Contrast-induced acute kidney injury: A review of practical points

Contrast-induced acute kidney injury: a review of definition, pathogenesis, risk factors, prevention and treatment

Contrast-induced acute kidney injury (CI-AKI) has become the third leading cause of hospital-acquired AKI, which seriously threatens the health of patients. To date, the precise pathogenesis of CI-AKI has remained not clear and may be related to the direct cytotoxicity, hypoxia and ischemia of medulla, and oxidative stress caused by iodine contrast medium, which have diverse physicochemical properties, including cytotoxicity, permeability and viscosity. The latest research shows that microRNAs (miRNAs) are also involved in apoptosis, pyroptosis, and autophagy which caused by iodine contrast medium (ICM), which may be implicated in the pathogenesis of CI-AKI. Unfortunately, effective therapy of CI-AKI is very limited at present. Therefore, effective prevention of CI-AKI is of great significance, and several preventive options, including hydration, antagonistic vasoconstriction, and antioxidant drugs, have been developed. Here, we review current knowledge about the features of iodine contrast medium, the definition, pathogenesis, molecular mechanism, risk factors, prevention and treatment of CI-AKI.

Prevention of post-contrast kidney injury in patients with cancer

Post-contrast acute kidney injury is defined as a nephropathy with an increase in serum creatinine of >0.3 mg/dL (or >26.5 μmol/L) or >1.5-times the baseline within 48-72 h of intravascular administration of a contrast medium. Patients with cancer have an increased risk of post-contrast acute kidney injury not only related to the frequent use of contrast medium for computed tomography scans but also to other factors, including the type of tumour, age, oncological therapies, use of other nephrotoxic agents and dehydration. Preventive strategies were developed and may be applied to different risk profiles. Patients at risk may be detected by recently published risk scores.

Berberine alleviates contrast-induced nephropathy by activating Akt/Foxo3a/Nrf2 signalling pathway

Contrast-induced nephropathy (CIN) is a condition that causes kidney damage in patients receiving angiography with iodine-based contrast agents. This study investigated the potential protective effects of berberine (BBR) against CIN and its underlying mechanisms. The researchers conducted both in vivo and in vitro experiments to explore BBR's renal protective effects. In the in vivo experiments, SD rats were used to create a CIN model, and different groups were established. The results showed that CIN model group exhibited impaired renal function, severe damage to renal tubular cells and increased apoptosis and ferroptosis. However, BBR treatment group demonstrated improved renal function, decreased apoptosis and ferroptosis. Similar results were observed in the in vitro experiments using HK-2 cells. BBR reduced ioversol-induced apoptosis and ferroptosis, and exerted its protective effects through Akt/Foxo3a/Nrf2 signalling pathway. BBR administration increased the expression of Foxo3a and Nrf2 while decreasing the levels of p-Akt and p-Foxo3a. In conclusion, this study revealed that BBR effectively inhibited ioversol-induced apoptosis and ferroptosis in vivo and in vitro. The protective effects of BBR were mediated through the modulation of Akt/Foxo3a/Nrf2 signalling pathway, leading to the alleviation of CIN. These findings suggest that BBR may have therapeutic potential for protecting against CIN in patients undergoing angiography with iodine-based contrast agents.

Age-Related Effect of Uric Acid on Contrast-Induced Acute Kidney Injury of Patients Undergoing Coronary Angiography

Background

The association between uric acid (UA) and contrast-induced acute kidney injury (CI-AKI) following coronary angiography (CAG) has been established. However, whether the association would vary with age remained undetermined.

Methods

We performed the retrospective analysis based on the Cardio-renal Improvement II study, (ClinicalTrials.gov NCT05050877), which enrolled consecutive patients undergoing coronary angiography in 5 teaching hospitals in China from 2007 to 2020. The primary outcome was CI-AKI defined as the rise of serum creatinine (SCr) ≥ 0.5 mg/dL or 25% compared with the baseline value within 48 hours following CAG. The effect of age on the association between uric acid and CI-AKI was assessed by the logistic regression model.

Results

A total of 36,550 patients (mean age 63.08±5.6-year-old, 41.7% men) were included in the study. After adjusting for the confounders, the risk of CI-AKI between each quartile of uric acid was insignificant in the young group. In patients of the middle group, lower UA was associated with a lower risk of CI-AKI while higher UA was associated with a higher risk (Q1 OR: 0.853, 95% CI: 0.734-0.993; Q4 OR: 1.797, 95% CI: 1.547-2.09). In patients of the elder group, lower and higher UA were both associated with a higher risk of CI-AKI (Q1 OR: 1.247, 95% CI: 1.003-1.553; Q4 OR: 1.688, 95% CI: 1.344-2.124). The restricted cubic spline indicated a non-linear association between UA and CI-AKI in middle and elder age groups but a linear association in the young age group.

Conclusion

The association between uric acid and CI-AKI vary in patients of different age. Patients with elder age should maintain a middle level of uric acid while patients with middle age should consider a lower level of uric acid to reduce the risk of CI-AKI. The level of UA was an insignificant risk factor for CI-AKI in young patients.

The safety of SGLT-2 inhibitors in diabetic patients submitted to elective percutaneous coronary intervention regarding kidney function: SAFE-PCI pilot study

BACKGROUND

Percutaneous coronary intervention (PCI) is one of the most performed well-succeeded therapeutic procedures worldwide, reducing symptoms and improving quality of life. Neutrophil Gelatinase-associated Lipocalin (NGAL) is a biomarker of acute kidney injury (AKI) produced early after an ischemic renal insult. Osmotic diuresis and the vasoconstriction of the afferent arteriole promoted by Sodium-glucose Cotransporter-2 Inhibitors (SGLT2i) generate a concern regarding the possibility of dehydration and consequent AKI. There is no consensus on the maintenance or discontinuation of SGTL2i in patients who will undergo PCI. This study aimed to evaluate the safety of empagliflozin in diabetic patients submitted to elective PCI regarding kidney function.

METHODS

SAFE-PCI trial is a prospective, open-label, randomized (1:1), single-center pilot study and a follow-up of 30 days. The SGLT2i empagliflozin 25 mg daily was initiated at least 15 days before PCI in the intervention group and maintained until the end of the follow-up period. Serum NGAL was collected 6 h after PCI and creatinine before PCI, 24 h, and 48 h after the procedure. As per protocol, both groups received optimal medical treatment and standard protocol of nephroprotection.

RESULTS

A total of 42 patients were randomized (22 patients in the iSGLT-2 group and 20 patients in the control group). There was no difference between-group baseline data. The primary outcome (NGAL and creatinine values post PCI) did not differ in both groups: the mean NGAL value was 199 ng/dL in the empagliflozin group and 150 ng/dL in the control group (p = 0.249). Although there was an initial increase in creatinine in the SGLT-2i group compared to the control group between baseline creatinine and pre-PCI and 24 h post-PCI creatinine, no difference was detected in creatinine 48 h post-PCI (p = 0.065). The incidence of CI-AKI, determined by KDIGO criteria, in the iSGLT2-group was 13.6% and 10.0% in the control group without statistical difference.

CONCLUSION

The present study showed that the use of empagliflozin is safe regarding kidney function during elective PCI in patients with T2D when compared with no use of SGLT2i. Trial registration Our clinical study is registered on ClinicalTrials.gov with the following number: NCT05037695.

The Potential Biotherapeutic Targets of Contrast-Induced Acute Kidney Injury

Contrast-induced acute kidney injury (CI-AKI) is manifested by an abrupt decline in kidney function as a consequence of intravascular exposure to contrast media. With the increased applicability of medical imaging and interventional procedures that utilize contrast media for clinical diagnosis, CI-AKI is becoming the leading cause of renal dysfunction. The pathophysiological mechanism associated with CI-AKI involves renal medullary hypoxia, the direct toxicity of contrast agents, oxidative stress, apoptosis, inflammation, and epigenetic regulation. To date, there is no effective therapy for CI-AKI, except for the development of strategies that could reduce the toxicity profiles of contrast media. While most of these strategies have failed, evidence has shown that the proper use of personalized hydration, contrast medium, and high-dose statins may reduce the occurrence of CI-AKI. However, adequate risk predication and attempts to develop preventive strategies can be considered as the key determinants that can help eliminate CI-AKI. Additionally, a deeper understanding of the pathophysiological mechanism of CI-AKI is crucial to uncover molecular targets for the prevention of CI-AKI. This review has taken a step further to solidify the current known molecular mechanisms of CI-AKI and elaborate the biomarkers that are used to detect early-stage CI-AKI. On this foundation, this review will analyze the molecular targets relating to apoptosis, inflammation, oxidative stress, and epigenetics, and, thus, provide a strong rationale for therapeutic intervention in the prevention of CI-AKI.

