Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial

Effect of periprocedural furosemide-induced diuresis with matched isotonic intravenous hydration in patients with chronic kidney disease undergoing transcatheter aortic valve implantation

BACKGROUND

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a serious complication which is associated with increased mortality. The RenalGuard system was developed to reduce the risk of AKI after contrast media exposition by furosemide-induced diuresis with matched isotonic intravenous hydration. The aim of this study was to examine the effect of the RenalGuard system on the occurrence of AKI after TAVI in patients with chronic kidney disease.

METHODS

The present study is a single-center randomized trial including patients with severe aortic valve stenosis undergoing TAVI. Overall, a total of 100 patients treated by TAVI between January 2017 and August 2018 were randomly assigned to a periprocedural treatment with the RenalGuard system or standard treatment by pre- and postprocedural intravenous hydration. Primary endpoint was the occurrence of AKI after TAVI, and secondary endpoints were assessed according to valve academic research consortium 2 criteria.

RESULTS

Overall, the prevalence of AKI was 18.4% (n = 18). The majority of these patients developed mild AKI according to stage 1. Comparing RenalGuard to standard therapy, no significant differences were observed in the occurrence of AKI (RenalGuard: 21.3%; control group: 15.7%; p = 0.651). In addition, there were no differences between the groups with regard to 30-day and 12-month mortality and procedure-associated complication rates.

CONCLUSION

In this randomized trial, we did not detect a reduction in AKI after TAVI by using the RenalGuard system. A substantial number of patients with chronic kidney disease developed AKI after TAVI, whereas the majority presented with mild AKI according to stage 1 (ClinicalTrials.gov number NCT04537325).

Diuresis-matched versus standard hydration in patients undergoing percutaneous cardiovascular procedures: meta-analysis of randomized clinical trials

INTRODUCTION AND OBJECTIVES

Contrast-associated acute kidney injury (CA-AKI) is a potential complication of procedures requiring administration of iodinated contrast medium. RenalGuard, which provides real-time matching of intravenous hydration with furosemide-induced diuresis, is an alternative to standard periprocedural hydration strategies. The evidence on RenalGuard in patients undergoing percutaneous cardiovascular procedures is sparse. We used a Bayesian framework to perform a meta-analysis of RenalGuard as a CA-AKI preventive strategy.

METHODS

We searched Medline, Cochrane Library and Web of Science for randomized trials of RenalGuard vs standard periprocedural hydration strategies. The primary outcome was CA-AKI. Secondary outcomes were all-cause death, cardiogenic shock, acute pulmonary edema, and renal failure requiring renal replacement therapy. A Bayesian random-effect risk ratio (RR) with corresponding 95% credibility interval (95%CrI) was calculated for each outcome. PROSPERO database number CRD42022378489.

RESULTS

Six studies were included. RenalGuard was associated with a significant relative reduction in CA-AKI (median RR, 0.54; 95%CrI, 0.31-0.86) and acute pulmonary edema (median RR, 0.35; 95%CrI, 0.12-0.87). No significant differences were observed for the other secondary endpoints [all-cause death (RR, 0.49; 95%CrI, 0.13-1.08), cardiogenic shock (RR, 0.06; 95%CrI, 0.00-1.91), and renal replacement therapy (RR, 0.52; 95%CrI, 0.18-1.18)]. The Bayesian analysis also showed that RenalGuard had a high probability of ranking first for all the secondary outcomes. These results were consistent in multiple sensitivity analyses.

CONCLUSIONS

In patients undergoing percutaneous cardiovascular procedures, RenalGuard was associated with a reduced risk of CA-AKI and acute pulmonary edema compared with standard periprocedural hydration strategies.

The effect of perioperative diuretic administration on acute kidney injury in patients with acute myocardial infarction after percutaneous coronary intervention: a real-world retrospective study

PURPOSE

The relationship between diuretic use and contrast-induced acute kidney injury (CI-AKI) after contrast exposure remains unclear. In this study, we conducted a retrospective analysis using propensity score matching (PSM) to investigate the effect of perioperative diuretic administration on contrast-induced acute kidney injury (CI-AKI) in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI).

METHODS

A total of 1894 patients with AMI who underwent PCI were retrospectively analyzed using PSM and multivariate models. Depending on whether diuretics were used, the patients were divided into two groups: the perioperative diuretic group (497 patients, 26.2%) and the non-diuretic group (1397 patients, 73.8%). And the relationship between perioperative diuretic administration and CI-AKI was evaluated by multiple regression models. Furthermore, Kaplan Meier survival curve ratio was used to evaluate and compare overall postoperative survival between the two groups.

RESULTS

Most patients who received diuretics were older (67 vs. 60 years, respectively, p < 0.001) and women (22.5% vs. 15.2%, p < 0.001) and had combined hypertension (62.8% vs. 47%, p < 0.001), atrial fibrillation (5.4% vs. 1.8%, p < 0.001), stroke (9.3% vs. 4.9%, p < 0.001), and diabetes mellitus (33.4% vs. 23.6%, p < 0.001) compared to those who did not. After the baseline characteristics were balanced using the PSM model, no significant difference was observed in the incidence of postoperative CI-AKI (22.7% vs. 19.5%, p = 0.356) and major cardiovascular adverse events (21.5% vs. 18.7%, p = 0.398). Multiple regression analysis showed no association between perioperative diuretic administration and postoperative CI-AKI occurrence (odds ratio: 1.14, 95% confidence interval: 0.86-1.51, p = 0.371). Further subgroup analysis and sensitivity analysis confirmed the above findings.

