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Murugan R, Boudreaux-Kelly MY, Kellum JA, Palevsky PM, Weisbord S. Contrast-associated acute kidney injury and cardiovascular events: a secondary analysis of the PRESERVE cohort. Clin Kidney J 2023; 16:2626-2638. [PMID: 38046040 PMCID: PMC10689134 DOI: 10.1093/ckj/sfad214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background Contrast-associated acute kidney injury (CA-AKI) has been associated with a higher risk of cardiovascular (CV) events. We studied the risk of CV events in chronic kidney disease (CKD) patients undergoing angiography and whether biomarkers can predict such events. We also explored whether CA-AKI mediates the association of pre-angiography estimated glomerular filtration rate (eGFR) on CV events. Methods We analysed participants from the Prevention of Serious Adverse Events following the Angiography (PRESERVE) trial. Urinary tissue inhibitor of matrix metalloproteinase [TIMP]-2 and insulin growth factor binding protein [IGFBP]-7, plasma brain-type natriuretic peptide (BNP), high sensitivity C-reactive protein (hs-CRP), and serum cardiac troponin-I (Tn-I) were assayed before and after angiography. We assessed the composite risk of CV events by day 90. Results Of the 922 participants, 119 (12.9%) developed CV events, and 73 (7.9%) developed CA-AKI. Most cases of CA-AKI (90%) were stage 1. There were no differences in urinary [TIMP-2]•[IGFBP7] concentrations or the proportion of patients with CA-AKI among those with and without CV events. Higher BNP, Tn-I, and hs-CRP were associated with CV events, but their discriminatory capacity was modest (AUROC <0.7). CA-AKI did not mediate the association of the pre-angiography eGFR on CV events. Conclusions Most episodes of CA-AKI are stage 1 AKI and are not associated with CV events. Less severe CA-AKI episodes also did not mediate the risk of pre-angiography eGFR on CV events. Our findings suggest that most CV events after contrast procedures are due to underlying CKD and CV risk factors rather than less severe CA-AKI episodes and should help enhance the utilization of clinically indicated contrast procedures among high-risk patients with CKD. Further research is required to examine whether moderate-to-severe CA-AKI episodes are associated with CV events.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Monique Y Boudreaux-Kelly
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A Kellum
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul M Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Steven Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Ye J, Liu C, Deng Z, Zhu Y, Zhang S. Risk factors associated with contrast-associated acute kidney injury in ST-segment elevation myocardial infarction patients: a systematic review and meta-analysis. BMJ Open 2023; 13:e070561. [PMID: 37380206 PMCID: PMC10410875 DOI: 10.1136/bmjopen-2022-070561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/13/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis was to evaluate the risk factors for contrast-associated acute kidney injury (CA-AKI) in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. DESIGN Systematic review and meta-analysis. DATA SOURCES We searched the databases of PubMed, Embase and Ovid, up to February 2022, for observational studies that investigated the association between risk factors and CA-AKI. RESULTS A total of 21 studies were included in the meta-analysis. Of the total 22 015 participants, 2728 developed CA-AKI. Pooled incidence was 11.91% (95% CI 9.69%, 14.14%). Patients with CA-AKI were more likely to be older, female, also had comorbidities (hypertension, diabetes, previous heart failure). Smoking (OR: 0.60; 95% CI 0.52, 0.69) and family history of CAD (coronary artery disease) (OR: 0.76; 95% CI 0.60, 0.95) were associated with lower risk of CA-AKI. Left anterior descending (LAD) artery occlusion (OR: 1.39; 95% CI 1.21, 1.59), left main disease (OR: 4.62; 95% CI 2.24, 9.53) and multivessel coronary disease (OR: 1.33; 95% CI 1.11, 1.60) were risk factors for CA-AKI. Contrast volume (weighted mean difference: 20.40; 95% CI 11.02, 29.79) was associated with increased risk in patients receiving iso-osmolar or low-osmolar non-ionic contrast. CONCLUSIONS In addition to the known risk factors, LAD artery infarction, left main disease and multivessel disease are risk factors for CA-AKI. The unexpected favourable association between smoking, as well as family history of CAD, and CA-AKI requires further investigation. PROSPERO REGISTRATION NUMBER CRD42021289868.
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Affiliation(s)
- Jiahao Ye
- Department of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, Guangdong Province, China
| | - Chaoyun Liu
- Department of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, Guangdong Province, China
| | - Zhanyu Deng
- Department of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, Guangdong Province, China
| | - Youfeng Zhu
- Department Of Intensive Care Unit, Guangzhou Red Cross Hospital, Guangzhou, Guangdong Province, China
| | - Shaoheng Zhang
- Department of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, Guangdong Province, China
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Fior D, Di Provvido S, Leni D, Corso R, Moramarco LP, Pileri M, Grasso RF, Santucci D, Faiella E. Spontaneous Soft Tissue Hematomas in Patients with Coagulation Impairment: Safety and Efficacy of Transarterial Embolization. Tomography 2023; 9:1083-1093. [PMID: 37368541 DOI: 10.3390/tomography9030089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this study is to report the authors' experience of percutaneous transarterial embolization (TAE) in patients with spontaneous soft tissue hematomas (SSTH) and active bleeding with anticoagulation impairment. The study retrospectively identified 78 patients who received a diagnosis of SSTH by CT scan and underwent TAE between 2010 and 2019 in a single trauma center. The patients were stratified using Popov classification into categories: 2A, 2B, 2C, and 3. The patient's 30-day survival after TAE was considered the primary outcome; immediate technical success, the need for additional TAE, and TAE-related complications were considered secondary outcomes. Immediate technical success, complication rate, and risk factors for death were analyzed. Follow-up stopped on day 30 from TAE. 27 patients (35%) fell into category 2A, 8 (10%) into category 2B, 4 (5%) into category 2C, and 39 (50%) into category 3. Immediate technical success was achieved in 77 patients (98.7%). Complications included damage at the arterial puncture site (2 patients, 2.5%) and acute kidney injury (24 patients, 31%). Only 2 patients (2.5%) had been discharged with a new diagnosis of chronic kidney disease. The 30-day overall mortality rate was 19% (15 patients). The mortality rate was higher in hemodynamically unstable patients, in Popov categories 2B, 2C, and 3, and in patients with an initial eGFR < 30 mL/min × 1.73 m2. The study demonstrated a higher mortality risk for categories 2B, 2C, and 3 compared to category 2A. Nonetheless, TAE has proven effective and safe in type 2A patients. Even though it is unclear whether type 2A patients could benefit from conservative treatment rather than TAE, in the authors' opinion, a TAE endovascular approach should be promptly considered for all patients in ACT with active bleeding demonstrated on CT scans.
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Affiliation(s)
- Davide Fior
- Department of Radiology, Sant'Anna Hospital, ASST Lariana, Via Ravona 20, San Fermo della Battaglia, 22042 Como, Italy
| | - Stefano Di Provvido
- Department of Radiology, Desio Hospital, ASST Brianza, Via Giuseppe Mazzini 1, Desio, 20832 Monza, Italy
| | - Davide Leni
- Department of Diagnostic Radiology, San Gerardo Hospital, ASST Monza, Via Gian Battista Pergolesi 33, 20900 Monza, Italy
| | - Rocco Corso
- Department of Diagnostic Radiology, San Gerardo Hospital, ASST Monza, Via Gian Battista Pergolesi 33, 20900 Monza, Italy
| | - Lorenzo Paolo Moramarco
- Department of Radiology, Sant'Anna Hospital, ASST Lariana, Via Ravona 20, San Fermo della Battaglia, 22042 Como, Italy
| | - Matteo Pileri
- Unit of Radiology and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Rome, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Rome, Italy
| | - Rosario Francesco Grasso
- Unit of Radiology and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Rome, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Rome, Italy
| | - Domiziana Santucci
- Unit of Radiology and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Rome, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Rome, Italy
| | - Eliodoro Faiella
- Unit of Radiology and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Rome, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Rome, Italy
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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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Brown JR, Solomon R, Stabler ME, Davis S, Carpenter-Song E, Zubkoff L, Westerman DM, Dorn C, Cox KC, Minter F, Jneid H, Currier JW, Athar SA, Girotra S, Leung C, Helton TJ, Agarwal A, Vidovich MI, Plomondon ME, Waldo SW, Aschbrenner KA, O'Malley AJ, Matheny ME. Team-Based Coaching Intervention to Improve Contrast-Associated Acute Kidney Injury: A Cluster-Randomized Trial. Clin J Am Soc Nephrol 2023; 18:315-326. [PMID: 36787125 PMCID: PMC10103221 DOI: 10.2215/cjn.0000000000000067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Up to 14% of patients in the United States undergoing cardiac catheterization each year experience AKI. Consistent use of risk minimization preventive strategies may improve outcomes. We hypothesized that team-based coaching in a Virtual Learning Collaborative (Collaborative) would reduce postprocedural AKI compared with Technical Assistance (Assistance), both with and without Automated Surveillance Reporting (Surveillance). METHODS The IMPROVE AKI trial was a 2×2 factorial cluster-randomized trial across 20 Veterans Affairs medical centers (VAMCs). Participating VAMCs received Assistance, Assistance with Surveillance, Collaborative, or Collaborative with Surveillance for 18 months to implement AKI prevention strategies. The Assistance and Collaborative approaches promoted hydration and limited NPO and contrast dye dosing. We fit logistic regression models for AKI with site-level random effects accounting for the clustering of patients within medical centers with a prespecified interest in exploring differences across the four intervention arms. RESULTS Among VAMCs' 4517 patients, 510 experienced AKI (235 AKI events among 1314 patients with preexisting CKD). AKI events in each intervention cluster were 110 (13%) in Assistance, 122 (11%) in Assistance with Surveillance, 190 (13%) in Collaborative, and 88 (8%) in Collaborative with Surveillance. Compared with sites receiving Assistance alone, case-mix-adjusted differences in AKI event proportions were -3% (95% confidence interval [CI], -4 to -3) for Assistance with Surveillance, -3% (95% CI, -3 to -2) for Collaborative, and -5% (95% CI, -6 to -5) for Collaborative with Surveillance. The Collaborative with Surveillance intervention cluster had a substantial 46% reduction in AKI compared with Assistance alone (adjusted odds ratio=0.54; 0.40-0.74). CONCLUSIONS This implementation trial estimates that the combination of Collaborative with Surveillance reduced the odds of AKI by 46% at VAMCs and is suggestive of a reduction among patients with CKD. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER IMPROVE AKI Cluster-Randomized Trial (IMPROVE-AKI), NCT03556293.
