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Griffiths RI, Bhave A, McGovern AM, Hargens LM, Solid CA, Amin AP. Clinical and economic outcomes of assigning percutaneous coronary intervention patients to contrast-sparing strategies based on the predicted risk of contrast-induced acute kidney injury. J Med Econ 2024; 27:663-670. [PMID: 38632967 DOI: 10.1080/13696998.2024.2334180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Contrast-sparing strategies have been developed for percutaneous coronary intervention (PCI) patients at increased risk of contrast-induced acute kidney injury (CI-AKI), and numerous CI-AKI risk prediction models have been created. However, the potential clinical and economic consequences of using predicted CI-AKI risk thresholds for assigning patients to contrast-sparing regimens have not been evaluated. We estimated the clinical and economic consequences of alternative CI-AKI risk thresholds for assigning Medicare PCI patients to contrast-sparing strategies. METHODS Medicare data were used to identify inpatient PCI from January 2017 to June 2021. A prediction model was developed to assign each patient a predicted probability of CI-AKI. Multivariable modeling was used to assign each patient two marginal predicted values for each of several clinical and economic outcomes based on (1) their underlying clinical and procedural characteristics plus their true CI-AKI status in the data and (2) their characteristics plus their counterfactual CI-AKI status. Specifically, CI-AKI patients above the predicted risk threshold for contrast-sparing were reassigned their no CI-AKI (counterfactual) outcomes. Expected event rates, resource use, and costs were estimated before and after those CI-AKI patients were reassigned their counterfactual outcomes. This entailed bootstrapped sampling of the full cohort. RESULTS Of the 542,813 patients in the study cohort, 5,802 (1.1%) had CI-AKI. The area under the receiver operating characteristic curve for the prediction model was 0.81. At a predicted risk threshold for CI-AKI of >2%, approximately 18.0% of PCI patients were assigned to contrast-sparing strategies, resulting in (/100,000 PCI patients) 121 fewer deaths, 58 fewer myocardial infarction readmissions, 4,303 fewer PCI hospital days, $11.3 million PCI cost savings, and $25.8 million total one-year cost savings, versus no contrast-sparing strategies. LIMITATIONS Claims data may not fully capture disease burden and are subject to inherent limitations such as coding inaccuracies. Further, the dataset used reflects only individuals with fee-for-service Medicare, and the results may not be generalizable to Medicare Advantage or other patient populations. CONCLUSIONS Assignment to contrast-sparing regimens at a predicted risk threshold close to the underlying incidence of CI-AKI is projected to result in significant clinical and economic benefits.
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Affiliation(s)
| | | | | | | | | | - Amit P Amin
- Rush College of Medicine, Rush University Medical Center, Chicago, IL, USA
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Feng Y, Wang AY, Jun M, Pu L, Weisbord SD, Bellomo R, Hong D, Gallagher M. Characterization of Risk Prediction Models for Acute Kidney Injury: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2313359. [PMID: 37184837 DOI: 10.1001/jamanetworkopen.2023.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Importance Despite the expansion of published prediction models for acute kidney injury (AKI), there is little evidence of uptake of these models beyond their local derivation nor data on their association with patient outcomes. Objective To systematically review published AKI prediction models across all clinical subsettings. Data Sources MEDLINE via PubMed (January 1946 to April 2021) and Embase (January 1947 to April 2021) were searched using medical subject headings and text words related to AKI and prediction models. Study Selection All studies that developed a prediction model for AKI, defined as a statistical model with at least 2 predictive variables to estimate future occurrence of AKI, were eligible for inclusion. There was no limitation on study populations or methodological designs. Data Extraction and Synthesis Two authors independently searched the literature, screened the studies, and extracted and analyzed the data following the Preferred Reporting Items for Systematic Review and Meta-analyses guideline. The data were pooled using a random-effects model, with subgroups defined by 4 clinical settings. Between-study heterogeneity was explored using multiple methods, and funnel plot analysis was used to identify publication bias. Main Outcomes and Measures C statistic was used to measure the discrimination of prediction models. Results Of the 6955 studies initially identified through literature searching, 150 studies, with 14.4 million participants, met the inclusion criteria. The study characteristics differed widely in design, population, AKI definition, and model performance assessments. The overall pooled C statistic was 0.80 (95% CI, 0.79-0.81), with pooled C statistics in different clinical subsettings ranging from 0.78 (95% CI, 0.75-0.80) to 0.82 (95% CI, 0.78-0.86). Between-study heterogeneity was high overall and in the different clinical settings (eg, contrast medium-associated AKI: I2 = 99.9%; P < .001), and multiple methods did not identify any clear sources. A high proportion of models had a high risk of bias (126 [84.4%]) according to the Prediction Model Risk Of Bias Assessment Tool. Conclusions and Relevance In this study, the discrimination of the published AKI prediction models was good, reflected by high C statistics; however, the wide variation in the clinical settings, populations, and predictive variables likely drives the highly heterogenous findings that limit clinical utility. Standardized procedures for development and validation of prediction models are urgently needed.