CONCLUSION

We found no significant association between perioperative diuretic administration and postoperative CI-AKI in patients with AMI who underwent PCI.

Simplified Rapid Hydration Prevents Contrast-Associated Acute Kidney Injury Among CKD Patients Undergoing Coronary Angiography

BACKGROUND

Patients with chronic kidney disease (CKD) undergoing coronary angiography (CAG) are at high risk of contrast-associated acute kidney injury (CA-AKI) and mortality. Therefore, there is a clinical need to explore safe, convenient, and effective strategies for preventing CA-AKI.

OBJECTIVES

This study sought to assess whether simplified rapid hydration is noninferior to standard hydration for CA-AKI prevention in patients with CKD.

METHODS

This multicenter, open-label, randomized controlled study was conducted across 21 teaching hospitals and included 1,002 patients with CKD. Patients were randomized to either simplified hydration (SH) (SH group, with normal saline from 1 hour before to 4 hours after CAG at a rate of 3 mL/kg/h) or standard hydration (control group, with normal saline 12 hours before and 12 hours after CAG at a rate of 1 mL/kg/h). The primary endpoint of CA-AKI was a ≥25% or 0.5-mg/dL rise in serum creatinine from baseline within 48 to 72 hours.

RESULTS

CA-AKI occurred in 29 of 466 (6.2%) patients in the SH group and in 38 of 455 (8.4%) patients in the control group (relative risk: 0.8; 95% CI: 0.5-1.2; P = 0.216). In addition, the risk of acute heart failure and 1-year major adverse cardiovascular events did not differ significantly between the groups. However, the median hydration duration was significantly shorter in the SH group than in the control group (6 vs 25 hours; P < 0.001).

CONCLUSIONS

In CKD patients undergoing CAG, SH is noninferior to standard hydration in preventing CA-AKI with a shorter hydration duration.

Effect of Vigileo/FloTrac System-Guided Aggressive Hydration in Acute Myocardial Infarction Patients to Prevent Contrast-Induced Nephropathy After Urgent Percutaneous Coronary Intervention

Tailored hydration strategies appear to provide an effective solution for preventing contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI). The Vigileo/FloTrac system could predict the patients' fluid responsiveness and tolerance to hydration. This prospective multicenter, randomized controlled, open-label study evaluated the efficacy of aggressive hydration guided by the Vigileo/FloTrac system for CIN prevention in patients with acute myocardial infarction (AMI). This trial enrolled patients with AMI undergoing urgent PCI, and these patients were randomized (1:1) to receive either aggressive hydration guided by Vigileo/FloTrac system (intervention group) or general hydration (control group). Patients with AMI in the intervention group received a loading dose of saline, and the hydration speed was adjusted according to the change of Vigileo/FloTrac index. The primary end point is CIN, which was defined as a >25% or >0.5 mg/100 ml increase in serum creatinine compared with baseline during the first 72 hours after urgent PCI. This trial was registered in ClinicalTrials.gov (NCT04382313). A total of 344 patients with AMI were enrolled and randomized in our trial, and the baseline characteristics, including risk factors of CIN, of the Vigileo/FloTrac-guided hydration group (n = 173) and control group (n = 171) were well balanced (all p >0.05). The total hydration volume in Vigileo/FloTrac-guided hydration group was significantly much more than control group (1,910 ± 600 vs 440 ± 90 ml, p <0.001). The incidence of CIN in the Vigileo/FloTrac-guided hydration group was significantly decreased than that in the control group (12.1% [21/173] vs 22.2% [38/171], p = 0.013). There was not significantly different in the incidence of acute heart failure after PCI (9.2% [16/173] vs 7.6% [13/171], p = 0.583). The incidence of main adverse cardiovascular events in the Vigileo/FloTrac-guided hydration group was lower than that in the control group but without statistically difference (30 events [17.3%] vs 38 events [22.2%], p = 0.256). In conclusion, Vigileo/FloTrac system-guided aggressive hydration could effectively decrease the risk of CIN for patients with AMI undergoing urgent PCI and avoid attack of acute heart failure at the same time.

Contrast removal from coronary sinus for prevention of contrast-induced nephropathy: a review

The occurrence of contrast-induced-nephropathy (CIN) is related to the amount of contrast administration. Any removal of contrast from systemic circulation before reaching the kidneys might be beneficial using a device that removes contrast from a coronary sinus (CS). This manuscript aims to review the available literature regarding contrast removal from CS during coronary angiography or intervention for the prevention of CIN.

The Effect of SGLT2 Inhibitors on the Development of Contrast-Induced Nephropathy in Diabetic Patients with Non-ST Segment Elevation Myocardial Infarction

Background and Objectives: Percutaneous procedures using contrast agents are modern diagnosis and treatment methods for cardiovascular diseases. Contrast use may cause nephropathy, especially in diabetic patients. SGLT2 inhibitors have strong cardioprotective and renal protective effects. In our study, we investigated the effectiveness of this drug group in preventing the development of Contrast-Induced Nephropathy (CIN). Materials and Methods: The results of 312 diabetic patients who underwent CAG were analyzed. The study group included 104 DM patients using SGLT2 and the control group did not use SGLT2. These groups were compared with each other in terms of clinical, demographic, and laboratory parameters. Results: The groups were similar characteristics. However, post-CAG creatinine values compared with before the procedure, the development of CIN was observed to be significantly less in the group using SGLT2 inhibitor (p = 0.03). When the results of the multivariate analysis were examined, it was seen that the use of SGLT2 inhibitors significantly reduced the risk of CIN (odds ratio (OR): 0.41, 95% confidence interval (CI): 0,142-0.966, p = 0.004). Conclusions: Our study showed that SGLT2 inhibitors may be protective against the development of CIN, especially in patients with comorbid conditions such as diabetes.