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Affiliation(s)
- Jeremiah R. Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Richard Solomon
- University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Meagan E. Stabler
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sharon Davis
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth Carpenter-Song
- Department of Psychiatry and Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham and VA Birmingham Health Care, Birmingham, Alabama
| | - Dax M. Westerman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad Dorn
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin C. Cox
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Freneka Minter
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Jesse W. Currier
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of Cardiology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - S. Ahmed Athar
- Section of Cardiology, Loma Linda VA Medical Center, Loma Linda, California
- Department of Medicine, Division of Cardiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Ajay Agarwal
- Wright State University Dayton VA Medical Center, Dayton, Ohio
| | - Mladen I. Vidovich
- Section of Cardiology, Jesse Brown VA Medical Center and Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | - Stephen W. Waldo
- CART Program, VHA Office of Quality and Safety, Washington, DC
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Kelly A. Aschbrenner
- Department of Psychiatry and Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - A. James O'Malley
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Michael E. Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Care Center, Tennessee Valley Healthcare System VA, Nashville, Tennessee
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Murugan R, Boudreaux-Kelly MY, Kellum JA, Palevsky PM, Weisbord S. Kidney Cell Cycle Arrest and Cardiac Biomarkers and Acute Kidney Injury Following Angiography: The Prevention of Serious Adverse Events Following Angiography (PRESERVE) Study. Kidney Med 2023; 5:100592. [PMID: 36874509 PMCID: PMC9976574 DOI: 10.1016/j.xkme.2022.100592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale & Objective Recent studies in patients with chronic kidney disease (CKD) indicate that most cases of contrast-associated acute kidney injury (CA-AKI) are mild and are not associated with elevation in kidney injury biomarkers. We used highly sensitive kidney cell cycle arrest and cardiac biomarkers to assess the risk of CA-AKI and major adverse kidney events in patients with CKD undergoing angiography. Study Design A retrospective study. Setting & Participants A subset of 922 participants from the Prevention of Serious Adverse Events following Angiography trial. Predictors Pre- and postangiography urinary tissue inhibitor of matrix metalloproteinase [TIMP]-2 and insulin growth factor binding protein [IGFBP]-7 were measured in 742 subjects, and plasma β natriuretic peptide (BNP) and high-sensitivity C-reactive protein (hs-CRP), and serum troponin (Tn) in 854 participants using samples obtained 1-2 hours before and 2-4 hours after angiography. Outcomes CA-AKI and major adverse kidney events. Analytical Approach We fitted logistic regression to examine association and area under the receiver operating characteristic curves for risk prediction. Results There were no differences in postangiography urinary [TIMP-2]•[IGFBP7], plasma BNP, serum Tn, and hs-CRP concentrations among patients with and without CA-AKI and major adverse kidney events. However, higher pre- and postangiography median plasma BNP (pre: 200.0 vs 71.5, pg/mL, P = 0.05; post: 165.0 vs 81 pg/mL, P = 0.02); serum Tn (pre: 0.03 vs 0.01, ng/mL, P < 0.001; post, 0.04 vs 0.02, ng/mL, P = 0.01); and hs-CRP (pre: 9.55 vs 3.40 mg/L, P = 0.01; post: 9.90 vs 3.20 mg/L, P = 0.002) concentrations were associated with major adverse kidney events, although their discriminatory capacity was only modest (area under the receiver operating characteristic curves <0.7). Limitations Most participants were men. Conclusions Most mild CA-AKI cases are not associated with urinary cell cycle arrest biomarker elevation. Significant elevation in preangiography cardiac biomarkers may reflect patients with more significant cardiovascular disease that may predispose to poor long-term outcomes independent of CA-AKI status.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - John A. Kellum
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M. Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Steven Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Biomarker Effectiveness Analysis in Contrast Nephropathy (BEACON) Study Investigators
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
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Ruff C, Artzner C, Nikoalou K, Grözinger G. Atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease patients: a narrative review. Cardiovasc Diagn Ther 2023; 13:133-146. [PMID: 36864951 PMCID: PMC9971292 DOI: 10.21037/cdt-22-53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/13/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective Vascular calcification (VC) and resulting vascular disease is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). CKD itself is increasingly recognized as a risk factor for cardiac and peripheral arterial disease (PAD). This paper examines the atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease (ESRD) patients. The literature was reviewed regarding the current status of medical and interventional management arteriosclerotic disease in patients with CKD. Lastly, three representative cases displaying typical endovascular treatment options are provided. Methods A literature search was performed in PubMed covering publications up to September 2021 as well as discussion with experts in the field. Key Content and Findings The high prevalence of atherosclerotic lesions in patients with chronic renal failure and high (re-)stenosis cause problems in the medium and long term as vascular calcium load represents one of the most widely encountered predictors of failure of endovascular treatment of PAD and future cardiovascular events (e.g., coronary calcium score). Patients with CKD also suffer from a greater risk for major vascular adverse events in general and worse revascularization outcomes following peripheral vascular intervention. A correlation between calcium burden and drug-coated balloon (DCB) performance has been established for PAD necessitating the need for different tools to cope with vascular calcium such as endoprosthesis or braided stents. Patients with CKD are at a higher risk of developing contrast-induced nephropathy (CIN). In addition to recommendations such as the administration of intravenous fluids, carbon dioxide (CO2) angiography is one option to potentially provide an effective and safe alternative both to iodine-based contrast media allergy and to the use of iodine-based contrast media in patients with CKD. Conclusions Management and endovascular procedures of patients with ESRD are complex. In the course of time, new endovascular therapy methods have been developed such as directional atherectomy (DA) and the so-called "pave-and-crack" technique to deal with high vascular calcium burden. Besides interventional therapy, vascular patients with CKD benefit from aggressive medical management.
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Affiliation(s)
- Christer Ruff
- Department of Neuroradiology, University Hospital Tuebingen, Tuebingen, Germany;,Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Christoph Artzner
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | | | - Gerd Grözinger
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
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Hunter J, Houchens N, Gupta A. Quality and safety in the literature: January 2023. BMJ Qual Saf 2023; 32:56-60. [PMID: 36549698 DOI: 10.1136/bmjqs-2022-015682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 12/24/2022]
Affiliation(s)
- John Hunter
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Cai A, Zhou T. Predictive Value of Hyperuricemia in Cardiac Patients with Post-Contrast Acute Kidney Injury (PC-AKI) and Different Basic Renal Functions: A Meta-Analysis. IRANIAN JOURNAL OF PUBLIC HEALTH 2022; 51:2641-2653. [PMID: 36742248 PMCID: PMC9874193 DOI: 10.18502/ijph.v51i12.11455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/20/2022] [Indexed: 12/29/2022]
Abstract
Background Uric acid level has shown a certain relationship with the incidence of post-contrast acute kidney injury (PC-AKI), whereas it remains controversial whether hyperuricemia can function as a predictor of PCAKI in patients with different basic creatinine serum level. The present meta-analysis aimed to investigate whether hyperuricemia is an independent risk factor for PC-AKI and to explore the relationship between hyperuricemia and basic renal function. Methods Relevant studies were retrieved via searching in PubMed, Embase, Cochrane Library, and WAN FANG electronic databases from inception to Jan 2022. Only studies published in English and Chinese languages were selected. Results Overall, 11892 patients from 15 studies were included. The results of the pooled analysis revealed that the incidence of PC-AKI was significantly higher in the hyperuricemia group than that in the normouricemic group (20.62% vs. 13.05%). Hyperuricemia was associated with an increased risk of the incidence of PC-AKI (odds ratio (OR): 2.48 [95% confidence interval (CI): 1.77-3.46%]). The pooled ORs for mortality and incidence of undergoing renal replacement therapy were 2.33 (95% CI:1.81-3.00) and 8.69 (95% CI:3.22-23.44%), respectively. Comparatively, the pre-existing renal dysfunction subgroup had a lower relative risk in the hyperuricemia population. Conclusion Hyperuricemia was found to be significantly associated with the incidence of PC-AKI. The effect of serum uric acid level on the incidence of PC-AKI was higher in patients with normal renal function, which could lay a foundation for the establishment of individualized schemes to prevent PC-AKI by urate-lowering therapy.
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Affiliation(s)
- Angshu Cai
- Queen Mary School, Nanchang University, Nanchang 330031, China
| | - Tian Zhou
- School of Basic Medical Sciences, Nanchang University, Nanchang, 330031, China,Corresponding Author:
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10
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Li X, Yuan F, Zhou L. Organ Crosstalk in Acute Kidney Injury: Evidence and Mechanisms. J Clin Med 2022; 11:jcm11226637. [PMID: 36431113 PMCID: PMC9693488 DOI: 10.3390/jcm11226637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Acute kidney injury (AKI) is becoming a public health problem worldwide. AKI is usually considered a complication of lung, heart, liver, gut, and brain disease, but recent findings have supported that injured kidney can also cause dysfunction of other organs, suggesting organ crosstalk existence in AKI. However, the organ crosstalk in AKI and the underlying mechanisms have not been broadly reviewed or fully investigated. In this review, we summarize recent clinical and laboratory findings of organ crosstalk in AKI and highlight the related molecular mechanisms. Moreover, their crosstalk involves inflammatory and immune responses, hemodynamic change, fluid homeostasis, hormone secretion, nerve reflex regulation, uremic toxin, and oxidative stress. Our review provides important clues for the intervention for AKI and investigates important therapeutic potential from a new perspective.
