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Lakhal K, Ehrmann S, Robert-Edan V. Iodinated contrast medium: Is there a re(n)al problem? A clinical vignette-based review. Crit Care 2020; 24:641. [PMID: 33168006 PMCID: PMC7653744 DOI: 10.1186/s13054-020-03365-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
As we were taught, for decades, that iodinated contrast-induced acute kidney injury should be dreaded, considerable efforts were made to find out effective measures in mitigating the renal risk of iodinated contrast media. Imaging procedures were frequently either downgraded (unenhanced imaging) or deferred as clinicians felt that the renal risk pertaining to contrast administration outweighed the benefits of an enhanced imaging. However, could we have missed the point? Among the abundant literature about iodinated contrast-associated acute kidney injury, recent meaningful advances may help sort out facts from false beliefs. Hence, there is increasing evidence that the nephrotoxicity directly attributable to modern iodinated CM has been exaggerated. Failure to demonstrate a clear benefit from most of the tested prophylactic measures might be an indirect consequence. However, the toxic potential of iodinated contrast media is well established experimentally and should not be overlooked completely when making clinical decisions. We herein review these advances in disease and pathophysiologic understanding and the associated clinical crossroads through a typical case vignette in the critical care setting.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France.
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, CHRU Tours, Tours France and Centre d'étude des Pathologies Respiratoires INSERM U1100, Université de Tours, Tours, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France
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Ehrmann S, Quartin A, Hobbs BP, Robert-Edan V, Cely C, Bell C, Lyons G, Pham T, Schein R, Geng Y, Lakhal K, Ng CS. Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis. Intensive Care Med 2017; 43:785-794. [PMID: 28197679 DOI: 10.1007/s00134-017-4700-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/27/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE Critically ill patients, among whom acute kidney injury is common, are often considered particularly vulnerable to iodinated contrast medium nephrotoxicity. However, the attributable incidence remains uncertain given the paucity of observational studies including a control group. This study assessed acute kidney injury incidence attributable to iodinated contrast media in critically ill patients based on new data accounting for sample and effect size and including a control group. METHODS Systematic review of studies measuring incidence of acute kidney injury in critically ill patients following contrast medium exposure compared to matched unexposed patients. Patient-level meta-analysis implementing a Bayesian nested mixed effects multiple logistic regression model. RESULTS Ten studies were identified; only four took into account the baseline acute kidney injury risk, three by patient matching (560 patients). Objective meta-analysis of these three studies (vague and impartial a priori hypothesis concerning attributable acute kidney injury risk) did not find that iodinated contrast media increased the incidence of acute kidney injury (odds ratio 0.95, 95% highest posterior density interval 0.45-1.62). Bayesian analysis demonstrated that, to conclude in favor of a statistically significant incidence of acute kidney injury attributable to contrast media despite this observed lack of association, one's a priori belief would have to be very strongly biased, assigning to previous uncontrolled reports 3-12 times the weight of evidence strength provided by the matched studies including a control group. CONCLUSIONS Meta-analysis of matched cohort studies of iodinated contrast medium exposure does not support a significant incidence of acute kidney injury attributable to iodinated contrast media in critically ill patients.
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Affiliation(s)
- Stephan Ehrmann
- Médecine Intensive Réanimation, Centre Hospitalier Régional et Universitaire de Tours, 37044, Tours, France. .,Faculté de Médecine, Université François Rabelais, Tours, France.
| | - Andrew Quartin
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Veterans Affairs Medical Center, Miami, FL, USA
| | - Brian P Hobbs
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Vincent Robert-Edan
- Réanimation Chirurgicale Polyvalente, Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France
| | - Cynthia Cely
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Veterans Affairs Medical Center, Miami, FL, USA
| | - Cynthia Bell
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Genevieve Lyons
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Tai Pham
- Réanimation et USC Médico-chirurgicale, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, 75970, Paris, France.,INSERM UMR 1153, ECSTRA Team, Paris, France.,Saint Michael's Hospital, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Roland Schein
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Veterans Affairs Medical Center, Miami, FL, USA
| | - Yimin Geng
- Research Medical Library, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Karim Lakhal
- Réanimation Chirurgicale Polyvalente, Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France
| | - Chaan S Ng
- Department of Radiology, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
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