Contrast-Associated Acute Kidney Injury in High-Risk Patients Undergoing Peripheral Vascular Interventions

Objective: This study aims to evaluate the use of prophylactic intravenous hydration (IV prophylaxis) and carbon dioxide (CO₂) angiography in reducing contrast associated-acute kidney injury (CA-AKI) and determine the overall incidence and risk factors of CA-AKI in high-risk patients undergoing peripheral vascular interventions (PVI). Method: Only patients undergoing elective PVI from 2017 to 2021 with chronic kidney disease (CKD) stage 3-5 in the Vascular Quality Initiative (VQI) database were included. Patients were grouped into IV prophylaxis vs no prophylaxis. The study's primary outcome was CA-AKI, defined as a rise in creatinine (>.5 mg/dL) or new dialysis within 48 hours following contrast administration. Standard univariate and multivariable (logistic regression) analyses were conducted. Results: A total of 4497 patients were identified. Of these, 65% received IV prophylaxis. The overall incidence of CA-AKI was .93%. No significant difference was seen in overall contrast volume (mean (SD): 66.89(49.54) vs 65.94(51.97) milliliters, P > .05) between the 2 groups. After adjusting for significant covariates, the use of IV prophylaxis (OR (95% CI): 1.54(.77-3.18), P = .25) and CO₂ angiography (OR (95%CI): .95(.44-2.08), P = .90) was not associated with a significant reduction in CA-AKI compared to the patients with no prophylaxis. The severity of CKD and diabetes were the only predictor of CA-AKI. Compared to patients with no CA-AKI, patients with CA-AKI were at risk of higher 30-day mortality (OR (95% CI): 11.09 (4.25-28.93)) and cardiopulmonary complications (OR (95% CI): 19.03 (8.74-41.39) following PVI (Both P < .001). Conclusion: Using a large national vascular database, our study demonstrates that prophylactic use of IV hydration and CO₂ angiography in high-risk CKD patients is not associated with a reduction in renal injury following PVI. Reduced kidney function and history of diabetes is an independent predictor of CA-AKI and patients that develop post-procedural AKI are at an increased risk of morbidity and mortality.

Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding

INTRODUCTION

Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment.

METHODS

Retrospective single-centre study over a 2-year period.

RESULTS

A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782).

CONCLUSIONS

The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

The triglyceride-glucose index and contrast-induced nephropathy in non-ST elevation myocardial infarction patients undergoing percutaneous coronary intervention

The triglyceride glucose (TyG) index is an indicator of insulin resistance and associated with increased risk of diabetes mellitus and cardiovascular events. Our study investigates the correlation between TyG index and contrast induced nephropathy (CIN) in non-diabetic patients with non-ST elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI). 350 non-diabetic NSTEMI patients (183, 52.3% male) undergoing PCI were retrospectively enrolled. The enrolled cohort was divided into 2 groups based on the calculated TyG index, namely values < 8.65 or higher. CIN was defined as an increase in serum creatinine > 25% or 0.5 mg/dL from baseline in the first 48 to 72 hours after PCI. A total of 56 (16%) cases of CIN were diagnosed. In contrast to patients with lower TyG indexes, patients with higher TyG indexes (≥8.65) had a higher frequency of CIN, 9.5%. versus 20.8% respectively (P .004). Patients with CIN also had higher TyG indexes (8.74 ± 0.12 vs 8.67 ± 0.11, P < .001). In addition, TyG index, age, and glomerular filtration rate were identified as independent risk factors for CIN in logistic regression model (OR: 2.5 CI: 1.3-4.6, P .006, OR: 1.0 CI: 1.0-1.1, P < .001, OR: 1.0 KI: 1.03-1.06, P .025). In the ROC analysis, the area under the curve predictive of CIN was 0.666 (P < .001, 95% [CI] 0.58-0.75) with a cutoff value of 8.69 (sensitivity 71,4%, specificity 55.1%) TyG index. Higher TyG indexes are associated with an increased risk of CIN in non-diabetic patients with NSTEMI.

Crosstalk among apoptosis, inflammation, and autophagy in relation to melatonin protective effect against contrast-induced nephropathy in rats

Contrast medium (CM) is a chemical substance that is used for imaging anatomical boundaries and to explore normal and abnormal physiological findings; the use of CM was associated with kidney injury and acute renal failure. Melatonin (M) possesses antioxidant, anti-inflammatory, and antiapoptotic effects in addition to autophagy modulation. This study aimed to investigate the protective effect of M against contrast-induced nephropathy (CIN) and its impact on the crosstalk between inflammasome, apoptosis, and autophagy in CIN. Male albino rats received M (10, 20, and 40 mg/kg/day, intraperitoneally) for 3 days. One hour after the last administration, rats were subjected to CIN induction (10 mg/kg indomethacin, double doses of l-NAME 10 mg/kg, i.v., and meglumine diatrizoate 60% 6 mL/kg, i.v.). CIN-induced kidney damage was evidenced through elevated kidney function biomarkers and induced renal histopathological changes. Pretreatment with M caused a significant decrease in nephrotoxicity biomarkers and histopathological alterations. Moreover, CIN-induced oxidative stress, NLRP3 inflammasome, and apoptosis were attenuated by M. Furthermore, M modulates autophagy in CIN rats. M inhibits CIN-induced NLRP3-inflammasome activation and apoptosis as well as enhances autophagy.

Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation

Background

Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain.

Methods

This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups.

Results

Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01).

Conclusion

Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Identifying and managing acute kidney injury

Acute kidney injury, previously referred to as acute renal failure, is a common and often preventable condition that is seen in patients in acute and primary care settings. Nurses in both settings should be able to identify and assess patients at risk of acute kidney injury, and those with developing acute kidney injury, and understand the principles of clinical management. Early identification can assist in prevention of acute kidney injury, while supportive management and interventions can prevent further deterioration in patients diagnosed with the condition. This article describes acute kidney injury and outlines the pathophysiology, staging, and signs and symptoms. The author also describes the clinical management of patients with acute kidney injury and the long-term effects of the condition.

Evaluation of Crocin Effect on Contrast-Induced Nephropathy Following Coronary Angiography or Angioplasty: A Randomized Controlled Trial

Contrast-induced nephropathy (CIN) is the third cause of hospital-acquired acute kidney injury. The CIN prophylactic strategies adopted to date, although not highly efficient, are mostly based on antioxidant activity and hydration therapy. This study was designed and conducted to evaluate crocin’s efficacy in the prevention of CIN in chronic kidney disease (CKD) patients undergoing coronary angiography/angioplasty. In this randomized clinical trial, a total of 110 eligible CKD stage 3 patients requiring contrast agent administration for coronary angiography/angioplasty were enrolled and randomly assigned to either crocin (n = 57) or control (n = 53) group. The patients in both groups received standard hydration therapy; nevertheless, in the crocin group, the patients were also orally administered three consecutive oral doses of 30 mg crocin tablets 1 day before up to 1 day after contrast media (CM) exposure. The primary endpoint was CIN incidence defined as an increase in serum creatinine (SrCr) level by ≥ 0.3 mg/dL or any change in urinary neutrophil gelatinase-associated lipocalin (NGAL) from the baseline within 48 hours of CM exposure. During 4 months, 130 patients were recruited. The mean age of the patients was 65.62 ± 9.05 years, and the majority of them were male (64.54%). The SrCr in the crocin group did not significantly increase within 48 hours of angiography/angioplasty. The changes in the urinary NGAL level were not significant in both groups. The CIN incidence was significantly lower in the crocin group than in the control group (1.75% and 13.2%; P = 0.028). Crocin administration plays an important nephron-protective role in the prevention of CIN.