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Affiliation(s)
- Yunlin Feng
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Amanda Y Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- The Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lei Pu
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Steven D Weisbord
- Renal Section, Medicine Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Daqing Hong
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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Sůva M, Kala P, Poloczek M, Kaňovský J, Štípal R, Radvan M, Hlasensky J, Hudec M, Brázdil V, Řehořová J. Contrast-induced acute kidney injury and its contemporary prevention. Front Cardiovasc Med 2022; 9:1073072. [PMID: 36561776 PMCID: PMC9763312 DOI: 10.3389/fcvm.2022.1073072] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Marek Sůva
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Kala
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia,*Correspondence: Petr Kala,
| | - Martin Poloczek
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jan Kaňovský
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Roman Štípal
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martin Radvan
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jiří Hlasensky
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martin Hudec
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Vojtěch Brázdil
- Department of Internal Medicine and Cardiology, University Hospital, Brno, Czechia,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jitka Řehořová
- Department of Internal Medicine and Gastroenterology, University Hospital, Brno, Czechia
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Miao S, Pan C, Li D, Shen S, Wen A. Endorsement of the TRIPOD statement and the reporting of studies developing contrast-induced nephropathy prediction models for the coronary angiography/percutaneous coronary intervention population: a cross-sectional study. BMJ Open 2022; 12:e052568. [PMID: 35190425 PMCID: PMC8862501 DOI: 10.1136/bmjopen-2021-052568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Clear and specific reporting of a research paper is essential for its validity and applicability. Some studies have revealed that the reporting of studies based on the clinical prediction models was generally insufficient based on the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist. However, the reporting of studies on contrast-induced nephropathy (CIN) prediction models in the coronary angiography (CAG)/percutaneous coronary intervention (PCI) population has not been thoroughly assessed. Thus, the aim is to evaluate the reporting of the studies on CIN prediction models for the CAG/PCI population using the TRIPOD checklist. DESIGN A cross-sectional study. METHODS PubMed and Embase were systematically searched from inception to 30 September 2021. Only the studies on the development of CIN prediction models for the CAG/PCI population were included. The data were extracted into a standardised spreadsheet designed in accordance with the 'TRIPOD Adherence Assessment Form'. The overall completeness of reporting of each model and each TRIPOD item were evaluated, and the reporting before and after the publication of the TRIPOD statement was compared. The linear relationship between model performance and TRIPOD adherence was also assessed. RESULTS We identified 36 studies that developed CIN prediction models for the CAG/PCI population. Median TRIPOD checklist adherence was 60% (34%-77%), and no significant improvement was found since the publication of the TRIPOD checklist (p=0.770). There was a significant difference in adherence to individual TRIPOD items, ranging from 0% to 100%. Moreover, most studies did not specify critical information within the Methods section. Only 5 studies (14%) explained how they arrived at the study size, and only 13 studies (36%) described how to handle missing data. In the Statistical analysis section, how the continuous predictors were modelled, the cut-points of categorical or categorised predictors, and the methods to choose the cut-points were only reported in 7 (19%), 6 (17%) and 1 (3%) of the studies, respectively. Nevertheless, no relationship was found between model performance and TRIPOD adherence in both the development and validation datasets (r=-0.260 and r=-0.069, respectively). CONCLUSIONS The reporting of CIN prediction models for the CAG/PCI population still needs to be improved based on the TRIPOD checklist. In order to promote further external validation and clinical application of the prediction models, more information should be provided in future studies.
