The global incidence and mortality of contrast-associated acute kidney injury following coronary angiography: a meta-analysis of 1.2 million patients

Efficacy and safety of nicorandil for prevention of contrast-induced nephropathy in patients undergoing coronary procedures: a systematic review and meta-analysis

BACKGROUND

Contrast-induced nephropathy (CIN) is a potentially serious complication of intravenous or intra-arterial contrast administration during angiographic procedures that results in renal dysfunction. CIN can increase the risk of mortality by three-fold. This meta-analysis assesses the efficacy and safety of nicorandil for the prevention of CIN in patients undergoing percutaneous coronary intervention (PCI) or coronary angiography (CAG).

METHODS

Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ClinicalTrials.gov were used to perform a thorough literature search from their inception to July 2024. Twelve randomized controlled trials (RCTs) were included. A random-effects meta-analysis was performed on RevMan and pooled estimates were presented as forest plots. The Mantel-Haenszel method was used for dichotomous outcomes and risk ratios (RRs) were calculated along with 95% confidence intervals (95% CI).

RESULTS

This meta-analysis included 2787 participants (nicorandil: 1418, control: 1394). The use of nicorandil was protective against CIN (RR 0.38, 95% CI 0.29-0.50). There was no significant difference in major adverse events between the groups (RR 0.77, 95% CI 0.52-1.13, p = 0.18). Similarly, the use of nicorandil did not affect the risk of developing stroke (RR 1.05, 95% CI: 0.38-2.95), myocardial infarction (RR 0.90, 95% CI: 0.56-1.43), heart failure (RR 0.81, 95% CI: 0.39-1.68), cardiac death (RR 0.90, 95% CI: 0.28-2.88) and dialysis (RR 0.70, 95% CI: 0.11-4.44).

CONCLUSION

This meta-analysis concludes that nicorandil reduces CIN incidence after PCI or CAG without significantly increasing major adverse events. However, further well-designed, large-scale RCTs are needed to strengthen the practical relevance before routine clinical use.

Reliability and quality of information provided by artificial intelligence chatbots on post-contrast acute kidney injury: an evaluation of diagnostic, preventive, and treatment guidance

OBJECTIVE

The aim of this study was to evaluate the reliability and quality of information provided by artificial intelligence chatbots regarding the diagnosis, preventive methods, and treatment of contrast-associated acute kidney injury, while also discussing their benefits and drawbacks.

METHODS

The most frequently asked questions regarding contrast-associated acute kidney injury on Google Trends between January 2022 and January 2024 were posed to four artificial intelligence chatbots: ChatGPT, Gemini, Copilot, and Perplexity. The responses were evaluated based on the DISCERN score, the Patient Education Materials Assessment Tool for Printable Materials score, the Web Resource Rating scale, the Coleman-Liau index, and a Likert scale.

RESULTS

As per the DISCERN score, the quality of information provided by Perplexity received a rating of "good", while the quality of information acquired by ChatGPT, Gemini, and Copilot was scored as "average." Based on the Coleman-Liau index, the readability of the responses was greater than 11 for all artificial intelligence chatbots, suggesting a high level of complexity requiring a university-level education. Similarly, the understandability and applicability scores on the Patient Education Materials Assessment Tool for Printable Materials and the Web Resource Rating scale were low for all artificial intelligence programs. In consideration of the Likert score, all artificial intelligence chatbots received favorable ratings.

CONCLUSIONS

While patients increasingly utilize artificial intelligence chatbots to acquire information about contrast-associated acute kidney injury, the readability and understandability of the information provided may be low.

Effects of iopromide contrast agents on kidney iNOS expression and tubular histopathology alterations