Survival and recovery modeling of acute kidney injury in critically ill adults

Objectives:

Acute kidney injury is common among the critically ill. However, the incidence, medication use, and outcomes of acute kidney injury have been variably described. We conducted a single-center, retrospective cohort study to examine the risk factors and correlates associated with acute kidney injury in critically ill adults with a particular focus on medication class usage.

Methods:

We reviewed the electronic medical records of all adult patients admitted to an intensive care unit between 1 February and 30 August 2020. Acute kidney injury was defined by the 2012 Kidney Disease: Improving Global Outcomes guidelines. Data included were demographics, comorbidities, symptoms, laboratory parameters, interventions, and outcomes. The primary outcome was acute kidney injury incidence. A Least Absolute Shrinkage and Selection Operator regression model was used to determine risk factors associated with acute kidney injury. Secondary outcomes including acute kidney injury recovery and intensive care unit mortality were analyzed using a Cox regression model.

Results:

Among 226 admitted patients, 108 (47.8%) experienced acute kidney injury. 37 (34.3%), 39 (36.1%), and 32 patients (29.6%) were classified as acute kidney injury stages I–III, respectively. Among the recovery and mortality cohorts, analgesics/sedatives, anti-infectives, and intravenous fluids were significant (p-value < 0.05). The medication classes IV-fluid electrolytes nutrition (96.7%), gastrointestinal (90.2%), and anti-infectives (81.5%) were associated with an increased odds of developing acute kidney injury, odd ratios: 1.27, 1.71, and 1.70, respectively. Cox regression analyses revealed a significantly increased time-varying mortality risk for acute kidney injury-stage III, hazard ratio: 4.72 (95% confidence interval: 1–22.33). In the recovery cohort, time to acute kidney injury recovery was significantly faster in stage I, hazard ratio: 9.14 (95% confidence interval: 2.14–39.06) cohort when compared to the stage III cohort.

Conclusion:

Evaluation of vital signs, laboratory, and medication use data may be useful to determine acute kidney injury risk stratification. The influence of particular medication classes further impacts the risk of developing acute kidney injury, necessitating the importance of examining pharmacotherapeutic regimens for early recognition of renal impairment and prevention.

The preventive effects of different doses of atorvastatin on contrast-induced acute kidney injury after CT perfusion

Background

Contrast‐induced acute kidney injury (CI‐AKI) is a severe complication among patients receiving intravascular contrast media. The purpose of this study was to investigate the preventive effects of pretreatment of atorvastatin at intensive doses on CI‐AKI after computed tomography (CT) perfusion.

Methods

The levels of serum creatinine (SCR), blood urea nitrogen (BUN), Cystatin C (CysC), estimated glomerular filtration rate (eGFR), high‐sensitivity C‐reactive protein (hs‐CRP), and interleukin‐6 (IL‐6) in patients were compared between the observation group receiving 40 mg/kg atorvastatin and the control group receiving 20 mg/kg atorvastatin before and 72 h after CT examination. In addition, the incidence of CI‐AKI was recorded.

Results

Compared with the control group, the incidence of renal injury in the observation group was significantly reduced, from 8% to 2% (χ² = 6.62, p = 0.010). In addition, there was no notable difference in the levels of Scr, BUN, CysC, hs‐CRP, and IL‐6 before CT examination between two groups (p > 0.05). The levels of SCR, BUN, CysC, hs‐CRP, and IL‐6 were increased, while the levels of eGFR were decreased in the control group at 72 h after CT examination (p < 0.05). At 72 h after CT enhancement, the levels of BUN, CysC, and hs‐CRP were prominently increased in the observation group (p < 0.05), while SCR, eGFR, and IL‐6 did not change (p > 0.05). Compared with the control group, the levels of SCR, BUN, CysC, eGFR, hs‐CRP, and IL‐6 in the observation group were significantly decreased at 72 h after CT examination (p < 0.05).

Conclusion

Intensive dose of atorvastatin pretreatment can prevent CI‐AKI undergoing CT perfusion through lowering inflammation as well as renal function indexes SCR, CysC, BUN, and eGFR.

Elevation of Preprocedural Systemic Immune Inflammation Level Increases the Risk of Contrast-Associated Acute Kidney Injury Following Coronary Angiography: A Multicenter Cohort Study

Background

Inflammation and immune responses play an important role in the pathophysiology of contrast-associated acute kidney injury (CA-AKI), and systemic immune inflammation index (SII) has recently emerged as a new parameter for immune and inflammatory response evaluation. However, limited research has been undertaken to explore the relationship between SII and CA-AKI following coronary angiography (CAG).

Patients and Methods

From January 2007 to December 2020, 46,333 patients undergoing CAG were included from 5 Chinese tertiary hospitals. SII was calculated as total peripheral platelets count × neutrophil-to-lymphocyte ratio. Patients were categorized by preprocedural SII quartiles: Q1 ≤404.5, Q2 >404.5 and ≤631.7, Q3 >631.7 and ≤1082.8, Q4 >1082.8. Univariable and multivariable logistic regression were used to reveal the link between preprocedural SII and CA-AKI.

Results

A total of the 46,333 patients (62.9 ± 11.5 years, female 28.1%) were included in the study. The incidence of CA-AKI was 8.4% in Q1 group, 8.7% in Q2 group, 9.4% in Q3 group, 15.1% in Q4 group. In the multivariable model, comparing the highest (Q4 group) to lowest (Q1 group) SII level categories, preprocedural SII was related to a higher risk of CA-AKI after fully adjusting for well-known confounders, and there was no statistically difference in the other two SII level categories (Q2 and Q3 groups) compared with Q1 group (adjusted model 3: Q2 group: OR: 0.98, 95% CI: 0.87–1.11, P = 0.771; Q3 group: OR: 1.04, 95% CI: 0.92–1.18, P = 0.553; Q4: OR: 1.65, 95% CI: 1.45–1.88, p < 0.001; P for trend < 0.001). Similar results were found for all the subgroups analysis except for patients undergoing PCI, and the interaction analyses for age, PCI and AMI were significant. In addition, Kaplan–Meier curves demonstrated that the lowest quartile group showed the worst all-cause mortality in a significant SII level-dependent manner among the four groups (Log rank test; p < 0.0001).

Conclusion

Elevated preprocedural SII level was a significant and independent risk factor for CA-AKI following CAG. Higher-quality prospective studies are needed to validate the predictive value of SII for CA-AKI.

Clinical impact of noncontrast percutaneous coronary intervention in patients with acute coronary syndrome

PURPOSE

Contrast-induced acute kidney injury (CI-AKI) is one of the common serious complications of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). This study aimed to assess the significance of noncontrast strategy in the setting of ACS.

METHODS

CI-AKI was defined as an increase in serum creatinine of ?0.5 mg/dL or ?1.25 times from the baseline. One-year worsening renal function (WRF) was defined as an increase of ?0.3mg/dL in serum creatinine from the baseline after PCI.

RESULTS

Of 250 ACS patients, 81 were treated with noncontrast PCI. The average doses of contrast medium in the noncontrast and conventional groups were 17 (9?22) ml and 150 (120?200) ml, respectively. CI-AKI was observed in 4 patients (5%) in the noncontrast group and 29 patients (17%) in the conventional group. Noncontrast PCI was associated with a lower incidence of CI-AKI (adjusted odds ratio, 0.26;95% confidence interval [CI], 0.08?0.82). The bootstrap method and inverse probability weighting led to similar results. CI-AKI was associated with a higher incidence of 1-year WRF (adjusted hazard ratio, 2.30;95% CI, 1.12?4.69), while noncontrast PCI was not.

CONCLUSIONS

Noncontrast PCI was associated with the lower incidence of CI-AKI in ACS patients. J. Med. Invest. 69 : 57-64, February, 2022.

