Efficacy of pentoxifylline in prevention of contrast-induced nephropathy in angioplasty patients

Pentoxifylline for the prevention of contrast-induced nephropathy: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To summarise current evidence on the use of pentoxifylline (PTX) to prevent contrast-induced nephropathy (CIN).

METHODS

The PubMed, Embase and CENTRAL databases were searched for randomised controlled trials including patients with and without PTX undergoing contrast media exposure. We analysed the incidence of CIN and serum creatinine changes before and after contrast media exposure. All statistical analyses were conducted with Review Manager V.5.3.

RESULTS

We finally enrolled in seven randomised controlled trials with a total of 1484 patients in this analysis. All of seven included studies were performed in patients undergoing angioplasty or stenting. The overall rates of CIN were 8.8% and 10.4% in the PTX groups and control groups, respectively. However, no significant reduction in the CIN rate was observed in the patients treated with PTX compared with the control groups (OR 0.81, 95% CI 0.57 to 1.13, I²=0, p=0.21). All studies reported no hospital mortality and the new requirement for dialysis during the trials.

CONCLUSION

Perioperative administration of PTX to patients undergoing angioplasty did not significantly reduce the development of CIN but showed some weak tendency of lower serum creatinine increase. Based on the available trials, the evidence does not support the administration of PTX for the prevention of CIN. More trials with larger sample sizes are needed to evaluate the role of PTX in CIN prevention.

Impact of Supplementation with Omega-3 in the Prevention of Contrast-Induced Nephropathy Following Elective Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease: A Randomized Placebo-Controlled Trial

Background:

Anti-oxidants were investigated in several studies as a preventive strategy for prevention of contrast-induced nephropathy (CIN). Omega-3 polyunsaturated fatty acids have antioxidant properties; however, their role in the prevention of CIN is still unknown. Therefore, in this study, we aimed to evaluate the efficacy of omega-3 supplementation in the prevention of contrast-induced nephropathy following elective percutaneous coronary intervention in patients with chronic kidney disease.

Methods:

This is a double-blinded and randomized clinical trial. Eighty eligible patients with glomerular filtration rate of 30-60 mL/min/1.73 m², scheduled to undergo elective PCI, were randomly divided into omega-3 (a single dose of 2500 mg omega-3 12 hours before PCI plus hydration therapy) or control (placebo plus hydration therapy) groups. Blood specimens for measuring serum creatinine and cystatin C were collected from each patient at baseline and 24 h after PCI.

Results:

Omega-3 did not show any significant effect on post-PCI serum creatinine and cystatin C compared to the controls. In addition, serum creatinine analysis showed that CIN occurred in 6 (16.2%) patients of the omega-3 and 4 (9.3%) patients of the control group (P = 0.50).

Conclusions:

Our results could not support the protective effect of a single dose of omega-3 in decreasing serum creatinine, serum cystatin C, and the incidence of CIN in patients with CKD undergoing PCI. To better evaluate the effect of omega-3, future studies with higher and/or multiple doses of omega-3 are highly recommended.

A randomized double-blinded placebo-controlled clinical trial on protective effects of pentoxifylline on gentamicin nephrotoxicity in infectious patients

BACKGROUND AND OBJECTIVE

Renal toxicity has limited gentamicin use in clinical practice. The aim of the present clinical trial was to assess the possible nephroprotective effects of pentoxifylline (PTX) against gentamicin nephrotoxicity.

MATERIALS AND METHODS

A multicenter, randomized, double-blind, placebo-controlled clinical trial was conducted on patients who had the indication for systemic gentamicin for at least 7 days. Sixty people were selected and randomly assigned. For patients in the intervention and control groups, 400 mg PTX sustained release tablet and placebo were given orally three times daily, respectively. Demographic, clinical, laboratory, and therapeutic information of patients were recorded. malondialdehyde (MDA) and tumor necrosis factor-alpha (TNF-α) levels in serum were measured on days 0 and 7.

RESULTS

The incidence of nephrotoxicity in the placebo group was 19.6 times higher than that in the PTX group (OR = 19.6, 95%CI = 3.08-114.32; P value = 0.001). The mean ± SD time onset of ATN was 4.00 ± 2.32 and 5.58 ± 1.59 days in PTX and placebo recipients, respectively (P value < 0.001). No significant differences were observed for hypokalemia, hypomagnesemia, potassium and magnesium wasting between the two groups. The mean ± SD levels of serum MDA and TNF-α at day 7 were significantly lower in the PTX compared to those in the placebo group (P value < 0.001 for both indexes).

