Prevention of contrast-induced acute kidney injury in patients undergoing cardiovascular procedures-a systematic review and network meta-analysis

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.

Treatment of dyslipidemia in acute coronary syndrome

Despite numerous improvements in the management of acute coronary syndrome(ACS), it is a major cause of mortality in India. Lipids play a critical role in pathogenesis of ACS and reduction of lipid parameters plays a pivotal role in secondary prevention. High total cholesterol and high low-density lipoprotein(LDL) are the major lipid abnormalities globally as well as in Indians. Among all the lipid parameters, LDL is the primary target of lipid-lowering therapies across the globe. High-dose statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and bempedoic acid are recommended therapies for LDL reduction in ACS patients. Statins have pleiotropic effects on the modulation of thrombogenesis, endothelial dysfunction, and myocardial protection. Multiple randomised controlled trials and meta-analyses have shown that the use of high-dose statin has significant benefits in ACS. LDL reduction goal is < 55 mg/dl or at least 50 % reduction from the baseline regardless of age or gender. Non-fasting LDL should be measured soon after the ACS as it varies minimally with food intake. The first line of therapy after ACS is to advise lifestyle modifications, combination therapy including high-dose statin with ezetimibe, and evaluation after 4-6 weeks of the index event. If the goal is not achieved then PCSK 9 inhibitors or Bempedoic acid should be used in combination with statins and ezetimibe to reduce recurrent ischaemic events. Despite the proven effect of these lipid-lowering therapies, undertreatment is still a big hurdle across the globe. Prohibitive costs, adverse effects, medication non-adherence, variation in health practice in different countries, and clinical inertia to prescribe this medication by physicians are the main reasons for the undertreatment.

Use of Prophylactic High-Dose Statin Therapy to Reduce Contrast-Induced Acute Kidney Injury in Adults Undergoing Acute Coronary Angiography: Evaluation of a Practice Change

BACKGROUND

Development of contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity, mortality, hospital length of stay, and overall health care costs.

OBJECTIVES

The purpose of this project was to evaluate a clinical practice change-the addition of high-dose statin therapy to standard renal protection measures-in adults undergoing acute cardiac catheterization procedures and assessing its effect on CI-AKI.

METHOD

The evaluation was a pretest/posttest descriptive design. Adult patients undergoing acute cardiac catheterization procedures were evaluated for the rate of CI-AKI before (10 months preimplementation, N = 283) and after (10 months postimplementation, N = 286) a recent practice change that added high-dose statin therapy (within 24 hours of dye exposure) to a standard renal protection bundle (intravenous fluids, maximum dye calculations, and avoidance of nephrotoxic medications). Outcomes included the rate of CI-AKI, stage of acute kidney injury, need for new hemodialysis, discharge disposition (alive or died in the hospital), and hospital length of stay.

RESULTS

Patients in the postintervention group that received renal protection bundle with high-dose statin had significantly lower incidence of CI-AKI (10.1% pre vs 3.2% post; P < .001). There were no significant differences in hospital length of stay, need for new hemodialysis, or mortality. Administration of high-dose statin within 24 hours of the cardiac catheterization procedure improved significantly (19.4% pre vs 74.1% post; P < .001). Adherence to all 5 components of the renal bundle improved post intervention (17% pre vs 73.4% post; P < .001).

DISCUSSION

The addition of a high-dose statin in addition to existing renal protective measures in patients with acute cardiac procedures is associated with a decreased incidence of CI-AKI.

Advances in the available pharmacotherapy for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

INTRODUCTION

Non-ST-segment elevation acute coronary syndromes (NSTE-ACS), including non-ST-segment-elevation myocardial infarction (NSTEMI) and unstable angina, represent a leading cause of mortality worldwide, with important socio-economic consequences. NSTEMI accounts for the majority of acute coronary syndromes and usually develops on the background of a nonocclusive thrombus. We searched for relevant literature in the field in PubMed and clinicaltrials.gov as of July 2022.

AREAS COVERED

A number of pharmacotherapies are currently available for treatment and secondary prevention, mainly including antithrombotic, lipid-lowering and anti-inflammatory drugs. Pretreatment with aspirin, anticoagulant and statin therapy is of key importance in the preprocedural phase, while pretreating with an oral P2Y12 inhibitor is not routinely indicated in patients undergoing early invasive management. For patients undergoing percutaneous coronary revascularization, pharmacotherapy essentially consists of antithrombotic drugs, which should be carefully selected. Finally, antithrombotic, lipid-lowering and anti-inflammatory drugs are important components of long-term secondary prevention after a NSTE-ACS.