Renal resistance index independently predicts worsening of renal function after coronary angiography

The renal resistance index (RRI) has been demonstrated to be a useful parameter that can detect patients at a high risk of worsening of renal function (WRF). This study was designed to evaluate the role of the RRI in predicting WRF mediated by the intravascular administration of contrast media. We enrolled patients who were referred for coronary angiography. Renal arterial echo-color Doppler was performed to calculate the RRI. WRF was defined as an increase of > 0.3 mg/dL and at least 25% of the baseline value in creatinine concentration 24-48 h after coronary angiography. Among the 148 patients enrolled in this study, 18 (12%) had WRF. In the multivariate logistic analysis, the RRI was independently associated with WRF (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09-1.36; p = 0.001). After angiography, the RRI significantly increased in both patients with and without WRF. In the receiver operating characteristic curve analyses for WRF, the RRI at baseline and after angiography showed similar accuracy, and the best cutoff value for predicting WRF was 70%. In patients undergoing coronary angiography, the RRI is independently associated with WRF, probably because it provides more accurate information about cardiorenal pathophysiological factors and reflects kidney hemodynamic status and flow reserve.

Role of modified hydration for preventing contrast-associated acute kidney injury in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

To assess the efficacy of modified hydration on contrast-associated acute kidney injury (CA-AKI) in ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (pPCI). A total of 438 patients were randomly assigned to 2 groups. The traditional hydration group (group I) was given at a rate of 1 ml/kg/h for 24 h, and the modified hydration group (group II) was given at a rate of 3 ml/kg/h in the first 4 h, and then reduced to 1 ml/kg/h for 12 h. 0.3 mg/kg of furosemide was given 1-h after hydration. The primary endpoint was the incidence of CA-AKI, and the secondary endpoint was the incidence of major adverse cardiovascular events (MACEs) during a median of 22.4 months (IQR 9.6, 32.6 months) follow-up. The incidence of CA-AKI was 8.7%. Among these, Group I was 9.1% and group II was 8.2%, respectively. There was no significant difference in CA-AKI and creatinine levels between the two hydration groups. Multivariable logistics regression analysis revealed that creatinine, white blood cells, and N-terminal pro-B-type natriuretic peptide were associated with CA-AKI. Moreover, CA-AKI was an independent predictor for all-cause death and cardiac death during the follow-up period. The modified hydration may reduce the incidence of CA-AKI, although this difference was not statistically significant. The relationship between CA-AKI and mortality strengthened as creatinine times above baseline increased. Mitigating the occurrence of CA-AKI may reduce all-cause death and cardiac death.

What Promotes Acute Kidney Injury in Patients with Myocardial Infarction and Multivessel Coronary Artery Disease-Contrast Media, Hydration Status or Something Else?

Multivessel coronary artery disease (MVCAD) is found in approximately 50% of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Although we have data showing the benefits of revascularization of significant non-culprit coronary lesions in patients with AMI, the optimal timing of angioplasty remains unclear. The most common reason for postponing subsequent percutaneous treatment is the fear of contrast-induced acute kidney injury (CI-AKI). Acute kidney injury (AKI) is common in patients with AMI undergoing PCI, and its etiology appears to be complex and incompletely understood. In this review, we discuss the definition, pathophysiology and risk factors of AKI in patients with AMI undergoing PCI. We present the impact of AKI on the course of hospitalization and distant prognosis of patients with AMI. Special attention was paid to the phenomenon of AKI in patients undergoing multivessel revascularization. We analyze the correlation between increased exposure to contrast medium (CM) and the risk of AKI in patients with AMI to provide information useful in the decision-making process about the optimal timing of revascularization of non-culprit lesions. In addition, we present diagnostic tools in the form of new biomarkers of AKI and discuss ways to prevent and mitigate the course of AKI.

Contrast-induced acute kidney injury and its contemporary prevention

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Enhanced stent visualization system for percutaneous coronary intervention in patients with chronic kidney disease: effects on contrast media volume and radiation exposure

Objective

We aimed to assess the impact of using enhanced stent visualization (ESV) systems on contrast media volume and radiation dose in percutaneous coronary intervention (PCI), especially for patients with chronic kidney disease (CKD).

Background

Coronary heart disease (CHD) is associated with chronic kidney disease (CKD), as they share a similar pathological pathway. In addition, the iodinated contrast media used for angiography is a risk factor for contrast-associated acute kidney injury (CA-AKI), which could aggravate the progression of CKD. We hypothesized that ESV systems have the potential to reduce the use of contrast media as well as the radiation dose; however, few studies have reported the impact on contrast media with the use of ESV systems.

Methods

We retrospectively collected 124 patients with acute coronary syndrome who underwent PCI from May 2020 to July 2021. The patients were divided into the ESV-guided group (n = 64) and angiography-guided group (n = 60). Procedural parameters, including contrast media volume, radiation exposure (in Air Kerma-AK and Dose Area Product-DAP), number of cines, cine frames, fluoroscopy and procedure time, were recorded and analysed.

