal systolic function compared with controls.

Comparison of the Relationship Between Inflammatory Markers and Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome After Coronary Angiography

Contrast-induced nephropathy (CIN) is one of the most important complications after invasive cardiovascular procedures. The neutrophil-to-lymphocyte ratio (NLR), mean platelet volume-to-lymphocyte ratio (MPVLR), and platelet-to-lymphocyte ratio (PLR) may be markers of the risk of CIN. We aimed to investigate the association of these indices with the development of CIN in patients with ST-elevation myocardial infarction and non-ST-elevation-acute coronary syndrome who underwent percutaneous coronary intervention. We retrospectively collected the data of patients with ACS after coronary angiography (CA); 564 patients were included (mean age, 62.3 ± 13.0 years; 41.1% female). We compared 62 (10.9%) patients who developed CIN and 502 patients who did not, after CA in terms of NLR, PLR, and MPVLR. Patients who developed CIN had significantly higher MPVLR, NLR, and PLR; the MPVLR (P ≤ .001) was an independent predictor of CIN. NLR, MPVLR, and PLR are simple, cheap, and easily accessible tests that can predict CIN; the MPVLR was the strongest of these predictors.

Investigating the Possible Protective Role of Direct Intra-arterial Administration of Mannitol and N-Acetylcysteine and Per Os Administration of Simvastatin Against Contrast-Induced Nephropathy: An Experimental Study in a Rabbit Model

PURPOSE

Contrast-induced nephropathy (CIN) is one of the leading causes of hospital-acquired acute kidney injury due to the use of iodinated contrast media in various interventional procedures like endovascular aneurysm repair. Its pathophysiology remains mostly unclear. The purpose of the present study was to comparatively study the possible protective role of direct intra-arterial administration of mannitol and acetylcysteine and per os administration of simvastatin in a histopathological level.

MATERIALS AND METHODS

In the present study, we administered iopromide directly in the infrarenal aorta of 24 New Zealand white rabbits after laparotomy. Animals were divided in four groups of six: G1 received iopromide with no protection, G2 iopromide with mannitol, G3 iopromide with acetylcysteine, and G4 iopromide with simvastatin. Renal function blood parameters were assessed prior to the administration, and in 48 h; histopathological evaluation of the kidneys was performed.

RESULTS

CIN was evident only in the no protection group G1. Moreover, G1 demonstrated significantly more severe lesions than groups G2, G3, and G4 regarding histopathological findings in glomeruli, vacuolization of tubular epithelial cells, tubular proteinaceous casts, and tubular necrosis. According to our results, intra-arterial administration of mannitol seems to be effective in protection against tubular necrosis.

CONCLUSION

In general, all three agents demonstrated a protective role in preventing the development of CIN, although it seems that there are various pathways that remain to be investigated further.

Preventive Effects of Nicorandil Against Contrast-Induced Nephropathy in Patients With Moderate Renal Insufficiency Undergoing Percutaneous Coronary Intervention

We investigated the preventive effect of nicorandil on contrast-induced nephropathy (CIN) in patients with moderate renal insufficiency undergoing percutaneous coronary intervention (PCI). A total of 250 patients with a creatinine clearance (crCl) ≤60 mL/min undergoing PCI were randomly assigned to either a nicorandil group (nicorandil 10 mg 3 times/d and hydration; n = 125) or a control group (hydration only; n = 125). The first end point was the incidence of CIN defined as an increase in serum creatinine (Scr) levels by ≥0.5 mg/dL or ≥25% within 72 hours after exposure to the contrast medium. The secondary end points were (1) changes in Scr, blood urea nitrogen, and crCl and (2) the incidence of major adverse events during hospitalization. The incidence of CIN was 1.6% (2/125) in the nicorandil group and 9.6% (12/125) in the control group ( P = .011). There was no obvious difference in the incidence of major adverse events during hospitalization between the nicorandil and the control group (4.0% vs 4.8%, P = 1.000). Multivariate logistic regression analysis showed that nicorandil was a protective factor for CIN (odds ratios = 0.126, 95% confidence interval: −19.996 to −0.932, P = .012). Prophylactic administration of nicorandil may prevent against CIN in patients with moderate renal insufficiency undergoing PCI.

Lipids: a personal view of the past decade

The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.

[Management of renal failure in old patients undergoing percutaneous cardiac interventions]

The elderly benefit from the advances of the interventional cardiology, especially for coronary artery disease and aortic valve stenosis. The prevalence of comorbidities is high in old population, but the benefit-risk balance remains often positive. Chronic kidney disease is frequent and amplifies the risks of contrast-induced nephropathy and acute kidney injury with an impact on clinical course and outcomes, and additional costs. Preventive strategies recognized as efficient to limit renal adverse events must be applied. Future approach may involve research in vulnerable old patients undergoing cardiac interventions.

