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Tsigkas G, Toulgaridis F, Apostolos A, Kalogeropoulos A, Karamasis GV, Vasilagkos G, Pappas L, Toutouzas K, Tsioufis K, Korkonikitas P, Tsiafoutis I, Hamilos M, Ziakas A, Kanakakis I, Moulias A, Zampakis P, Davlouros P. CCTA-Guided Invasive Coronary Angiography in Patients With CABG: A Multicenter, Randomized Study. Circ Cardiovasc Interv 2024; 17:e014045. [PMID: 39286899 DOI: 10.1161/circinterventions.124.014045] [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: 01/30/2024] [Accepted: 06/19/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) in patients with post-coronary artery bypass graft (CABG) has a high diagnostic accuracy for visualization of grafts. Invasive coronary angiography (ICA) in patients with CABG is associated with increased procedural time, contrast agent administration, radiation exposure, and complications, compared with non-CABG patients. The aim of this multicenter, randomized controlled trial was to compare the strategy of CCTA-guided ICA versus classic ICA in patients with prior CABG. METHODS Patients with prior CABG were randomly assigned (1:1 ratio) to have a CCTA before ICA (CCTA-ICA, group A) or not (ICA-only, group B). The primary end point of the study was the total volume (milliliters) of the contrast agent administered. RESULTS A total of 251 patients were randomized, and 225 were included in analysis; 110 in group A and 115 in group B. The total contrast volume was higher in group A (184.5 [143-255] versus 154 [102-240] mL; P=0.001). The contrast volume administered during the invasive procedure was lower in group A (101.5 [60-151] versus 154 [102-240]; P<0.001). Total fluoroscopy time was decreased in group A (480 [259-873] versus 594 [360-1080] seconds; P=0.027), but total effective dose was increased (24.1 [17.7-32] versus 10.8 [5.6-18] mSv; P<0.001). The rate of contrast-induced nephropathy, periprocedural complications, and major adverse cardiac events during 3 to 5 and 30 days did not differ significantly between the 2 groups. CONCLUSIONS A CCTA-directed ICA strategy for patients with CABG is associated with expedition of the invasive procedure, and less fluoroscopy time, at the cost of higher total contrast volume and effective radiation dose, compared with the classic ICA approach. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04631809.
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Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology (G.T., G.V., A.M., P.D.), University Hospital of Patras, Greece
| | - Fotios Toulgaridis
- Second Department of Cardiology (F.T.), "Evangelismos" General Hospital of Athens, Greece
| | - Anastasios Apostolos
- First Department of Cardiology, "Hippocration" University Hospital of Athens, Greece (A.A., K. Toutouzas, K. Tsioufis)
| | | | - Grigoris V Karamasis
- Second Department of Cardiology, "Attikon'' University Hospital of Athens, Greece (G.V.K.)
| | - Georgios Vasilagkos
- Department of Cardiology (G.T., G.V., A.M., P.D.), University Hospital of Patras, Greece
| | - Loukas Pappas
- First Department of Cardiology (L.P.), "Evangelismos" General Hospital of Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, "Hippocration" University Hospital of Athens, Greece (A.A., K. Toutouzas, K. Tsioufis)
| | - Konstantinos Tsioufis
- First Department of Cardiology, "Hippocration" University Hospital of Athens, Greece (A.A., K. Toutouzas, K. Tsioufis)
| | | | - Ioannis Tsiafoutis
- First Department of Cardiology, "Red Cross" General Hospital of Athens, Greece (I.T.)
| | - Michalis Hamilos
- Department of Cardiology, "PAGNI" University Hospital of Heraklion, Creta, Greece (M.H.)
| | - Antonios Ziakas
- First Department of Cardiology, "AHEPA" University Hospital of Thessaloniki, Greece (A.Z.)
| | - Ioannis Kanakakis
- Department of Cardiology, "Alexandra" General Hospital of Athens, Greece (I.K.)