Results

The groups were comparable regarding the patient characteristics. There was a significant reduction in contrast media volume (174.7 ± 29.6 ml vs.132.6 ± 22.3 ml, p = 0.0001), radiation exposure (776 (499 - 1200) mGy vs. 1065 (791 - 1603) mGy, p = 0.002 in AK; 43 (37 - 73) Gycm2 vs. 80 (64 - 133) Gycm2, p = 0.030 in DAP) and procedure time (53.06 ± 21.20 min vs. 72.00 ± 30.55 min, p = 0.01) with the use of ESV systems. Similar results were observed in the subgroup analysis for the patients with CKD.

Conclusion

This study suggested that the use of ESV is associated with reduced contrast media usage, radiation dose and procedure time during PCI. The same results were observed in a subgroup analysis in patients with CKD, and this shows that ESV-guided PCI has the potential to reduce renal impairment and mitigate the progression of CKD for those CHD patients with CKD.

[Monocentric experience of the RenalGuard® system to limit post-contrast acute kidney injury in patients at high-risk undergoing interventional coronary procedures]

BACKGROUND

Despite an often favorable risk/benefit ratio, patients with severe chronic kidney disease are sometimes declined for interventional coronary procedures, due to the risk of acute kidney injury post-contrast (AKI-PC). A large preventive supply of intravenous fluid may be problematic in this population. The RenalGuard® system allows hyperhydration by maintaining a stable volemia through an enhanced diuresis.

METHODS AND RESULTS

This work reports the evaluation of the RenalGuard® system in 25 consecutive patients with chronic kidney disease (glomerular filtration rate < 40 mL/min/1.73 m²) requiring an interventional coronary procedure (coronary angiography and/or percutaneous coronary intervention) and at high risk of IRA-PC. An increase in serum creatinine ≥ 26.5 µmol/L at 48-72 hours (AKI-PC definition) was observed in 4 patients (16%). The mean glomerular filtration rate was 26 ± 8 mL/min/1.73 m² at 48-72 hours versus 25 ± 8 mL/min/1.73 m² at baseline. No patient presented with an increase in serum creatinine ≥ 1.5 from baseline, stage 2 or 3 AKI, or acute pulmonary edema. No renal replacement therapy was necessary. One death unrelated to AKI-PC occurred during hospital stay.

CONCLUSIONS

This single-center observational study suggests that the RenalGuard® system, allowing diuresis-adjusted hyperhydration, is safe and useful for patients at high risk of AKI-PC after an interventional coronary procedure.

The Relationship between Rate and Volume of Intravenous Fluid Administration and Kidney Outcomes after Angiography

BACKGROUND AND OBJECTIVES

Contrast-associated AKI may result in higher morbidity and mortality. Intravenous fluid administration remains the mainstay for prevention. There is a lack of consensus on the optimal administration strategy. We studied the association of periprocedure fluid administration with contrast-associated AKI, defined as an increase in serum creatinine of at least 25% or 0.5 mg/dl from baseline at 3-5 days after angiography, and 90-day need for dialysis, death, or a 50% increase in serum creatinine.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a secondary analysis of 4671 PRESERVE participants who underwent angiographic procedures. Although fluid type was randomized, strategy of administration was at the discretion of the clinician. We divided the study cohort into quartiles by total fluid volume. We performed multivariable logistic regression, adjusting for clinically important covariates. We tested for the interaction between fluid volume and duration of fluid administration, categorized as <6 or ≥6 hours.

RESULTS

The mean (SD) age was 70 (8) years, 94% of participants were male, and median (interquartile range) eGFR was 60 (41-60) ml/min per 1.73 m2. The range of fluid administered was 89-882 ml in quartile 1 and 1258-2790 ml in quartile 4. Compared with the highest quartile (quartile 4) of fluid volume, we found a significantly higher risk of the primary outcome in quartile 1 (adjusted odds ratio, 1.58; 95% confidence interval, 1.06 to 2.38) but not in quartiles 2 and 3 compared with quartile 4. There was no difference in the incidence of contrast-associated AKI across the quartiles. The interaction between volume and duration was not significant for any of the outcomes.

CONCLUSIONS

We found that administration of a total volume of 1000 ml, starting at least 1 hour before contrast injection and continuing postcontrast for a total of 6 hours, is associated with a similar risk of adverse outcomes as larger volumes of intravenous fluids administered for periods >6 hours. Mean fluid volumes <964 ml may be associated with a higher risk for the primary outcome, although residual confounding cannot be excluded.

Fluid administration strategies for the prevention of contrast-associated acute kidney injury

PURPOSE OF REVIEW

The known timing of contrast media exposure in patients identified as high-risk for contrast-associated acute kidney injury (CA-AKI) enables the use of strategies to prevent this complication of intravascular contrast media exposure. Although multiple preventive strategies have been proposed, periprocedural fluid administration remains as the primary preventive strategy. This is a critical review of the current evidence evaluating a variety of fluid administration strategies in CA-AKI.

RECENT FINDINGS

Fluid administration strategies to prevent CA-AKI include comparisons of intravenous (i.v.) to no fluid administration, different fluid solutions, duration of fluid administration, oral hydration, left ventricular end diastolic-pressure guided fluid administration and forced diuresis techniques.

SUMMARY

Despite an abundance of fluid administration trials, it is difficult to make definitive recommendations about preventive fluid administration strategies due to low scientific quality of published studies. The literature supports use of i.v. compared with no fluid administration, especially in high-risk patients undergoing intra-arterial contrast media exposure. Use of isotonic saline is recommended over 0.45% saline or isotonic sodium bicarbonate. Logistical considerations support shortened over longer i.v. fluid administration strategies, despite an absence of evidence of equivalent efficacy. Current literature does not support oral hydration for high-risk patients. The use of tailored fluid administration in heart failure patients and forced diuresis with matching fluid administration are promising new fluid administration strategies.