Contrast-induced acute kidney injury is a common complication marked by reduced kidney function within 48  hours of contrast administration. The aim of this study was to evaluate renal function, anatomy, and molecular changes at 24  hours, 48  hours, and 72  hours post-iodinated contrast media (ICM) administration. This true-experimental study used a post-test-only control group design. Rats underwent unilateral nephrectomy, followed by intravenous injection of ICM using iopromide 370  mg iodine/mL per rat at a dose of 231  mg iodine, and were then divided into four groups: control (C), rats terminated at 24  hours after iopromide administration (E24), rats terminated at 48  hours after iopromide administration (E48), and rats terminated at 72  hours (E72) after iopromide administration, with eight rats per group. Renal function (BUN and SCr levels) remained unchanged after 24, 48, and 72  hours of iopromide administration. Iopromide increased renal tubular damage, as shown by higher histopathological scores for loss of brush border and tubular necrosis, except for proteinaceous casts, where histopathological scores increase especially within the first 24  hours and decrease after 72  hours. Iopromide significantly altered iNOS expression in the glomerulus at 24 and 48  hours, and iNOS expression was decreased after 72  hours. iNOS expression in the intrarenal vascular and tubules was unaffected by iopromide administration. In conclusion, this study found no changes in renal function parameters, improvement in proteinaceous casts, and increased iNOS expression in the glomerulus, offering new insights into the effects of contrast on kidneys.

Early Acute Kidney Injury in Stroke Patients Submitted to Endovascular Treatment: A Cohort Study

Background/Objectives: Acute kidney injury (AKI) is a potential complication of cardiovascular disorders and is associated with worse outcome. The aim of this study was to assess the incidence of early AKI after endovascular therapy for acute ischemic stroke, identify predictors for this complication, and test the association between AKI and mortality or death or dependency. Methods: This was a single-center cohort study involving consecutive patients with acute ischemic stroke submitted to endovascular therapy between 2015 and 2022. AKI was defined according to the KDIGO criteria and evaluated at 48 h. Other outcomes of interest were vital status and functional dependency at 3 months using the modified Rankin Scale, with death or dependency being defined as a score > 2. An adjustment for potential confounders was performed using logistic regression. Results: Overall, 1150 patients were included in the analysis, with a mean age of 74 years and a slight female preponderance (56%). The median NIHSS was 15, the mean onset-to-groin time was 392 min, and 92% of patients were successfully recanalized. The overall incidence rate of AKI was 6%. On univariate analysis, patients with AKI were older (p = 0.002), had a longer time to EVT (p = 0.042), higher NIHSS (p = 0.006), higher blood glucose (p = 0.033), and lower baseline glomerular filtration rate (GFR) (p < 0.001). After adjustment for confounders, AKI was independently associated with NIHSS (p = 0.012), time to treatment (p = 0.004), and lower baseline GFR (p < 0.001). AKI was also independently associated with higher mortality (OR = 2.302, p = 0.003). Conclusions: Patients with impaired baseline renal function and more severe stroke are at higher risk of AKI, and AKI begets worse stroke outcome. Better strategies are required to optimize treatment outcome in these patients and avert this vicious cycle.

Complication Rates Following Cerebral and Coronary Angiography: Nationwide Analysis 2008-2014

Catheter-based angiography is an essential procedure for the diagnosis and treatment of vascular complications in patients. Since cerebral and coronary angiography are similar techniques that utilize the same access sites and general principles, the associated risks overlap and should be identified to help direct patient care. The purpose of this study was to determine complication rates in a combined cohort of cerebral and coronary angiography patients, as well as conduct a comparative analysis of coronary and cerebral angiography complications. The National Inpatient Sample was queried from 2008 to 2014 to identify patients who underwent coronary or cerebral angiography. After assessment of baseline characteristics, complication rates, and disposition in the combined cohort, propensity matching was utilized to create sub-cohorts of coronary and cerebral angiography patients based on demographics and comorbidities. Comparative analysis of procedural complications and disposition was then performed. A total of 3,763,651 hospitalizations were included in our study cohort (3,505,715 coronary angiographies and 257,936 cerebral angiographies). The median age was 62.9 years, with females being 46.42%. The most prevalent comorbidities in the overall cohort were hypertension (69.92%), coronary artery disease (69.48%), smoking (35.64%), and diabetes mellitus (35.13%). Propensity matching demonstrated that the cerebral angiography cohort had lower rates of acute and unspecified renal failure (5.4% vs 9.2%, OR 0.57, 95% CI, 0.53-0.61, P < 0.001), hemorrhage/hematoma formation (0.8% vs 1.3%, OR 0.63, 95% CI, 0.54-0.73, P < 0.001), and equivalent rates of retroperitoneum hematoma formation (0.03% vs 0.04%, OR 1.49, 95% CI, 0.76-2.90, P = 0.247) and arterial embolism/thrombus formation (0.3% vs 0.3%, OR 1.01, 95% CI, 0.81-1.27, P = 0.900). Our study showed both cerebral and coronary angiography have generally low rates of procedural complications. Matched cohort analysis demonstrated that cerebral angiography patients are at no greater risk for complications than coronary angiography patients.

