A New Risk Factor Profile for Contrast-Induced Acute Kidney Injury in Patients Who Underwent an Emergency Percutaneous Coronary Intervention

C-Reactive Protein to Albumin Ratio as a Predictor of Contrast-Induced Nephropathy After Carotid Angiography

This study evaluated the role of the C-reactive protein (CRP)/albumin ratio (CAR) in estimating the probability of occurring contrast-induced nephropathy (CIN) after carotid artery angiography (CAAG). Patients (n = 410) who had CAAG for carotid artery stenosis (CAS) were included in this study. A spike in serum creatinine was used to define CIN within 72 h of the procedure (>.5 mg/dL or >25% above baseline). CAR was calculated by dividing the CRP by the albumin level. Patients with CIN had higher numbers of white blood cells (P = .002), numbers of neutrophils (P = .007), neutrophil-lymphocyte ratios (P = .026), high-sensitivity CRP levels (P < .001), and CAR levels (P < .001) than those without CIN. They were also older (P < .001) and more likely to have diabetes mellitus (P = .006) and hypertension (P = .016). According to receiver operator characteristic curve (ROC) analysis, the CAR value has a 75% sensitivity and a 68% specificity for identifying CIN at a cutoff of 1.8. Also, NLR and CRP predicted CIN with 71% sensitivity and 67% specificity, 71% sensitivity and 66% specificity at the best cutoff values of 1.96 and 7.91, respectively. According the present study, in patients with CAS, the development of CIN after CAAG is independently correlated with CAR at admission.

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.

A risk score model of contrast-induced acute kidney injury in patients with emergency percutaneous coronary interventions

Background

The previously built score models of contrast-induced acute kidney injury (CI-AKI) were principally founded on selective percutaneous coronary intervention (PCI) cases. Our study was to form a risk score model of CI-AKI and make a temporal validation in a population who underwent emergency PCIs.

Methods

We included patients who underwent emergency PCIs from 2013 to 2018 and divided them into the derivation and validation cohorts. Logistic regression analysis was harnessed to create the risk model. In this research, we defined CI-AKI as an increase in serum creatinine (SCr) ≥0.5 mg/dL (44.2 μmol/L) above baseline within seven days following exposure to contrast medium.

Results

A total of 3564 patients who underwent emergency PCIs were enrolled and divided into the derivation (2376 cases) and validation cohorts (1188 cases), with CI-AKI incidence of 6.61 and 5.39%, respectively. By logistic analysis, the CI-AKI risk score model was constituted by 8 variables: female (1 point), history of transient ischemic attack (TIA)/stroke (1 point), left ventricular ejection fraction (LVEF) classification (1 point per class), big endothelin-1 (ET-1) classification (1 point per class), estimated glomerular filtration rate (eGFR) classification (1 point per class), intra-aortic balloon pump (IABP) application (1 point), left anterior descending (LAD) stented (1 point), and administration of diuretic (2 points). The patients could be further divided into three groups: low-risk, moderate-risk, and high-risk groups, in accordance with the risk scores of 3–6, 7–10, and ≥11 points, and to the CI-AKI rates of 1.4, 11.9, and 42.6%. The CI-AKI risk score model performed well in discrimination (C statistic = 0.787, 95% CI: 0.731–0.844) and calibration ability, and showed a superior clinical utility.

Conclusion

We developed a simple CI-AKI risk score model which performs well as a tool for CI-AKI prediction in patients who underwent emergency PCIs.

A Novel Predictor of Contrast-Induced Nephropathy in Patients With Carotid Artery Disease; the Systemic Immune Inflammation Index

Contrast-induced nephropathy (CIN) is associated with increased mortality and morbidity. The present study investigated the role of systemic immune inflammation index (SII) in predicting the risk of developing CIN after carotid artery angiography (CAAG). This study included 262 patients who underwent CAAG for symptomatic carotid artery stenosis (CAS). Simultaneous carotid stenting was applied to 232 of these patients. CIN was defined as an increase in serum creatinine level ≥.5 mg/dL or ≥25% above baseline within 72 hours after the procedure. The SII score was calculated as platelet × neutrophil/lymphocyte counts. Patients who developed CIN, had higher glucose (P = .009), total cholesterol (P < .001), low density lipoprotein cholesterol (<.001), and high sensitivity C-reactive protein (P = .001) levels, as well as greater neutrophil counts (P < .001), platelet counts (P < .001), neutrophil-lymphocyte ratio (P < .001), and SII score (P < .001) than those who did not develop CIN. The Receiver Operating Characteristic analysis showed that at a cutoff of 519.9, the SII exhibited 80% sensitivity and 64% specificity for detecting CIN. SII levels on admission were independently associated with CIN development after CAAG in patients with CAS.