EXPERT OPINION

This article reviews the evidence supporting recommendation on pharmacotherapy in patients presenting with a NSTE-ACS. Several randomized clinical trials are still ongoing and are expected to further inform scientific knowledge and clinical practice, with the final aim to improve the treatment of NSTE-ACS patients.

N-acetylcysteine in the Prevention of Contrast-induced Acute Kidney Injury: a Systematic Review and Meta-analysis of Randomized Controlled Clinical Trials

Aim. To analyze the currently available published randomized controlled clinical trials to evaluate the effect of N-acetylcysteine on the incidence of contrast-induced acute kidney injury (CI-AKI).

Material and methods. The meta-analysis was performed in accordance with the PRISMA guidelines based on a search of existing literature in the PubMed/MEDLINE database for the period from 2015 to 16 February 2022. Keywords included MeSH terms «acute kidney injury» or «contrast-induced nephropathy» or «AKI» or «CIN» and «contrast media» and «N-acetylcysteine». The RoB 2 tool was used to assess study bias.

Results: When searching based on the initially selected statistics, 98 publications were identified, some of them were excluded from the analysis due to non-compliance with the inclusion criteria in this meta-analysis, 7 studies of unused sources of detection were ultimately selected, the total number of patients in the discovery was 10394.The results of the meta-analysis revealed that in patients treated with N-acetylcysteine CI-AKI developed with the same frequency as in patients who did not observe such therapy as a prophylaxis for this disease (odds ratio 1.06, 95% confidence interval 0.911.23, p=0.46).

Conclusion. The use of N-acytelcysteine does not offer any advantage in reducing the incidence of CI-AKI compared with the administration of saline solutions (sodium bicarbonate or sodium chloride 0.9%) or placebo.

Statins in High Cardiovascular Risk Patients: Do Comorbidities and Characteristics Matter?

Atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality are decreasing in high-income countries, but ASCVD remains the leading cause of morbidity and mortality in high-income countries. Over the past few decades, major risk factors for ASCVD, including LDL cholesterol (LDL-C), have been identified. Statins are the drug of choice for patients at increased risk of ASCVD and remain one of the most commonly used and effective drugs for reducing LDL cholesterol and the risk of mortality and coronary artery disease in high-risk groups. Unfortunately, doctors tend to under-prescribe or under-dose these drugs, mostly out of fear of side effects. The latest guidelines emphasize that treatment intensity should increase with increasing cardiovascular risk and that the decision to initiate intervention remains a matter of individual consideration and shared decision-making. The purpose of this review was to analyze the indications for initiation or continuation of statin therapy in different categories of patient with high cardiovascular risk, considering their complexity and comorbidities in order to personalize treatment.

National Cardiovascular Data Registry-Acute Kidney Injury (NCDR) vs. Mehran risk models for prediction of contrast-induced nephropathy and need for dialysis after coronary angiography in a German patient cohort

BACKGROUND

Contrast-induced nephropathy (CIN) is a major adverse event in patients undergoing coronary angiography. The Mehran risk model is the gold-standard for CIN risk prediction. However, its performance in comparison to more contemporary National Cardiovascular Data Registry-Acute Kidney Injury (NCDR-AKI) risk models remains unknown. We aimed to compare both in this study.

METHODS AND RESULTS

Predictions of Mehran and NCDR-AKI risk models and clinical events of CIN and need for dialysis were assessed in a total of 2067 patients undergoing coronary angiography with or without percutaneous coronary intervention. Risk models were compared regarding discrimination (receiver operating characteristic analysis), net reclassification improvement (NRI) and calibration (graphical and statistical analysis). The NCDR risk model showed superior risk discrimination for predicting CIN (NCDR c-index 0.75, 95% CI 0.72-0.78; vs. Mehran c-index 0.69, 95% CI 0.66-0.72, p < 0.01), and continuous NRI (0.22; 95% CI 0.12-0.32; p < 0.01) compared to the Mehran model. The NCDR risk model tended to underestimate the risk of CIN, while the Mehran model was more evenly calibrated. For the prediction of need for dialysis, NCDR-AKI-D also discriminated risk better (c-index 0.85, 95% CI 0.79-0.91; vs. Mehran c-index 0.75, 95% CI 0.66-0.84; p_NCDRvsMehran < 0.01), but continuous NRI showed no benefit and calibration analysis revealed an underestimation of dialysis risk.