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Affiliation(s)
- Simeng Miao
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Pharmacy, Shanxi Cancer Hospital, Taiyuan, Shanxi, China
| | - Chen Pan
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Su Shen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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5
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Zhang F, Lu Z, Wang F. Advances in the pathogenesis and prevention of contrast-induced nephropathy. Life Sci 2020; 259:118379. [PMID: 32890604 DOI: 10.1016/j.lfs.2020.118379] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/18/2020] [Accepted: 08/31/2020] [Indexed: 12/11/2022]
Abstract
With the increasing application of medical imaging contrast materials, contrast-induced nephropathy has become one of the leading causes of iatrogenic renal insufficiency. The underlying mechanism is associated with renal medullary hypoxia, direct toxicity of contrast agents, oxidative stress, apoptosis, immune/inflammation and epigenetic regulation in contrast-induced nephropathy. Up to date, there is no effective therapy for contrast-induced nephropathy, and thus risk predication and effective preventive strategies are keys to reduce the occurrence of contrast-induced nephropathy. It was found that the proper use of contrast medium, personalized hydration, and high-dose statins may reduce the occurrence of contrast-induced nephropathy, while antioxidants have not shown significant therapeutic benefits. Additionally, the role of remote ischemia preconditioning and vasodilators in the prevention of contrast-induced nephropathy needs further study. This review aims to discuss the incidence, pathogenesis, risk prediction, and preventive strategies for contrast-induced nephropathy.
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Affiliation(s)
- Fangfei Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Zeyuan Lu
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Feng Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China.
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Wang W, Qu W, Sun D, Liu X. Meta-analysis of effect of renin-angiotensin-aldosterone system blockers on contrast-induced nephropathy. J Renin Angiotensin Aldosterone Syst 2020; 21:1470320320919587. [PMID: 32370685 PMCID: PMC7227145 DOI: 10.1177/1470320320919587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: The purpose of this study was to systematically evaluate the effect of renin–angiotensin–aldosterone system blockers on the incidence of contrast-induced nephropathy in patients undergoing coronary angiography or percutaneous coronary intervention. Methods: A systematic literature search of several databases was conducted to identify studies that met the inclusion criteria. A total of 12 studies with 14 trials that performed studies on a total of 4864 patients (2484 treated with renin–angiotensin–aldosterone system blockers and 2380 in the control group) were included. The primary endpoint was the overall incidence of contrast-induced nephropathy. Analyses were performed with STATA version 12.0. Results: The overall contrast-induced nephropathy incidence in renin–angiotensin–aldosterone system blocker and control groups was 10.43% and 6.81%, respectively. The pooled relative risk of contrast-induced nephropathy incidence was 1.22 (95% confidence interval: 0.81–1.84) in the renin–angiotensin–aldosterone system blocker group. An increased risk of developing contrast-induced nephropathy in the renin–angiotensin–aldosterone system blocker group was observed among older people, non-Asians, chronic users, and studies with larger sample size, and the pooled RRs and 95% confidence intervals were 2.02 (1.21–3.36), 2.30 (1.41–3.76), 1.69 (1.10–2.59) and 1.83 (1.28–2.63), respectively. Conclusions: Intervention with renin–angiotensin–aldosterone system blockers was associated with an increased risk of contrast-induced nephropathy among non-Asians, chronic users, older people, and studies with larger sample size. Large clinical trials with strict inclusion criteria are needed to confirm our results and to evaluate the effect further.
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Affiliation(s)
- Weidong Wang
- Department of Nephrology, The First Hospital of China Medical University, People's Republic of China
| | - Wei Qu
- Department of Nephrology, The First Hospital of China Medical University, People's Republic of China
| | - Dan Sun
- Department of Nephrology, The First Hospital of China Medical University, People's Republic of China
| | - Xiaodan Liu
- Department of Nephrology, The First Hospital of China Medical University, People's Republic of China
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7
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Yin W, Zhou G, Zhou L, Liu M, Xie Y, Wang J, Zuo S, Liu K, Hu C, Chen L, Yang H, Zuo X. Validation of pre-operative risk scores of contrast-induced acute kidney injury in a Chinese cohort. BMC Nephrol 2020; 21:45. [PMID: 32041557 PMCID: PMC7011449 DOI: 10.1186/s12882-020-1700-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/20/2020] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Wenjun Yin
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Ge Zhou
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Lingyun Zhou
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Mancang Liu
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Yueliang Xie
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jianglin Wang
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Shanru Zuo
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Kun Liu
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Linhua Chen
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Huiqin Yang
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xiaocong Zuo
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China. .,Center of Clinical Pharmacology, The Third Xiangya Hospital of Central South University, Changsha, China.