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11
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Soomro QH, Anand ST, Weisbord SD, Gallagher MP, Ferguson RE, Palevsky PM, Bhatt DL, Parikh CR, Kaufman JS. The Relationship between Rate and Volume of Intravenous Fluid Administration and Kidney Outcomes after Angiography. Clin J Am Soc Nephrol 2022; 17:1446-1456. [PMID: 36008352 PMCID: PMC9528263 DOI: 10.2215/cjn.02160222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/27/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Contrast-associated AKI may result in higher morbidity and mortality. Intravenous fluid administration remains the mainstay for prevention. There is a lack of consensus on the optimal administration strategy. We studied the association of periprocedure fluid administration with contrast-associated AKI, defined as an increase in serum creatinine of at least 25% or 0.5 mg/dl from baseline at 3-5 days after angiography, and 90-day need for dialysis, death, or a 50% increase in serum creatinine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a secondary analysis of 4671 PRESERVE participants who underwent angiographic procedures. Although fluid type was randomized, strategy of administration was at the discretion of the clinician. We divided the study cohort into quartiles by total fluid volume. We performed multivariable logistic regression, adjusting for clinically important covariates. We tested for the interaction between fluid volume and duration of fluid administration, categorized as <6 or ≥6 hours. RESULTS The mean (SD) age was 70 (8) years, 94% of participants were male, and median (interquartile range) eGFR was 60 (41-60) ml/min per 1.73 m2. The range of fluid administered was 89-882 ml in quartile 1 and 1258-2790 ml in quartile 4. Compared with the highest quartile (quartile 4) of fluid volume, we found a significantly higher risk of the primary outcome in quartile 1 (adjusted odds ratio, 1.58; 95% confidence interval, 1.06 to 2.38) but not in quartiles 2 and 3 compared with quartile 4. There was no difference in the incidence of contrast-associated AKI across the quartiles. The interaction between volume and duration was not significant for any of the outcomes. CONCLUSIONS We found that administration of a total volume of 1000 ml, starting at least 1 hour before contrast injection and continuing postcontrast for a total of 6 hours, is associated with a similar risk of adverse outcomes as larger volumes of intravenous fluids administered for periods >6 hours. Mean fluid volumes <964 ml may be associated with a higher risk for the primary outcome, although residual confounding cannot be excluded.
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Affiliation(s)
| | - Sonia T. Anand
- VA Boston Health Care System Massachusetts Veterans Epidemiology Research and Information Center, Boston, Massachusetts
| | - Steven D. Weisbord
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Ryan E. Ferguson
- VA Boston Health Care System Massachusetts Veterans Epidemiology Research and Information Center, Boston, Massachusetts
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Paul M. Palevsky
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Chirag R. Parikh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James S. Kaufman
- New York University Grossman School of Medicine, New York, New York
- Renal Section, VA New York Harbor Healthcare Center, New York, New York
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12
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Kraft WK. Clinical Pharmacology and the Best Use of Public Research Investment. Clin Pharmacol Ther 2022; 111:1185-1188. [PMID: 35586960 DOI: 10.1002/cpt.2590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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13
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Xie W, Zhou Y, Liao Z, Lin B. Effect of Oral Hydration on Contrast-Induced Acute Kidney Injury among Patients after Primary Percutaneous Coronary Intervention. Cardiorenal Med 2021; 11:243-251. [PMID: 34823253 DOI: 10.1159/000520088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the protective effect of oral hydration volume to weight ratio (OHV/W) on contrast-induced acute kidney injury (CI-AKI) among patients with ST-elevation myocardial infarction (STEMI) following percutaneous coronary intervention (PCI). METHODS A total of 754 patients with STEMI undergoing PCI were selected. Each patient was encouraged to drink as much water as possible 24 h after PCI. Total volume intake was recorded for all patients. The ratio of OHV/W was calculated. The occurrence of CI-AKI was defined as ≥0.5 mg/dL absolute or ≥25% relative increase in serum creatinine within 48-72 h following PCI. Logistic regression analysis and generalized additive model were performed to evaluate the relationship between OHV/W and CI-AKI. RESULTS There was a nonlinear relationship between OHV/W and CI-AKI with an inflection point of 15.69 mL/kg. On the right side of the inflection point (OHV/W ≥15.69 mL/kg), a negative relationship was detected between OHV/W and CI-AKI (HR = 0.90, 95% CI: 0.82∼0.98, p = 0.0126). However, no relationship was observed between OHV/W and CI-AKI on the left of inflection point (HR = 1.19, 95% CI: 0.95∼1.49, p = 0.1302). Subgroup analysis showed that significant interactions were observed only for gender difference (p for interaction = 0.0155), male patients had a significantly lower risk of CI-AKI (HR = 0.84, 95% CI: 0.75∼0.93, p = 0.0012). CONCLUSION OHV/W ≥15.6 mL/kg for 24 h post-procedure may be an effective preventive strategy of CI-AKI. In addition, male patients may particularly benefit from OHV to prevent CI-AKI.
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Affiliation(s)
- Weining Xie
- Department of Scientific Research, Guangdong Province Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, China,
| | - Yuge Zhou
- Affiliated Guangdong Hospital of Integrated Traditional Chinese and Western Medicine of Guangzhou University of Chinese Medicine, Foshan, China
| | - Zhishan Liao
- Department of Cardiology, Guangdong Province Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, China
| | - Biying Lin
- Department of Nephrology, Guangdong Province Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, China
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the use of iodinated contrast media in patients with kidney disease 2018. Clin Exp Nephrol 2020; 24:1-44. [PMID: 31709463 PMCID: PMC6949208 DOI: 10.1007/s10157-019-01750-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hiromitsu Hayashi
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiology Department, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Fujigaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taichi Sato
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tomoyuki Fujikura
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Toei
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ryusuke Murakami
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadateru Takayama
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yukinobu Yagyu
- Department of Radiology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Gunma, Japan
| | | | - Yugo Ito
- Department of Nephrology, St. Luke's International Hospital, Tokyo, Japan
| | - Ryo Miyazawa
- Department of Radiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Tomonari Ogawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Aichi, Japan
| | - Eri Koshi
- Department of Nephrology, Komaki City Hospital, Aichi, Japan
| | - Tomoki Kosugi
- Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshinari Yasuda
- Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
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15
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Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD, Parikh CR. Postangiography Increases in Serum Creatinine and Biomarkers of Injury and Repair. Clin J Am Soc Nephrol 2020; 15:1240-1250. [PMID: 32839195 PMCID: PMC7480551 DOI: 10.2215/cjn.15931219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2-4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. RESULTS Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (-30 [-71, -9] mg/dl) and those without contrast-associated AKI (-27 [-53, -10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). CONCLUSIONS The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.
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Affiliation(s)
- Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania .,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Paul M Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - James S Kaufman
- Division of Nephrology, Veterans Affairs New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | | | - Steven D Weisbord
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Medical Service and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Chandiramani R, Cao D, Nicolas J, Mehran R. Contrast-induced acute kidney injury. Cardiovasc Interv Ther 2020; 35:209-217. [PMID: 32253719 DOI: 10.1007/s12928-020-00660-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 01/26/2023]
Abstract
Although major advancements in the field of cardiology have allowed for an increasing number of patients to undergo minimally invasive imaging and interventional procedures, contrast-induced acute kidney injury (CI-AKI) continues to be a dreaded complication among patients receiving intravascular contrast media. CI-AKI is characterized by progressive decline in kidney function within a few days of contrast medium administration. Physiological changes resulting from the direct nephrotoxic effect of contrast media on tubular epithelial cells and release of vasoactive molecules have been implicated in creating a state of increased oxidative stress and subsequent ischemic renal cell injury. Over the last several years, preventive strategies involving intravenous hydration, pharmaceutical agents and renal replacement therapies have resulted in lower rates of CI-AKI. However, due to the evolving paradigm of diagnostic and therapeutic interventions, several unanswered questions remain. This review highlights the epidemiology, pathogenesis and preventive strategies of CI-AKI.
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Affiliation(s)
- Rishi Chandiramani
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Davide Cao
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Johny Nicolas
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA.
