A comparison between two different definitions of contrast-associated acute kidney injury for long-term mortality in patients with diabetes undergoing coronary angiography: a prospective cohort study

A Comparison Between Two Different Definitions of Contrast-Associated Acute Kidney Injury for Long-Term Mortality in Patients with Chronic Kidney Disease Undergoing Coronary Angiography

Background

Contrast-associated acute kidney injury (CA-AKI) is a prevalent complication following coronary angiography (CAG). However, there is ongoing controversy surrounding its precise definition. Although previous studies have demonstrated the successful application of appropriate definitions in managing high-risk CA-AKI patients, there remains limited research on the association between different definitions and prognosis specifically in patients with chronic kidney disease (CKD).

Methods

A total of 4197 CKD patients undergoing coronary angiography (CAG) were included in this study. Two definitions of contrast-associated acute kidney injury (CA-AKI) were used: CA-AKIA, which was defined as an increase of ≥0.5 mg/dL or >25% in serum creatinine (SCr) from baseline within 72 hours after CAG, and CA-AKIB, which was defined as an increase of ≥0.3 mg/dL or >50% in SCr from baseline within 48 hours after CAG. Cox regression analysis was employed to assess the association between these two definitions and long-term mortality. Additionally, population attributable risks (PARs) were calculated to evaluate the impact of CA-AKI definitions on long-term prognosis.

Results

During the median follow-up period of 4.70 (2.50-7.78) years, the overall long-term mortality was 23.6%, and the long-term mortality in patients with CA-AKI according to both CA-AKIA and CA-AKIB criteria were 33.5% and 33.8%, respectively. We found that CA-AKIA (HR: 1.45, 95% CI: 1.23-1.70, p<0.001) and CA-AKIB (HR: 1.44, 95% CI: 1.23-1.69, p<0.001) were associated with long-term mortality. The PARs were the highest for CA-AKIA (5.87%), followed by CA-AKIB (5.70%).

Conclusion

Contrast-associated acute kidney injury (CA-AKI) is a frequently observed complication in CKD patients undergoing coronary angiography (CAG), and both definitions of CA-AKI are significantly correlated with a poor long-term prognosis. Consequently, in the clinical management of CKD patients, it is crucial to prioritize CA-AKI, irrespective of the specific CA-AKI definition used.

Anemia and periprocedural complications determine contrast-associated acute kidney injury after recanalization of chronic coronary occlusions in chronic kidney disease

BACKGROUND

Contrast-associated acute kidney injury (CA-AKI) is a potential risk associated with the percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO) particularly with pre-existing chronic kidney disease (CKD). The determinants of CA-AKI in patients with pre-existing CKD in an era of advanced strategies of CTO recanalization techniques need to be considered for a risk evaluation of the procedure.

METHODS

A consecutive cohort of 2504 recanalization procedures for a CTO between 2013 and 2022 was analyzed. Of these, 514 (20.5%) were done in patients with CKD (estimated glomerular filtration rate < 60 ml/min based on the most recently used CKD Epidemiology Collaboration equation).

RESULTS

The rate of patients classified to have CKD would be lower with 14.2% using the Cockcroft-Gault equation, and 18.1% using the modified Modification of Diet in Renal Disease equation. The technical success was high with 94.9% and 96.8% (p = 0.04) between patients with and without CKD. The incidence of CA-AKI was 9.9% versus 4.3% (p < 0.001). The major determinants of CA-AKI in patients with CKD were the presence of diabetes and a reduced ejection fraction, as well as periprocedural blood loss, whereas a higher baseline hemoglobin and the use of the radial approach prevented CA-AKI.

CONCLUSIONS

In patients with CKD CTO PCI could be performed successfully at a higher cost of CA-AKI. Correcting preprocedural anemia and avoiding intraprocedural blood loss may reduce the incidence of CA-AKI.