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Onoda H, Ueno H, Hashimoto M, Kuwahara H, Sobajima M, Kinugawa K. Clinical Advantages of Using Low Tube Voltage in Third-Generation 192-Slice Dual-Source Computed Tomographic Angiography Before Transcatheter Aortic Valve Implantation. Int Heart J 2019; 60:1091-1097. [PMID: 31484865 DOI: 10.1536/ihj.18-693] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Low-voltage computed tomographic angiography (CTA) is a highly effective technique to reduce contrast media volume. We sought to examine the suitability of low tube voltage CTA with a reduced contrast media volume protocol using third-generation 192-slice dual-source CT in patients undergoing transcatheter aortic valve implantation (TAVI). CTA was performed to aid TAVI planning for 40 consecutive patients with severe aortic stenosis. For the first 10 patients (120/100 kV group), we used a conventional tube voltage combined CTA protocol (an ECG-gated helical scan; 120 kV, non-gated helical scan; 100 kV). For the subsequent 30 patients (70-kV group), we adopted a low tube voltage CTA protocol. We evaluated vascular attenuation, image noise, contrast-to-noise ratio (CNR), and renal function. The mean contrast media (CM) volume was 77.7 ± 17.7 mL in the 120/100-kV group and 30.9 ± 6.3 mL in the 70-kV group (P < 0.001). In the images of the aortic valve complex, the mean attenuation was not significant difference for both groups. In the images of the aorto-femoral arteries, mean attenuation was > 250 Hounsfield Units and CNR was > 10 in all vascular segments for both groups. There was no significant difference in the change of renal function in the 70-kV group, but renal function in the 120/100-kV group decreased within 1-3 months after CTA. Low tube voltage CTA using third-generation dual-source CT is suitable to assess procedural planning for TAVI. This approach maintains image quality and reduces the required CM volume.
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Affiliation(s)
- Hiroshi Onoda
- Second Department of Internal Medicine, University of Toyama
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama
| | | | | | - Mitsuo Sobajima
- Second Department of Internal Medicine, University of Toyama
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Gosling R, Iqbal J. Predicting contrast induced nephropathy in patients undergoing percutaneous coronary intervention. J Thorac Dis 2019; 11:2672-2674. [PMID: 31463090 PMCID: PMC6688022 DOI: 10.21037/jtd.2019.06.48] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 06/18/2019] [Indexed: 02/18/2024]
Affiliation(s)
- Rebecca Gosling
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Javaid Iqbal
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
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10
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Yi Y, Zhao XM, Wu RZ, Wang Y, Vembar M, Jin ZY, Wang YN. Low Dose and Low Contrast Medium Coronary CT Angiography Using Dual-Layer Spectral Detector CT. Int Heart J 2019; 60:608-617. [PMID: 31105142 DOI: 10.1536/ihj.18-340] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the present study was to investigate the performance of low keV mono-energetic reconstructions in spectral coronary computed tomography angiography (CCTA) using spectral detector CT (SDCT) with reduced contrast media and radiation dose.Sixty patients were randomly assigned to Groups A and B (both n = 30) to undergo CCTA on a dual-layer SDCT with tube voltage 120 kVp and 100 kVp (average tube current: 108.5 and 73.8 mAs, respectively), with contrast media volume of 36 mL used in both groups. The mono-energetic 40-80 keV and conventional 120 kVp images in Group A and conventional 100 kVp images in Group B were reconstructed. Quantitative and qualitative image quality (IQ) were evaluated in the aortic root and distal segments of the coronary arteries.The patient characteristics were not significantly different between the two groups (all P≥ 0.47), nor was the effective radiation dose (1.5 ± 0.3 and 1.4 ± 0.3 mSv, P = 0.20). The quantitative IQ in aorta and coronary arteries of mono-energetic 40-60 keV was superior to conventional 120 kVp and 100 kVp images (all P < 0.05). The noise in spectral images was lower compared to conventional images (all P < 0.01). The subjective IQ score of 40-50 keV images was not significantly different from that of 100 kVp images (P > 0.8).The mono-energetic 40-50 keV reconstructions from spectral CCTA using SDCT provide improved IQ compared to conventional techniques while facilitating reduced radiation dose and contrast media.