Kidney protection strategy lowers the risk of contrast-associated acute kidney injury

We developed a comprehensive kidney protection strategy (KPS), which comprises left ventricular end-diastolic pressure-guided saline hydration, ultralow contrast coronary angiography, and a staged coronary revascularization procedure under suitable conditions. This study aimed to investigate KPS's effect on the risk of developing contrast-associated acute kidney injury (CA-AKI) among persons with moderate-to-advanced kidney insufficiency (KI). Seventy patients who had undergone cardiac catheterization with an estimated glomerular filtration rate (eGFR) of 15-45 mL/min/1.73 m2 were investigated retrospectively. Among these, 19 patients who had received KPS and 51 who had undergone cardiac catheterization with usual care (UC) were enrolled. CA-AKI was defined as a 0.3-mg/dL increase in serum creatinine levels or dialysis initiation within 72 h after contrast exposure. The inverse probability of treatment weighting (IPTW)-adjusted cohort was analyzed according to the Mehran 2 risk categories. Patients' mean age was 73.3 ± 9.6 years; mean eGFR was 29.8 ± 8.5 mL/min/1.73 m2; and median of Mehran 2 risk score, 8. Most patients presented with acute myocardial infarction (AMI) or heart failure, and one-fifth of the administered cardiac catheterizations were emergency procedures. After the IPTW adjustment, the KPS group showed a significantly lower CA-AKI risk than the UC group (4% vs. 20.4%; odds ratio 0.19, 95% confidence interval 0.05-0.66). This effect was consistent across various subgroups according to different variables, including old age, AMI, advanced KI, high-risk category, left ventricular systolic dysfunction, and multivessel disease. Conclusively, KPS may reduce the CA-AKI risk in high-risk patients with moderate-to-advanced KI who have undergone cardiac catheterization.

Intraprocedural continuous saline infusion lines significantly reduce the incidence of acute kidney injury during endovascular procedures for stroke and myocardial infarction: evidence from a systematic review and meta-regression

BACKGROUND

Contrast media used in mechanical therapies for stroke and myocardial infarction represent a significant cause of acute kidney injury (AKI) in acute medical scenarios. Although the continuous saline infusion line (CSIL) is a standard procedure to prevent thrombus formation within the catheter during neurovascular interventions of mechanical thrombectomy (MT), it is not utilized in percutaneous coronary interventions (PCI).

METHODS

A systematic review of the incidence of AKI after MT for stroke treatment was performed. These data were compared with those reported in the literature regarding the incidence of AKI after PCI for acute myocardial infarction. A random-effect model meta-regression was performed to explore the effects of CSIL on AKI incidence, using clinical details as covariates.

RESULTS

A total of 18 and 33 studies on MT and PCI were included, respectively, with 69,464 patients (30,138 [43.4%] for MT and 39,326 [56.6%] for PCI). The mean age was 63.6 years±5.8 with male 66.6%±12.8. Chronic kidney disease ranged 2.0-50.3%. Diabetes prevalence spanned 11.1% to 53.0%. Smoking status had a prevalence of 7.5-72.0%. Incidence of AKI proved highly variable (I2=98%, Cochrane's Q 2985), and appeared significantly lower in the MT subgroup than in the PCI subgroups (respectively 8.3% [95% confidence interval: 4.7-11.9%] vs. 14.7 [12.6-16.8%], P<0.05). Meta-regression showed that CSIL was significantly associated with a decreased incidence of AKI (OR=0.93 [1.001-1.16]; P=0.03).

CONCLUSIONS

Implementation of CSIL during endovascular procedures in acute settings was associated with a significant decrease in the risk of AKI, and its safety should be routinely considered in such interventions.

Impact of iodinated contrast shortage on contrast-associated acute kidney injury: a single center experience

BACKGROUND

In March 2022, a COVID-19 outbreak disrupted the global supply of iodine contrast media (ICM). Healthcare systems implemented contrast-saving strategies to maintain their remaining ICM supplies. This study sought to determine the impact of contrast shortage on the incidence of contrast-associated acute kidney injury (CA-AKI).