Contrast-Associated Acute Kidney Injury

Contrast-associated acute kidney injury (CA-AKI) is an impairment of renal function, which occurs within days of intravascular administration of iodinated contrast media. Taking into account that minimally invasive cardiac interventions are becoming increasingly popular, compared to traditional surgery, given their impact on prognosis and costs, CA-AKI remains a subject of increasing interest for patients and physicians. This review summarizes the epidemiology and risk stratification, diagnostic criteria, pathophysiology and clinical implications of CA-AKI, providing evidence for the most studied preventive strategies.

Forced Diuresis with Matched Isotonic Intravenous Hydration Prevents Renal Contrast Media Accumulation

The accumulation of contrast media in the kidneys might lead to contrast-induced acute kidney injury. In this prospective, controlled observational study, we aimed to evaluate whether forced diuresis with matched isotonic intravenous hydration prevents the accumulation of contrast media in the kidneys of patients undergoing cardiac interventional procedures. We compared the intensity of contrast media accumulation as observed in nephrograms following these procedures, with and without peri-procedural controlled renal flushing. The study group consisted of 25 patients with impaired renal function treated with the RenalGuard system. The two control groups included 25 patients with normal kidney function and 8 patients with impaired renal function undergoing similar procedures with routine pre-procedural hydration, but without controlled renal flushing. Renal contrast media accumulation at the end of each procedure was scored by blinded cardiologists. The renal contrast accumulation score (CAS) in the study group was significantly lower, with a median score of 0 (IQR (0-0)) compared with 1.5 (IQR (1-2)) in the normal renal function control group and 1 (IQR (0.38-1.62)) in the impaired renal function control group (p < 0.001 and 0.003, respectively). In a multivariate analysis of CAS, RenalGuard treatment was independently associated with lower CAS compared to both control groups. In conclusion, RenalGuard use prevents renal contrast accumulation in patients with impaired renal function undergoing cardiac procedures with intra-arterial contrast media injection.

Hydration for prevention of kidney injury after primary coronary intervention for acute myocardial infarction: a randomised clinical trial

OBJECTIVE

To evaluate the efficacy of aggressive hydration compared with general hydration for contrast-induced acute kidney injury (CI-AKI) prevention among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

METHODS

The Aggressive hydraTion in patients with STEMI undergoing pPCI to prevenT Contrast-Induced Acute Kidney Injury study is an open-label, randomised controlled study at 15 teaching hospitals in China. A total of 560 adult patients were randomly assigned (1:1) to receive aggressive hydration or general hydration treatment. Aggressive hydration group received preprocedural loading dose of 125/250 mL normal saline within 30 min, followed by postprocedural hydration performed for 4 hours under left ventricular end-diastolic pressure guidance and additional hydration until 24 hours after pPCI. General hydration group received ≤500 mL 0.9% saline at 1 mL/kg/hour for 6 hours after randomisation. The primary end point is CI-AKI, defined as a >25% or 0.5 mg/dL increased in serum creatinine from baseline during the first 48-72 hours after primary angioplasty. The safety end point is acute heart failure.

RESULTS

From July 2014 to May 2018, 469 patients were enrolled in the final analysis. CI-AKI occurred less frequently in aggressive hydration group than in general hydration group (21.8% vs 31.1%; risk ratio (RR) 0.70, 95% CI 0.52 to 0.96). Acute heart failure did not significantly differ between the aggressive hydration group and the general hydration group (8.1% vs 6.4%, RR 1.13, 95% CI 0.66 to 2.44). Several subgroup analysis showed the better effect of aggressive hydration in CI-AKI prevention in male, renal insufficient and non-anterior myocardial infarction participants.

CONCLUSIONS

Comparing with general hydration, the peri-operative aggressive hydration seems to be safe and effective in preventing CI-AKI among patients with STEMI undergoing pPCI.

Tailored Versus Standard Hydration to Prevent Acute Kidney Injury After Percutaneous Coronary Intervention: Network Meta-Analysis

Background

Contrast‐induced acute kidney injury (CI‐AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI‐AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion‐rate hydration strategies.

Methods and Results

A systematic review and network meta‐analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI‐AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate–guided, central venous pressure–guided, left ventricular end‐diastolic pressure–guided, and bioimpedance vector analysis–guided hydration. Primary endpoint was CI‐AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate–guided and central venous pressure–guided hydration were associated with a lower incidence of CI‐AKI compared with fixed‐rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19–0.54] and OR, 0.45 [95% CI, 0.21–0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate–guided hydration is advantageous in terms of both CI‐AKI prevention and pulmonary edema incidence when compared with other approaches.

Conclusions

Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline‐supported fixed‐rate hydration for CI‐AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate–guided hydration as the most convenient strategy in terms of effectiveness and safety.

[Contrast-induced acute kidney injury]

The nephrotoxicity of iodinated contrast agent/media is defined by acute renal failure occurring within 48 to 72 hours after injection of iodized contrast product, in the absence of other etiology. The risk factors for contrast agent renal injury must systematically be sought before the exam. The presence of risk factors, including the existence of a renal failure defined by a creatinine clearance (eGFR) of less than 60 mL/min/1.73 m², requires to take prevention measures including hydration. If eGFR is less than 30 mL/min/1.73 m², the advice of a nephrologist is necessary.