Acute kidney injury in diabetes mellitus: Epidemiology, diagnostic, and therapeutic concepts

Acute kidney injury (AKI) and diabetes mellitus (DM) are public health problems that cause a high socioeconomic burden worldwide. In recent years, the landscape of AKI etiology has shifted: Emerging evidence has demonstrated that DM is an independent risk factor for the onset of AKI, while an alternative perspective considers AKI as a bona fide complication of DM. Therefore, it is necessary to systematically characterize the features of AKI in DM. In this review, we summarized the epidemiology of AKI in DM. While focusing on circulation- and tissue-specific microenvironment changes after DM, we described the active cellular and molecular mechanisms of increased kidney susceptibility to AKI under DM stress. We also reviewed the current diagnostic and therapeutic strategies for AKI in DM recommended in the clinic. Updated recognition of the epidemiology, pathophysiology, diagnosis, and medications of AKI in DM is believed to reveal a path to mitigate the frequency of AKI and DM comorbidity that will ultimately improve the quality of life in DM patients.

Comparison Between Two Definitions of Contrast-Associated Acute Kidney Injury in Patients With Congestive Heart Failure

Background

Different definitions of contrast-associated acute kidney injury (CA-AKI) have different predictive effects on prognosis. However, few studies explored the relationship between these definitions and long-term prognosis in patients with congestive heart failure (CHF). Thus, we aimed to evaluate this association and compared the population attributable risks (PAR) of different CA-AKI definitions.

Methods

This study enrolled 2,207 consecutive patients with CHF undergoing coronary angiography (CAG) in Guangdong Provincial People's Hospital. Two different definitions of CA-AKI were used: CA-AKI_A was defined as an increase ≥.5 mg/dl or > 25% in serum creatinine (SCr) from baseline within 72 h after CAG, and CA-AKI_B was defined as an increase of ≥.3 mg/dl or > 50% in SCr from baseline within 48 h after CAG. Kaplan-Meier methods and Cox regression were applied to evaluate the association between CA-AKI with long-term mortality. Population attributable risk (PAR) of different definitions for long-term prognosis was also calculated.

Results

During the 3.8-year median follow-up (interquartile range 2.1-6), the overall long-term mortality was 24.9%, and the long-term mortality in patients with the definitions of CA-AKI_A and CA-AKI_B were 30.4% and 34.3%, respectively. We found that CA-AKI_A (HR: 1.44, 95% CI 1.19-1.74) and CA-AKI_B (HR: 1.48, 95% CI 1.21-1.80) were associated with long-term mortality. The PAR was higher for CA-AKI_A (9.6% vs. 8%).

Conclusions

Our findings suggested that CA-AKI was associated with long-term mortality in patients with CHF irrespective of its definitions. The CA-AKI_A was a much better definition of CA-AKI in patients with CHF due to its higher PAR. For these patients, cardiologists should pay more attention to the presence of CA-AKI, especially CA-AKI_A.

Machine learning prediction model of acute kidney injury after percutaneous coronary intervention

Acute kidney injury (AKI) after percutaneous coronary intervention (PCI) is associated with a significant risk of morbidity and mortality. The traditional risk model provided by the National Cardiovascular Data Registry (NCDR) is useful for predicting the preprocedural risk of AKI, although the scoring system requires a number of clinical contents. We sought to examine whether machine learning (ML) techniques could predict AKI with fewer NCDR-AKI risk model variables within a comparable PCI database in Japan. We evaluated 19,222 consecutive patients undergoing PCI between 2008 and 2019 in a Japanese multicenter registry. AKI was defined as an absolute or a relative increase in serum creatinine of 0.3 mg/dL or 50%. The data were split into training (N = 16,644; 2008-2017) and testing datasets (N = 2578; 2017-2019). The area under the curve (AUC) was calculated using the light gradient boosting model (GBM) with selected variables by Lasso and SHapley Additive exPlanations (SHAP) methods among 12 traditional variables, excluding the use of an intra-aortic balloon pump, since its use was considered operator-dependent. The incidence of AKI was 9.4% in the cohort. Lasso and SHAP methods demonstrated that seven variables (age, eGFR, preprocedural hemoglobin, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction/unstable angina, heart failure symptoms, and cardiogenic shock) were pertinent. AUC calculated by the light GBM with seven variables had a performance similar to that of the conventional logistic regression prediction model that included 12 variables (light GBM, AUC [training/testing datasets]: 0.779/0.772; logistic regression, AUC [training/testing datasets]: 0.797/0.755). The AKI risk model after PCI using ML enabled adequate risk quantification with fewer variables. ML techniques may aid in enhancing the international use of validated risk models.