Nephrotoxicity in cancer treatment: An update

It has been estimated that nearly 80% of anticancer drug-treated patients receive potentially nephrotoxic drugs, while the kidneys play a central role in the excretion of anticancer drugs. Nephrotoxicity has long been a serious complication that hampers the effectiveness of cancer treatment and continues to influence both mortality and length of hospitalization among cancer patients exposed to either conventional cytotoxic agents or targeted therapies. Kidney injury arising from anticancer drugs tends to be associated with preexisting comorbidities, advanced cancer stage, and the use of concomitant non-chemotherapeutic nephrotoxic drugs. Despite the prevalence and impact of kidney injury on therapeutic outcomes, the field is sorely lacking in an understanding of the mechanisms driving cancer drug-induced renal pathophysiology, resulting in quite limited and largely ineffective management of anticancer drug-induced nephrotoxicity. Consequently, there is a clear imperative for understanding the basis for nephrotoxic manifestations of anticancer agents for the successful management of kidney injury by these drugs. This article provides an overview of current preclinical research on the nephrotoxicity of cancer treatments and highlights prospective approaches to mitigate cancer therapy-related renal toxicity.

Risk factors for acute renal injury caused by contrast media after percutaneous coronary intervention and coronary angiography: A protocol for systematic review and meta-analysis

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) caused by contrast medium is one of the common complications of percutaneous coronary intervention (PCI)/coronary angiography (CAG). Early identification of the risk factors of CI-AKI in patients with PCI/CAG and help clinical staff to prevent and intervene as soon as possible is very important to improve the clinical outcome of patients. Although domestic and foreign scholars have studied and summarized the risk factors of CI-AKI in PCI/CAG, the conclusions are not the same. Therefore, in this study, meta-analysis was used to summarize the risk factors of CI-AKI in patients with PCI/CAG, and to explore the characteristics of high-risk groups of CI-AKI, to provide reference for early identification and prevention of clinical doctors and nurses.

METHODS

We will search related literature of PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database. Eligible studies will be screened based on inclusion criteria, and data extraction, risk of bias assessment, publication bias assessment, subgroup analysis, and quality assessment will be performed. Review Manager version 5.3 software will be used for data analysis. Each process is independently conducted by 2 researchers, and if there is any objection, it will be submitted to the third researcher for resolution.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSIONS

The results of this analysis can be used to generate a risk prediction model and provide an intervention strategy for the occurrence of CI-AKI in PCI/CAG.

“MYH9 mutation and squamous cell cancer of the tongue in a young adult: a novel case report”

Background

The incidence of tongue cancer in young adults is on the rise. This trend is more pronounced in females. Although the aetiology is still unclear, there is mounting evidence that genetic syndromes can play a key role in development of oral cancers in this patient group. We report the first case of oral squamous cell carcinoma (oSCC) in a young adult with an MYH9-related disorder (MYH9-RD).

Case presentation

A 19-year-old female with a germline MYH9 variant (missense variant in exon 2: c.287C > T, (p.Ser96Leu)) was referred to the head and neck surgery department for investigation of a painful, thick right tongue ulcer. She was diagnosed with Epstein syndrome, an MYH9-RD, at 12 years of age. Her main phenotypic features were profound thrombocytopenia and marked renal impairment. The tongue biopsy confirmed SCC. Preoperative positron emission tomography (PET) revealed avidity in the right tongue and ipsilateral level 2A neck lymph node. With substantial preoperative multidisciplinary input, she underwent cancer ablation and microvascular free flap reconstruction. Her pathology showed a 35 mm diameter, 14 mm thick moderately differentiated SCC with perineural and lymphovascular invasion. Two out of 38 right neck nodes were positive for metastasis with extranodal extension. None of the 34 left neck nodes was involved.

She had an uneventful recovery and was discharged home on day 6 postoperative day. On day 15 postoperative day, she had catastrophic bleeding in the neck with a respiratory arrest after a forceful cough. She required an emergency tracheostomy and returned to the theatre for haemostasis. Following a short inpatient stay, she was again discharged home and underwent adjuvant therapy consisting of external beam radiotherapy of 60Gy in 30 fractions. On clinical examination and PET at 6 months after surgery, she had no evidence of disease recurrence.

Conclusions

MYH9-RD can present with advanced locoregional oral cavity malignancy at an early age. The combination of profound thrombocytopenia and marked renal impairment can impact heavily on routine major head and neck cancer surgery and adjuvant treatment. This rare and challenging condition underlines the importance of early detection of cancer and multidisciplinary team input.

Nephrotoxins and acute kidney injury - The consensus of the Taiwan acute kidney injury Task Force

The Taiwan Acute Kidney Injury (AKI) Task Force conducted a review of data and developed a consensus regarding nephrotoxins and AKI. This consensus covers: (1) contrast-associated AKI; (2) drug-induced nephrotoxicity; (3) prevention of drug-associated AKI; (4) follow up after AKI; (5) re-initiation of medication after AKI. Strategies for the avoidance of contrast media related AKI, including peri-procedural hydration, sodium bicarbonate solutions, oral N-acetylcysteine, and iso-osmolar/low-osmolar non-ionic iodinated contrast media have been recommended, given the respective evidence levels. Regarding anticoagulants, both warfarin and new oral anticoagulants have potential nephrotoxicity, and dosage should be reduced if renal pathology exam proves renal injury. Recommended strategies to prevent drug related AKI have included assessment of 5R/(6R) reactions - risk, recognition, response, renal support, rehabilitation and (research), use of AKI alert system and computerized decision support. In terms of antibiotics-associated AKI, avoiding concomitant administration of vancomycin and piperacillin-tazobactam, monitoring vancomycin trough level, switching from vancomycin to teicoplanin in high-risk patients, and replacing conventional amphotericin B with lipid-based amphotericin B have been shown to reduce drug related AKI. With respect to non-steroidal anti-inflammatory drug associated AKI, it is recommended to use these drugs cautiously in the elderly and in patients receiving renin-angiotensin-aldosterone system inhibitors/diuretics triple combinations.

Contrast-induced acute kidney injury after computed tomography with contrast media in patients with cardiovascular diseases

Aim. To assess the frequency of contrast-induced acute kidney injury (CI-AKI) in patients with cardiovascular diseases (CVD) undergoing computed tomography (CT) with intravenous contrast media. Materials and methods. In prospective observational study (ClinicalTrials.gov ID NCT04666389) were included 51 patients with CVD undergoing CT with intravenous contrast media administration. The primary endpoint was CI-AKI according to KDIGO criteria [the 25% rise (or 0.5 mg/dl) of serum creatinine from baseline assessed 4872 hours after administration of contrast media]. There were 51% of women included in the study. The average age was 61.741.5. The most frequent cardiovascular disease was hypertension in both men and women 52 and 39% respectively. Results. CI-AKI was diagnosed in 2 (3.92%) patients. At the same time, it was not possible to establish statistically significant relationship (p0.05) between risk factors and the development of CI-AKI. Conclusion. Cardiovascular diseases may increase the risk of CI-AKI after CT with intravenous contrast media administration. Therefore, it is recommended to evaluate the serum creatinine concentration in such patients.

Medical complications and outcome after endovascular therapy for acute ischemic stroke

AIM

Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT.

METHODS

Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015-2019.

RESULTS

A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9-7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1-1.5)), male gender (1.9 (1.1-1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0-1.2)) were associated with medical complications.

CONCLUSION

Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome.

Rhabdomyolysis following coronary angiography: an unexpected detection on 99mTc-methyl diphosphonate bone scintigraphy

Background

Bone scintigraphy is an appropriate tool in the management of cancers for the detection of bone metastasis. Technetium 99 m-methylene diphosphonate (99mTc-MDP) is commonly used as a bone-seeking agent. The bones take up 99mTc-MDP through a process called chemisorption, which is more evident in areas of increased osteoblastic activities. Nevertheless, extra-osseous 99mTc-MDP uptake is an infrequent occurrence, which warrants a thorough clinical assessment to evaluate such findings. An example of extraosseous uptake discovery is rhabdomyolysis, which requires prompt recognition and immediate management. Rhabdomyolysis secondary to an adverse reaction towards iodinated contrast material is a rare condition that warrants a high index of clinical suspicion.