Left Ventricular End-Diastolic Pressure Versus Urine Flow Rate-Guided Hydration in Preventing Contrast-Associated Acute Kidney Injury

OBJECTIVES

This study compared left ventricular end-diastolic pressure (LVEDP)-guided and urine flow rate (UFR)-guided hydration.

BACKGROUND

Tailored hydration regimens improve the prevention of contrast-associated acute kidney injury (CA-AKI).

METHODS

Between July 15, 2015, and June 6, 2019, patients at high risk for CA-AKI scheduled for coronary and peripheral procedures were randomized to 2 groups: 1) normal saline infusion rate adjusted according to the LVEDP (LVEDP-guided group); and 2) hydration controlled by the RenalGuard System in order to reach UFR ≥300 ml/h (UFR-guided group). The primary endpoint was the composite of CA-AKI (i.e., serum creatinine increase ≥25% or ≥0.5 mg/dl at 48 h) and acute pulmonary edema (PE). Major adverse events (all-cause death, renal failure requiring dialysis, PE, and sustained kidney injury) at 1 month were assessed.

RESULTS

The primary endpoint occurred in 20 of 351 (5.7%) patients in the UFR-guided group and in 36 of 351 (10.3%) patients in the LVEDP-guided group (relative risk [RR]: 0.560; 95% confidence interval [CI]: 0.390 to 0.790; p = 0.036). CA-AKI and PE rates in the UFR-guided group and LVEDP-guided group were 5.7% and 10.0% (RR: 0.570; 95% CI: 0.300 to 0.960; p = 0.048), and, respectively, 0.3% and 2.0% (RR: 0.070; 95% CI: 0.020 to 1.160; p = 0.069). Three patients in the UFR-guided group experienced complications related to the Foley catheter. Hypokalemia rate was 6.2% in the UFR-guided group and 2.3% in the LVEDP-guided group (p = 0.013). The 1-month major adverse events rate was 7.1% in the UFR-guided group and 12.0% in the LVEDP-guided group (p = 0.030).

CONCLUSIONS

The study demonstrates that UFR-guided hydration is superior to LVEDP-guided hydration to prevent the composite of CA-AKI and PE.

Acute kidney injury after radial or femoral artery access in ST-segment elevation myocardial infarction: AKI-SAFARI

BACKGROUND

Acute kidney injury (AKI) complicating primary percutaneous coronary intervention (PCI) is an independent predictor of short- and long-term outcomes in patients presenting with ST-elevation myocardial infarction (STEMI). Prior studies suggest a lower incidence of AKI in patients undergoing PCI through radial artery compared to femoral artery access; however, no randomized clinical trials have specifically investigated this question in patients presenting with STEMI.

METHODS

To determine whether radial access (RA) is associated with a reduced frequency of AKI following primary PCI, we performed a substudy of the SAFARI-STEMI trial. The SAFARI-STEMI trial was an open-label, multicenter trial, which randomized patients presenting with STEMI to RA or femoral access (FA), between July 2011 and December 2018. The primary outcome of this post hoc analysis was the incidence of AKI, defined as an absolute (>0.5 mg/dL) or relative (>25%) increase in serum creatinine from baseline.

RESULTS

In total 2,285 (99.3%) of the patients enrolled in SAFARI-STEMI were included in the analysis-1,132 RA and 1,153 FA. AKI occurred in 243 (21.5%) RA patients and 226 (19.6%) FA patients (RR: 0.91, 95% CI: 0.78-1.07, P = .27). An absolute increase in serum creatinine >0.5 mg/dL was seen in 49 (4.3%) radial and 52 (4.5%) femoral patients (RR: 1.04, 95% CI: 0.71-1.53, P = .83). AKI was lower in both groups when the KDIGO definition was applied (RA 11.9% vs FA 10.8%; RR: 0.90, 95% CI: 0.72-1.13, P = .38).

CONCLUSIONS

Among STEMI patients enrolled in the SAFARI-STEMI trial, there was no association between catheterization access site and AKI, irrespective of the definition applied. These results challenge the independent association between catheterization access site and AKI noted in prior investigations.

RenalGuard system and conventional hydration for preventing contrast-associated acute kidney injury in patients undergoing cardiac interventional procedures: A systematic review and meta-analysis

BACKGROUND

Contrast-associated acute kidney injury (CA-AKI) can increase the mortality of patients undergoing transcatheter aortic valve replacement (TAVR) or percutaneous coronary intervention (PCI). The purpose of this paper was to compare the efficacy of the RenalGuard System and conventional hydration regimen in preventing CA-AKI in patients with TAVR or PCI.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Clinical Trials (last updated July 11, 2020) for suitable reports. The primary outcome was the occurrence of CA-AKI. The secondary outcomes were renal replacement therapy (RRT), major cardiovascular events (MACEs), and other adverse complications.

RESULTS

The search strategy yielded 270 studies (with data for 2067 participants). In the subgroup of PCI, low incidence of CA-AKI (6.7% vs 15.7%; 95%CI: 0.27 to 0.54; I² = 8%; P < 0.00001) associate with RenalGuard group (RG) rather than control group (CG). Similarly, in the subgroup of TAVR, a low incidence of CA-AKI (15.6% vs 26.9%; 95%CI: 0.35 to 0.82; I² = 88%; P = 0.004) relates to RG. However, this result is highly heterogeneous. Compare with conventional hydration, RenalGuard significantly reduce the incidence of pulmonary edema (1.5%vs4.1%; 95%CI: 0.18 to 0.72; I² = 0%; P = 0.004).