The Ratio of Fibrinogen to Albumin as a Predictor of Contrast-Induced Nephropathy After Carotid Angiography

Contrast-induced nephropathy (CIN) is acute kidney failure that occurs after exposure to contrast agent. There is no sensitive biomarker to predict the development of CIN. In a retrospective study, we investigated the predictive value of the fibrinogen to albumin ratio (FAR) to determine the risk of CIN in patients (N = 246) who underwent carotid angiography. Contrast-induced nephropathy was defined as a 0.5 mg/dL or 25% increase in serum creatinine levels 48 to 72 hours following exposure to a radiocontrast agent. Patients were grouped according to whether they developed CIN or not, that is, CIN(-) and CIN(+) groups, respectively. Contrast-induced nephropathy developed in 39 (15.8%) of all the patients. The fibrinogen levels, neutrophil to lymphocyte ratio (NLR), and FAR in the CIN (+) group were higher than in the CIN (-) group ( P < .001). Multivariate analysis showed that age, diabetes, NLR, platelet-lymphocyte ratio, and FAR were independent risk factors for CIN. The area under the curve (AUC) of FAR was 0.800 for the prediction of CIN, and the best cutoff value was 57.4 with sensitivity, specificity, positive predictive value, and negative predictive value of 74.4%, 60.8%, 26.4%, and 92.7%, respectively. The FAR may be useful as a predictor of CIN.

Vitamins for Prevention of Contrast-induced Acute Kidney Injury: A Systematic Review and Trial Sequential Analysis

BACKGROUND

To date, universally accepted preventive measures for contrast-induced acute kidney injury (CI-AKI) do not exist, and they warrant further research.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of vitamins, including vitamin C and E, for prevention of CI-AKI.

METHODS

We electronically searched the MEDLINE, EMBASE, and Cochrane databases. The outcome of interest was the incidence of CI-AKI.

RESULTS

A total of 19 studies were included in this meta-analysis. Pooled analysis showed that vitamin C plus saline [relative risk (RR) = 0.63, 95% confidence interval (CI) 0.49-0.82, p = 0.0005] and vitamin E plus saline (RR = 0.39, 95% CI 0.24-0.62, p < 0.0001) significantly reduced the incidence of CI-AKI compared to saline alone. The effect of vitamin C plus saline was further confirmed by trial sequential analysis (TSA). However, TSA indicated that more trials are required to confirm the efficacy of vitamin E plus saline. There was no significant difference in preventing CI-AKI between vitamin C and N-acetylcysteine (NAC) (RR = 0.90, 95% CI 0.47-1.71, p = 0.75), between vitamin C plus NAC and saline (RR = 0.62, 95% CI 0.30-1.30, p =  0.20), as well as between vitamin C plus NAC and NAC (RR = 0.97, 95% CI 0.49-1.92, p = 0.93).

CONCLUSIONS

Vitamin C plus saline administration is effective at reducing the risk of CI-AKI. Evidence for the use of vitamin E plus saline in this context is encouraging, but more trials are required. Furthermore, this meta-analysis and TSA indicated insufficient power to draw a definitive conclusion on the effect of vitamin C plus NAC, versus saline or NAC alone, which needs to be explored further.

Post-contrast acute kidney injury. Part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients : Recommendations for updated ESUR Contrast Medium Safety Committee guidelines

OBJECTIVES

The Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) has updated its 2011 guidelines on the prevention of post-contrast acute kidney injury (PC-AKI). The results of the literature review and the recommendations based on it, which were used to prepare the new guidelines, are presented in two papers. AREAS COVERED IN PART 2: Topics reviewed include stratification of PC-AKI risk, the need to withdraw nephrotoxic medication, PC-AKI prophylaxis with hydration or drugs, the use of metformin in diabetic patients receiving contrast medium and the need to alter dialysis schedules in patients receiving contrast medium.

KEY POINTS

• In CKD, hydration reduces the PC-AKI risk • Intravenous normal saline and intravenous sodium bicarbonate provide equally effective prophylaxis • No drugs have been consistently shown to reduce the risk of PC-AKI • Stop metformin from the time of contrast medium administration if eGFR < 30 ml/min/1.73 m 2 • Dialysis schedules need not change when intravascular contrast medium is given.

A Bayesian network meta-analysis of preventive strategies for contrast-induced nephropathy after cardiac catheterization

BACKGROUND

The optimal preventive strategy for contrast induced acute kidney injury (CIAKI) in patients undergoing cardiac catheterization remains uncertain.