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17
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Weisbord SD, Palevsky PM, Kaufman JS, Wu H, Androsenko M, Ferguson RE, Parikh CR, Bhatt DL, Gallagher M. Contrast-Associated Acute Kidney Injury and Serious Adverse Outcomes Following Angiography. J Am Coll Cardiol 2020; 75:1311-1320. [DOI: 10.1016/j.jacc.2020.01.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
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18
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Post-contrast acute kidney injury in a hospitalized population: short-, mid-, and long-term outcome and risk factors for adverse events. Eur Radiol 2020; 30:3516-3527. [PMID: 32080754 PMCID: PMC7248019 DOI: 10.1007/s00330-020-06690-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/12/2020] [Accepted: 01/29/2020] [Indexed: 12/21/2022]
Abstract
Objectives To investigate the prognosis including major adverse kidney events within 30 days (MAKE30) and 90-day and 1-year adverse outcome in hospitalized patients with post-contrast acute kidney injury (PC-AKI) to identify high-risk factors. Methods This retrospective observational study included 288 PC-AKI patients selected from 277,898 patients admitted to hospitals from January 2015 to December 2015. PC-AKI was defined according to the 2018 guideline of European Society of Urogenital Radiology. Multivariable Cox regression and logistic regression analyses were used to analyze main outcome and risk factors. Results PC-AKI patients with AKI stage ≥ 2 had much higher incidence of MAKE30 than those with AKI stage 1 (RR = 7.027, 95% CI 4.918–10.039). Persistent renal dysfunction, heart failure, central nervous system failure, baseline eGFR < 60 mL/min/1.73 m2, oliguria or anuria, blood urea nitrogen ≥ 7.14 mmol/L, respiratory failure, and shock were independent risk factors of 90-day or 1-year adverse prognosis (p < 0.05). Compared with transient renal dysfunction, PC-AKI patients with persistent renal dysfunction had a higher all-cause mortality rate (RR = 3.768, 95% CI 1.612–8.810; RR = 4.106, 95% CI 1.765–9.551) as well as combined endpoints of death, chronic kidney disease, or end-stage renal disease (OR = 3.685, 95% CI 1.628–8.340; OR = 5.209, 95% CI 1.730–15.681) within 90 days or 1 year. Conclusions PC-AKI is not always a transient, benign creatininopathy, but can result in adverse outcome. AKI stage is independently correlated to MAKE30 and persistent renal dysfunction may exaggerate the risk of long-term adverse events. Key Points • PC-AKI can result in adverse outcome such as persistent renal dysfunction, dialysis, chronic kidney disease (CKD), end-stage renal disease (ESRD), or death. • AKI stage is independently correlated to MAKE30. • Persistent renal dysfunction may exaggerate the risk of long-term adverse events. Electronic supplementary material The online version of this article (10.1007/s00330-020-06690-3) contains supplementary material, which is available to authorized users.
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19
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Parikh CR, Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD. Kidney Biomarkers of Injury and Repair as Predictors of Contrast-Associated AKI: A Substudy of the PRESERVE Trial. Am J Kidney Dis 2020; 75:187-194. [PMID: 31547939 PMCID: PMC7012712 DOI: 10.1053/j.ajkd.2019.06.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
RATIONALE & OBJECTIVE The PRESERVE trial used a 2 × 2 factorial design to compare intravenous saline solution with intravenous sodium bicarbonate solution and oral N-acetylcysteine with placebo for the prevention of 90-day major adverse kidney events and death (MAKE-D) and contrast-associated acute kidney injury (CA-AKI) among patients with chronic kidney disease undergoing angiography. In this ancillary study, we evaluated the predictive capacities of preangiography injury and repair proteins in urine and plasma for MAKE-D, CA-AKI, and their impact on trial design. STUDY DESIGN Longitudinal analysis. SETTING & PARTICIPANTS A subset of participants from the PRESERVE trial. EXPOSURES Injury (KIM-1, NGAL, and IL-18) and repair (MCP-1, UMOD, and YKL-40) proteins in urine and plasma 1 to 2 hours preangiography. OUTCOMES MAKE-D and CA-AKI. ANALYTICAL APPROACH We analyzed the associations of preangiography biomarkers with MAKE-D and with CA-AKI. We evaluated whether the biomarker levels could enrich the MAKE-D event rate and improve future clinical trial efficiency through an online biomarker prognostic enrichment tool available at prognosticenrichment.com. RESULTS We measured plasma biomarkers in 916 participants and urine biomarkers in 797 participants. After adjusting for urinary albumin-creatinine ratio and baseline estimated glomerular filtration rate, preangiography levels of 4 plasma (KIM-1, NGAL, UMOD, and YKL-40) and 3 urine (NGAL, IL-18, and YKL-40) biomarkers were associated with MAKE-D. Only plasma KIM-1 level was significantly associated with CA-AKI after adjustment. Biomarker levels provided modest discriminatory capacity for MAKE-D. Screening patients using the 50th percentile of preangiography plasma KIM-1 or YKL-40 levels would have reduced the required sample size by 30% (∼2,000 participants). LIMITATIONS Evaluation of prognostic enrichment does not account for changing trial costs, time needed to screen patients, or loss to follow-up. Most participants were male, limiting the generalizability of our findings. CONCLUSIONS Preangiography levels of injury and repair biomarkers modestly predict the development of MAKE-D and can be used to improve the efficiency of future CA-AKI trials.
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Affiliation(s)
- Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - James S Kaufman
- Division of Nephrology, VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY
| | | | - Steven D Weisbord
- VA Pittsburgh Healthcare System, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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20
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Garcia S, Bhatt DL, Gallagher M, Jneid H, Kaufman J, Palevsky PM, Wu H, Weisbord SD. Strategies to Reduce Acute Kidney Injury and Improve Clinical Outcomes Following Percutaneous Coronary Intervention: A Subgroup Analysis of the PRESERVE Trial. JACC Cardiovasc Interv 2019; 11:2254-2261. [PMID: 30466822 DOI: 10.1016/j.jcin.2018.07.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to compare intravenous (IV) sodium bicarbonate with IV sodium chloride and oral acetylcysteine with placebo for the prevention of contrast-associated acute kidney injury (CAAKI) and intermediate-term adverse outcomes. BACKGROUND Data are conflicting on the optimal strategy to reduce CAAKI and related complications after percutaneous coronary intervention (PCI). METHODS The PRESERVE (Prevention of Serious Adverse Events Following Angiography) trial used a 2 × 2 factorial design to randomize 5,177 patients with stage III or IV chronic kidney disease undergoing angiography to IV 1.26% sodium bicarbonate or IV 0.9% sodium chloride and 5 days of oral acetylcysteine or placebo. A subgroup analysis was conducted of the efficacy of these interventions in patients who underwent PCI during the study angiographic examination. The primary endpoint was a composite of death, need for dialysis, or persistent kidney impairment at 90 days; CAAKI was a secondary endpoint. RESULTS A total of 1,161 PRESERVE patients (mean age 69 ± 8 years) underwent PCI. The median estimated glomerular filtration rate was 50.7 ml/min/1.73 m2 (interquartile range: 41.7 to 60.1 ml/min/1.73 m2), and 952 patients (82%) had diabetes mellitus. The primary endpoint occurred in 15 of 568 patients (2.6%) in the IV sodium bicarbonate group and 24 of 593 patients (4.0%) in the IV sodium chloride group (odds ratio: 0.64; 95% confidence interval: 0.33 to 1.24; p for interaction = 0.41) and in 23 of 598 patients (3.8%) in the acetylcysteine group and 16 of 563 patients (2.8%) in the placebo group (odds ratio: 1.37; 95% confidence interval: 0.71 to 2.62; p for interaction = 0.29). There were no significant between-group differences in the rates of CAAKI. CONCLUSIONS Among patients with CKD undergoing PCI, there was no benefit of IV sodium bicarbonate over IV sodium chloride or of acetylcysteine over placebo for the prevention of CAAKI or intermediate-term adverse outcomes.
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Affiliation(s)
- Santiago Garcia
- Minneapolis VA Healthcare System, University of Minnesota, Minneapolis Heart Institute, Minneapolis, Minnesota.
| | - Deepak L Bhatt
- VA Boston Healthcare System and Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | | | - Hani Jneid
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
| | - James Kaufman
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hongsheng Wu
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Steven D Weisbord
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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21
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Abstract
Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine, decrease in urine output, or both. AKI occurs in approximately 10-15% of patients admitted to hospital, while its incidence in intensive care has been reported in more than 50% of patients. Kidney dysfunction or damage can occur over a longer period or follow AKI in a continuum with acute and chronic kidney disease. Biomarkers of kidney injury or stress are new tools for risk assessment and could possibly guide therapy. AKI is not a single disease but rather a loose collection of syndromes as diverse as sepsis, cardiorenal syndrome, and urinary tract obstruction. The approach to a patient with AKI depends on the clinical context and can also vary by resource availability. Although the effectiveness of several widely applied treatments is still controversial, evidence for several interventions, especially when used together, has increased over the past decade.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy; International Renal Research Institute of Vicenza, Vicenza, Italy; Department of Nephrology, San Bortolo Hospital, Vicenza, Italy.