METHODS

This was a retrospective study of 265 patients undergoing 278 percutaneous coronary interventions (PCI) during 4-month periods prior to (9/1/2021 to 12/31/2021) and during (5/1/2022 to 8/31/2022) contrast shortage at a single center. The primary endpoint was the incidence of CA-AKI between study periods.

RESULTS

A total of 148 and 130 PCIs were performed before and during contrast shortage, respectively. The incidence of CA-AKI significantly decreased from 11.5% to 4.6% during contrast shortage (P = 0.04). During the shortage, average contrast volume per PCI was significantly lower (123 ± 62 mL vs 88 ± 46 mL, P < 0.001), while coronary imaging was significantly higher (34.3% vs 50%, P = 0.009) compared to preshortage. All-cause mortality at discharge was comparable between study periods (2.8% vs 3.3%, respectively; P = 0.90).

CONCLUSION

The scarcity of ICM for PCI procedures in this single-center experience was associated with a significant increase in the utilization of intravascular imaging and a significant reduction in CA-AKI.

[Effectiveness of the DyeVert Power XT system during percutaneous coronary interventions]

Introduction and objectives

Contrast-induced-acute kidney injury (CI-AKI) is a potential complication of angiographic procedures. The DyeVert Contrast Reduction system (Osprey Medical, United States) is a device to reduce the concentration of contrast medium (CM) in the kidneys by decreasing the amount of CM delivered to patients. Unlike manual systems, few data are available on the DyeVert Power XT system, which is used in conjunction with automated contrast injection. The main aim of our study was to evaluate its effectiveness during percutaneous coronary interventions (PCI).

Methods

Between 2020 and 2022, 101 patients who underwent PCI with the DyeVert Power XT system (case group) were enrolled to evaluate the amount of CM saved through the use of this device, as well as the rate, severity, and predictors of CI-AKI. Patients who underwent PCI without the use of the device (control group) were enrolled to create a matched group allowing assessment of differences in CM and the CI-AKI rate.

Results

In the case group, the amount of CM saved was 114 ± 42 mL, representing an average of 32% of the total CM. Fourteen patients (13.9%) developed CI-AKI. The only independent predictors of CI-AKI were hematocrit (OR, 0.86; 95%CI, 0.74-0.99; P = .04) and ejection fraction (OR, 0.88; 95%CI, 0.82-0.95; P = .001). As a result of diversion by the device, the amount of CM delivered was lower in the case group than in controls (252 vs 267 mL; P = .42), but this difference was nonsignificant. Equally, the reduction in CI-AKI (14.3% vs 16.3%) was nonsignificant.

Conclusions

Hematocrit and ejection fraction may be more important predictors of CI-AKI than the CM volume normally used during PCI in the general population. The net practical benefit of DyeVert Power XT was low.

Acute kidney injury after endovascular therapy in acute stroke patients: systematic review with meta-analysis

AIMS

Endovascular therapy (EVT) is a highly effective stroke treatment, but it requires the administration of contrast media which puts patients at risk of acute kidney injury (AKI). AKI is associated with increased morbidity and mortality in cardiovascular patients.

METHODS

PubMed, Scopus, ISI and the Cochrane Library were systematically searched for observational and experimental studies assessing the occurrence of AKI in adult acute stroke patients submitted to EVT. Two independent reviewers collected study data regarding study setting, period, source of data, and AKI definition and predictors, the outcomes of interest being AKI incidence and 90-day death or dependency (modified Rankin Scale score ≥3). These outcomes were pooled using random effect models, and heterogeneity was measured using the I2 statistic.

RESULTS

22 studies were identified and included in the analysis, involving 32 034 patients. Pooled incidence of AKI was 7% (95% CI 5% to 10%), but heterogeneity was high across studies (I2=98%), and not accounted for by the definition of AKI used. The most frequently reported AKI predictors were impaired baseline renal function (5 studies) and diabetes (3 studies); 3 studies (2103 patients) reported data on death and 4 studies (2424 patients) reported data on dependency. Overall, AKI was associated with both outcomes, with ORs of 6.21 (95% CI 3.52 to 10.96) and 2.86 (95% CI 1.88 to 4.37), respectively. Heterogeneity was low for both analyses (I2=0%).