Case presentation

We present a case of a 75-year-old gentleman with underlying benign prostatic hypertrophy, and chronic kidney disease who had undergone a coronary angiography examination and intervention for ischemic heart disease. Pre-scheduled bone scintigraphy with 99mTc-MDP for the work-up of raised serum prostate-specific antigen (PSA) was performed 2 weeks post coronary angiography examination. Whole-body bone scan with single-photon emission computed tomography/computed tomography (SPECT/CT) images showed an unexpected finding of extensive extra-osseous uptake in the muscles and soft tissues. Additional investigations confirmed the diagnosis of rhabdomyolysis. Nevertheless, despite the prompt recognition, administration of treatment and supportive care, the patient succumbed to life-threatening complications.

Conclusion

This case highlights the importance of recognising and identifying the pattern of extra-osseous uptake on bone scintigraphy imaging to ensure early intervention of severe and life-threatening conditions such as rhabdomyolysis.

Renal Recovery in Critically Ill Adult Patients Treated with Veno-Venous Or Veno-Arterial Extra Corporeal Membrane Oxygenation: a Retrospective Cohort Analysis

Introduction

Patients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development.

Aim of the study

In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups.

Material and methods

The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes.

Results

Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13).

Conclusions

Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.

Albuminuria Pre-Emptively Identifies Cardiac Patients at Risk of Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) is a complication associated with the administration of contrast media (CM). The CIN diagnosis is based on creatinine, a biomarker late and insensitive. The objective proposed was to evaluate the ability of novel biomarkers to detect patients susceptible to suffering CIN before CM administration. The study was carried out with patients undergoing cardiac catheterization involving CM. Patients were divided into two groups: (1) CIN, patients who developed this pathology; (2) control, patients who did not suffer CIN. Prior to the administration of CM, urine samples were collected to measure proteinuria, N-acetyl-β-d-glucosaminidase, neutrophil gelatinase-associated lipocalin and kidney injury molecule-1, albumin, transferrin, t-gelsolin and GM2 ganglioside activator protein (GM2AP). The risk factors advanced age, low body mass index and low estimated glomerular filtration rate; and the urinary biomarkers albumin, transferrin and GM2AP showed significant predictive capacity. Of all of them, albuminuria demonstrated the highest diagnostic power. When a cutoff point was established for albuminuria at values still considered subclinical (10–30 µg/mg Cr_u), it was found that there was a high incidence of CIN (40–75%). Therefore, albuminuria could be applied as a new diagnostic tool to prevent and predict CIN with P4 medicine criteria, independently of risk factors and comorbidities.

Atrial Fibrillation and Chronic Kidney Disease-A Risky Combination for Post-Contrast Acute Kidney Injury

Atrial fibrillation (AF) symptoms may mimic coronary artery disease (CAD) which reflects the difficulties in qualifying AF patients for invasive diagnostics. A substantial number of coronary angiographies may be unnecessary or even put patients at risk of post-contrast acute kidney injury (PC-AKI), especially patients with chronic kidney disease (CKD). We aimed to investigate the hypothesis indicating higher prevalence of PC-AKI in patients with AF scheduled for coronary angiography. The study population comprised of 8026 patients referred for elective coronarography including 1621 with AF. In the comparison of prevalence of PC-AKI in distinguished groups we can see that kidney impairment was twice more frequent in patients with AF in both groups with CKD (CKD (+)/AF (+) 6.24% vs. CKD (+)/AF (−) 3.04%) and without CKD (CKD (−)/AF (+) 2.32% vs. CKD (−)/AF (−) 1.22%). In our study, post-contrast acute kidney disease is twice more frequent in patients with AF, especially in subgroup with chronic kidney disease scheduled for coronary angiography. Additionally, having in mind results of previous studies stating that AF is associated with non-obstructive coronary lesions on angiography, patients with AF and CKD may be unnecessarily exposed to contrast agent and possible complications.

Contrast-free percutaneous pulmonary valve replacement: a safe approach for valve-in-valve procedures

Introduction

Percutaneous pulmonary valve replacement (PPVI) continues to gather pace in pediatric and adult congenital practice. This is fueled by an expanding repertoire of devices, techniques and equipment to suit the heterogenous anatomical landscape of patients with lesions of the right ventricular outflow tract (RVOT). Contrast-induced nephropathy is a real risk for teenagers and adults with congenital heart disease (CHD).

Aim

To present a series of patients who underwent PPVI without formal RVOT angiography and propose case selection criteria for patients who may safely benefit from this approach.

Material and methods

We retrospectively collected PPVI data from the preceding 2 years at our institution identifying patients who had been listed as suitable for consideration for contrast-free PPVI from our multidisciplinary team (MDT) meeting based on predefined criteria. Demographic, clinical, imaging and hemodynamic data were collected. Data were analyzed using SPSS.

Results

Twenty-one patients were identified. All patients had a technically successful implantation with improvements seen in invasive and echocardiographic hemodynamic measurements. 90% of patients had a bio-prosthetic valve (BPV) in situ prior to PPVI. One patient had a complication which may have been recognized earlier with post-intervention RVOT contrast injection.

Conclusions

Zero-contrast PPVI is technically feasible and the suitability criteria for those who might benefit are potentially straightforward. The advent of fusion and 3D imaging in cardiac catheterization laboratories is likely to expand our capacity to perform more procedures with less contrast. Patients with bio-prosthetic valves in the pulmonary position may benefit from contrast-free percutaneous pulmonary valve implantation.

Acute kidney injury in patients with acute coronary syndrome after percutaneous coronary intervention: pathophysiologies, risk factors and preventive measures

Background: Percutaneous coronary intervention (PCI) has been an effective treatment for acute coronary syndrome (ACS) patients. Acute kidney injury (AKI) is one of the common complications after PCI, which seriously affects the living quality and survival time of patients. The approach followed for the patient with AKI after PCI depends on the clinical context and may vary by resource availability. Summary: This review focuses on the pathophysiologies, influencing factors, and preventive measures of AKI in patients with ACS after PCI. The knowledge may better serve the patients and improve their outcomes. Key Messages: Many studies have been carried out for the definition and standard of AKI in the past few years. Etiologies of AKI after PCI included renal damage of contrast medium and atherosclerotic embolism, cardiac insufficiency and surgical factors on renal function. Basic conditions, treatment modalities, and perioperative changes are major risk factors of AKI. Studies have reported that the prevention of contrast-induced nephropathy, modulating the volume overload, some pharmaceuticals and blood purification treatment are helpful to prevent the occurrence of AKI.

Protection of coenzyme Q10 against contrast-induced acute kidney injury in male diabetic rats

BACKGROUND

Diabetes mellitus (DM) is a major risk factor for contrast-induced acute kidney injury (CI-AKI). DM and CI-AKI result in oxidative damage and inflammation that can be reduced when treated with the coenzyme Q-10 (CoQ10). The aim of this study was to investigate the therapeutic potential of CoQ10 in renal function, renal hemodynamics, oxidative profile and renal histology in diabetic rats subjected to CI-AKI.

METHODS

Wistar rats, male, randomized into five groups: citrate: control animals received citrate buffer (streptozotocin vehicle, 0.4 mL); Tween: control animals of CoQ10 treatment received 1% Tween 80 (CoQ10 vehicle, 0.5 mL); DM: animals that received streptozotocin (60 mg/kg); DM + IC: DM animals treated with iodinated contrast (IC, 6 mL/kg); DM + IC + CoQ10: DM animals treated with CoQ10 (10 mg/kg) and that received IC (6 mL/kg). The protocols lasted 4 weeks. An evaluation was made to measure renal function, inulin clearance and serum creatinine, renal hemodynamics by renal blood flow (RBF) and renal vascular resistance (RVR), markers of oxidative stress such as urinary peroxides and nitrate, lipid peroxidation, thiols in renal tissue and renal histological analysis.

RESULTS

DM animals showed reduced renal function, which was followed by an increase inserum creatinine and significant reduction of inulin clearance and RBF. It was noticed an increase in RVR and redox imbalance with higher urinary peroxides and nitrate lipid peroxidation levels with depletion of thiols in renal tissue. IC treatment exacerbated these changes in DM + IC. CoQ10 administration ameliorated renal function, prevented hemodynamic changes and neutralized oxidative damage and progression of the histologic damage in the DM + IC + CoQ10 group.

CONCLUSION

This study demonstrated the renoprotection properties of CoQ10 in an experimental model of risk factor of DM for CI-AKI. CoQ10 presented an antioxidant effect on the CI-AKI in male diabetic rats by improving renal function and renal hemodynamics, preserving morphology and reducing oxidative stress.