| | - Athanasios Moulias
- Department of Cardiology (G.T., G.V., A.M., P.D.), University Hospital of Patras, Greece
| | - Petros Zampakis
- Department of Radiology (P.Z.), University Hospital of Patras, Greece
| | - Periklis Davlouros
- Department of Cardiology (G.T., G.V., A.M., P.D.), University Hospital of Patras, Greece
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Mehta R, Sorbo D, Ronco F, Ronco C. Key Considerations regarding the Renal Risks of Iodinated Contrast Media: The Nephrologist's Role. Cardiorenal Med 2023; 13:324-331. [PMID: 37757781 PMCID: PMC10664334 DOI: 10.1159/000533282] [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: 03/27/2023] [Accepted: 06/23/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The administration of iodinated contrast medium during diagnostic and therapeutic procedures has always been associated with the fear of causing acute kidney injury (AKI) or an exacerbation of chronic kidney disease. This has led, on the one hand, to the deterrence, when possible, of the use of contrast medium (preferring other imaging methods with the risk of loss of diagnostic power), and on the other hand, to the trialling of multiple prophylaxis protocols in an attempt to reduce the risk of kidney injury. SUMMARY A literature review on contrast-induced (CI)-AKI risk mitigation strategies was performed, focussing on the recognition of individual risk factors and on the most recent evidence regarding prophylaxis. KEY MESSAGES Nephrologists can contribute significantly in the CI-AKI context, from the early stages of the decision-making process to stratifying patients by risk, individualising prophylaxis measures based on the risk profile, and ensuring appropriate evaluation of kidney function and damage post-procedure to improve care.
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Affiliation(s)
- Ravindra Mehta
- Division of Nephrology-Hypertension University of California – San Diego, San Diego, CA, USA
| | - David Sorbo
- Nephrology, Dialysis and Transplantation Unit, St. Bortolo Hospital, ULSS8 Berica, Vicenza, Italy
| | - Federico Ronco
- Interventional Cardiology – Department of Cardiac Thoracic and Vascular Sciences Ospedale dell’Angelo – Mestre (Venice), Venice, Italy
| | - Claudio Ronco
- Nephrology, Dialysis and Transplantation Unit and International Renal Research Institute, St Bortolo Hospital, ULSS8 Berica, Vicenza, Italy
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Wang B, Zheng Y, Li H, Chen S, Zhou Z, Lun Z, Ying M, Zhang L, Mai Z, Liu L, Zhou Z, Lin M, Yang Y, Chen J, Liu Y, Liu J, Chen S, Tan N. Comparison Between Two Definitions of Contrast-Associated Acute Kidney Injury in Patients With Congestive Heart Failure. Front Cardiovasc Med 2022; 9:763656. [PMID: 35571185 PMCID: PMC9094707 DOI: 10.3389/fcvm.2022.763656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
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-AKIA was defined as an increase ≥.5 mg/dl or > 25% in serum creatinine (SCr) from baseline within 72 h after CAG, and CA-AKIB 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-AKIA and CA-AKIB were 30.4% and 34.3%, respectively. We found that CA-AKIA (HR: 1.44, 95% CI 1.19-1.74) and CA-AKIB (HR: 1.48, 95% CI 1.21-1.80) were associated with long-term mortality. The PAR was higher for CA-AKIA (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-AKIA 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-AKIA.
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Affiliation(s)
- Bo Wang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yiying Zheng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Cardiology, People's Hospital of Yangjiang, Yangjiang, China
| | - Huanqiang Li
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuling Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ziyou Zhou
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
| | - Zhubin Lun
- The First School of Clinical Medicine, Guangdong Medical University, Zhanjiang, China
| | - Ming Ying
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lingyu Zhang
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| | - Ziling Mai
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
| | - Liwei Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Ziqing Zhou
- School of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Mengfei Lin
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| | - Yongquan Yang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
- *Correspondence: Jin Liu
| | - Shiqun Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
- Shiqun Chen
| | - Ning Tan
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, Guangdong Provincial People's Hospital, South China University of Technology, Guangzhou, China
- Ning Tan
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Michel P, Amione-Guerra J, Sheikh O, Jameson LC, Bansal S, Prasad A. Meta-analysis of intravascular volume expansion strategies to prevent contrast-associated acute kidney injury following invasive angiography. Catheter Cardiovasc Interv 2021; 98:1120-1132. [PMID: 33185335 DOI: 10.1002/ccd.29387] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To perform a detailed analysis of published data regarding intravascular volume expansion to prevent contrast-associated acute kidney injury (CA-AKI) and to determine if an ideal dose of IV fluids can be recommended. BACKGROUND Administration of contrast media during invasive angiography is associated with CA-AKI. Intravascular volume expansion is the most effective intervention to prevent CA-AKI, yet evidenced based protocols are lacking. METHODS Literature review and meta-analysis of randomized controlled trials (RCT) of patients receiving IV volume expansion as prophylaxis for CA-AKI was performed. Normal saline, Lactated Ringer's and sodium bicarbonate were included. The primary outcome was incidence of CA-AKI. RESULTS 37 RCTs studying 12,166 patients were included. Mean age was 67 ± 5 years, 70% of the patients were male. 68% had chronic kidney disease, 41% diabetes, and 30% heart failure. The incidence of CA-AKI was 9.5% (95% CI: 8-12%). IV expansion versus no volume administration was associated with a lower risk of CA-AKI (RR:0.62; 95% CI: 0.49-0.77, p < .001). Intensive IV volume expansion was associated with a reduced risk of CA-AKI(RR: 0.66; 95%CI: 0.52-0.85, p < .01). The intensive IV volume expansion arm received significantly more fluids than the standard protocols: 1,574(1,123 - 1,913) ml versus 849(558-1,067) ml (p = .03) without significant difference in the duration of infusion (median of 12 vs. 17 hr, p = .1) or pulmonary edema (1.7% vs 1.3%, p = .7). CONCLUSIONS Despite high variability in protocols used, IV volume expansion is effective in preventing CA-AKI. Intensive IVF expansion (median 1.6 L over 17 hr) was associated with decreased risk of CA-AKI.