OBJECTIVE

We conducted Bayesian network meta-analysis (NMA) to compare different preventive strategies for CIAKI in these cohorts.

METHODS

Forty-nine randomized controlled trials were extracted using MEDLINE, EMBASE and CENTRAL data bases (inception-1st December 2017). We calculated median of the odds ratio (OR) with the corresponding 95% credible interval (CrI). The ranking probability of each treatment was based on SUCRA (surface under the cumulative ranking curve).

RESULTS

In NMA of 28,063 patients [normal saline (NS: 9716 patients), sodium bicarbonate (NaHCO3: 4484 patients), statin (2542 patients), N-acetylcysteine (NAC: 3006 patients), NAC + NaHCO3 (774 patients), NS + NAC (3807 patients), NS + NaHCO3 (135 patients) and placebo (3599 patients)], statins reduced the relative risk of CIAKI compared with NS (OR: 0.50; 95% CrI, 0.25-0.99), and placebo (OR: 0.44; 95% CrI, 0.24-0.83). Subgroup analyses showed that in patients receiving low osmolar contrast, statins reduced the relative risk of CIAKI by 58% versus NS, and 51% versus placebo. There were no significant differences across all the treatments in terms of risk of hemodialysis or all-cause mortality. Statins had the highest probability for reducing the risk of CIAKI (SUCRA, 0.86), risk of hemodialysis (SUCRA, 0.88) and all-cause mortality (SUCRA, 0.81).

CONCLUSION

Statins were the superior preventive strategy for reducing the risk of CIAKI compared with NS alone and placebo.

Diastolic dysfunction predicts the risk of contrast-induced nephropathy and outcome post-emergency percutaneous coronary intervention in AMI patients with preserved ejection fraction

Patients with acute myocardial infarction (AMI) and reduced left ventricular ejection fraction (LVEF) are at high risk of contrast-induced nephropathy (CIN). However, the risk factors of CIN in AMI patients with preserved LVEF remain largely unknown now. The present study explored the relationship between LV diastolic function and CIN in this patient cohort. The present prospective cohort study enrolled 379 AMI patients with preserved LVEF (≥ 50%) who underwent emergency percutaneous coronary interventions (PCI). Transthoracic echocardiography was performed before PCI using a portable echocardiography system. Diastolic function was graded as normal, indeterminate and diastolic dysfunction according to the current recommendation of the American Society of Echocardiography and the European Association of Cardiovascular Imaging. A total of 88 patients (23.2%) developed CIN. Multivariate logistic regression analysis showed that both diastolic dysfunction (DD) and the mitral E velocity to mitral annular tissue Doppler E' velocity ratio (E/E') were independent predictors of CIN (P < 0.001). Other independent risk factors of CIN included increased Mehran score, ST-segment-elevation myocardial infarction, higher HbA1c and left anterior descending lesion, as well as the use of diuretics. Multivariate Cox regression analysis found that CIN, DD, higher N-terminal pro-B-type natriuretic peptide and HbA1c were independent predictors of MACE 2 years after AMI. Diastolic dysfunction determined before emergency PCI is linked with increased risk of CIN in AMI patients with preserved LVEF. CIN and diastolic dysfunction are independent predictors of MACE at 2 years in this patient cohort.

Prevention of contrast-induced nephropathy by limb ischemic preconditioning: underlying mechanisms and clinical effects

Contrast-induced nephropathy (CIN) is an important complication following diagnostic radiographic imaging and interventional therapy. It results from administration of intravascular iodinated contrast media (CM) and is currently the third most common cause of hospital-acquired acute kidney injury. CIN is associated with increased morbidity, prolonged hospitalization, and higher mortality. Although the importance of CIN is widely appreciated, and its occurrence can be mitigated by the use of pre- and posthydration protocols and low osmolar instead of high osmolar iodine-containing CM, specific prophylactic therapy is lacking. Remote ischemic preconditioning (RIPC), induced through short cycles of ischemia-reperfusion applied to the limb, is an intriguing new strategy that has been shown to reduce myocardial infarction size in patients undergoing emergency percutaneous coronary intervention. Furthermore, multiple proof-of-principle clinical studies have suggested benefit in several other ischemia-reperfusion syndromes, including stroke. Perhaps somewhat surprisingly, RIPC also is emerging as a promising strategy for CIN prevention. In this review, we discuss current clinical and experimental developments regarding the biology of CIN, concentrating on the pathophysiology of CIN, and cellular and molecular mechanisms by which limb ischemic preconditioning may confer renal protection in clinical and experimental models of CIN.