CONCLUSIONS

AKI affects 7% of acute stroke patients submitted to EVT and identifies a subgroup of patients for which treatment outcomes are suboptimal, with an increased risk of death and dependency.

Contrast-Induced Nephropathy in Interventional Cardiology: Incidence, Risk Factors, and Identification of High-Risk Patients

AIM

This study aimed to study contrast-induced nephropathy (CIN) or more recent nomenclature contrast-associated acute kidney injury (CI-AKI) in patients undergoing percutaneous coronary procedures, evaluating CIN incidence, risk factors (RFs), and high-risk patients with CIN.  Methods: This is a prospective, observational, unicentric trial of patients who underwent coronary angiography and/or percutaneous coronary intervention (PCI) in the University Hospital Center (UHC) "Mother Teresa" in Tirana, Albania, during 2016-2018. CIN was defined as an increase of 25% and/or by 0.5 mg/dL of serum creatinine (SCr) and high-risk patients with CIN as an increase by 50% and/or by 2 mg/dL and/or need for dialysis compared to the basal pre-procedural values. We evaluated RFs for CIN: preexisting renal lesion (PRL), heart failure (HF), age, diabetes mellitus (DM), anemia, and contrast quantity.  Results: The incidence of CIN resulted in 14.4%. HF, PRL, and age ≥65 years resulted in independent RFs for CIN, whereas anemia, DM, and contrast quantity >100 mL did not. PRL proved to be the most important RF for CIN, whereas HF was the only independent RF for high-risk CIN patients.

CONCLUSIONS

The incidence of CIN coincides with the results in the literature. PRL, HF, and age ≥65 years resulted in independent RFs for CIN; more and larger trials are needed to evaluate DM, anemia, and contrast quantity related to their impact on CIN. High-risk patients with CIN represent the most problematic patients of this pathology.

Contrast media volume reduction with the DyeVertTM system to prevent acute kidney injury in stable patients undergoing coronary procedures

BACKGROUND

Contrast associated acute kidney injury (CA-AKI) can lead to an increased risk of adverse events. Contrast media (CM) volume reduction has been advocated as a pivotal strategy to prevent CA-AKI in stable patients undergoing percutaneous coronary procedures.

AIMS

To compare the effectiveness of CM volume reduction with the DyeVertTM system versus conventional strategy in reducing the risk of CA-AKI.

METHODS

We prospectively collected data from 136 patients with stable coronary artery disease at high risk of CA-AKI treated with left ventricular end diastolic pressure (LVEDP)- guided hydration and undergoing interventions with the use of the DyeVertTM (Osprey Medical Inc.) system. Patients previously enrolled in the LVEDP-guided hydration arm of the "Renal Insufficiency Following Contrast MEDIA Administration triaL III" (REMEDIAL III) were considered as controls. Propensity score was used to perform 1:1 matching to adjust for major confounders. The primary outcome was the occurrence of CA-AKI, as defined by an absolute increase of creatinine values ≥0.3 mg/dL at 48 h.

RESULTS

Patients in the DyeVert group were treated with a significant lower CM volume (median: 47.5 vs. 84.0 mL, p < 0.001). The trend in creatinine increase was lower (p = 0.004) and the Δ of creatinine (0-48 h) showed a higher drop (-0.18 vs. -0.10 mg/dL, p = 0.036) in the DyeVert group. The risk of CA-AKI was significantly lower in DyeVert group compared to control group (5.1% vs. 16.8%; odds ratio 0.27, 95% confidence interval [0.12-0.61]).

CONCLUSIONS

CM volume reduction with the DyeVertTM system seems to be superior to conventional strategies in reducing the occurrence of CA-AKI.

Development of real-time individualized risk prediction models for contrast associated acute kidney injury and 30-day dialysis after contrast enhanced computed tomography

PURPOSE

This study aimed to develop preprocedural real-time artificial intelligence (AI)-based systems for predicting individualized risks of contrast-associated acute kidney injury (CA-AKI) and dialysis requirement within 30 days following contrast-enhanced computed tomography (CECT).