Proteomics reveals urine apolipoprotein A-I as a potential biomarker of acute kidney injury following percutaneous coronary intervention in elderly patients

The aim of the present study was to investigate how changes in the lipid composition are involved in early stages of acute kidney injury (AKI) following percutaneous coronary intervention (PCI-AKI) in elderly patients. A prospective nested case-control study was performed. Alterations in the urine protein accumulation were investigated in patients with and without PCI-AKI using isobaric tags for relative and absolute quantitation (iTRAQ). In addition, differentially expressed proteins (DEPs) related to lipids were confirmed using parallel reaction monitoring (PRM)-based targeted proteomics. From the cohort of elderly patients (>60 years of age), 14 (12.28%) developed AKI within 48 h after PCI. No significant differences were detected between the AKI and control (CON) groups for serum creatinine at 24 h following treatment (P=0.27). Among the DEPs that overlapped in both the AKI-24 h/AKI-Pre (AKI group at 24 h post-PCI vs. pre-PCI) and AKI-24 h/CON-24 h groups (AKI group vs. CON group at 24 h post-PCI), only apolipoprotein A-I (apoA-I) was related to lipids, which displayed a significant upregulation in expression levels. The protein expression levels of apoA-I displayed a 5.98-fold increase at 24 h after PCI from the baseline and a 2.09-fold increase compared with the control group as determined using PRM, which exhibited a similar trend to the iTRAQ results. Using protein-protein interaction analyses, apoA-I was determined to be functionally linked to the complement and coagulation cascades, the renin-angiotensin system and the hypoxia-inducible factor-1 signaling pathway. Using the pathway analysis tool from the Kyoto Encyclopedia of Genes and Genomes, several pathways were identified to be associated with apoA-I, including fat digestion and absorption, vitamin digestion and absorption, as well as the peroxisome proliferator activated receptor signaling pathway. In conclusion, apoA-I may be a promising biomarker for the early diagnosis of PCI-AKI in elderly patients. The role of apoA-I in the pathobiology of PCI-AKI requires further exploration.

High-Density Lipoproteins and Acute Kidney Injury

High-density lipoprotein (HDL) particles, best known for their anti-atherosclerotic effects, also may play a beneficial role during acute renal stress. HDL from healthy human beings also shows anti-inflammatory and anti-oxidant capacities, promotes endothelial function and repair, and serves as a systemic signaling mechanism facilitating rapid interorgan communication during times of physiologic stress. Higher concentrations of HDL are associated with less acute kidney injury after sepsis, cardiac and vascular surgery, and contrast-exposure during percutaneous coronary interventions. A better understanding of the interplay between HDL and the kidney both under homeostatic conditions and under acute physiologic stress could lead to the identification of novel risk factors and therapeutic targets for acute kidney injury prevention and treatment in the future.

Can sodium fluorescein cause contrast-induced nephropathy?

BACKGROUND

Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury (AKI), and can be diagnosed when the etiology of AKI is unclear other than via a contrast agent. Fluorescent angiography (FAG) with fluorescein sodium dye is generally considered to be safe for patients with kidney diseases. However, it remains unresolved whether or not FAG can induce CIN.

METHODS

Patients from two tertiary hospitals who underwent FAG and had serum creatinine results within 4 weeks before FAG and 3 days after FAG between 2001 and 2017 were retrieved. Cases with concurrent iodinated contrast imaging or undergoing dialysis were excluded from the analysis. CIN was defined by two criteria: CIN criteria as >0.5 mg/dL or >25% increase in serum creatinine (sCr) level within 3 days after FAG, and contrast-induced acute kidney injury (CIAKI) criteria as ≥0.3 mg/dL increase within 2 days or ≥50% increase within 7 days after FAG.

RESULTS

A total of 979 patients were screened, and we found 124 patients with AKI after FAG. After excluding 32 patients with clear causes of AKI other than FAG, the incidence rates of CIN were 7.3% by CIN criteria and 6.4% by CIAKI criteria. CIN incidence had a U-shaped distribution according to chronic kidney disease (CKD) stages in CIN criteria, while linear association between CIN incidence and CKD stages were found in CIAKI criteria. Kaplan-Meier curves showed the CIN group was significantly associated with end-stage renal disease (ESRD) progression (log-rank P < 0.001, in both CIN criteria and CIAKI criteria), and adjusted hazard ratios by multivariable Cox regression were 2.23 [95% confidence interval (CI) 1.468-3.378] in CIN criteria and 2.17 (95% CI 1.462-3.232) in CIAKI criteria.

CONCLUSIONS

According to CIN and CIAKI criteria, FAG may cause CIN and appeared to be a possible risk factor for ESRD progression. However, CIN or CIAKI criteria themselves may overestimate AKI and require meticulous attention to the interpretation of results.

Assessment of Gadobutrol Safety in Combination with Ionizing Radiation Using a Preclinical MRI-Guided Radiotherapy Model

MR-linac technology enhances the precision of therapeutic radiation by clarifying the tumor-normal tissue interface and provides the potential for adaptive treatment planning. Accurate delineation of tumors on diagnostic magnetic resonance imaging (MRI) frequently requires gadolinium-based contrast agents (GBCAs). Despite generally being considered safe, previous literature suggests that GBCAs are capable of contrast-induced acute kidney injury (AKI). It is unclear if the risk for AKI is enhanced when GBCAs are administered concurrently with ionizing radiotherapy. During irradiation, gadolinium may be liberated from its chelator which may induce AKI. The goal of this work was to determine if radiation combined with GBCAs increased the incidence of AKI. Using a preclinical MRI-guided irradiation system, where MRI acquisitions and radiation delivery are performed in rapid succession, tumor-bearing mice with normal kidney function were injected with GBCA and treated with 2, 8 or 18 Gy irradiation. Renal function was assessed on days three and seven postirradiation to assess for AKI. No clinically relevant changes in blood urea nitrogen and creatinine were observed in any combination of GBCA and radiation dose. From these data, we conclude that GBCA in combination with radiation does not increase the risk for AKI in mice. Additional investigation of multiple doses of GBCA administered concurrently with irradiation is warranted to evaluate the risk of chronic kidney injury.

Biochemical Markers in the Prediction of Contrast-induced Acute Kidney Injury

For many years clinicians have been searching for "kidney troponin"- a simple diagnostic tool to assess the risk of acute kidney injury (AKI). Recently, the rise in the variety of contrast-related procedures (contrast computed tomography (CT), percutaneous coronary intervention (PCI) and angiography) has resulted in the increased number of contrast-induced acute kidney injuries (CI-AKI). CIAKI remains an important cause of overall mortality, prolonged hospitalisation and it increases the total costs of therapy. The consequences of kidney dysfunction affect the quality of life and they may lead to disability as well. Despite extensive worldwide research, there are no sensitive and reliable methods of CI-AKI prediction. Kidney Injury Molecule 1 (KIM-1) and Neutrophil Gelatinase Lipocalin (NGAL) have been considered as kidney-specific molecules. High concentrations of these substances before the implementation of contrast-related procedures have been suggested to enable the estimation of kidney vulnerability to CI-AKI and they seem to have the predictive potential for cardiovascular events and overall mortality. According to other authors, routine determination of known inflammation factors (e.g., CRP, WBC, and neutrophil count) may be helpful in the prediction of CIAKI. However, the results of clinical trials provide contrasting results. The pathomechanism of contrast- induced nephropathy remains unclear. Due to its prevalence, the evaluation of the risk of acute kidney injury remains a serious problem to be solved. This paper reviews pathophysiology and suggested optimal markers facilitating the prediction of contrast-induced acute kidney injury.

Concepts, Role, and Advances on Nail Imaging

This review discusses, from a practical point of view, the most common imaging techniques and their applications in nail pathologies with some technical considerations. There are several imaging techniques for studying the nail, and all of them require proper devices and trained operators. The highest axial resolution and a more extensive range of applications are provided by ultrasound, which currently is the first-choice imaging technique for evaluating nail conditions. A correlation of state-of-the-art clinical and imaging figures supports the review of this topic.