| | - Rinaldo Bellomo
- Critical Care Department, Austin Hospital, Melbourne, VIC, Australia
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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22
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the Use of Iodinated Contrast Media in Patients With Kidney Disease 2018. Circ J 2019; 83:2572-2607. [PMID: 31708511 DOI: 10.1253/circj.cj-19-0783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshitaka Isaka
- Japanese Society of Nephrology.,Department of Nephrology, Osaka University Graduate School of Medicine
| | - Hiromitsu Hayashi
- Japan Radiological Society.,Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School
| | - Kazutaka Aonuma
- the Japanese Circulation Society.,Cardiology Department, Institute of Clinical Medicine, University of Tsukuba
| | - Masaru Horio
- Japanese Society of Nephrology.,Kansai Medical Hospital
| | - Yoshio Terada
- Japanese Society of Nephrology.,Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University
| | - Kent Doi
- Japanese Society of Nephrology.,Department of Acute Medicine, The University of Tokyo
| | - Yoshihide Fujigaki
- Japanese Society of Nephrology.,Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Hideo Yasuda
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Taichi Sato
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Tomoyuki Fujikura
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Ryohei Kuwatsuru
- Japan Radiological Society.,Department of Radiology, Graduate School of Medicine, Juntendo University
| | - Hiroshi Toei
- Japan Radiological Society.,Department of Radiology, Graduate School of Medicine, Juntendo University
| | - Ryusuke Murakami
- Japan Radiological Society.,Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School
| | - Yoshihiko Saito
- the Japanese Circulation Society.,Department of Cardiovascular Medicine, Nara Medical University
| | - Atsushi Hirayama
- the Japanese Circulation Society.,Department of Cardiology, Osaka Police Hospital
| | - Toyoaki Murohara
- the Japanese Circulation Society.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Akira Sato
- the Japanese Circulation Society.,Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Hideki Ishii
- the Japanese Circulation Society.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tadateru Takayama
- the Japanese Circulation Society.,Division of General Medicine, Department of Medicine, Nihon University School of Medicine
| | - Makoto Watanabe
- the Japanese Circulation Society.,Department of Cardiovascular Medicine, Nara Medical University
| | - Kazuo Awai
- Japan Radiological Society.,Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Seitaro Oda
- Japan Radiological Society.,Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Takamichi Murakami
- Japan Radiological Society.,Department of Radiology, Kobe University Graduate School of Medicine
| | - Yukinobu Yagyu
- Japan Radiological Society.,Department of Radiology, Kindai University, Faculty of Medicine
| | - Nobuhiko Joki
- Japanese Society of Nephrology.,Division of Nephrology, Toho University Ohashi Medical Center
| | - Yasuhiro Komatsu
- Japanese Society of Nephrology.,Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine
| | | | - Yugo Ito
- Japanese Society of Nephrology.,Department of Nephrology, St. Luke's International Hospital
| | - Ryo Miyazawa
- Japan Radiological Society.,Department of Radiology, St. Luke's International Hospital
| | - Yoshihiko Kanno
- Japanese Society of Nephrology.,Department of Nephrology, Tokyo Medical University
| | - Tomonari Ogawa
- Japanese Society of Nephrology.,Department of Nephrology & Hypertension, Saitama Medical Center
| | - Hiroki Hayashi
- Japanese Society of Nephrology.,Department of Nephrology, Fujita Health University School of Medicine
| | - Eri Koshi
- Japanese Society of Nephrology.,Department of Nephrology, Komaki City Hospital
| | - Tomoki Kosugi
- Japanese Society of Nephrology.,Nephrology, Nagoya University Graduate School of Medicine
| | - Yoshinari Yasuda
- Japanese Society of Nephrology.,Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine
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23
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the use of iodinated contrast media in patients with kidney disease 2018. Jpn J Radiol 2019; 38:3-46. [PMID: 31709498 DOI: 10.1007/s11604-019-00850-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hiromitsu Hayashi
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiology Department, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Fujigaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taichi Sato
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tomoyuki Fujikura
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Toei
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ryusuke Murakami
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadateru Takayama
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yukinobu Yagyu
- Department of Radiology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Gunma, Japan
| | | | - Yugo Ito
- Department of Nephrology, St. Luke's International Hospital, Tokyo, Japan
| | - Ryo Miyazawa
- Department of Radiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Tomonari Ogawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Aichi, Japan
| | - Eri Koshi
- Department of Nephrology, Komaki City Hospital, Aichi, Japan
| | - Tomoki Kosugi
- Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshinari Yasuda
- Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
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24
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Scarfe L, Menshikh A, Newton E, Zhu Y, Delgado R, Finney C, de Caestecker MP. Long-term outcomes in mouse models of ischemia-reperfusion-induced acute kidney injury. Am J Physiol Renal Physiol 2019; 317:F1068-F1080. [PMID: 31411074 PMCID: PMC7132317 DOI: 10.1152/ajprenal.00305.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/31/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023] Open
Abstract
Severe acute kidney injury has a high mortality and is a risk factor for progressive chronic kidney disease. None of the potential therapies that have been identified in preclinical studies have successfully improved clinical outcomes. This failure is partly because animal models rarely reflect the complexity of human disease: most preclinical studies are short term and are commonly performed in healthy, young, male mice. Therapies that are effective in preclinical models that share common clinical features seen in patients with acute kidney injury, including genetic diversity, different sexes, and comorbidities, and evaluate long-term outcomes are more likely to predict success in the clinic. Here, we evaluated susceptibility to chronic kidney disease after ischemia-reperfusion injury with delayed nephrectomy by monitoring long-term functional and histological responses to injury. We defined conditions required to induce long-term postinjury renal dysfunction and fibrosis without increased mortality in a reproducible way and evaluate effect of mouse strains, sexes, and preexisting diabetes on these responses.
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Affiliation(s)
- Lauren Scarfe
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Menshikh
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily Newton
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yuantee Zhu
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Rachel Delgado
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Charlene Finney
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark P de Caestecker
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
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25
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Usai MV, Gerwing M, Gottschalk A, Sporns P, Heindel W, Oberhuber A, Wildgruber M, Köhler M. Intra-arterial catheter-directed CT angiography for assessment of endovascular aortic aneurysm repair. PLoS One 2019; 14:e0221375. [PMID: 31504047 PMCID: PMC6736289 DOI: 10.1371/journal.pone.0221375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/05/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety as well as associated image quality of catheter-directed CT angiography (CCTA) with a low dose of iodine contrast agent compared to intravenous CTA in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS Retrospective data analysis of 92 patients undergoing EVAR between January 2009 and December 2017 was performed. Patients were divided in two groups; those receiving CTA (n = 59) after intravenous contrast agent application and those receiving CCTA (n = 33) via an intraarterial catheter placed in the descending aorta. Demographic and cardiovascular risk factors as well as renal function parameters before, immediately after and 6-60 months after EVAR were evaluated. As primary endpoint, changes in serum creatinine levels in the two groups were evaluated. Secondary endpoints encompassed complications associated with intraarterial catheter placement. Objective (signal-to-noise ratios) and subjective image quality (5-point Likert scale) were compared. RESULTS Amount of contrast medium was significantly lower in CCTA compared to i.v. CTA (23 ± 7 ml vs. 119 ± 15 ml, p<0.0001). Patients undergoing catheter-directed CTA had higher baseline creatinine values compared to the group with intravenous iodine application (1.9 ± 0.6 mg/dl vs. 1.3 ± 0.5 mg/dl; p<0.0001). Follow-up serum creatinine levels however did not show significant alterations between the two groups (1.9 ± 0.4 mg/dl vs. 1.3 ± 0.5 mg/dl). No major complications were detected in the CCTA group. Signal-to-noise ratio (SNR) was comparable between i.v. CTA and CCTA (8.5 ± 4.6 vs. 7.7 ± 4.0; p = 0.37) and subjective image similarly revealed no differences with a good interobserver agreement (ICC = 0.647). CONCLUSIONS Catheter-directed CTA is safe and provides comparable image quality with a substantial retrenchment of the needed amount of iodine-based contrast medium. However, no benefit of the reduced contrast medium protocol with respect to renal function was observed.
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Affiliation(s)
- Marco V. Usai
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Mirjam Gerwing
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive Care and Pain Medicine, Münster, University Hospital Münster, Germany
| | - Peter Sporns
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Walter Heindel
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Moritz Wildgruber
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
- * E-mail:
| | - Michael Köhler
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
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26
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Hoste EAJ, Kellum JA, Selby NM, Zarbock A, Palevsky PM, Bagshaw SM, Goldstein SL, Cerdá J, Chawla LS. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol 2019; 14:607-625. [PMID: 30135570 DOI: 10.1038/s41581-018-0052-0] [Citation(s) in RCA: 639] [Impact Index Per Article: 127.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. In addition to retention of waste products, impaired electrolyte homeostasis and altered drug concentrations, AKI induces a generalized inflammatory response that affects distant organs. Full recovery of kidney function is uncommon, which leaves these patients at risk of long-term morbidity and death. Estimates of AKI prevalence range from <1% to 66%. These variations can be explained by not only population differences but also inconsistent use of standardized AKI classification criteria. The aetiology and incidence of AKI also differ between high-income and low-to-middle-income countries. High-income countries show a lower incidence of AKI than do low-to-middle-income countries, where contaminated water and endemic diseases such as malaria contribute to a high burden of AKI. Outcomes of AKI are similar to or more severe than those of patients in high-income countries. In all resource settings, suboptimal early recognition and care of patients with AKI impede their recovery and lead to high mortality, which highlights unmet needs for improved detection and diagnosis of AKI and for efforts to improve care for these patients.
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Affiliation(s)
- Eric A J Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium.
| | - John A Kellum
- Center for Critical Care Nephrology, Pittsburgh, PA, USA
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Campus, Nottingham, UK
| | - Alexander Zarbock
- University of Münster, Department of Anesthesiology, Intensive Care and Pain Medicine, Münster, Germany
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jorge Cerdá
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA
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27
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Weisbord SD, Gallagher M. Web Exclusive. Annals for Hospitalists Inpatient Notes - Preventing Contrast-Associated Acute Kidney Injury-Putting the Issue to Rest. Ann Intern Med 2019; 171:HO2-HO3. [PMID: 31307092 DOI: 10.7326/m19-1846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Steven D Weisbord
- Renal Section and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (S.D.W.)
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28
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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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29
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Faucon AL, Bobrie G, Clément O. Nephrotoxicity of iodinated contrast media: From pathophysiology to prevention strategies. Eur J Radiol 2019; 116:231-241. [DOI: 10.1016/j.ejrad.2019.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 12/28/2022]
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30
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Zhang W, Zhang J, Yang B, Wu K, Lin H, Wang Y, Zhou L, Wang H, Zeng C, Chen X, Wang Z, Zhu J, Songming C. Effectiveness of oral hydration in preventing contrast-induced acute kidney injury in patients undergoing coronary angiography or intervention: a pairwise and network meta-analysis. Coron Artery Dis 2018; 29:286-293. [PMID: 29381498 DOI: 10.1097/mca.0000000000000607] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The effectiveness of oral hydration in preventing contrast-induced acute kidney injury (CI-AKI) in patients undergoing coronary angiography or intervention has not been well established. This study aims to evaluate the efficacy of oral hydration compared with intravenous hydration and other frequently used hydration strategies. METHODS PubMed, Embase, Web of Science, and the Cochrane central register of controlled trials were searched from inception to 8 October 2017. To be eligible for analysis, studies had to evaluate the relative efficacy of different prophylactic hydration strategies. We selected and assessed the studies that fulfilled the inclusion criteria and carried out a pairwise and network meta-analysis using RevMan5.2 and Aggregate Data Drug Information System 1.16.8 software. RESULTS A total of four studies (538 participants) were included in our pairwise meta-analysis and 1754 participants from eight studies with four frequently used hydration strategies were included in a network meta-analysis. Pairwise meta-analysis indicated that oral hydration was as effective as intravenous hydration for the prevention of CI-AKI (5.88 vs. 8.43%; odds ratio: 0.73; 95% confidence interval: 0.36-1.47; P>0.05), with no significant heterogeneity between studies. Network meta-analysis showed that there was no significant difference in the prevention of CI-AKI. However, the rank probability plot suggested that oral plus intravenous hydration had a higher probability (51%) of being the best strategy, followed by diuretic plus intravenous hydration (39%) and oral hydration alone (10%). Intravenous hydration alone was the strategy with the highest probability (70%) of being the worst hydration strategy. CONCLUSION Our study shows that oral hydration is not inferior to intravenous hydration for the prevention of CI-AKI in patients with normal or mild-to-moderate renal dysfunction undergoing coronary angiography or intervention.