CONCLUSIONS

RenalGuard System can lessen the risk of CA-AKI and RRT in patients undergoing PCI. But for patients experiencing TAVR, due to unique hemodynamic effects, the role of RenalGuard remains questionable. RenalGuard is more secure than conventional hydration. Future work should elucidate the feasibility and safety of this prophylactic intervention in cardiac interventional therapy.

[Contrast medium-induced acute kidney injury-Consensus paper of the working group "Heart and Kidney" of the German Cardiac Society and the German Society of Nephrology]

This consensus paper summarizes the expert consensus and recommendations of the working group "Heart and Kidney" of the German Cardiac Society (DGK) and the German Society of Nephrology (DGfN) on contrast medium-induced acute kidney injury. Potentially nephrotoxic contrast agents containing iodine are frequently used in interventional medicine and for computer tomography diagnostics. Acute kidney injury occurs in approximately 8-17% of patients exposed to contrast media. The risk factors and underlying pathophysiology are discussed and recommendations for the prophylaxis and treatment of contrast medium-induced acute nephropathy are presented.

Five-year follow-up of patients with radio-contrast-induced acute renal injury. Can intravenous sodium-bicarbonate improve long-term outcomes?

BACKGROUND/PURPOSE

Radiocontrast-induced acute kidney injury (RAKI) is a frequent complication during angiography and is associated with adverse prognosis. Most of the studies evaluating the long-term outcome of patients with RAKI are based on institutional registries. This is the first prospective study to evaluate the 5-year outcomes of patients with RAKI, and assess the effect of sodium bicarbonate (SB) in the long-term outcomes of patients with chronic kidney disease (CKD) undergoing non-emergent coronary angiography.

MATERIALS/METHODS

382 CKD stage III-IV patients undergoing elective non-emergent coronary angiography were randomized to SB (n = 192) or normal saline (NS) solution (n = 190). Incidence of RAKI, in-hospital, 1- and 5-year mortality and renal replacement therapy (RRT), and 5-year major adverse renal and cardiovascular events (MARCE) were compared between groups. Outcomes of patient with and without RAKI were compared after five-years of prospective follow-up. Multivariate predictors of RAKI and death at 5-years were determined.

RESULTS

The use of SB did not improve the incidence of RAKI, in-hospital outcomes, survival, and freedom from RRT or MARCE after 5-years of follow-up. Patients that developed RAKI had a significantly higher mortality at 1-year [8.9% Vs. 1.2%] and 5-years (36% Vs. 11%) (P < 0.01).

CONCLUSIONS

Hydration with SB showed no benefit compared to NS in preventing RAKI. The use of SB was not superior to NS after 5-years of follow-up regarding MARCE, survival or freedom of RRT. Five-year mortality among patients who developed RAKI remains high, and further research is needed to find the best preventive strategy for this high-risk group of patients.

SUMMARY

Radiocontrast-induced acute-kidney-injury (RAKI) is associated with poor long-term outcomes in observational and short-term studies. Hydration with sodium bicarbonate (SB) had been evaluated in the prevention of RAKI; but its long-term effect has not been evaluated. We randomized 382 high high-risk patients undergoing coronary angiography to SB or normal saline following them for five years. SB showed no benefit in preventing RAKI, decreasing major adverse renal and cardiovascular events, improving survival or freedom from dialysis after 5-years. This is the first study to follow patients with RAKI for a period of 5-years, showing a significantly higher mortality in this group of patients.

Preventing contrast-induced nephropathy (CIN) with herbal medicines: A review

OBJECTIVES

Currently, the use of iodinated contrast media in diagnostic imaging has been increased in clinical medicine. Contrast-induced nephropathy (CIN) is an important adverse effect of contrast media injection. According to the significant role of oxidative stress in the pathophysiology of CIN, different herbal antioxidants have been used for the prevention of nephropathy in different studies. In this review, we discussed the preventive effects of herbal medicine and natural products against CIN.

METHODS

We searched the electronic databases or search engines including PubMed, Scopus, ISI, Google Scholar with search terms such as "Contrast-induced nephropathy" and "Herbal medicine," "Contrast acute kidney injury" AND "natural products" and similar headings such as plant and extract.

RESULTS

Known medicinal plants and active ingredients such as green tea, ginger, garlic, silymarin, curcumin, resveratrol, and thymoquinone have been examined for prophylactic effects or treatment of contrast media nephropathy.

CONCLUSION

Herbal medicines have promising effects in the laboratory-based studies for the prevention and/or treatment of CIN. However, more practical and completed clinical trials are needed to investigate the clinical benefits of natural products against CIN.

Effect of Combining Furosemide With Standard Hydration Therapy on Contrast-Induced Acute Kidney Injury Following Coronary Angiography or Intervention in a High-Risk Population

This study aimed to investigate whether combining furosemide with standard hydration therapy results in increased preventive effects on contrast-induced acute kidney injury (CI-AKI) following coronary angiography (CA) or percutaneous coronary intervention (PCI). Patients (n = 230) were enrolled in the study and were randomized to the furosemide group or the control group. Patients in the furosemide group received 0.2 to 0.5 mg/kg of furosemide as a continuous intravenous infusion for 24 hours postoperatively and the same standard hydration regimen received by the control group. Blood samples were obtained 24 hours before and 48 hours after the procedure and urine volume was recorded postprocedure. Patients were followed up for an average of 6 months after the procedure. The incidence of CI-AKI in the furosemide group was significantly lower than that in the control group (8.7% vs 18.3%, P = .034). Multivariate logistic regression showed that age-glomerular filtration rate-ejection fraction score and V/estimated glomerular filtration rate ratio were independent risk factors for CI-AKI. During the average 6-month follow-up, incidence of major adverse cardiovascular events (MACEs) in the furosemide group was also significantly lower. Furosemide combined with standard hydration therapy may reduce the incidence of CI-AKI and MACEs following CA or PCI.