CONCLUSION

The co-administration of 400 mg PTX orally three times daily along with gentamicin was both well-tolerated and effective in preventing the nephrotoxicity of gentamicin in patients with different infectious diseases.

Dysregulation of HULC promotes contrast-induced nephropathy (CIN) via regulating signaling pathway of miRNA-512 and prostaglandin E1 (PGE1)

It has been shown that contrast-induced nephropathy (CIN) can be attenuated by the administration of PGE1. As an enzyme responsible for the production of PGE1, PTGS1 was confirmed in this study as a miR-512 target. Meanwhile, HULC has been identified as a competing endogenous RNA of miR-512. Therefore, in this study, we tested the diagnostic value of HULC and miR-512 in subjects with or without CIN. In addition, we evaluated the regulatory relationship among HULC, miR-512, PTGS1 and PGE1 in vitro. We enrolled 320 patients with coronary heart disease and divided them into a CIN group and a non-CIN group. Subsequently, we detected the differential expression of miR-512, HULC and PGE1 in the two groups. We also used a dual luciferase reporter assay to evaluate the regulatory relationship among HULC, miR-512, PTGS1 and PGE1 in THP-1 cells. In patients with CIN, the expression levels of HULC and PGE1 were lower, but the expression level of miR-512 was higher. MiR-512 could directly bind to and negatively regulate the expression of PTGS1 and HULC. The expression of HULC was positively correlated with the expression of PTGS1 and PGE1, while negatively correlated with the expression of miR-512. The findings of this study demonstrated that deregulation of lncRNA-HULC/miR-512/PTGS1/PGE1 might be involved in the pathogenesis of CIN.

Pentoxifylline for the prevention of contrast-induced nephropathy in diabetic patients undergoing angioplasty: a randomized controlled trial

OBJECTIVES

Contrast-induced nephropathy (CIN) is one of the most important complications of contrast media. We aimed to evaluate the preventive effects of pentoxifylline (PTX) on CIN in diabetic patients undergoing angioplasty using cystatin C.

MATERIALS AND METHODS

The present study was a randomized clinical trial, which was investigated the impact of PTX in the prevention of CIN among 90 diabetic patients undergoing the angioplasty using cystatin C as a novel biomarker of renal injury. The patients randomly were allocated 1:1 into the intervention and the control groups. The intervention group received a total of 1200 mg PTX orally before the angioplasty. The serum level of cystatin C and creatinine was measured at baseline and 24 h after the procedure.

RESULTS

The incidence of CIN was 8.9% in the PTX group vs. 6.7% in the control group (p = 1.00). The baseline level of cystatin C was 1.31 ± 0.39 mg/L in the PTX group and 1.24 ± 0.42 mg/L in the control group (p = 0.561). After angioplasty, the level of cystatin C was increased to 1.33 ± 0.61 in PTX group and to 1.31 ± 0.47 in the control group but was not statistically significant. The similar pattern was also seen in the level of serum creatinine.

CONCLUSIONS

The results of this study did not support the potential benefit of PTX in the prevention of CIN in diabetic patients undergoing angioplasty.

Effectiveness of contrast-associated acute kidney injury prevention methods; a systematic review and network meta-analysis

BACKGROUND

Different methods to prevent contrast-associated acute kidney injury (CA-AKI) have been proposed in recent years. We performed a mixed treatment comparison to evaluate and rank suggested interventions.

METHODS

A comprehensive Systematic review and a Bayesian network meta-analysis of randomised controlled trials was completed. Results were tabulated and graphically represented using a network diagram; forest plots and league tables were shown to rank treatments by the surface under the cumulative ranking curve (SUCRA). A stacked bar chart rankogram was generated. We performed main analysis with 200 RCTs and three analyses according to contrast media and high or normal baseline renal profile that includes 173, 112 & 60 RCTs respectively.

RESULTS

We have included 200 trials with 42,273 patients and 44 interventions. The primary outcome was CI-AKI, defined as ≥25% relative increase or ≥ 0.5 mg/dl increase from baseline creatinine one to 5 days post contrast exposure. The top ranked interventions through different analyses were Allopurinol, Prostaglandin E1 (PGE1) & Oxygen (0.9647, 0.7809 & 0.7527 in the main analysis). Comparatively, reference treatment intravenous hydration was ranked lower but better than Placebo (0.3124 VS 0.2694 in the main analysis).

CONCLUSION

Multiple CA-AKI preventive interventions have been tested in RCTs. This network evaluates data for all the explored options. The results suggest that some options (particularly allopurinol, PGE1 & Oxygen) deserve further evaluation in a larger well-designed RCTs.

