Biomarkers for the early prediction of contrast-induced nephropathy after percutaneous coronary intervention in adults: A systematic review and meta-analysis

SGLT2 Inhibitors and the Risk of Contrast-Associated Nephropathy Following Angiographic Intervention: Contradictory Concepts and Clinical Outcomes

The use of SGLT2 inhibitors (SGLT2is) has been found in large clinical studies to slow the progression of chronic kidney disease (CKD) and to lower the risk of acute kidney injury (AKI). Recent reports suggest that SGLT2is may also reduce the likelihood of developing radiocontrast-associated nephropathy (CAN) following contrast-enhanced imaging and intravascular interventions. This review underscores potential pitfalls and confounders in these studies and calls for caution in adopting their conclusions regarding the safety and renoprotective potency of SGLT2is, in particular in patients at high risk, with advanced CKD and hemodynamic instability undergoing coronary intervention. This caution is particularly warranted since both SGLT2is and contrast media intensify medullary hypoxia in the already hypoxic diabetic kidney and their combination may lead to medullary hypoxic damage, a principal component of CAN. Further studies are needed to evaluate this dispute, particularly in patients at high risk, and to reveal whether SGLT2is indeed provide renal protection or are hazardous during contrast-enhanced imaging and vascular interventions.

Current updates in radiocontrast-associated acute kidney injury

Contrast-associated acute kidney injury (CA-AKI) is an abrupt decline in kidney function occurring after a recent exposure to iodinated radiocontrast media. CA-AKI presents as elevated serum creatinine level or decreased urine output. CA-AKI is the third leading cause of inpatient AKI. The incidence of CA-AKI varies according to patient population characteristics, ranging from 5% in the general population to as high as 30% in special populations with preexisting comorbidities such as diabetes mellitus, cardiovascular disease, and chronic kidney disease. The development of CA-AKI places a heavy toll on patients and the healthcare system secondary to increased patient morbidity, mortality, hospital length of stay, readmission risk, and healthcare cost. Patients undergoing cardiac catheterization are of special interest, since they have higher risk of developing CA-AKI and its associated complications. The recognition, prevention, and management of CA-AKI has improved over the past few years with the introduction of fluid management guidelines, using less nephrotoxic radiocontrast media, and preprocedural CA-AKI risk assessment. Future advancements in patients' CA-AKI risk stratification and early detection will facilitate prompt initiation of mitigation treatment plans and decrease associated complications.

Key Considerations regarding the Renal Risks of Iodinated Contrast Media: The Nephrologist's Role

BACKGROUND

The administration of iodinated contrast medium during diagnostic and therapeutic procedures has always been associated with the fear of causing acute kidney injury (AKI) or an exacerbation of chronic kidney disease. This has led, on the one hand, to the deterrence, when possible, of the use of contrast medium (preferring other imaging methods with the risk of loss of diagnostic power), and on the other hand, to the trialling of multiple prophylaxis protocols in an attempt to reduce the risk of kidney injury.

SUMMARY

A literature review on contrast-induced (CI)-AKI risk mitigation strategies was performed, focussing on the recognition of individual risk factors and on the most recent evidence regarding prophylaxis.

KEY MESSAGES

Nephrologists can contribute significantly in the CI-AKI context, from the early stages of the decision-making process to stratifying patients by risk, individualising prophylaxis measures based on the risk profile, and ensuring appropriate evaluation of kidney function and damage post-procedure to improve care.

Parameters influencing renal response to SGLT2 inhibitors and GLP1 receptor agonists in type 2 diabetes patients with preserved renal function: a comparative, prospective study

PURPOSE

SGLT2 inhibitors (SGLT2i) and GLP1 receptor agonists (GLP1-RA) protect the kidney in type 2 diabetes (T2DM) subjects. The role of patient's phenotype years before starting the treatment in determining the kidney response to these drugs has never been evaluated.

SUBJECTS AND METHODS

Clinical and biochemical parameters were collected in 92 T2DM patients with preserved kidney function from year -4 (T-4) to year +3 (T+3) from the introduction of semaglutide or empagliflozin (T0). Glomerular filtration rate (eGFR) slopes were evaluated to identify eGFR changes (ΔGFR) and predictors of treatment response. Urinary markers of kidney impairment were measured at T0, including KIM-1, TNFR1 and L-FABP.

RESULTS

Characteristics of patients on semaglutide (n = 46) or empagliflozin (n = 37) were similar at T-4 and T0. ΔGFR from T0 to T+3 was -5.5 [-10.0; -0.7] vs -2.6 [-102.4] ml/min/1.73 m² for GLP1-RA and SGLT2i, respectively (p = ns). Compared with patients with a slower eGFR decline, those with ΔGFR > 5 ml/min/1.73 m² from T0 to T+3 (49%) or ΔGFR > 10 ml/min/1.73 m² from T-4 to T+3 (25%) had similar characteristics and urinary markers at T-4 and T0. The latter group showed greater eGFR decline from T-3 to T0, which tended to be delayed more by SGLT2i than GLP1-RA (p = 0.09).

CONCLUSION

In our cohort, subjects with T2DM and preserved renal function show similar eGFR response to treatment with GLP1-RA or SGLT2i. Baseline urinary biomarkers or prior phenotyping do not predict treatment response. An early eGFR decline identifies patients prone to lose more eGFR over time, who may benefit more from SGLT2i treatment.

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.

Procalcitonin and High APACHE (Acute Physiological and Chronic Health Evaluation) Level Are Associated with the Course of Acute Kidney Injury in Patients with SARS-CoV-2

BACKGROUND

Acute kidney injury (AKI) is associated with poor outcomes in patients infected with SARS-CoV-2. Sepsis, direct injury to kidney cells by the virus, and severe systemic inflammation are mechanisms implicated in its development. We investigated the association between inflammatory markers (C-reactive protein, procalcitonin, D-dimer, lactate dehydrogenase, and ferritin) in patients infected with SARS-CoV-2 and the development of AKI.

METHODS

A prospective cohort study performed at the Civil Hospital (Dr. Juan I. Menchaca) Guadalajara, Mexico, included patients aged >18 years with a diagnosis of SARS-CoV-2 pneumonia confirmed by RT-PCR and who did or did not present with AKI (KDIGO) while hospitalized. Biomarkers of inflammation were recorded, and kidney function was estimated using the CKD-EPI formula.

RESULTS

291 patients were included (68% males; average age, 57 years). The incidence of AKI was 40.5% (118 patients); 21% developed stage 1 AKI, 6% developed stage 2 AKI, and 14% developed stage 3 AKI. The development of AKI was associated with higher phosphate (p = 0.002) (RR 1.39, CI 95% 1.13-1.72), high procalcitonin levels at hospital admission (p = 0.005) (RR 2.09, CI 95% 1.26-3.50), and high APACHE scores (p = 0.011) (RR 2.0, CI 95% 1.17-3.40). The survival analysis free of AKI according to procalcitonin levels and APACHE scores demonstrated a lower survival in patients with procalcitonin >0.5 ng/ml (p = 0.001) and APACHE >15 points (p = 0.004).

CONCLUSIONS

Phosphate, high procalcitonin levels, and APACHE levels >15 were predictors of AKI development in patients hospitalized with COVID-19.