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Affiliation(s)
- Yan Yi
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Xue-Mei Zhao
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Run-Ze Wu
- CT Clinical Science, Philips Healthcare, Cleveland
| | - Yun Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Mani Vembar
- CT Clinical Science, Philips Healthcare, Cleveland
| | - Zheng-Yu Jin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Yi-Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
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11
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Hayakawa N, Kodera S, Ohki N, Kushida S, Morita H, Kanda J, Komuro I. Endovascular Therapy Using Diluted Contrast Medium for Critical Limb Ischemia in a Patient with Chronic Kidney Disease. Int Heart J 2019; 60:226-230. [PMID: 30464136 DOI: 10.1536/ihj.18-125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A high percentage of patients with critical limb ischemia have concurrent chronic kidney disease (CKD). However, endovascular therapy (EVT) can be problematic in CKD patients. Thus, we developed a method of EVT using digital subtraction angiography (DSA) with diluted contrast medium (low-concentration DSA), wherein DSA parameters were adjusted for diluted contrast angiography (1:10 dilution). Herein, we report the case of an 88-year-old woman with a foot wound and severe CKD. Her estimated glomerular filtration rate was 7.9 mL/minute/1.73 m2. Therefore, EVT was performed with low-concentration DSA. Control angiography revealed total occlusion of the anterotibial and posterotibial arteries as well as severe stenosis of the peroneal artery. EVT with ballooning of the below-the-knee (BTK) lesions resulted in sufficient flow to the wound. Angiographic images of sufficient quality and visible wound blush were obtained with 1:10 diluted contrast medium. Because only 20 mL of contrast medium was required, renal function was preserved. EVT using DSA with diluted contrast medium was shown to be an effective BTK intervention in this CKD patient.
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Affiliation(s)
- Naoki Hayakawa
- Department of Cardiovascular Medicine, Asahi General Hospital
| | - Satoshi Kodera
- Department of Cardiovascular Medicine, Asahi General Hospital.,Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | | | | | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Junji Kanda
- Department of Cardiovascular Medicine, Asahi General Hospital
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
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12
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Sanan N, Rowane M, Hostoffer R. Radiologic Contrast Media Desensitization for Delayed Cardiac Catheterization. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2019; 10:2152656719892844. [PMID: 31897351 PMCID: PMC6918493 DOI: 10.1177/2152656719892844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This protocol for rapid desensitization to intravenous radiographic contrast material (RCM) improves the strategy first reported by Uppal et al. Desensitization is a validated preventative measure for medical emergencies, such as cardiac catheterization, when patients present with histories of anaphylactoid reactions to the allergen of concern. The patient required another catheterization that was modified to repeat the final dosage of 320 mg/mL of Visipaque®, accommodating cardiac catheterization postponement, contrary to readministration of doses 4 (0.625 mg/mL) and 8 (10 mg/mL) as reported in Uppal et al. Our risk score calculations suggested that the patient was at low risk of contrast-induced nephropathy (CIN) that did not necessitate reduced dosage. No complications were reported following catheterization. We propose repetition of the final RCM dosage as a more effective and efficient desensitization strategy, as long as the scoring system does not indicate high risk for CIN.
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Affiliation(s)
- Neha Sanan
- Department of Pulmonary and Critical Care, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Marija Rowane
- Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio
| | - Robert Hostoffer
- Department of Pulmonary and Critical Care, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Allergy/Immunology Associates, Inc., Mayfield Heights, Ohio
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13
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Lin KY, Wu ZY, You ZB, Zheng WP, Lin CJ, Jiang H, Ruan JM, Guo YS, Zhu PL. Pre-Procedural N-Terminal Pro-B Type Natriuretic Peptide Predicts Contrast-Induced Acute Kidney Injury and Long-Term Outcome in Elderly Patients After Elective Percutaneous Coronary Intervention. Int Heart J 2018; 59:926-934. [PMID: 30158378 DOI: 10.1536/ihj.17-573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the study is to evaluate the association of pre-procedural N-terminal pro-B type natriuretic peptide (NT-proBNP) with contrast-induced acute kidney injury (CI-AKI) and long-term outcomes in elderly patients undergoing elective percutaneous coronary intervention (PCI).A total of 540 patients aged ≥ 75 years who had undergone elective PCI between January 2012 and December 2015 were enrolled in this study. Admission NT-proBNP levels were measured before PCI. CI-AKI was defined as a relative increase in serum creatinine (SCr) of ≥50%, or an absolute increase of ≥ 0.3 mg/dL, occurring within 48 hours after contrast medium exposure. The predictive value of NT-proBNP for predicting CI-AKI was assessed by receiver operating characteristic (ROC) and multivariable logistic regression analysis.A total of 54 (10.0%) patients developed CI-AKI. The best cutoff value of NT-pro-BNP for detecting CI-AKI was 1133 pg/mL with 66.7% sensitivity and 70.8% specificity according to the ROC analysis (C statistic = 0.719; 95% CI, 0.679-0.756). Multivariable analysis demonstrated that Lg-NT-proBNP is significantly related to CI-AKI (odds ratio [OR] = 3.892; 95% CI, 1.996-7.590; P < 0.001). Cox regression analysis showed that Lg-NT-proBNP is associated with long-term mortality (adjusted hazard ratio [HR] = 2.158; 95% CI, 1.246-3.740; P = 0.006) during follow-up.Pre-procedural NT-proBNP is a significant and independent predictor of CI-AKI and long-term mortality in elderly patients following elective PCI, and the best cutoff point for predicting CI-AKI was 1133 pg/mL.