Effects of hydration combined with Shenfu injection on contrast-induced acute kidney injury in acute coronary syndrome patients undergoing percutaneous coronary intervention

The aim of the present study was to evaluate the efficacy and safety of the Shenfu injection (SFI) in the prevention of contrast-induced acute kidney injury (CI-AKI) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). A single-center prospective and randomized controlled trial was performed and 148 ACS patients undergoing PCI were divided randomly into control (n=74; receiving only 0.9% sodium chloride solution for routine hydration) and intervention (n=74; based upon routine hydration and receiving SFI) groups. Serum creatinine (Scr), blood urea nitrogen and urinary neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at the start, and 1 and 2 days after PCI. Among the 148 patients, 14 (9.4%) experienced CI-AKI subsequent to the procedure. CI-AKI occurred in 2.7% of the SFI group and 16.2% of the control group (P<0.05). The incidence of CI-AKI was lower in the intervention group when compared with the control. No serious adverse effects were observed in all patients. No differences between the levels of Scr and estimated glomerular filtration rate in the two groups were identified. However, 12 h after PCI, the urinary NGAL level in the control group was significantly higher than that in the SFI group (P<0.05). Thus, hydration combined with SFI was identified to be more effective than hydration with sodium chloride in the prevention of CI-AKI in ACS patients undergoing PCI.

Toward a Framework for Benefit-Risk Assessment in Diagnostic Imaging: Identifying Scenario-specific Criteria

RATIONALE AND OBJECTIVES

Diagnostic imaging has many effects and there is no common definition of value in diagnostic radiology. As benefit-risk trade-offs are rarely made explicit, it is not clear which framework is used in clinical guideline development. We describe initial steps toward the creation of a benefit-risk framework for diagnostic radiology.

MATERIALS AND METHODS

We performed a literature search and an online survey of physicians to identify and collect benefit-risk criteria (BRC) relevant to diagnostic imaging tests. We operationalized a process for selection of BRC with the use of four clinical use case scenarios that vary by diagnostic alternatives and clinical indication. Respondent BRC selections were compared across clinical scenarios and between radiologists and nonradiologists.

RESULTS

Thirty-six BRC were identified and organized into three domains: (1) those that account for differences attributable only to the test or device (n = 17); (2) those that account for clinical management and provider experiences (n = 12); and (3) those that capture patient experience (n = 7). Forty-eight survey participants selected 22 criteria from the initial list in the survey (9-11 per case). Engaging ordering physicians increased the number of criteria selected in each of the four clinical scenarios presented. We developed a process for standardizing selection of BRC in guideline development.

CONCLUSION

These results suggest that a process relying on elements of comparative effectiveness and the use of standardized BRC may ensure consistent examination of differences among alternatives by way of making explicit implicit trade-offs that otherwise enter the decision-making space and detract from consistency and transparency. These findings also highlight the need for multidisciplinary teams that include input from ordering physicians.

Short-Term High-Dose Vitamin E to Prevent Contrast Medium-Induced Acute Kidney Injury in Patients With Chronic Kidney Disease Undergoing Elective Coronary Angiography: A Randomized Placebo-Controlled Trial

Background

Contrast medium–induced acute kidney injury (CIAKI) is a leading cause of acquired renal impairment. The effects of antioxidants have been conflicting regarding the prevention of CIAKI. We performed a study of vitamin E use to decrease CIAKI in patients undergoing elective coronary angiography.

Methods and Results

In a placebo‐controlled randomized trial at 2 centers in Iran, 300 patients with chronic kidney disease—defined as estimated glomerular filtration rate <60 mL/min per 1.73 m²—were randomized 1:1 to receive 0.9% saline infusion 12 hours prior to and after intervention combined with 600 mg vitamin E 12 hours before plus 400 mg vitamin E 2 hours before coronary angiography or to receive placebo. The primary end point was the development of CIAKI, defined as an increase ≥0.5 mg/dL or ≥25% in serum creatinine that peaked within 72 hours. Based on an intention‐to‐treat analysis, CIAKI developed in 10 (6.7%) and 21 (14.1%) patients in the vitamin E and placebo groups, respectively (P=0.037). Change in white blood cell count from baseline to peak value was greater in the vitamin E group compared with the placebo group (−500 [−1500 to 200] versus 100 [−900 to 600]×10³/mL, P=0.001). In multivariate analysis, vitamin E (odds ratio 0.408, 95% CI 0.170–0.982, P=0.045) and baseline Mehran score (odds ratio 1.257, 95% CI 1.007–1.569; P=0.043) predicted CIAKI.