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Affiliation(s)
- Weidai Zhang
- Departments of Cardiology
- Nephrology, The First Affiliated Hospital of Shantou University Medical College
- Department of Postgraduate Education, Medical College of Shantou University, Shantou, Guangdong, China
| | | | | | - Kefei Wu
- Department of Postgraduate Education, Medical College of Shantou University, Shantou, Guangdong, China
| | - Hanfei Lin
- Department of Postgraduate Education, Medical College of Shantou University, Shantou, Guangdong, China
| | | | | | | | | | - Xiao Chen
- Nephrology, The First Affiliated Hospital of Shantou University Medical College
| | - Zhixing Wang
- Nephrology, The First Affiliated Hospital of Shantou University Medical College
| | - Junxing Zhu
- Nephrology, The First Affiliated Hospital of Shantou University Medical College
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31
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Contrast-Induced Nephropathy: Update on the Use of Crystalloids and Pharmacological Measures. Int J Nephrol 2018; 2018:5727309. [PMID: 29854458 PMCID: PMC5954945 DOI: 10.1155/2018/5727309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/21/2018] [Accepted: 03/14/2018] [Indexed: 01/04/2023] Open
Abstract
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.
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Weisbord SD, Gallagher M, Jneid H, Garcia S, Cass A, Thwin SS, Conner TA, Chertow GM, Bhatt DL, Shunk K, Parikh CR, McFalls EO, Brophy M, Ferguson R, Wu H, Androsenko M, Myles J, Kaufman J, Palevsky PM. Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine. N Engl J Med 2018; 378:603-614. [PMID: 29130810 DOI: 10.1056/nejmoa1710933] [Citation(s) in RCA: 305] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intravenous sodium bicarbonate and oral acetylcysteine are widely used to prevent acute kidney injury and associated adverse outcomes after angiography without definitive evidence of their efficacy. METHODS Using a 2-by-2 factorial design, we randomly assigned 5177 patients at high risk for renal complications who were scheduled for angiography to receive intravenous 1.26% sodium bicarbonate or intravenous 0.9% sodium chloride and 5 days of oral acetylcysteine or oral placebo; of these patients, 4993 were included in the modified intention-to-treat analysis. The primary end point was a composite of death, the need for dialysis, or a persistent increase of at least 50% from baseline in the serum creatinine level at 90 days. Contrast-associated acute kidney injury was a secondary end point. RESULTS The sponsor stopped the trial after a prespecified interim analysis. There was no interaction between sodium bicarbonate and acetylcysteine with respect to the primary end point (P=0.33). The primary end point occurred in 110 of 2511 patients (4.4%) in the sodium bicarbonate group as compared with 116 of 2482 (4.7%) in the sodium chloride group (odds ratio, 0.93; 95% confidence interval [CI], 0.72 to 1.22; P=0.62) and in 114 of 2495 patients (4.6%) in the acetylcysteine group as compared with 112 of 2498 (4.5%) in the placebo group (odds ratio, 1.02; 95% CI, 0.78 to 1.33; P=0.88). There were no significant between-group differences in the rates of contrast-associated acute kidney injury. CONCLUSIONS Among patients at high risk for renal complications who were undergoing angiography, there was no benefit of intravenous sodium bicarbonate over intravenous sodium chloride or of oral acetylcysteine over placebo for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days or for the prevention of contrast-associated acute kidney injury. (Funded by the U.S. Department of Veterans Affairs Office of Research and Development and the National Health and Medical Research Council of Australia; PRESERVE ClinicalTrials.gov number, NCT01467466 .).
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Affiliation(s)
- Steven D Weisbord
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Martin Gallagher
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Hani Jneid
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Santiago Garcia
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Alan Cass
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Soe-Soe Thwin
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Todd A Conner
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Glenn M Chertow
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Deepak L Bhatt
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Kendrick Shunk
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Chirag R Parikh
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Edward O McFalls
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Mary Brophy
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Ryan Ferguson
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Hongsheng Wu
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Maria Androsenko
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - John Myles
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - James Kaufman
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
| | - Paul M Palevsky
- From the Veterans Affairs (VA) Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W., P.M.P.); University of Sydney (M.G.) and the George Institute for Global Health, University of New South Wales (M.G., A.C.), Sydney, and the Menzies School of Health Research, Darwin, NT (A.C.) - all in Australia; Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (H.J.); Minneapolis VA Health Care System and University of Minnesota, Minneapolis (S.G., E.O.M.); VA Cooperative Studies Program Coordinating Center (S.S.T., M.B., R.F., H.W., M.A., J.M., J.K.) and the Cardiology Section (D.L.B.), VA Boston Healthcare System, and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School (D.L.B.) - all in Boston; VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM (T.A.C.); Stanford University Department of Medicine, Palo Alto (G.M.C.), and San Francisco VA Medical Center and University of California, San Francisco, San Francisco (K.S.) - all in California; and the VA Connecticut Healthcare System and Program of Applied Translational Research, Yale University, New Haven (C.R.P.)
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Comparative efficacy of pharmacological interventions for contrast-induced nephropathy prevention after coronary angiography: a network meta-analysis from randomized trials. Int Urol Nephrol 2018; 50:1085-1095. [DOI: 10.1007/s11255-018-1814-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/29/2018] [Indexed: 12/13/2022]
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Abstract
No therapies have been shown to improve outcomes in patients with acute kidney injury (AKI). Given the high morbidity and mortality associated with AKI this represents an important unmet medical need. A common feature of all of the therapeutic development efforts for AKI is that none were driven by target selection or preclinical modeling that was based primarily on human data. This is important when considering a heterogeneous and dynamic condition such as AKI, in which in the absence of more accurate molecular classifications, clinical cohorts are likely to include patients with different types of injury at different stages in the injury and repair continuum. The National Institutes of Health precision medicine initiative offers an opportunity to address this. By creating a molecular tissue atlas of AKI, defining patient subgroups, and identifying critical cells and pathways involved in human AKI, this initiative has the potential to transform our current approach to therapeutic discovery. In this review, we discuss the opportunities and challenges that this initiative presents, with a specific focus on AKI, what additional efforts will be needed to apply these discoveries to therapeutic development, and how we believe this effort might lead to the development of new therapeutics for subsets of patients with AKI.
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Affiliation(s)
- Mark de Caestecker
- Nephrology Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Raymond Harris
- Nephrology Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Dósa E, Heltai K, Radovits T, Molnár G, Kapocsi J, Merkely B, Fu R, Doolittle ND, Tóth GB, Urdang Z, Neuwelt EA. Dose escalation study of intravenous and intra-arterial N-acetylcysteine for the prevention of oto- and nephrotoxicity of cisplatin with a contrast-induced nephropathy model in patients with renal insufficiency. Fluids Barriers CNS 2017; 14:26. [PMID: 28974245 PMCID: PMC5627439 DOI: 10.1186/s12987-017-0075-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/18/2017] [Indexed: 12/02/2022] Open
Abstract
Background Cisplatin neuro-, oto-, and nephrotoxicity are major problems in children with malignant tumors, including medulloblastoma, negatively impacting educational achievement, socioemotional development, and overall quality of life. The blood-labyrinth barrier is somewhat permeable to cisplatin, and sensory hair cells and cochlear supporting cells are highly sensitive to this toxic drug. Several chemoprotective agents such as N-acetylcysteine (NAC) were utilized experimentally to avoid these potentially serious and life-long side effects, although no clinical phase I trial was performed before. The purpose of this study was to establish the maximum tolerated dose (MTD) and pharmacokinetics of both intravenous (IV) and intra-arterial (IA) NAC in adults with chronic kidney disease to be used in further trials on oto- and nephroprotection in pediatric patients receiving platinum therapy. Methods Due to ethical considerations in pediatric tumor patients, we used a clinical population of adults with non-neoplastic disease. Subjects with stage three or worse renal failure who had any endovascular procedure were enrolled in a prospective, non-randomized, single center trial to determine the MTD for NAC. We initially aimed to evaluate three patients each at 150, 300, 600, 900, and 1200 mg/kg NAC. The MTD was defined as one dose level below the dose producing grade 3 or 4 toxicity. Serum NAC levels were assessed before, 5 and 15 min post NAC. Twenty-eight subjects (15 men; mean age 72.2 ± 6.8 years) received NAC IV (N = 13) or IA (N = 15). Results The first participant to experience grade 4 toxicity was at the 600 mg/kg IV dose, at which time the protocol was modified to add an additional dose level of 450 mg/kg NAC. Subsequently, no severe NAC-related toxicity arose and 450 mg/kg NAC was found to be the MTD in both IV and IA groups. Blood levels of NAC showed a linear dose response (p < 0.01). Five min after either IV or IA NAC MTD dose administration, serum NAC levels reached the 2–3 mM concentration which seemed to be nephroprotective in previous preclinical studies. Conclusions In adults with kidney impairment, NAC can be safely given both IV and IA at a dose of 450 mg/kg. Additional studies are needed to confirm oto- and nephroprotective properties in the setting of cisplatin treatment. Clinical Trial Registration URL: https://eudract.ema.europa.eu. Unique identifier: 2011-000887-92
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Affiliation(s)
- Edit Dósa
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Krisztina Heltai
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Gabriella Molnár
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Judit Kapocsi
- 1st Department of Internal Medicine, Semmelweis University, 26 Üllői Street, Budapest, 1085, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Rongwei Fu
- Public Health & Preventive Medicine, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, CB669, Portland, OR, 97329, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Gerda B Tóth
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Zachary Urdang
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA. .,Department of Neurosurgery, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA. .,Portland Veterans Affairs Medical Center, 3710 S.W. US Veterans Hospital Rd, Portland, OR, 97239, USA. .,Blood-Brain Barrier and Neuro-Oncology Program, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, L603, Portland, OR, 97239, USA.