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Affiliation(s)
- Kai-Yang Lin
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Zhi-Yong Wu
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Zhe-Bin You
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Wei-Ping Zheng
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Chun-Jin Lin
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Hui Jiang
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Jing-Ming Ruan
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Yan-Song Guo
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Peng-Li Zhu
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
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14
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Uppal S, DeCicco AE, Intini A, Josephson RA. Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography. Int Heart J 2018; 59:622-625. [PMID: 29628477 DOI: 10.1536/ihj.17-395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Allergic reactions to contrast media are a frequently reported complication of coronary angiography. The majority of patients experience mild, self-limited episodes, but in rare cases patients may experience severe, persistent symptoms. A strategy of premedication with corticosteroids and anti-histamines and an optimal selection of contrast agent is almost always successful in averting contrast reactions, yet a select few patients will continue to have breakthrough events. This is a case of recurrent, severe allergy to contrast media despite standard precautions complicating the treatment of non-ST elevation myocardial infarction (NSTEMI). Our patient was successfully managed with a strategy of rapid desensitization to iodinated contrast media achieved by administering progressively incremental doses of the media.
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Affiliation(s)
- Saurav Uppal
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Anthony E DeCicco
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Anselma Intini
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine.,Department of Medicine, Louis Stokes Veteran Affairs Medical Center
| | - Richard A Josephson
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
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15
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You ZB, Lin KY, Zheng WP, Lin CJ, Lin F, Guo TL, Zhu PL, Guo YS. Association of prealbumin levels with contrast-induced acute kidney injury in elderly patients with elective percutaneous coronary intervention. Clin Interv Aging 2018; 13:641-649. [PMID: 29713148 PMCID: PMC5909788 DOI: 10.2147/cia.s162764] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Purpose Inflammatory factors play a critical role in contrast-induced acute kidney injury (CI-AKI). Prealbumin, a nutritional and inflammatory indicator, is a well-established predictor of short- and long-term outcomes in numerous clinical conditions. The current study investigated the association of pre-procedural prealbumin levels with CI-AKI and long-term outcomes in geriatric patients after elective percutaneous coronary intervention (PCI). Patients and methods A total of 558 patients aged≥75 years, who underwent elective PCI between January 2012 and December 2015, were selected for the current study. Pre-procedural prealbumin levels were measured before PCI. Multivariable logistic regression and Cox proportional hazard regression analyses were performed to identify the independent risk factors for CI-AKI and long-term mortality. Results Out of 558 patients, 54 developed CI-AKI. The optimal cutoff value of prealbumin for detecting CI-AKI was 185.5 mg/L with 62.7% sensitivity and 70.4% specificity based on the receiver operating characteristic analysis (C-statistic=0.710; 95% confidence interval [CI] 0.673–0.751). Multivariable analysis demonstrated that prealbumin≤185.5 mg/L was significantly associated with CI-AKI (odds ratio [OR] 0.397; 95% CI 0.195–0.808; P=0.011). Cox regression analysis demonstrated that prealbumin≤185.5 mg/L was associated with long-term mortality (adjusted hazard ratio [HR] 0.525; 95% CI 0.289–0.952; P=0.034) during the follow-up. Conclusion Pre-procedural levels of prealbumin were independently associated with an increased risk of CI-AKI and long-term mortality in elderly patients undergoing elective PCI.
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Affiliation(s)
- Zhe-Bin You
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Kai-Yang Lin
- Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fujian Medical University, Fuzhou, People's Republic of China
| | - Wei-Ping Zheng
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Chun-Jin Lin
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Fan Lin
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Tai-Lin Guo
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Peng-Li Zhu
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Yan-Song Guo
- Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fujian Medical University, Fuzhou, People's Republic of China
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