Conclusions

Prophylactic short‐term high‐dose vitamin E combined with 0.9% saline infusion is superior to placebo for prevention of CIAKI in patients undergoing elective coronary angiography.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02070679.

Preventive effect of reduced glutathione on contrast-induced nephropathy in elderly patients undergoing coronary angiography or intervention: a randomized, controlled trial

Coronary angiography can be a high-risk condition for the incidence of contrast-induced nephropathy (CIN) in elderly patients. Reduced glutathione, under a variety of mechanisms, may prevent CIN in this procedure. We prospectively examined whether hydration with reduced glutathione is superior to hydration alone for prevention of CIN in an elderly Han Chinese population. A total of 505 patients (271 males and 234 females) aged 75 years or older who underwent non-emergency coronary angiography or an intervention were randomly divided into two groups. The treatment group received hydration with reduced glutathione (n=262) and the control group received hydration alone (n=243). Serum creatinine and blood urea nitrogen levels were measured prior to coronary angiography and 48 h after this procedure. The primary endpoint was occurrence of CIN, which was defined as 25% or 44.2 µmol/L above baseline serum creatinine levels 48 h after the procedure. The overall incidence of CIN was 6.49% in the treatment group and 7.41% in the control group, with no significant difference between the groups (P=0.68). In subgroup analysis by percutaneous coronary intervention, no significant differences were found between the two groups. In summary, reduced glutathione added to optimal hydration does not further decrease the risk of CIN in elderly patients undergoing coronary angiography or an intervention.

Preventive effect of pentoxifylline on contrast-induced acute kidney injury in hypercholesterolemic rats

Oxidative stress is an important mechanism of contrast-induced acute kidney injury (CIAKI). The optimal strategy to prevent CIAKI remains unclear. The aim of the present study was to assess the effect of pentoxifylline, a nonspecific phosphodiesterase inhibitor, on the prevention of CIAKI. A total of 32 healthy male Sprague-Dawley rats were randomly divided into normal dietary group (NN; n=8) and a high cholesterol-supplemented dietary group (HN; 4% cholesterol and 1% cholic acid; n=24). At the end of eight weeks, the rats in the high cholesterol diet group were randomly divided into three subgroups (n=8 in each group). CIAKI was induced in two of the subgroups via intravenous injection of the radiocontrast media iohexol (10 ml/kg). Pentoxifylline (50 mg/kg) was administered to one of the iohexol-treated groups via intraperitoneal injection 12 h prior to and following contrast media (CM) injection. Kidney function parameters and oxidative stress markers were then measured. The renal pathological changes were evaluated using hematoxylin and eosin staining and scored semi-quantitatively. In iohexol-injected rats, serum creatinine (Scr), renal pathological scores, renal malondialdehyde (MDA) content, renal NADPH oxidase activity, fractional excretion of sodium (FENa%) and fractional excretion of potassium (FEK%) were significantly increased (P<0.01). The Scr, histologic scores, renal MDA content, NADPH oxidase activity, FENa% and FEK% in the rats treated with pentoxifylline prior to iohexol were observed to be reduced compared with those in rats treated with iohexol alone (P<0.01). This suggests that pentoxifylline significantly attenuates renal injuries, including tubular necrosis and proteinaceous casts induced by CM. It may be concluded that pentoxifylline protected the renal tissue from the nephrotoxicity induced by low-osmolar CM via an antioxidant effect.

Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) represents an important adverse effect of contrast media (CM) administration. Contrast-induced nephropathy is associated with prolonged hospitalization as well as increased cardiovascular morbidity, renal morbidity, and all-cause mortality. Several risk factors may predict CIN incidence, and various scores and ratios have been proposed to identify high-risk patients. Novel biomarkers may provide an earlier diagnosis of CIN. A multifactorial approach is required for CIN prevention including hydration, administration of low- or iso-osmolar CM, minimizing CM volume, and statin administration. Renal function may deteriorate after CM administration, even in the absence of CIN. Therefore, this deterioration may not be an “all or none” phenomenon; it may well occur in many patients receiving CM, with/without CIN, and may prove to be an underestimated risk factor. Patients should be followed up for longer periods as outpatients after CM exposure to assess kidney function and predict subsequent increased morbidity and mortality.

Different interventions in preventing contrast-induced nephropathy after percutaneous coronary intervention

BACKGROUND

This study aimed to observe the preventive potential of different hydration solutions on contrast-induced nephropathy (CIN) after percutaneous coronary intervention.