Nutritional Risk Screening 2002 was associated with acute kidney injury and mortality in patients with acute coronary syndrome: Insight from the REACP study

BACKGROUND AND AIMS

Acute kidney injury (AKI) is a common complication of acute coronary syndrome (ACS), and is associated with increased risk of morbidity and mortality. We aimed to evaluate the impact of malnutrition risk at admission assessed using Nutritional Risk Screening 2002 (NRS-2002) on AKI and mortality in patients with ACS.

METHODS AND RESULTS

We enrolled 3185 ACS patients from the retrospective multi-centre study. AKI was defined as criteria of the 2012 Kidney Disease Improving Global Outcomes. Risk of malnutrition was defined as NRS-2002 score ≥3. The end points were AKI and all-cause mortality. There were 926 (29.1%) patients with risk of malnutrition and 481 (15.1%) patients complicated with AKI during hospitalisation, and 378 (12.0%) patients died during the 13.1 (8.5-20.4) months of follow-up. Patients with NRS-2002 score ≥3 had a higher incidence of AKI and all-cause mortality (P < 0.001). Multivariate logistic and Cox regression analysis showed that the adjusted odd ratios and hazard ratios of categorised NRS-2002 (<3 vs. ≥3) for AKI and mortality were 1.643 (95% confidence interval: 1.242-2.172, P < 0.001) and 2.026 (95% confidence interval: 1.491-2.753, P < 0.001), respectively. In structural equation modelling, the indirect effects of NRS-2002 on mortality via AKI were 54.1% (P < 0.001).

CONCLUSION

The risk of malnutrition assessed using NRS-2002 was useful in identifying high-risk patients with AKI and mortality, and patients with ACS may benefit from further nutritional intervention and prevention of AKI.

REGISTRATION NUMBER

ChiCTR1900024657.

Impact of concomitant peripheral artery disease on contrast-induced acute kidney injury and mortality in patients with acute coronary syndrome after percutaneous coronary intervention

Subclinical peripheral artery disease (PAD) might be associated with pathophysiology of contrast-induced acute kidney injury (CI-AKI). We hypothesized that concomitant PAD in patients with the acute coronary syndrome (ACS) would represent a high-risk subgroup with a greater incidence of CI-AKI, both of which lead to higher mortality after percutaneous coronary intervention (PCI). Six hundred and seventy-five consecutive patients with ACS who underwent PCI and examination of ankle-brachial index (ABI) were analyzed retrospectively. The presence of PAD was defined as an ABI < 0.9. We investigated whether (1) PAD was an independent predictor of CI-AKI (≥ 0.3 mg/dL or ≥ 50% relative increase in serum creatinine within 48 h after PCI) and (2) PAD and CI-AKI were independently associated with long-term mortality. Of the 675 patients with ACS, 114 (17%) exhibited PAD. The incidence of CI-AKI was significantly higher in PAD patients, compared with the remaining patients (12% vs. 4%, p < 0.001). Multivariate logistic regression analysis revealed that the presence of PAD was an independent predictor for the development of CI-AKI [odds ratio 2.50, 95% confidence interval (CI) 1.07-5.73, p < 0.05]. During the median 4-year follow-up, there were 65 incidents of all-cause death. In the multivariate Cox proportional hazard regression analysis, the presence of PAD [hazard ratio (HR) 2.08, 95% CI 1.17-3.65, p < 0.05] and CI-AKI (HR 2.23, 95% CI 1.08-4.26, p < 0.05) were associated with an increased risk of all-cause mortality. Assessment of ABI provides useful information for predicting CI-AKI and long-term mortality in patients with ACS after PCI.

Validation of pre-operative risk scores of contrast-induced acute kidney injury in a Chinese cohort

Background

Pre-operative risk scores are more valuable than post-procedure risk scores because of lacking effective treatment for contrast-induced acute kidney injury (CI-AKI). A number of pre-operative risk scores have been developed, but due to lack of effective external validation, most of them are also difficult to apply accurately in clinical practice. It is necessary to review and validate the published pre-operative risk scores for CI-AKI.