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Semler MW, Wanderer JP, Ehrenfeld JM, Stollings JL, Self WH, Siew ED, Wang L, Byrne DW, Shaw AD, Bernard GR, Rice TW. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med 2017; 195:1362-1372. [PMID: 27749094 DOI: 10.1164/rccm.201607-1345oc] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Saline is the intravenous fluid most commonly administered to critically ill adults, but it may be associated with acute kidney injury and death. Whether use of balanced crystalloids rather than saline affects patient outcomes remains unknown. OBJECTIVES To pilot a cluster-randomized, multiple-crossover trial using software tools within the electronic health record to compare saline to balanced crystalloids. METHODS This was a cluster-randomized, multiple-crossover trial among 974 adults admitted to a tertiary medical intensive care unit from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A). Enrollment, fluid delivery, and data collection were performed using software tools within the electronic health record. The primary outcome was the difference between study groups in the proportion of isotonic crystalloid administered that was saline. The secondary outcome was major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or persistent renal dysfunction. MEASUREMENTS AND MAIN RESULTS Patients assigned to saline (n = 454) and balanced crystalloids (n = 520) were similar at baseline and received similar volumes of crystalloid by 30 days (median [interquartile range]: 1,424 ml [500-3,377] vs. 1,617 ml [500-3,628]; P = 0.40). Saline made up a larger proportion of the isotonic crystalloid given in the saline group than in the balanced crystalloid group (91% vs. 21%; P < 0.001). MAKE30 did not differ between groups (24.7% vs. 24.6%; P = 0.98). CONCLUSIONS An electronic health record-embedded, cluster-randomized, multiple-crossover trial comparing saline with balanced crystalloids can produce well-balanced study groups and separation in crystalloid receipt. Clinical trial registered with www.clinicaltrials.gov (NCT 02345486).
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Affiliation(s)
| | | | - Jesse M Ehrenfeld
- 2 Department of Anesthesiology.,3 Department of Biomedical Informatics
| | | | | | - Edward D Siew
- 6 Vanderbilt Center for Kidney Disease and Integrated Program for AKI, Division of Nephrology and Hypertension, and
| | - Li Wang
- 7 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel W Byrne
- 7 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Todd W Rice
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine
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McCullough PA, Choi JP, Feghali GA, Schussler JM, Stoler RM, Vallabahn RC, Mehta A. Contrast-Induced Acute Kidney Injury. J Am Coll Cardiol 2017; 68:1465-1473. [PMID: 27659469 DOI: 10.1016/j.jacc.2016.05.099] [Citation(s) in RCA: 255] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 04/20/2016] [Accepted: 05/03/2016] [Indexed: 12/31/2022]
Abstract
Coronary angiography and percutaneous intervention rely on the use of iodinated intravascular contrast for vessel and chamber imaging. Despite advancements in imaging and interventional techniques, iodinated contrast continues to pose a risk of contrast-induced acute kidney injury (CI-AKI) for a subgroup of patients at risk for this complication. There has been a consistent and graded signal of risk for associated outcomes including need for renal replacement therapy, rehospitalization, and death, according to the incidence and severity of CI-AKI. This paper reviews the epidemiology, pathophysiology, prognosis, and management of CI-AKI as it applies to the cardiac catheterization laboratory.
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Affiliation(s)
- Peter A McCullough
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas; Baylor Heart and Vascular Institute, Dallas, Texas; Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; The Heart Hospital Baylor Plano, Plano, Texas.
| | - James P Choi
- Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Georges A Feghali
- Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | | | - Robert M Stoler
- Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Ravi C Vallabahn
- Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Ankit Mehta
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas
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38
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Mamoulakis C, Tsarouhas K, Fragkiadoulaki I, Heretis I, Wilks MF, Spandidos DA, Tsitsimpikou C, Tsatsakis A. Contrast-induced nephropathy: Basic concepts, pathophysiological implications and prevention strategies. Pharmacol Ther 2017. [PMID: 28642116 DOI: 10.1016/j.pharmthera.2017.06.009] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Contrast-induced nephropathy (CIN) is reversible acute renal failure observed following administration of iodinated contrast media (CM) during angiographic or other medical procedures such as urography. There are various mechanisms through which CM develop their nephrotoxic effects, including oxidative stress and apoptosis. CIN is a real-life, albeit not very rare, entity. Exact pathophysiology remains obscure and no standard diagnostic criteria apply. The Acute Kidney Injury Network criteria was recently employed but its incidence/clinical significance warrants further clarification based on recent methodological advancements, because most published studies to date were contaminated by bias. The current study is a comprehensive review conducted to provide an overview of the basic concepts of CIN and summarize recent knowledge on its pathophysiology and the evidence supporting potential prevention strategies. CIN is expected to increase morbidity, hospital stay and mortality, while all patients scheduled to receive CM should undergo risk assessment for CIN and high-risk patients may be considered candidates for prevention strategies. The value of using compounds with antioxidant properties other than sodium bicarbonate, remains controversial, warranting further clinical investigation.
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Affiliation(s)
- Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece.
| | | | - Irini Fragkiadoulaki
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, Heraklion 71003, Greece
| | - Ioannis Heretis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Martin F Wilks
- Swiss Centre for Applied Human Toxicology, University of Basel, CH-4055 Basel, Switzerland
| | - Demetrios A Spandidos
- Department of Virology, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Christina Tsitsimpikou
- Department of Hazardous Substances, Mixtures and Articles, General Chemical State Laboratory of Greece, Ampelokipi, Athens, Greece
| | - Aristides Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, Heraklion 71003, Greece
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39
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Do C. Intravenous Contrast: Friend or Foe? A Review on Contrast-Induced Nephropathy. Adv Chronic Kidney Dis 2017; 24:147-149. [PMID: 28501076 DOI: 10.1053/j.ackd.2017.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intravenous iodinated contrast is used in many contrasted imaging studies ranging from computed tomography to angiography. The risks of contrast-induced nephropathy (CIN) and its incidence have not been clearly defined. Most iodinated contrast media used today are hypertonic compared with serum osmolality and pose biological risks. However, the risk of CIN in the general population may be overestimated. Confounding risk factors may contribute to acute kidney injury other than attributable risk of contrast exposure. In high-risk populations such as in those with CKD, CIN risk may be higher and thus caution should be exerted with contrast exposure. The volumes of contrast should be minimized as much as possible and hemodynamic status should be optimized before contrast administration.
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40
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Bahrainwala JZ, Leonberg-Yoo AK, Rudnick MR. Use of Radiocontrast Agents in CKD and ESRD. Semin Dial 2017; 30:290-304. [DOI: 10.1111/sdi.12593] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jehan Z Bahrainwala
- Renal-Electrolyte and Hypertension Division; Department of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Amanda K Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division; Department of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Michael R Rudnick
- Renal-Electrolyte and Hypertension Division; Department of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
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41
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Semler MW, Self WH, Wang L, Byrne DW, Wanderer JP, Ehrenfeld JM, Stollings JL, Kumar AB, Hernandez A, Guillamondegui OD, May AK, Siew ED, Shaw AD, Bernard GR, Rice TW. Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial. Trials 2017; 18:129. [PMID: 28302179 PMCID: PMC5356286 DOI: 10.1186/s13063-017-1871-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/01/2017] [Indexed: 11/17/2022] Open
Abstract
Background Saline, the intravenous fluid most commonly administered to critically ill adults, contains a high chloride content, which may be associated with acute kidney injury and death. Whether using balanced crystalloids rather than saline decreases the risk of acute kidney injury and death among critically ill adults remains unknown. Methods The Isotonic Solutions and Major Adverse Renal Events Trial (SMART) is a pragmatic, cluster-level allocation, cluster-level crossover trial being conducted between 1 June 2015 and 30 April 2017 in five intensive care units at Vanderbilt University Medical Center in Nashville, TN, USA. SMART compares saline (0.9% sodium chloride) with balanced crystalloids (clinician’s choice of lactated Ringer’s solution or Plasma-Lyte A®). Each intensive care unit is assigned to provide either saline or balanced crystalloids each month, with the assigned crystalloid alternating monthly over the course of the trial. All adults admitted to participating intensive care units during the study period are enrolled and followed until hospital discharge or 30 days after enrollment. The anticipated enrollment is approximately 14,000 patients. The primary outcome is Major Adverse Kidney Events within 30 days—the composite of in-hospital death, receipt of new renal replacement therapy, or persistent renal dysfunction (discharge creatinine ≥200% of baseline creatinine). Secondary clinical outcomes include in-hospital mortality, intensive care unit-free days, ventilator-free days, vasopressor-free days, and renal replacement therapy-free days. Secondary renal outcomes include new renal replacement therapy receipt, persistent renal dysfunction, and incidence of stage 2 or higher acute kidney injury. Discussion This ongoing pragmatic trial will provide the largest and most comprehensive comparison to date of clinical outcomes with saline versus balanced crystalloids among critically ill adults. Trial registration For logistical reasons, SMART was prospectively registered separately for the medical ICU (SMART-MED; ClinicalTrials.gov identifier: NCT02444988; registered on 11 May 2015; date of first patient enrollment: 1 June 2015) and the nonmedical ICUs (SMART-SURG; ClinicalTrials.gov identifier: NCT02547779; registered on 9 September 2015; date of first patient enrollment: 1 October 2015). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1871-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA.