METHODS

We initially screened 627 patients who were admitted to the Division of Cardiology, Beijing Anzhen Hospital between October 2010 and October 2011. The research subjects were randomly divided into four groups and were given: normal physiological saline (PS), sodium bicarbonate (SB), oral administration of PS + N-acetylcysteine (NAC) (PS + NAC), or oral administration of SB + NAC (SB + NAC). These patients were administered a hypotonic nonionic contrast agent, and the incidence of CIN in each group was observed.

RESULTS

The total incidence rate of CIN was 4.47 %, while the CIN incidence rates in the PS group, the SB group, the PS + NAC group and the SB + NAC group were 3.11, 5.03, 4.46 and 5.33 %, respectively. The differences between these groups were not statistically significant (P = 0.238), and for patients with diabetes and/or renal dysfunction, the incidence rates of CIN among the four groups did not show statistically significant differences (P = 0.238, 0.156, 0.287).

CONCLUSION

Use of PS, SB, and NAC caused no significant reduction in the incidence of CIN, but in high-risk patients with diabetes and/or renal dysfunction, SB + NAC might be superior to the application of isotonic crystalloid solution.

Prevention of contrast-induced nephropathy with prostaglandin E1 in high-risk patients undergoing percutaneous coronary intervention

PURPOSE

Contrast-induced nephropathy (CIN) is an important complication in the use of iodinated contrast media. The present study aimed to assess the safety and efficacy of prostaglandin E1 (PGE1) in prevention of CIN in patients with high-risk factors undergoing percutaneous coronary intervention (PCI).

METHODS

The study group consisted of 163 patients who had undergone a coronary intervention procedure between January 1, 2012 and October 31, 2012. Study participants were randomly assigned to either the PGE1 group (82 patients) or the control group (81 patients). Patients in the PGE1 group received PGE1 intravenous infusion of 20 ng/kg/min for 6 h before and after the administration of contrast media. The control group received 0.9 % sodium chloride solution for routine hydration only. A nonionic, low-osmolality contrast agent was used in our laboratory at this time. Serum creatinine (Scr) values and estimated glomerular filtration rate were measured before and within 48 h of the administration of contrast agents. CIN was defined as an increase of ≥0.5 mg/dL or ≥ a 25 % increase in Scr concentrations over baseline within 48 h of angiography.

RESULTS

The amount of contrast agent administered was similar for the PGE1 and control groups (156 ± 63 vs. 161 ± 68 mL, P > 0.05). The incidence of CIN was lower in the PGE1 group than in the control group (3.7 vs. 11.1 %, P < 0.05). No serious adverse effects were observed.

CONCLUSIONS

In patients with high-risk factors undergoing PCI, the use of PGE1 for prevention of CIN is safe and efficacious.

Alprostadil plays a protective role in contrast-induced nephropathy in the elderly

PURPOSE

To evaluate the protective effects of alprostadil on contrast-induced nephropathy (CIN) in elderly patients.

METHODS

We randomized 370 patients into the control or alprostadil group. The patients in the control group were injected with 100 ml sterile saline and the patients in the alprostadil group with alprostadil (0.4 μg/kg/day) in 100 ml sterile saline before and after iohexol-enhanced (100 ml) computed tomography (CT). Serum creatinine (Scr), blood urea nitrogen (BUN), cystatin C (CysC), and creatinine clearance (Ccr) were analyzed or calculated. ΔScr and ΔCysC were determined by the changes between baseline and highest Scr and CysC levels. The standard for CIN was a postdose Scr increase >44.2 μmol/l or >25 % over baseline.

RESULTS

In the control group, peak Scr (P < 0.05) and ΔScr (P < 0.01) were higher than those in the alprostadil group. The postdose CysC at 24 h (P < 0.05), 48 h (P < 0.05), and 72 h (P < 0.05), peak CysC (P < 0.01), and ΔCysC (P < 0.05) in the control group were higher than those in the alprostadil group. The incidence of CIN in the control group was 22.2 %, which was higher than in the alprostadil group (9.1 %, P < 0.01). Subgroup analyses in patients with advanced age (≥ 80 years), concomitant hypertension or diabetes, and abnormal baseline renal function (Ccr ≤ 60 ml/min) showed that the alprostadil group had lower ΔScr and ΔCysC than the control group after contrast-enhanced CT examination in all four subgroups (P < 0.05 or P < 0.01).

CONCLUSIONS

In this cohort of older patients undergoing contrast CT, the use of alprostadil reduced the incidence of CIN.