Contrast-induced nephropathy in patients with chronic kidney disease and peripheral arterial disease

Patients with Different Stages of Chronic Kidney Disease Undergoing Intravenous Contrast-Enhanced Computed Tomography-The Incidence of Contrast-Associated Acute Kidney Injury

Introduction: Iodinated contrast medium (CM) is the third most common cause of acute kidney injury (AKI). However, the association is poorly known between the definitions of AKI between different stages of chronic kidney disease after intravenous CM administration. Methods: The dataset, covering a period of ~15 years (1 June 2008 to 31 March 2015), consisted of 20,018 non-dialytic adult patients who had received intravenous injections of non-ionic iso-osmolar CM, iodixanol, for enhanced computed tomography imaging. Contrast-associated AKI (CA-AKI), dialysis-required AKI, and mortality were analyzed. Results: A total of 12,271 participants were enrolled. CA-AKI increased significantly starting from stage 3A onward (p < 0.001). In summary, incidences of CA-AKI against different levels of chronic kidney disease were as follows: stage 1 (8.3%) = stage 2 (6.7%) < stage 3A (9.9%) < stage 3B (14.3%) < stage 4 (20.5%) = stage 5 (20.4%). The incidences of dialysis within 30 days were as follows: stage 1 (1%) = stage 2 (1.4%) = stage 3A (2.7%) < stage 3B (5.7%) < stage 4 (18%) < stage 5 (54.1%). The prediction of dialysis was good based on the baseline serum creatinine > 1.5 mg/dL (72.78% of sensitivity, 86.07% of specificity, 0.851 of area under curve) or baseline estimated glomerular filtration rate ≤ 38.49 mL/min/1.732 m2 (70.19% of sensitivity, 89.08% of specificity, 0.853 of area under curve). In multivariate Cox regression analysis model for CA-AKI, independent risk factors were stage 4 chronic kidney disease (p = 0.001) and shock (p = 0.001). Conclusion: Baseline serum creatinine and estimated glomerular filtration rate were good predictors for dialysis-required AKI. CA-AKI increased significantly since stage 3A chronic kidney disease. Stage 4 and 5 chronic kidney disease have the same risk for CA-AKI, but stage 5 chronic kidney disease has markedly higher risk for dialysis.

Mehran 2 Contrast-Associated Acute Kidney Injury Risk Score: Is it Applicable to the Asian Percutaneous Coronary Intervention Population?

Contrast-associated acute kidney injury (CA-AKI) can occur after percutaneous coronary intervention (PCI). The Mehran score is the gold standard for predicting CA-AKI risk, and it has recently been updated. The Mehran 2 CA-AKI risk score, based on existing variables in patients undergoing PCI, can accurately differentiate the risk of CA-AKI. This study aimed to verify whether the new Mehran score is applicable to the Asian PCI population. The study included the clinical data of 2487 patients undergoing PCI from August 2020 to February 2022. The goodness-of-fit test (Hosmer-Lemeshow) was used to evaluate the correction ability of the Mehran 2 score, and the area under the receiver operating characteristic curve (ROC) was used to evaluate the accuracy of the Mehran 2 score in predicting CA-AKI. CA-AKI occurred in 28 of 2487 patients, with an incidence rate of 1.12%. The proportion of high risk factors for AKI in the cohort was lower than that in the Mehran 2 cohort (a large contemporary PCI cohort to develop the Mehran 2 score). The Mehran 2 risk score had excellent goodness-of-fit (χ2 = 5.320, df = 6, P = 0.503) and high predictive accuracy (area under the ROC curve 0.836, P < 0.0001). The Mehran 2 score shows good predictive and correction performance in the Asian population and has good clinical application value. The inclusion of the Mehran 2 risk score in patients hospitalised for coronary angiography appears to be good practice.

Contrast-induced nephropathy in non-cardiac vascular procedures, a narrative review: Part 2

This is Part 2 of a narrative review summarizing the literature on CIN after non-cardiac vascular diagnostic or therapeutic procedures, focusing on peripheral artery disease (PAD) and renal artery stenosis (RAS). Part 1 discussed CIN in relation to aortic aneurysms and carotid stenosis. We comment on the incidence, biomarkers, risk factors, and consequences of CIN in patients with PAD or RAS, as well as on strategies to prevent CIN. Future perspectives in the field of CIN in relation to non-cardiac vascular procedures are also considered.

Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference

The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.

Acute kidney injury following endovascular intervention for peripheral artery disease

BACKGROUND

The incidence of, and risk factors for, acute kidney injury (AKI) after endovascular intervention for peripheral artery disease (PAD) remain unknown. The aim of this study was to assess the proportion of patients who develop AKI and explore the risk factors.

METHODS

Prospectively collected data on patients undergoing femoropopliteal endovascular intervention for symptomatic PAD across three vascular centres were analysed. The proportion of patients developing AKI (according to the Kidney Disease Improving Global Outcomes definition) within 48 h, and the proportion developing the composite Major Adverse Kidney Events (MAKE) endpoints (death, dialysis, drop in estimated glomerular filtration rate at least 25 per cent) at 30 days (MAKE30) and remains 90 days (MAKE90) were calculated. Multivariable regression analysis was used to assess predictors of AKI, and the association between AKI and death.