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse M Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Avinash B Kumar
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Addison K May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Vanderbilt Integrated Program for AKI Research (VIP-AKI), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA
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43
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Affiliation(s)
- Richard Solomon
- From the Divisions of Nephrology and Hypertension (R.S.) and Cardiology (H.L.D.), Larner School of Medicine at the University of Vermont, Burlington
| | - Harold L. Dauerman
- From the Divisions of Nephrology and Hypertension (R.S.) and Cardiology (H.L.D.), Larner School of Medicine at the University of Vermont, Burlington
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Meta-Analysis of Individual Patient Data of Sodium Bicarbonate and Sodium Chloride for All-Cause Mortality After Coronary Angiography. Am J Cardiol 2016; 118:1473-1479. [PMID: 27642111 DOI: 10.1016/j.amjcard.2016.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 12/22/2022]
Abstract
We sought to examine the relation between sodium bicarbonate prophylaxis for contrast-associated nephropathy (CAN) and mortality. We conducted an individual patient data meta-analysis from multiple randomized controlled trials. We obtained individual patient data sets for 7 of 10 eligible trials (2,292 of 2,764 participants). For the remaining 3 trials, time-to-event data were imputed based on follow-up periods described in their original reports. We included all trials that compared periprocedural intravenous sodium bicarbonate to periprocedural intravenous sodium chloride in patients undergoing coronary angiography or other intra-arterial interventions. Included trials were determined by consensus according to predefined eligibility criteria. The primary outcome was all-cause mortality hazard, defined as time from randomization to death. In 10 trials with a total of 2,764 participants, sodium bicarbonate was associated with lower mortality hazard than sodium chloride at 1 year (hazard ratio 0.61, 95% confidence interval [CI] 0.41 to 0.89, p = 0.011). Although periprocedural sodium bicarbonate was associated with a reduction in the incidence of CAN (relative risk 0.75, 95% CI 0.62 to 0.91, p = 0.003), there exists a statistically significant interaction between the effect on mortality and the occurrence of CAN (hazard ratio 5.65, 95% CI 3.58 to 8.92, p <0.001) for up to 1-year mortality. Periprocedural intravenous sodium bicarbonate seems to be associated with a reduction in long-term mortality in patients undergoing coronary angiography or other intra-arterial interventions.
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45
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Samuel JP, Bell CS. Unique Study Designs in Nephrology: N-of-1 Trials and Other Designs. Adv Chronic Kidney Dis 2016; 23:351-354. [PMID: 28115077 DOI: 10.1053/j.ackd.2016.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/14/2016] [Indexed: 01/15/2023]
Abstract
Alternatives to the traditional parallel-group trial design may be required to answer clinical questions in special populations, rare conditions, or with limited resources. N-of-1 trials are a unique trial design which can inform personalized evidence-based decisions for the patient when data from traditional clinical trials are lacking or not generalizable. A concise overview of factorial design, cluster randomization, adaptive designs, crossover studies, and n-of-1 trials will be provided along with pertinent examples in nephrology. The indication for analysis strategies such as equivalence and noninferiority trials will be discussed, as well as analytic pitfalls.
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46
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Zarkowsky DS, Hicks CW, Bostock IC, Stone DH, Eslami M, Goodney PP. Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair. J Vasc Surg 2016; 64:1278-1285.e1. [PMID: 27478004 PMCID: PMC5079759 DOI: 10.1016/j.jvs.2016.04.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/10/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors. METHODS All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction. RESULTS This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P < .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction. CONCLUSIONS Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.
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Affiliation(s)
- Devin S Zarkowsky
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Md
| | - Ian C Bostock
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mohammad Eslami
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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47
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Leaf DE, Waikar SS. End Points for Clinical Trials in Acute Kidney Injury. Am J Kidney Dis 2016; 69:108-116. [PMID: 27599630 DOI: 10.1053/j.ajkd.2016.05.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/25/2016] [Indexed: 01/09/2023]
Abstract
Acute kidney injury (AKI) is an increasingly common and feared complication in hospitalized patients. The selection of appropriate primary and secondary end points is critical to the design and eventual success of clinical trials aimed at preventing and treating AKI. In this article, we provide an overview of AKI definitions and suggestions on the rational selection of end points for clinical trials in various settings, including the prevention of contrast-induced AKI, prevention of cardiac surgery-associated AKI, treatment of established AKI, and treatment of dialysis-requiring AKI.
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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48
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Rowe ES, Rowe VD, Biswas S, Mosher G, Insisienmay L, Ozias MK, Gralinski MR, Hunter J, Barnett JS. Preclinical Studies of a Kidney Safe Iodinated Contrast Agent. J Neuroimaging 2016; 26:511-8. [PMID: 27171830 PMCID: PMC5084786 DOI: 10.1111/jon.12356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/30/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Contrast-induced acute kidney injury (CI-AKI) is a serious complication of the use of iodinated contrast agents. This problem is particularly acute in interventional neurology and interventional cardiology, probably due to the intra-arterial route of injection, high contrast volumes, and preexisting risk factors of these patients. In an attempt to develop a contrast agent that is less damaging to the kidneys, we have studied the effects of adding a small amount of the substituted cyclodextrin, sulfobutyl-ether-β-cyclodextrin (SBECD), to iohexol in rodent models of renal toxicity. METHODS Renally compromised mice and rats were injected with iohexol and iohexol-SBECD via the tail vein. The renal pathology, creatinine clearance, and survival benefits of iohexol-SBECD were studied. The safety of direct intra-arterial injection of the iohexol-SBECD formulation was studied in a dog heart model system. Mechanism of action studies in cell culture model using a human kidney cell line was performed using flow cytometry. RESULTS Nephrotoxicity was significantly reduced using iohexol-SBECD compared to iohexol alone, at mole ratios of iohexol:SBECD of 1:0.025. SBECD increased survival from 50% to 88% in a rat survival study. In the dog heart model, iohexol-SBECD was safe. Cell culture studies suggest that SBECD interferes with the early stages of contrast-induced apoptosis in a human renal cell line. CONCLUSION We have shown that the addition of a small amount of SBECD (one molecule of SBECD per 40 iohexol molecules) significantly protects rodent kidneys from CI-AKI. Further development of this new formulation of iodinated contrast is warranted.
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Semler MW, Rice TW, Shaw AD, Siew ED, Self WH, Kumar AB, Byrne DW, Ehrenfeld JM, Wanderer JP. Identification of Major Adverse Kidney Events Within the Electronic Health Record. J Med Syst 2016; 40:167. [PMID: 27234478 PMCID: PMC5791539 DOI: 10.1007/s10916-016-0528-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/20/2016] [Indexed: 12/28/2022]
Abstract
Acute kidney injury is common among critically ill adults and is associated with increased mortality and morbidity. The Major Adverse Kidney Events by 30 days (MAKE30) composite of death, new renal replacement therapy, or persistent renal dysfunction is recommended as a patient-centered outcome for pragmatic trials involving acute kidney injury. Accurate electronic detection of the MAKE30 endpoint using data within the electronic health record (EHR) could facilitate the use of the EHR in large-scale kidney injury research. In an observational study using prospectively collected data from 200 admissions to a single medical intensive care unit, we tested the performance of electronically-extracted data in identifying the MAKE30 composite compared to the reference standard of two-physician manual chart review. The incidence of MAKE30 on manual-review was 16 %, which included 8.5 % for in-hospital mortality, 3.5 % for new renal replacement therapy, and 8.5 % for persistent renal dysfunction. There was strong agreement between the electronic and manual assessment of MAKE30 (98.5 % agreement [95 % CI 96.5-100.0 %]; kappa 0.95 [95 % CI 0.87-1.00]; P < 0.001), with only three patients misclassified by electronic assessment. Performance of the electronic MAKE30 assessment was similar among patients with and without CKD and with and without a measured serum creatinine in the 12 months prior to hospital admission. In summary, accurately identifying the MAKE30 composite outcome using EHR data collected as a part of routine care appears feasible.
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Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S., T-2220 MCN, Nashville, TN, 37232-2650, USA.
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S., T-2220 MCN, Nashville, TN, 37232-2650, USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Avinash B Kumar
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse M Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Prasad A, Sohn A, Morales J, Williams K, Bailey SR, Levin D, McCullough PA, Mehran R, Lopez-Cruz G, Harder J. Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of Society of Cardiovascular Angiography and Intervention (SCAI) cardiologists. Catheter Cardiovasc Interv 2016; 89:383-392. [DOI: 10.1002/ccd.26628] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/01/2016] [Accepted: 05/23/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Anand Prasad
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Aaron Sohn
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Jonathan Morales
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Ken Williams
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Steven R. Bailey
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Daniel Levin
- Department of Medicine, Division of Cardiology; The University of Texas Health Science Center San Antonio; San Antonio Texas
| | | | - Roxana Mehran
- Department of Medicine, Division of Cardiology; The Zena and Michael A. Wiener Cardiovascular Institute at the Icahn School of Medicine at Mount Sinai; Mount Sinai
| | | | - Joel Harder
- The Society of Cardiovascular Angiography and Interventions; Washington, DC
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