METHOD

This single-center, retrospective study analyzed adult patients from emergency or in-patient departments who underwent CECT; 18,895 patients were included after excluding those who were already on dialysis, had stage V chronic kidney disease, or had missing data regarding serum creatinine levels within 7 days before and after CECT. Clinical parameters, laboratory data, medication exposure, and comorbid diseases were selected as predictive features. The patients were randomly divided into model training and testing groups at a 7:3 ratio. Logistic regression (LR) and random forest (RF) were employed to create prediction models, which were evaluated using receiver operating characteristic curves.

RESULTS

The incidence rates of CA-AKI and dialysis within 30 days post-CECT were 6.69% and 0.98%, respectively. For CA-AKI prediction, LR and RF exhibited similar performance, with areas under curve (AUCs) of 0.769 and 0.757, respectively. For 30-day dialysis prediction, LR (AUC, 0.863) and RF (AUC, 0.872) also exhibited similar performance. Relative to eGFR-alone, the LR and RF models produced significantly higher AUCs for CA-AKI prediction (LR vs. eGFR alone, 0.769 vs. 0.626, p < 0.001) and 30-day dialysis prediction (RF vs. eGFR alone, 0.872 vs. 0.738, p < 0.001).

CONCLUSIONS

The proposed AI prediction models significantly outperformed eGFR-alone for predicting the CA-AKI and 30-day dialysis risks of emergency department and hospitalized patients who underwent CECT.

Delayed PCI is not beneficial for STEMI patients with impaired renal function: a retrospective cohort study

BACKGROUND

Preexisting impaired renal function (IRF) and contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) are important prognostic parameters, but it is unknown whether delayed PCI is still beneficial for STEMI patients with IRF.

METHODS

A retrospective single-center cohort study was performed in 164 patients who presented at least 12 h after symptom onset, and were diagnosed with STEMI and IRF. They were assigned to two groups to receive PCI plus optimal medical therapy (OMT) and OMT alone respectively. Clinical outcomes at 30 days and 1 year were compared between two groups, and hazard ratio for survival was analyzed using Cox regression model. A power analysis demanded 34 patients in each group to produce a power of 90% and a P value of 0.05.

RESULTS

The 30-day mortality was significantly lower in PCI group (n = 126) than in non-PCI group (n = 38) (11.1% versus 28.9%, P = 0.018), while there was no significant difference in the 1-year mortality and incidence of cardiovascular comorbidities between the two groups. Cox regression analysis showed that patients with IRF didn't benefit from receiving PCI on survival rate (P = 0.267).

CONCLUSIONS

Delayed PCI is not beneficial on one-year clinical outcomes for STEMI patients with IRF.

Investigating the Prevalence of Contrast-associated Nephropathy and the Related Risk Factors in Patients Undergoing Elective Angioplasty

Objective

Contrast-associated nephropathy (CAN) is a sudden decrease in kidney function following contrast media administration. Considering the importance of CAN in the patient's outcome and the high prevalence of this complication in cardiac catheterizing centers, this study was designed to investigate the prevalence and the related risk factors of CAN in patients undergoing angioplasty in Chamran Heart Hospital, Isfahan, Iran, from January 2022 to June 2022.

Methods

The inclusion criteria were adult patients above 18 admitted for elective percutaneous coronary intervention (PCI). Patient demographic information, underlying diseases and medications, dehydration state, type and amount of contrast media, and serum levels of blood urea nitrogen (BUN) and serum creatinine (SrCr) at 24 and 72 h after contrast injection were all recorded.

Findings

Out of 340, 128 patients developed CAN after PCI, giving an incidence of 37.64%. Adjusted analysis showed a significant relation between age over 65, the amount of contrast media administered, and the use of furosemide with the incidence of CAN. However, adjusted logistic regression analysis failed to show any significant relationship between the risk of CAN and the hydration status of the patients at 24 and 48 h after receiving contrast media as diagnosed by BUN/SrCr >20.

Conclusion

The prevalence of CAN in this study was higher than in other studies since this high-risk population was under risk factors such as arterial injection of contrast material and a higher amount of contrast material administration. In addition, advanced age, volume of contrast material, and previous or concurrent furosemide administration were associated with an increased risk of CAN.

Fibrinogen-to-Albumin Ratio Predicts Postcontrast Acute Kidney Injury in Patients with Non-ST Elevation Acute Coronary Syndrome after Implantation of Drug-Eluting Stents

Background

Postcontrast acute kidney injury (PC-AKI) is an adverse reaction to iodinated contrast agents. In this study, we investigated the use of fibrinogen-to-albumin ratio (FAR) as a novel inflammatory marker to track the development and progression of PC-AKI in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) after the implantation of drug-eluting stents (DESs).