RESULTS

Some 2041 patients were included in the analysis. AKI developed in 239 patients (11.7 per cent), with 47 (2.3 per cent) requiring dialysis within 30 days, and 18 (0.9 per cent) requiring ongoing dialysis. The MAKE30 and MAKE90 composite endpoints were reached in 358 (17.5 per cent) and 449 (22.0 per cent) patients respectively. Risk factors for AKI were age, sex, congestive heart failure, chronic limb-threatening ischaemia, emergency procedure, and pre-existing chronic kidney disease. AKI, dementia, congestive heart failure, and major amputation were risk factors for medium-term mortality.

CONCLUSION

AKI is a common complication after intervention for PAD and is associated with medium-term mortality.

Nomogram for contrast-induced acute kidney injury in patients with chronic kidney disease undergoing coronary angiography in China: a cohort study

OBJECTIVES

To establish a nomogram for contrast-induced acute kidney injury (CI-AKI) risk assessment among patients with chronic kidney disease (CKD) undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI).

DESIGN

Prospective observational cohort study.

SETTING

Southern China.

INTERVENTIONS

None.

PARTICIPANTS

643 consecutive patients with CKD (defined as estimated glomerular filtration rate calculated by Modification of Diet in Renal Disease formula <60 mL/min/1.73 mm2) were enrolled.

OUTCOME MEASURES

The end point was CI-AKI defined as serum creatinine elevation ≥0.5 mg/dL or 25% from baseline within the first 48-72 hours following contrast exposure.Predictors of CI-AKI were selected by multivariable logistic regression and stepwise approach. A nomogram based on these predictors was constructed and compared with the classic Mehran Score. For validation, a bootstrap method (1000 times) was performed.

RESULTS

The nomogram including age, weight, heart rate, hypotension, PCI and β-blocker demonstrated a better predictive value than the classic Mehran Score (area under the curve: 0.78 vs 0.71, p=0.024), as well as a well-fitted calibration curve (χ2=12.146, p=0.145). Validation through the bootstrap method (1000 times) also indicated a good discriminative power (adjusted C-statistic: 0.76).

CONCLUSIONS

With fewer predictors and higher discriminative power, the present nomogram may be a simple and reliable tool to identify patients with CKD at risk of CI-AKI, whereas further external validations are needed.

Carbon dioxide (CO2) angiography as an option for endovascular abdominal aortic aneurysm repair (EVAR) in patients with chronic kidney disease (CKD)

To assess feasibility, efficacy and safety of carbon dioxide (CO₂) digital subtraction angiography (DSA) to guide endovascular aneurysm repair (EVAR) in a cohort of patients with chronic kidney disease (CKD). After Ethical Committee approval, the records of 13 patients (all male, mean age 74.6 ± 8.0 years) with CKD, who underwent EVAR to exclude an abdominal aortic aneurysm (AAA) under CO₂ angiography guidance, were reviewed. The AAA to be excluded had a mean diameter of 52.0 ± 8.0 mm. CO₂ angiography was performed by automatic (n = 7) or hand (n = 6) injection. The endograft was correctly placed and the AAA was excluded in all cases, without any surgical conversions. Two patients (15.4%) had an endoleak: one type-Ia, detected by CO₂-DSA and effectively treated with prosthesis dilatation; one type-III, detected by CO₂-DSA, confirmed using 10 ml of ICM, and conservatively managed. In one patient, CO₂ angiograms were considered of too low quality for guiding the procedure and 200 ml of ICM were administered. Overall, 11 patients (84.6%) underwent a successful EVAR under the guidance of the sole CO₂ angiography. No patients suffered from major complications, including those typically CO₂-related. Two patients suffered from abdominal pain during the procedure secondary to a transient splanchnic perfusion's reduction due to CO₂, and one patient had a worsening of renal function probably caused by a cholesterol embolization during the procedure. In patients with CKD, EVAR under CO₂ angiography guidance is feasible, effective, and safe.

Post-Hoc Study: Intravenous Hydration Treatment in Chinese Patients with High Risk of Contrast-Induced Nephropathy Following Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) develops after the injection of iodinated contrast media. This is a post hoc analysis of the data obtained from the TRUST study, which was a prospective, multicentre, observational study conducted to evaluate the safety and tolerability of the contrast medium iopromide in patients undergoing cardiac catheterization from August 2010 to September 2011 in China, conducted to explore the current status, trends and risk predictors of hydration treatment. The status of hydration to prevent CIN in each patient was recorded. Of the total 17,139 patients from the TRUST study (mean age, 60.33 ± 10.38 years), the overall hydration usage was 46.1% in patients undergoing percutaneous coronary intervention (PCI) and 77.4%, 51.7%, and 48.5% in patients with pre-existing renal disease, diabetes mellitus, and hypertension, respectively. The proportion of hydration use increased from 36.5% to 55.5% from August 2010 to September 2011, which was independently associated with risk predictors like older age, pre-existing renal disease, hypertension, diabetes mellitus, prior myocardial infarction, ST segment elevation MI, high contrast dose, multi-vessel disease and reduced LVEF (<45%). Overall, the usage of intravenous hydration treatment for patients with a high risk of CIN following PCI was high in China.