Materials and methods

We systematically searched PubMed and EMBASE databases for studies of CI-AKI pre-operative risk scores and assessed their calibration and discriminatory in a cohort of 2669 patients undergoing coronary angiography or percutaneous coronary intervention (PCI) from September 2007 to July 2017. The definitions of CI-AKI may affect the validation results, so three definition were included in this study, CI-AKI broad1 was defined as an increase in serum creatinine (Scr) of 44.2 μmol/L or 25%; CI-AKI broad2, an increase in Scr of 44.2 μmol/L or 50%; and CI-AKI-narrow, an increase in Scr of 44.2 μmol/L. The calibration of the model was assessed with the Hosmer-Lemeshow test and the discriminatory capacity was identified by C-statistic.

Results

Of the 8 pre-operative risk scores for CI-AKI identified, 7 were single-center study and only 1 was based on multi-center study. In addition, 7 of the scores were just validated internally and only Chen score was externally validated. In the validation cohort of 2669 patients, the incidence of CI-AKI ranged from 3.0%(Liu) to 16.4%(Chen) for these scores. Furthermore, the incidence of CI-AKI was 6.59% (178) for CI-AKI broad1, 1.44% (39) for CI-AKI broad2, and 0.67% (18) for CI-AKI-narrow. For CI-AKI broads, C-statistics varied from 0.44 to 0.57. For CI-AKI-narrow, the Maioli score had the best discrimination and calibration, what’s more, the C-statistics of Maioli, Chen, Liu and Ghani was ≥0.7.

Conclusion

Most pre-operative risk scores were established based on single-center studies and most of them lacked external validation. For CI-AKI broads, the prediction accuracy of all risk scores was low. The Maioli score had the best discrimination and calibration, when using the CI-AKI-narrow definition.

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.

Relationship between High Level of Estimated Glomerular Filtration Rate and Contrast-Induced Acute Kidney Injury in Patients who Underwent an Emergency Percutaneous Coronary Intervention

Background

Mounts of studies have shown that low estimated glomerular filtration rate (eGFR) is associated with increased risk of adverse outcomes in patients with coronary artery disease. However, high level of eGFR was less reported. In the study, we aimed to explore the relationship between the baseline eGFR, especially the high level, and contrast-induced acute kidney injury (CI-AKI) in a Chinese population who underwent an emergency percutaneous coronary intervention (PCI).

Methods

Patients who underwent an emergency PCI from 2013 to 2015 were enrolled and divided into five groups as eGFR decreasing. Baseline characteristics were collected and analyzed. The rates of CI-AKI and the composite endpoint (including nonfatal myocardial infarction, revascularization, stroke, and all-cause death) at 6- and 12-month follow-up were compared. Logistic analysis for CI-AKI was performed.

Results

A total of 1061 patients were included and the overall CI-AKI rate was 22.7% (241/1061). The separate rates were 77.8% (7/9) in Group 1 (eGFR ≥120 ml·min^-1·1.73 m^-2), 26.0% (118/454) in Group 2 (120 ml·min^-1·1.73 m^-2> eGFR ≥90 ml·min^-1·1.73m^-2), 18.3% (86/469) in Group 3 (90 ml·min^-1·1.73 m^-2> eGFR ≥60 ml·min^-1·1.73 m^-2), 21.8% (26/119) in Group 4 (60 ml·min^-1·1.73 m^-2> eGFR ≥30 ml·min^-1·1.73 m^-2), and 40.0% (4/10) in Group 5 (eGFR <30 ml·min^-1·1.73 m^-2), with statistical significance (χ² = 25.19, P < 0.001). The rates of CI-AKI in five groups were 77.8%, 26.0%, 18.3%, 21.8%, and 40.0%, respectively, showing a U-typed curve as eGFR decreasing (the higher the level of eGFR, the higher the CI-AKI occurrence in case of eGFR ≥60 ml·min^-1·1.73 m^-2). The composite endpoint rates in five groups were 0, 0.9%, 2.1%, 6.7%, and 0 at 6-month follow-up, respectively, and 0, 3.3%, 3.4%, 16.0%, and 30.0% at 12-month follow-up, respectively, both with significant differences (χ² = 16.26, P = 0.009 at 6-month follow-up, and χ² = 49.05, P < 0.001 at 12-month follow-up). The logistic analysis confirmed that eGFR was one of independent risk factors of CI-AKI in emergency PCI patients.

Conclusions

High level of eGFR might be associated with increased risk of CI-AKI in patients with emergency PCI, implying for future studies and risk stratification in clinical practice.

Impact of Clopidogrel on Mortality in Patients With Acute Heart Failure Stratified by Coronary Artery Disease: Findings From the Arabian Gulf Acute Heart Failure Registry (Gulf CARE)

We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.