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Affiliation(s)
- Pablo Michel
- Department of Medicine, Division of Cardiology, Rutgers New Jersey Medical School, Newark
| | - Javier Amione-Guerra
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas
| | - Omar Sheikh
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas
| | - Lauren C Jameson
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas
| | - Shweta Bansal
- Department of Medicine, Division of Nephrology, University of Texas Health Science Center, San Antonio, Texas
| | - Anand Prasad
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas
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5
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Xu T, Lin M, Shen X, Wang M, Zhang W, Zhao L, Li D, Luan Y, Zhang W. Association of the classification and severity of heart failure with the incidence of contrast-induced acute kidney injury. Sci Rep 2021; 11:15348. [PMID: 34321588 PMCID: PMC8319404 DOI: 10.1038/s41598-021-94910-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/16/2021] [Indexed: 01/02/2023] Open
Abstract
Congestive heart failure (HF) is a known risk factor of contrast-induced acute kidney injury (CI-AKI). However, the relationship of the classification and severity of HF with CI-AKI remains under-explored. From January 2009 to April 2019, we recruited patients undergoing elective PCI who had complete pre- and post-operative creatinine data. According to the levels of ejection fraction (EF), HF was classified as HF with reduced EF (HFrEF) [EF < 40%], HF with mid-range EF (HFmrEF) [EF 40–49%] and HF with preserved EF (HFpEF) [EF ≥ 50%]. CI-AKI was defined as an increase of either 25% or 0.5 mg/dL (44.2 μmoI/L) in serum baseline creatinine level within 72 h following the administration of the contrast agent. A total of 3848 patients were included in the study; mean age 67 years old, 33.9% females, 48.1% with HF, and 16.9% with CI-AKI. In multivariate logistic regression analysis, HF was an independent risk factor for CI-AKI (OR 1.316, p value < 0.05). Among patients with HF, decreased levels of EF (OR 0.985, p value < 0.05) and elevated levels of N-terminal pro b-type natriuretic peptide (NT-proBNP) (OR 1.168, p value < 0.05) were risk factors for CI-AKI. These results were consistent in subgroup analysis. Patients with HFrEF were more likely to develop CI-AKI than those with HFmrEF or HFpEF (OR 0.852, p value = 0.031). Additionally, lower levels of EF were risk factors for CI-AKI in the HFrEF and HFmrEF groups, but not in the HFpEF group. NT-proBNP was an independent risk factor for CI-AKI in the HFrEF, HFmrEF and HFpEF groups. Elevated levels of NT-proBNP are independent risk factors for CI-AKI irrespective of the classification of HF. Lower levels of EF were risk factors for CI-AKI in the HFrEF and HFmrEF groups, but not in the HFpEF group.
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Affiliation(s)
- Tian Xu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Maoning Lin
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Xiaohua Shen
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Min Wang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Wenjuan Zhang
- Department of Information Technology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, China
| | - Liding Zhao
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Duanbin Li
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China
| | - Yi Luan
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China. .,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China.
| | - Wenbin Zhang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, People's Republic of China. .,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, 310016, China.