Contrast-Associated Acute Kidney Injury in Patients with and without Diabetes Mellitus Undergoing Computed Tomography Angiography and Local Thrombolysis for Acute Lower Limb Ischemia

PurposeRepetitive iodinated contrast media exposure may be harmful for the kidneys. The aim of the present study was to evaluate if patients with diabetes mellitus (DM) undergoing CT angiography (CTA) and local continuous thrombolysis for acute lower limb ischemia (ALI) had an increased risk of developing contrast-associated acute kidney injury (CA-AKI) compared to patients without DM. Methods: This is a retrospective study of patients undergoing CTA and local continuous thrombolysis due to ALI between 2001 and 2018. CA-AKI was defined as a 25% increase in serum creatinine within 72 hours after latest contrast administration. Results: There was no difference (P = .30) in the frequency of CA-AKI between patients with (27.9%; n = 43) and without DM (20.6%; n = 170). Among patients with CA-AKI, patients with DM had a lower (P < .001) estimated glomerular filtration rate (eGFR) at discharge (55 ml/min/1.73 m²) than at admission (70 ml/min/1.73 m²), while no such difference was found in the group without DM (P = .20). The gram-iodine dose/eGFR ratio was higher (P < .001) in patients with CA-AKI (median 1.49, [IQR 1.34-1.81]) than in those who did not develop CA-AKI (median 1.05 [IQR 1.00-1.13]). There was a trend that gram-iodine dose/eGFR ratio (OR 1.42/standard deviation increment, 95% CI 1.00-2.02; P = .050) was associated with an increased risk of CA-AKI, after adjusting for DM, age, and gender. Conclusions: The frequency of CA-AKI was high after CTA and local continuous thrombolysis for ALI without shown increased frequency for the DM group. Among patients with CA-AKI, however, patients with DM had worse renal function at discharge than those without DM. The gram-iodine dose/eGFR ratio in these patients needs to be lower to improve renal outcomes, particularly in patients with DM.

A Comparison Between Two Definitions of Contrast-Associated Acute Kidney Injury for Long-Term Mortality in Elderly and Non-elderly Patients After Elective Percutaneous Coronary Intervention

Background: Contrast-associated acute kidney injury (CA-AKI) is responsible for a substantial proportion of the observed mortality that occurs after percutaneous coronary intervention (PCI), particularly in elderly patients. However, there has been significant and debate over whether the optimal definition of CA-AKI persists over prolonged periods due to variations in the prevalence and effects on prognosis. In this study, we aimed to identify whether different definitions of CA-AKI exert differential impacts on long-term mortality when compared between elderly and non-elderly patients receiving elective PCI. Methods: We prospectively investigated 5,587 consenting patients undergoing elective PCI between January 2012 and December 2018. We considered two classical definitions of CA-AKI from the European Society of Urogenital Radiology (ESUR) and the Acute Kidney Injury Network (AKIN). Multivariable Cox regression analysis was used to investigate the association between CA-AKI and long-term mortality. We also performed interaction and stratified analyses according to age (≤75 or >75 years). Results: The incidence of CA-AKI according to the ESUR and AKIN definitions was 18.7 and 6.1%, respectively. After a median follow-up of 2.1 years, multivariable Cox regression analysis indicated that CA-AKI according to the AKIN definition was a risk factor for long-term mortality in the overall population [hazard ratio (HR) = 2.20; 95% confidential interval (CI): 1.51-3.22; p < 0.001]; however, this was not the case for the ESUR definition (HR = 1.27; 95% CI: 0.92-1.76; p = 0.153). Further interaction analysis identified a significant interaction between age and the ESUR definition (p = 0.040). Stratified analyses also found an association between the ESUR definition and long-term mortality in patients >75 years of age (p = 0.011), but not in patients ≤75 years of age (p = 0.657). Conclusion: As a stringent definition of CA-AKI, the AKIN definition was significantly associated with long-term mortality in both non-elderly and elderly patients. However, in elderly patients, the more lenient definition provided by the ESUR was also significantly correlated with long-term mortality, which could sensitively identify high-risk elderly patients and may provide a better alternative.