Methods

A total of 872 patients with NSTE-ACS were enrolled in this study. PC-AKI was identified when serum creatinine (SCr) levels increased >26.5 mol/L (0.3 mg/dL) or was 1.5 times the baseline level within 48-72 h of exposure to an iodinated contrast agent. The effects of different variables on PC-AKI were evaluated using univariate regression analysis. Multivariate logistic regression analysis was used to determine the independent predictors of PC-AKI. The predictive value of FAR was assessed by estimating the area under the receiver operating characteristic (ROC) curve.

Results

In total, 114 (13.1%) patients developed PC-AKI. The patients with PC-AKI had lower albumin levels (40.5 ± 3.4 vs. 39.0 ± 3.5, P < 0.001), higher fibrinogen levels (3.7 ± 0.6 vs. 4.1 ± 0.5, P < 0.001), and higher FAR levels (9.2 ± 1.7 vs. 10.5 ± 1.7, P < 0.001) than those with non-PC-AKI. There were no significant differences in the preoperative SCr levels between the two groups. After adjusting for confounding factors, FAR was found to be an independent predictor of PC-AKI (OR = 1.478, 95% CI = 1.298-1.684, P < 0.001). ROC analysis revealed that for PC-AKI prediction, the area under the curve for FAR was 0.702. The optimum cut-off value of FAR was 10.0, with a sensitivity of 64.9% and a specificity of 69.8%. Moreover, FAR had a higher predictive value for PC-AKI than the Mehran score (0.702 vs. 0.645).

Conclusion

Our study showed that elevated preoperative FAR was closely associated with the development of PC-AKI in patients with NSTE-ACS after implantation of DESs. Therefore, it may be worth monitoring FAR as a guide for using preventive measures to avoid the development of PC-AKI.

Prevention and Management of AKI in ACS Patients Undergoing Invasive Treatments

PURPOSE OF REVIEW

Management of patients presenting with acute coronary syndrome (ACS) includes invasive procedures that may increase the risk of acute kidney injury (AKI). AKI adversely affects the outcomes of such procedures and complicates the management of ACS. We have summarized several strategies for the prevention and management of AKI in this critical patient group including in the pre-procedural, intraprocedural, and post-procedural settings.

RECENT FINDINGS

Definitive prevention and management strategies for AKI in patients presenting with ACS requiring invasive management can be confounded by the variation in data outcomes. Pre-procedural hydration with normal saline when accounting for time to catheterization, radial artery access, contrast stewardship, and close monitoring of renal function after catheterization should be implemented.

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.

DyeVert Contrast Reduction System Use in Patients Undergoing Coronary and/or Peripheral Angiography: A Systematic Literature Review and Meta-Analysis

Background

Contrast-associated acute kidney injury (CA-AKI) is an important adverse effect associated with injecting iodinated intra-arterial contrast media (CM) during coronary angiography. The DyeVert™ Contrast Reduction System is a medical device intended to reduce the intra-arterial CM volume (CMV) administered. The aim of this study was to assess DyeVert System clinical effectiveness and safety by implementing a systematic review and meta-analysis of existing evidence.

Methods

Systematic electronic literature searches were conducted in MEDLINE, Embase, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and the International Clinical Trials Registry Platform database. Relevant data were extracted from included studies and meta-analyses were performed to synthesize evidence across studies.

Results

The review included 17 eligible studies involving 1,731 DyeVert System cases and 1,387 control cases (without the use of DyeVert). Meta-analyses demonstrated use of the DyeVert System reduced CMV delivered to the patient by 39.27% (95% CI, 36.10-42.48%, P < 0.001), reduced CMV/baseline renal function ratios (Hedges's g, -0.56; 95% CI, -0.70 to -0.42, P < 0.001) and percentage of cases exceeding the maximum CMV threshold (risk difference -0.31, 95% CI, -0.48 to -0.13, P < 0.001) while maintaining adequate image quality in 98% of cases. DyeVert System cases demonstrated lower CA-AKI incidence vs. controls (absolute risk reduction 5.00% (95% CI, 0.40-9.80%; P = 0.03), relative risk 0.60 (95% CI, 0.40-0.90; P = 0.01) with a pooled estimate of the number needed to treat with the DyeVert System to avoid 1 CA-AKI event of 20.