CONCLUSION

In German patients undergoing coronary angiography, the modern NCDR risk model for predicting contrast-induced nephropathy showed superior discrimination compared to the GRACE model while showing less accurate calibration. Results for the outcome 'need for dialysis' were equivocal.

Tailored Versus Standard Hydration to Prevent Acute Kidney Injury After Percutaneous Coronary Intervention: Network Meta-Analysis

Background

Contrast‐induced acute kidney injury (CI‐AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI‐AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion‐rate hydration strategies.

Methods and Results

A systematic review and network meta‐analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI‐AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate–guided, central venous pressure–guided, left ventricular end‐diastolic pressure–guided, and bioimpedance vector analysis–guided hydration. Primary endpoint was CI‐AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate–guided and central venous pressure–guided hydration were associated with a lower incidence of CI‐AKI compared with fixed‐rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19–0.54] and OR, 0.45 [95% CI, 0.21–0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate–guided hydration is advantageous in terms of both CI‐AKI prevention and pulmonary edema incidence when compared with other approaches.

Conclusions

Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline‐supported fixed‐rate hydration for CI‐AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate–guided hydration as the most convenient strategy in terms of effectiveness and safety.

Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.

Benefit of primary percutaneous coronary interventions in the elderly with ST segment elevation myocardial infarction

Objective

Primary percutaneous coronary intervention (P-PCI) has demonstrated its efficacy in patients with ST segment elevation myocardial infarction (STEMI). However, patients with STEMI ≥75 years receive less P-PCI than younger patients despite their higher in-hospital morbimortality. The objective of this analysis was to determine the effectiveness of P-PCI in patients with STEMI ≥75 years.

Methods

We included 979 patients with STEMI ≥75 years, from the ATención HOspitalaria del Síndrome coronario study, a registry of 8142 consecutive patients with acute coronary syndrome admitted at 31 Spanish hospitals in 2014–2016. We calculated a propensity score (PS) for the indication of P-PCI. Patients that received or not P-PCI were matched by PS. Using logistic regression, we compared the effectiveness of performing P-PCI versus non-performance for the composite primary event, which included death, reinfarction, acute pulmonary oedema or cardiogenic shock during hospitalisation.

Results

Of the included patients, 81.5 % received P-PCI. The matching provided two groups of 169 patients with and without P-PCI. Compared with its non-performance, P-PCI presented a composite event OR adjusted by PS of 0.55 (95% CI 0.34 to 0.89).

Conclusions

Receiving a P-PCI was significantly associated with a reduced risk of major intrahospital complications in patients with STEMI aged 75 years or older.

Kidney function stratified outcomes of percutaneous left atrial appendage occlusion in patients with atrial fibrillation and high bleeding risk

Background: Patients with chronic kidney disease (CKD) and atrial fibrillation have increased risks for stroke and bleeding under oral anticoagulation (OAC). We investigated an alternative therapy of percutaneous left atrial appendage occlusion (LAAO) in CKD patients in this study.Methods: Consecutive patients undergoing LAAO were included in a retrospective analysis and stratified for kidney function into CKD/Non-CKD groups (cutoff eGFR 60 ml/min). Procedural characteristics, in-hospital and follow-up events were analysed and compared between groups.Results: LAAO was performed in 146 patients (81 CKD; 65 Non-CKD), mean follow-up was 391 days. Groups differed in eGFR (40.1 (CKD) vs. 75.1 (Non-CKD) ml/min) and CHA₂DS₂VASc scores (4.65 ± 1.3 (CKD) vs. 4.06 ± 1.4 (Non-CKD)). Procedural success was 98.6%, contrast-induced acute kidney injury was significantly more frequent in CKD patients (11.1% vs. 0%; p = .004). Follow-up mortality was higher in CKD (10.5/100 PY vs. 4.2/100 PY; p = .156). Follow-up stroke rates were 2.3/100 (CKD) patient-years (PY) and 1.4/100 PY (Non-CKD) (p = 1.000), corresponding to a relative risk reduction (RRR) of 60% (all), 68% (CKD) and 71% (Non-CKD) compared to expected stroke rates. Follow-up major bleeding rates were 3.5/100 PY (CKD) and 4.2/100 PY (Non-CKD), corresponding to RRR of 57% (all), 61% (CKD) and 53% (Non-CKD) compared to OAC.Conclusions: Left atrial appendage occlusion shows comparable efficacy for stroke and bleeding prevention in CKD and Non-CKD patients. CKD patients experience more adverse events during follow-up and a significantly increased risk for periprocedural contrast-induced acute kidney injury.