Imaging and surgical predictive factors for postoperative hemorrhage after partial nephrectomy and clinical results of trans-arterial embolization

ABSTRACT

Partial nephrectomy (PN) has been established as the standard treatment for T1 renal tumors, and postoperative hemorrhage due to vascular complications is a rare but potentially life-threatening complication reported after PN. Thus, this study evaluated the imaging and surgical factors associated with postoperative hemorrhage after PN and the clinical results of trans-arterial embolization. A retrospective review of the institutional PN database was performed from May 2012 to January 2019, revealing that we performed 810 PN procedures at our institution. In total, 12 patients were referred to the interventional radiology department for vascular complications after the procedure. Patients with and without transarterial embolization (TAE) were age- and sex-matched with 56 patients. Preoperative imaging characteristics and operative details were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of hemorrhage. Furthermore, renal functions at diagnosis, after operation or embolization for TAE cases, and at the last follow-up were recorded. A diagnosis of hemorrhage was made at a median of 4 (range, 0-25) days after surgery. The majority of patients (50%) presented with gross hematuria. T test revealed higher renal tumor-parenchyma contact area (TPA) (P = .0407), Length-A (P = .0136), Length-P (P = .0267), operation time (P = .0214) and estimated blood loss (P = .0043) in patients with hemorrhage than in controls. Binary logistic regression analysis identified TPA (P = .048) and estimated blood loss (P = .042) as independent predictors for postoperative hemorrhage with an area under the ROC curve of 0.705 (64% sensitivity and 79% specificity). In conclusion, the occurrence of hemorrhage after PN was associated with a larger TPA and more estimated blood loss during the procedure. In patients who underwent selective TAE, renal function remained comparable with that of controls.

A High Triglyceride-Glucose Index Is Associated With Contrast-Induced Acute Kidney Injury in Chinese Patients With Type 2 Diabetes Mellitus

Background and Objectives

Triglyceride-glucose (TyG) is an emerging vital indicator of insulin resistance and is associated with increased risk of T2DM and cardiovascular events. We aimed to explore the TyG index and contrast-induced acute kidney injury (CI-AKI) in patients with type 2 diabetes who underwent coronary angiology.

Methods

This study enrolled 928 patients with suspected coronary artery disease who underwent coronary angiology or percutaneous coronary intervention in Zhongda hospital. Patient data were divided into quartiles according to the TyG index: group 1: TyG ≤ 8.62; group 2: 8.629.45. CI-AKI was diagnosed according to the KIDIGO criteria. Demographic data, hematological parameters, coronary angiology data, and medications were all recorded. We calculated the TyG index using the following formula: ln [fasting TG (mg/dL)×FPG (mg/dL)/2].

Results

Patients who developed CI-AKI exhibited significantly higher TyG index levels compared to patients who did not develop CI-AKI. The incidence of CI-AKI sharply increased with increasing TyG. Univariate and multivariate analysis identified TyG as an independent risk factor for CI-AKI. The AUC of the ROC curve was as high as 0.728 when the value of TyG was 8.88. The corresponding sensitivity was as high as 94.9%. Adding the variable TyG to the model for predicting CI-AKI risk further increased the predictive value of the model from 80.4% to 82%.

Conclusions

High TyG is closely associated with increased incidence of CI-AKI, demonstrating that TyG is an independent risk factor for CI-AKI. TyG has potentially predictive value for CI-AKI and may play a crucial role in risk stratification in clinical practice.

Use of O-arm With Intraoperative Arteriography for Localization and Stealth Navigation of the Vertebral Arteries During Posterior Cervical Spine Surgery

BACKGROUND

Vertebral artery injury (VAI) can be a devastating complication during cervical spine surgery. Although considered a rare occurrence overall, incidences of VAI have been reported in the ranges of 0.07% to 8%. Such injuries have the potential for catastrophic consequences, including blood loss, permanent morbid neurologic injury, and even death. The introduction of intraoperative navigation using either preoperative or intraoperative imaging has now been widely adopted in current practice so as to try and minimize adverse outcomes while giving real-time, dynamic information of the operative field. The use of the O-arm Surgical Imaging System during cervical spine surgery allows one to obtain high-resolution, accurate intraoperative imaging, and when used in concert with forms of intraoperative navigation, it can help with instrumentation and safety. However, patients undergoing cervical spine surgery do not routinely undergo preoperative vascular imaging, particularly with regard to anterior cervical or posterior high-cervical surgeries, where the incidence of VAI, in comparison with other cervical surgeries, has been reported to be the highest.

METHODS

Here we present the use of intraoperative O-arm-based arteriography for integration with navigation for vertebral artery localization during C1 to C3 posterior instrumentation and fusion of an unstable C2 fracture in a 54-year-old man.

RESULTS

The patient did not experience any intraoperative VAI and was subsequently discharged with no focal neurologic deficits.

CONCLUSIONS

Detailed in our report is our protocol and procedure for obtaining and using intraoperative angiographic images.

CLINICAL RELEVANCE

Case report detailing O arm for intraoperative identification of vertebral arteries during C1-C3 posterior instrumentation and fusion with pre-operative unilateral vertebral artery injury.

Contrast-associated acute kidney injury: An update of risk factors, risk factor scores, and preventive measures

As lifespans lengthen, age-related diseases such as cardiovascular disease and diabetes are becoming more prevalent. Correspondingly, the use of contrast agents for medical imaging is also becoming more common, and there is increasing awareness of contrast-associated acute kidney injury (CA-AKI). There is no specific treatment for CA-AKI, and clinicians currently focus on prevention, interventions that alter its pathogenesis, and identification of risk factors. Although the incidence of CA-AKI is low in the general population, the risk of CA-AKI can reach 20% to 30% in patients with multiple risk factors. Many models have been applied in the clinic to assess the risk factors for CA-AKI, enable identification of high-risk groups, and improve clinical management. Hypotonic or isotonic contrast media are recommended to prevent CA-AKI in high-risk patients. Patients with risk factors should avoid using contrast media multiple times within a short period of time. All nephrotoxic drugs should be stopped at least 24 h before the administration of contrast media in high-risk populations, and adequate hydration is recommended for all patients. This review summarizes the pathophysiology of CA-AKI and the progress in diagnosis and differential diagnosis; updates the risk factors and risk factor scoring systems; reviews the latest advances related to prevention and treatment; discusses current problems in epidemiological studies; and highlights the importance of identifying high-risk subjects to control modifiable risk factors and use of a rating scale to estimate the risk and implement appropriate prevention strategies.

Physical Training Is a Potential Modifier of Risk for Contrast-Induced Acute Kidney Injury in Diabetes Mellitus

Background

Iodinated contrast (IC) is a leading cause of hospital-based acute kidney injury (AKI). Contrast-induced acute kidney injury (CI-AKI) is a decline in renal function due to iodinated contrast administration and occurs more frequently in individuals with increasingly common risk factors, such as diabetes mellitus (DM). Physical training (PT) can have renoprotective effects on CI-AKI in diabetic nephropathy. The aim of this study was to evaluate the injury in kidneys of diabetic rats submitted to treatment with IC, evaluating the impact of PT on hemodynamics and renal function in addition to oxidative profile in diabetic rats submitted to IC-AKI.

Materials and Methods

Adult male Wistar rats are randomized into four groups: citrate (n = 7): control group, citrate buffer (streptozotocin-STZ vehicle), intravenous tail (iv), single dose; DM (n = 7): STZ, 60 mg/kg, iv, single dose; DM+IC (n = 7): DM rats treated with IC (sodium meglumine ioxithalamate, 6 mL/kg, intraperitoneal (ip), single dose); DM+IC+PT (n = 7): DM rats treated with IC as mentioned and submitted to physical training. Renal function parameters (inulin clearance, neutrophil gelatinase-associated lipocalin (NGAL), serum creatinine, and urinary albumin), hemodynamics (renal blood flow and renal vascular resistance), and oxidative profile (urinary peroxides, urinary TBARS, urinary nitric oxide, and renal tissue thiols) were evaluated.