Conclusion

DyeVert System use significantly reduces CMV delivered to the patient, CMV/baseline renal function ratios, and CA-AKI incidence while maintaining image quality. Accordingly, the device may serve as an adjunctive, procedure-based strategy to prevent CA-AKI. Future multi-center studies are needed to further assess effects of minimizing CMV on endpoints such as CA-AKI prevention, incidence of adverse cardiac and renal events, and health care costs.

Predictive value of combining the level of fibrinogen and CHA2DS2-VASC Score for contrast-induced acute kidney injury in patients with acute coronary syndromes undergoing percutaneous coronary intervention

OBJECTIVE

The present study aimed to investigate the value of preprocedural fibrinogen (FIB) combined with CHA2DS2-VASC scores in the risk prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS).

METHOD

A total of 934 patients (mean age 63.9 ± 11.5 years, and 32.1% female), who were admitted to our hospital for ACS and underwent PCI, were retrospectively enrolled. The patients were divided into two groups: non-CI-AKI group (n = 787) and CI-AKI group (n = 147). Contrast-induced acute kidney injury was defined as an increase of ≥ 0.5 mg/dL or ≥ 25% serum creatinine within 48-72 h after PCI. Spearman correlation analysis was used to determine the relationship between FIB and CHA2DS2-VASC scores.

RESULTS

Patients with high baseline FIB levels and high CHA2DS2-VASC scores had higher CI-AKI incidence. On spearman correlation analysis, FIB and CHA2DS2-VASC scores were positively correlated (R = 0.236, P < 0.001). The ROC statistical analysis showed that the combination had 63.3% sensitivity with 72.6% specificity for the development of CI-AKI (area under the curve: 0.727, 95% CI 0.697-0.755, P < 0.001). A total of 934 ACS patients were divided into low-risk group (404 cases), medium-risk group (383 cases) and high-risk group (147 cases) according to the cut-off values of FIB and CHA2DS2-VASC scores. The incidence of CI-AKI was higher in the high-risk group than in the low-risk and medium-risk groups (Log-rank χ2 = 104.505, 56.647. P < 0.001). Multivariate analysis revealed that albumin (OR = 0.913, 95% CI 0.867-0.962), FIB (OR = 1.451, 95% CI 1.185-1.77), CHA2DS2-VASC score (OR = 1.271, 95% CI 1.504-1.78) were the independent risk factors of CI-AKI (p < 0.05).

CONCLUSION

The preprocedural fibrinogen combined with CHA2DS2-VASC score is independently associated with the risk of CI-AKI in ACS patients treated by PCI.

Mehran 2 Contrast-Associated Acute Kidney Injury Risk Score: Is it Applicable to the Asian Percutaneous Coronary Intervention Population?

Contrast-associated acute kidney injury (CA-AKI) can occur after percutaneous coronary intervention (PCI). The Mehran score is the gold standard for predicting CA-AKI risk, and it has recently been updated. The Mehran 2 CA-AKI risk score, based on existing variables in patients undergoing PCI, can accurately differentiate the risk of CA-AKI. This study aimed to verify whether the new Mehran score is applicable to the Asian PCI population. The study included the clinical data of 2487 patients undergoing PCI from August 2020 to February 2022. The goodness-of-fit test (Hosmer-Lemeshow) was used to evaluate the correction ability of the Mehran 2 score, and the area under the receiver operating characteristic curve (ROC) was used to evaluate the accuracy of the Mehran 2 score in predicting CA-AKI. CA-AKI occurred in 28 of 2487 patients, with an incidence rate of 1.12%. The proportion of high risk factors for AKI in the cohort was lower than that in the Mehran 2 cohort (a large contemporary PCI cohort to develop the Mehran 2 score). The Mehran 2 risk score had excellent goodness-of-fit (χ2 = 5.320, df = 6, P = 0.503) and high predictive accuracy (area under the ROC curve 0.836, P < 0.0001). The Mehran 2 score shows good predictive and correction performance in the Asian population and has good clinical application value. The inclusion of the Mehran 2 risk score in patients hospitalised for coronary angiography appears to be good practice.