Pharmacologic Prophylaxis of Contrast-Induced Nephropathy

Different pharmacologic agents have been tested in the effort to prevent contrast-induced acute kidney injury (AKI) in the last two decades. To date, however, no individual drug has received unanimous approval for this aim. Since 2014 statins have been included as preventive treatment in the European guidelines for revascularization procedures in cardiac patients. The present update presents the latest findings in this field focusing on the changing paradigms in the definition and consequently the approach to nephroprotection that considers clinical prognosis as the major issue. We note the current shift from attention to contrast-induced AKI to contrast-associated AKI.

Community Health Care Quality Standards to Prevent Acute Kidney Injury and Its Consequences

As the incidence of acute kidney injury (AKI) increases, prevention strategies are needed across the health care continuum, which begins in the community. Recognizing this knowledge gap, the 22nd Acute Disease Quality Initiative (ADQI) was tasked to discuss the evidence for quality-of-care measurement and care processes to prevent AKI and its consequences in the community. Using a modified Delphi process, an international and interdisciplinary group provided a framework to identify and monitor patients with AKI in the community. The recommendations propose that risk stratification involve both susceptibilities (eg, chronic kidney disease) and exposures (eg, coronary angiography), with the latter triggering a Kidney Health Assessment. This assessment should include blood pressure, serum creatinine, and urine dipstick, followed by a Kidney Health Response to prevent AKI that encompasses cessation of unnecessary medications, minimization of nephrotoxins, patient education, and ongoing monitoring until the exposure resolves. These recommendations give community health care providers and health systems a starting point for quality improvement initiatives to prevent AKI and its consequences in the community.

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.

Effects of probucol on contrast-induced acute kidney injury in patients undergoing percutaneous coronary intervention

OBJECTIVE

This study was performed to explore the effects of probucol on contrast-induced acute kidney injury (CIAKI) in patients with coronary heart disease undergoing percutaneous coronary intervention (PCI).

METHODS

In total, 220 patients undergoing PCI were randomly assigned to either the control group (hydration from 12 hours before to 12 hours after contrast administration; n = 110) or the probucol group (hydration plus probucol 500 mg twice daily 1 day before and 3 days after the operation; n = 110). The primary endpoint was the occurrence of serum creatinine (Scr)-based CIAKI, defined as an absolute increase in Scr by 0.5 mg/dl (44.2 μmol/L) or a relative 25% increase from baseline within 48 to 72 hours after exposure to contrast medium. The secondary outcomes were composite variations in Scr, blood urea nitrogen (BUN), creatinine clearance rate (Ccr) within 48 to 72 hours, and major adverse events during hospitalization or the 7-day follow-up period after PCI.

RESULTS

The overall incidence of Scr-based CIAKI was 7.3% (16/220): 5.5% (6/110) in the control group and 9.1% (10/110) in the probucol group (χ = 1.078, P = .298). There were no significant differences in the occurrence rate of major adverse events during hospitalization or the 7-day follow-up period after PCI between the groups. Multivariate logistic regression analysis showed that probucol was not an independent protective factor for CIAKI (odds ratio, 1.825; 95% confidence interval, 0.639-5.212; P = .261). However, hydration was an independent protective factor (odds ratio, 0.997; 95% confidence interval, 0.995-0.999; P = .004).

CONCLUSION

Probucol cannot effectively reduce the incidence of CIAKI through its anti-inflammatory and antioxidative stress effects.

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.

Contrast-Induced Nephropathy: Update on the Use of Crystalloids and Pharmacological Measures

Contrast-induced nephropathy (CIN) is a frequent and severe complication in subjects receiving iodinated contrast media for diagnostic or therapeutic purposes. Several preventive strategies were evaluated in the past. Recent clinical studies and meta-analyses delivered some new aspects on preventive measures used in the past and present. We will discuss all pharmacological and nonpharmacological procedures. Finally, we will suggest individualized recommendations for CIN prevention.

Nicorandil for the prevention of contrast-induced nephropathy: A meta-analysis of randomized controlled trials

INTRODUCTION

Nicorandil has been suggested as a preventative strategy against the incidence of contrast-induced nephropathy (CIN). However, results of relevant randomized controlled trials (RCTs) were inconsistent.