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6
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Renin-angiotensin-aldosterone system inhibition decreased contrast-associated acute kidney injury in chronic kidney disease patients. J Formos Med Assoc 2020; 120:641-650. [PMID: 32762878 DOI: 10.1016/j.jfma.2020.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/PURPOSE Chronic kidney disease (CKD) is a risk factor for contrast associated acute kidney injury (CA-AKI). The risk of renin-angiotensin-aldosterone system inhibitor (RASi) use in patients with CKD before the administration of contrast is not clear. METHODS In this nested case-control study, 8668 patients received contrast computed tomography (CT) from 2013 to 2018 during index administration in a multicenter hospital cohort. The identification of AKI is based on the Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria within 48 h after contrast medium used. RESULTS Finally, 986 patients (age, 63.36 ± 12.22; men, 72.92%) with CKD (estimated glomerular filtration rate (eGFR) = 35.0 ± 19.8 mL/min/1.73 m2) were eligible for analysis. After the index date, RASi users (n = 315) were less likely to develop CA-AKI (13.65% vs 30.4%, p < 0.001), and had a lower hospital mortality (8.25% vs 19.23%, p < 0.001) compared with non-users. The pre-contrast use of RASi decrease the risk of AKI (OR, 0.342, p < 0.001) and hospital mortality (OR, 0.602, p = 0.045). Even a few defined daily doses (DDDs) of RASi treatment, more than 0.02 prior to contrast CT could attenuate CA-AKI. The hospital mortality was higher in RASi non-users if their eGFR value was more than 17.9 mL/min/1.73 m2. CONCLUSION RASi use in patients with CKD prior to contrast CT has the potential to mitigate the incidence of AKI and hospital mortality. Even a low dose of RASi will noticeably decrease the risk of AKI and will not increase the risk of hyperkalemia.
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Bugani G, Ponticelli F, Giannini F, Gallo F, Gaudenzi E, Laricchia A, Fisicaro A, Cimaglia P, Mangieri A, Gardi I, Colombo A. Practical guide to prevention of contrast-induced acute kidney injury after percutaneous coronary intervention. Catheter Cardiovasc Interv 2020; 97:443-450. [PMID: 31967390 DOI: 10.1002/ccd.28740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/12/2019] [Accepted: 01/11/2020] [Indexed: 11/06/2022]
Abstract
Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.
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Affiliation(s)
- Giulia Bugani
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
| | - Francesco Ponticelli
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Francesco Gallo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy.,Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Eleonora Gaudenzi
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
| | - Alessandra Laricchia
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Andrea Fisicaro
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Paolo Cimaglia
- Cardiology Department, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Antonio Mangieri
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Ilja Gardi
- Cardiology Department, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy.,Emo GVM Centro Cuore Columbus, Interventional Cardiology Unit, Milan, Italy
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8
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Ward DB, Valentovic MA. Contrast Induced Acute Kidney Injury and Direct Cytotoxicity of Iodinated Radiocontrast Media on Renal Proximal Tubule Cells. J Pharmacol Exp Ther 2019; 370:160-171. [PMID: 31101680 DOI: 10.1124/jpet.119.257337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022] Open
Abstract
The administration of intravenous iodinated radiocontrast media (RCM) to visualize internal structures during diagnostic procedures has increased exponentially since their first use in 1928. A serious side effect of RCM exposure is contrast-induced acute kidney injury (CI-AKI), which is defined as an abrupt and prolonged decline in renal function occurring 48-72 hours after injection. Multiple attempts have been made to decrease the toxicity of RCM by altering ionic strength and osmolarity, yet there is little evidence to substantiate that a specific RCM is superior in avoiding CI-AKI. RCM-associated kidney dysfunction is largely attributed to alterations in renal hemodynamics, specifically renal vasoconstriction; however, numerous studies indicate direct cytotoxicity as a source of epithelial damage. Exposure of in vitro renal proximal tubule cells to RCM has been shown to affect proximal tubule epithelium in the following manner: 1) changes to cellular morphology in the form of vacuolization; 2) increased production of reactive oxygen species, resulting in oxidative stress; 3) mitochondrial dysfunction, resulting in decreased efficiency of the electron transport chain and ATP production; 4) perturbation of the protein folding capacity of the endoplasmic reticulum (ER) (activating the unfolded protein response and inducing ER stress); and 5) decreased activity of cell survival kinases. The present review focuses on the direct cytotoxicity of RCM on proximal tubule cells in the absence of in vivo complications, such as alterations in renal hemodynamics or cytokine influence.
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Affiliation(s)
- Dakota B Ward
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
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