Results

It was possible to observe a decrease in inulin clearance, renal blood flow, and thiols in renal tissue accompanied by an increase in urinary flow, serum creatinine, urinary albumin, renal vascular resistance, urinary peroxides, urinary nitrate, and TBARS in the DM group compared to the citrate group. The DM+IC group showed a reduction in inulin clearance, and the renal dysfunction was also seen by the increased NGAL. Renal hemodynamics and oxidative profile compared were also worsened in the DM group. PT improved renal function by increasing renal blood flow and thiol levels in renal tissue and reduced renal vascular resistance, metabolites of reactive oxygen, nitrogen species, and lipid peroxidation in the DM+IC+PT group compared to DM+IC.

Conclusions

Our results confirmed that DM induction increases renal vulnerability to the toxicity of IC and an association between DM with IC predisposes to severe AKI with reduced renal function alongside with renal hemodynamic alterations and oxidative mechanism of injury. The PT showed a renoprotective effect in DM animals subjected to damage with IC by modulating renal hemodynamics and oxidative profile, confirming a potential to modify the risk of CI-AKI when diabetes mellitus is present.

Temporal trends of acute kidney injury in patients undergoing percutaneous coronary intervention over a span of 12 years

BACKGROUND

AKI is a known complication of PCI and is associated with higher rates of adverse events. We assessed temporal trends in rates of AKI, factors associated with risk of AKI and prognosis.

METHODS

From a prospective registry of patients undergoing PCI at two hospitals of the Rabin Medical Center, 15,153 consecutive patients were assessed at two time periods: 2006-2012 and 2012-2018. AKI was defined as either a relative elevation of ≥25% in serum creatinine or an absolute elevation of ≥0.5 mg/dl in serum creatinine at 48 h post PCI.

RESULTS

Data for 7913 patients from 2006 to 2012 and 7240 during 2012-2018 was available for analysis. Mean age was 65.0 ± 11.9y and 66.0 ± 12.3y (p < 0.001) and baseline creatinine was 1.08 ± 0.87 mg/dl and 1.15 ± 0.97 mg/dl, respectively (p < 0.001). Rates of AKI were 11.1% in the early and 7.3% in the late period (p < 0.001). Following adjustment, risk of AKI was lower in the late period (OR- 0.72; 95% CI 0.61-0.85, p < 0.001). AKI was associated with increased MACE (HR 1.62; 95% CI 1.44-1.82, p < 0.001 for the early period and HR 2.11; 95% CI 1.80-2.46, P < 0.001 for the late period) and death (HR 1.86; 95% CI 1.64-2.11, p < 0.001; HR 2.4; 95% CI 2.02-2.86; p < 0.001) in both time periods.

CONCLUSIONS

Over time, there was an improvement in the rates of post-PCI AKI. Increased adverse outcomes were evident at both periods. Further research is warranted, to further reduce peri-procedural AKI which is associated with impaired prognosis.

Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients

Background

Coronavirus disease 2019 (COVID-19) may predispose to venous thromboembolism. We determined factors independently associated with computed tomography pulmonary angiography (CTPA)-confirmed pulmonary embolism (PE) in hospitalised severe COVID-19 patients.

Methods

Among all (n=349) patients hospitalised for COVID-19 in a university hospital in a French region with a high rate of COVID-19, we analysed patients who underwent CTPA for clinical signs of severe disease (oxygen saturation measured by pulse oximetry ≤93% or breathing rate ≥30 breaths·min⁻¹) or rapid clinical worsening. Multivariable analysis was performed using Firth penalised maximum likelihood estimates.

Results

162 (46.4%) patients underwent CTPA (mean±sd age 65.6±13.0 years; 67.3% male (95% CI 59.5–75.5%). PE was diagnosed in 44 (27.2%) patients. Most PEs were segmental and the rate of PE-related right ventricular dysfunction was 15.9%. By multivariable analysis, the only two significant predictors of CTPA-confirmed PE were D-dimer level and the lack of any anticoagulant therapy (OR 4.0 (95% CI 2.4–6.7) per additional quartile and OR 4.5 (95% CI 1.1–7.4), respectively). Receiver operating characteristic curve analysis identified a D-dimer cut-off value of 2590 ng·mL⁻¹ to best predict occurrence of PE (area under the curve 0.88, p<0.001, sensitivity 83.3%, specificity 83.8%). D-dimer level >2590 ng·mL⁻¹ was associated with a 17-fold increase in the adjusted risk of PE.

Conclusion

Elevated D-dimers (>2590 ng·mL⁻¹) and absence of anticoagulant therapy predict PE in hospitalised COVID-19 patients with clinical signs of severity. These data strengthen the evidence base in favour of systematic anticoagulation, and suggest wider use of D-dimer guided CTPA to screen for PE in acutely ill hospitalised patients with COVID-19.

We studied predictors of pulmonary embolism in severe COVID-19 and found that D-dimer level and lack of any anticoagulant therapy were associated with a 17-fold and four-fold increase in PE, respectively, in COVID-19 patients with clinical signs of severityhttps://bit.ly/2ETfAfo

A novel risk assessment model of contrast-induced nephropathy after percutaneous coronary intervention in patients with diabetes

The purpose of our study was to develop a simple clinical pre-procedure risk model based on clinical characteristics for the prediction of contrast-induced nephropathy (CIN) and major adverse cardiac events (MACEs) after percutaneous coronary intervention (PCI) in patients with diabetes. A total of 1113 patients with diabetes who underwent PCI with contrast exposure were randomized into a development group (n = 742) and a validation group (n = 371) in a 2:1 ratio. CIN was defined as an increase of either 25% or 0.5 mg/dL (44.2 μmol/L) in serum creatinine within 72 hours after contrast infusion. A simple CIN risk score based on independent predictors was established. Four variables were identified for our risk score model: LVEF < 40%, acute coronary syndrome (ACS), eGFR < 60, and contrast volume > 300 mL. Based on this new CIN risk score, the incidence of CIN had a significant trend with increased predicting score values of 5.9%, 32.9% and 60.0%, corresponding to low-, moderate- and high-risk groups, respectively. The novel risk assessment exhibited moderate discrimination ability for predicting CIN, with an AUC of 0.759 [95% CI 0.668-0.852, P = .001] in the validation cohort. It also had similar prognostic values for one-year follow-up MACE (C-statistic: 0.705 and 0.606 for new risk score and Mehran score, respectively). This novel risk prediction model could be effective for preventing nephropathy in diabetic patients receiving contrast media during surgical procedures.

Hepatocyte Growth Factor Mimetic ANG-3777 for Cardiac Surgery-Associated Acute Kidney Injury

Introduction

Nearly one-third of patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB) experience cardiac surgery–associated (CSA) acute kidney injury (AKI); 5% require renal replacement therapy. ANG-3777 is a hepatocyte growth factor mimetic. In vitro, ANG-3777 reduces apoptosis and increases cell proliferation, migration, morphogenesis, and angiogenesis in injured kidneys. In animal models, ANG-3777 mitigates the effects of renal damage secondary to ischemia reperfusion injury and nephrotoxic chemicals. Phase 2 data in AKI of renal transplantation have shown improved renal function and comparable safety relative to placebo. The Guard Against Renal Damage (GUARD) study is a phase 2 proof of concept trial of ANG-3777 in CSA-AKI.

Methods

GUARD is a 240-patient, multicenter, double-blind, randomized placebo-controlled trial to assess the efficacy and safety of ANG-3777 in patients at elevated pre-surgery risk for AKI undergoing coronary artery bypass graft (CABG) or heart valve repair/replacement requiring CPB. Subjects are randomized 1:1 to receive ANG-3777 (2 mg/kg) or placebo. Study drug is dosed via 4 daily intravenous 30-minute infusions. The first dose is administered less than 4 hours after completing CPB, second at 24 ± 2 hours post-CPB, with two subsequent doses at 24 ± 2 hours after the previous dose.

Results

The primary efficacy endpoint is percent change from baseline serum creatinine to mean area under the curve from days 2 through 6. Secondary endpoints include change in estimated glomerular filtration rate from baseline to day 30, the proportion of patients diagnosed with AKI by stage through day 5, and the length of CSA-AKI hospitalization. Safety will include adverse events and laboratory measures.

Conclusion

This phase 2 study of ANG-3777 provides data to develop a phase 3 registrational study in this medically complex condition.