AIMS

We performed a meta-analysis of RCTs to evaluate the preventive efficacy of periprocedural treatment of nicorandil against the incidence of CIN.

METHODS

Relevant RCTs were identified via search of PubMed, Embase, and Cochrane's Library databases. Results were pooled using a random-effect model. Subgroup analyses were performed to evaluate the potential influence of administering routes on the efficacy of nicorandil against CIN incidence.

RESULTS

Four RCTs with 709 patients were included. Treatment of nicorandil significantly reduced the incidence of CIN as compared with controls (risk ration [RR]: 0.38, 95% confidence interval [CI]: 0.19 ~ 0.74, P = .005) with moderate heterogeneity (I²  = 33%). Results of subsequent subgroup analysis showed that nicorandil significantly reduced the risk of CIN if orally administered (RR: 0.32, P < .001), but did not if intravenously administered (RR: 0.47, I²  = 68%). Moreover, treatment with nicorandil was associated with significantly less increment of SCr (weight mean difference [WMD]: -3.98%, P < .001) and a tendency of less increment of cystatin C (WMD: -3.86%, P = .08) after 48-hour contrast exposure as compared with controls.

CONCLUSIONS

Periprocedural treatment with nicorandil may be preventative against the incidence of CIN in patients undergoing contrast exposure. The influence of periprocedural nicorandil on clinical outcome in these patients deserves further investigation.

The efficacy of probucol combined with hydration in preventing contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention: a multicenter, prospective, randomized controlled study

PURPOSE

To investigate the preventive effect of probucol combined with hydration on contrast-induced nephropathy (CIN) in patients with coronary heart disease undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 641 patients undergoing PCI were randomly assigned to either a probucol group (probucol 500 mg twice daily and hydration; n = 321) or a control group (hydration only; n = 320). The primary endpoint was the incidence of CIN, defined as an increase in serum creatinine (Scr) by ≥ 44.2 μmol/L or ≥ 25% within 72 h after the administration of contrast agent. Secondary endpoints were changes in Scr, cystatin-C (Cys-C), creatinine clearance rate (Ccr), C-reactive protein (CRP), superoxide dismutase (SOD), and glutathione (GSH) within 72 h, and major adverse events during hospitalization or the 14-day follow-up period.

RESULTS

The incidence of CIN was 4.0% (13/321) in the probucol group and 10.9% (35/320) in the control group. The probucol group had lower Cys-C and higher Ccr at 48 and 72 h after PCI compared with the control group. At 48 and 72 h following the operation, Cys-C and CRP were lower in the probucol group compared with the control group, but Ccr, SOD, and GSH were higher. There were no differences in the incidence of major adverse events during hospitalization or the 14-day follow-up between the groups. Multivariate logistic regression analysis showed that probucol was an independent protective factor for CIN.

CONCLUSIONS

Probucol combined with hydration more effectively decreased the incidence of CIN in patients with coronary heart disease undergoing PCI compared with hydration alone.

Protective Role for Antioxidants in Acute Kidney Disease

Acute kidney injury causes significant morbidity and mortality in the community and clinic. Various pathologies, including renal and cardiovascular disease, traumatic injury/rhabdomyolysis, sepsis, and nephrotoxicity, that cause acute kidney injury (AKI), induce general or regional decreases in renal blood flow. The ensuing renal hypoxia and ischemia promotes the formation of reactive oxygen species (ROS) such as superoxide radical anions, peroxides, and hydroxyl radicals, that can oxidatively damage biomolecules and membranes, and affect organelle function and induce renal tubule cell injury, inflammation, and vascular dysfunction. Acute kidney injury is associated with increased oxidative damage, and various endogenous and synthetic antioxidants that mitigate source and derived oxidants are beneficial in cell-based and animal studies. However, the benefit of synthetic antioxidant supplementation in human acute kidney injury and renal disease remains to be realized. The endogenous low-molecular weight, non-proteinaceous antioxidant, ascorbate (vitamin C), is a promising therapeutic in human renal injury in critical illness and nephrotoxicity. Ascorbate may exert significant protection by reducing reactive oxygen species and renal oxidative damage via its antioxidant activity, and/or by its non-antioxidant functions in maintaining hydroxylase and monooxygenase enzymes, and endothelium and vascular function. Ascorbate supplementation may be particularly important in renal injury patients with low vitamin C status.