Advances in the pathogenesis and prevention of contrast-induced nephropathy

With the increasing application of medical imaging contrast materials, contrast-induced nephropathy has become one of the leading causes of iatrogenic renal insufficiency. The underlying mechanism is associated with renal medullary hypoxia, direct toxicity of contrast agents, oxidative stress, apoptosis, immune/inflammation and epigenetic regulation in contrast-induced nephropathy. Up to date, there is no effective therapy for contrast-induced nephropathy, and thus risk predication and effective preventive strategies are keys to reduce the occurrence of contrast-induced nephropathy. It was found that the proper use of contrast medium, personalized hydration, and high-dose statins may reduce the occurrence of contrast-induced nephropathy, while antioxidants have not shown significant therapeutic benefits. Additionally, the role of remote ischemia preconditioning and vasodilators in the prevention of contrast-induced nephropathy needs further study. This review aims to discuss the incidence, pathogenesis, risk prediction, and preventive strategies for contrast-induced nephropathy.

Bioimpedance Analysis–Guided Volume Expansion for the Prevention of Contrast-Induced Acute Kidney Injury (the BELIEVE Pilot Randomized Controlled Trial)

Introduction

Peri-procedural i.v. fluid administration is important for the prevention of contrast-induced acute kidney injury (CI-AKI). However, standardized fluid management protocols may not be suitable for all patients. We therefore wished to determine whether an individualized fluid administration protocol guided by measuring extracellular water (ECW) using bioimpedance analysis (BIA) would be safe and would reduce the incidence CI-AKI compared to a standardized fluid administration prescription.

Methods

In this pilot, randomized, parallel-group, single-blind, controlled trial, we compared the effect of BIA-guided isotonic bicarbonate administration according to the ratio of ECW to total body water (ECW/TBW) to our standard isotonic bicarbonate protocol in regard to the safety and efficacy of preventing CI-AKI in chronic kidney disease patients undergoing elective cardiac angiography. Our primary outcome was the incidence of CI-AKI, which was defined as a ≥0.3 mg/dl or 150% increase in serum creatinine concentration within 48 to 72 hours after cardiac angiography.

Results

We studied 61 patients, 30 in the bioimpedance group and 31 in the control group. Age was similar (72.5 ± 7 vs. 71.4 ± 7.9 years), as were body mass index (25.5 vs. 25.8 kg/m²) and baseline serum creatinine (1.3 ± 0.3 vs. 1.4 ± 0.4 mg/dl). The peri-procedural fluid volume administered was significantly greater in the BIA-guided hydration group (899.0 ± 252.7 ml vs. 594.4 ± 125.9 ml, P < .01). The incidence of CI-AKI was 3.3% in BIA-guided hydration group and 6.5% in the control group (relative risk = 0.52, 95% confidence interval = 0.05−5.40, P = 1.00). Adverse events reported were comparable between groups (6.7% vs. 6.5%, P = 1.00).

Conclusions

The overall incidence of CI-AKI after cardiac angiography in our patients with mild-to-moderate renal insufficiency was lower than anticipated. Isotonic bicarbonate administration guided by bioimpedance measurements was safe, and probably led to a lower incidence of CI-AKI, although this not reach statistical significance.

Hydration: Intravenous and Oral: Approaches, Principals, and Differing Regimens: Is It What Goes in or What Comes Out That Is Important?

The literature (in English) was accessed to review the evidence that administration of fluids is protective of contrast-associated acute kidney injury (CA-AKI). The evidence was evaluated with the intent of understanding mechanisms of protection. Prospective randomized trials comparing oral versus intravenous fluid, sodium chloride versus no intravenous fluid, sodium bicarbonate versus sodium chloride, and forced matched hydration versus intravenous sodium chloride provided the data. In general, the more fluid administered, the lower the incidence of CA-AKI. However, understanding the mechanism of this beneficial effect suggests that it is the urine output that most directly affects the incidence of CA-AKI.

A Practical Approach to Preventing Renal Complications in the Catheterization Laboratory

Contrast-induced acute kidney injury is a common complication in patients undergoing invasive procedures and is associated with increased mortality and morbidity. There is no effective approach to the management of this complication, and prevention remains of paramount importance. The 3 pillars of prevention are identification of high-risk patients, appropriate hydration before and after contrast exposure, eGFR-based contrast dosing and use of ultra-low contrast volume in high-risk patients. Most evidence supporting these practices is derived from patients undergoing coronary angiography or percutaneous coronary intervention but these basic principles can be applied to most patients undergoing contrast-based procedures in the catheterization laboratory.

Hydration Strategies for Preventing Contrast-Induced Acute Kidney Injury: A Systematic Review and Bayesian Network Meta-Analysis

Aims

Many previous studies have examined the effect of different hydration strategies on prevention of contrast-induced acute kidney injury (CI-AKI), but the optimal strategy is unknown. We performed a network meta-analysis (NWM) of these previous studies to identify the optimal strategy.

Methods and Results

Web of Science, PubMed, OVID Medline, and Cochrane Library were searched from their inception dates to September 30, 2018. Randomized controlled trials (RCTs) were selected based on strict inclusion criteria, and a Bayesian NWM was performed using WinBUGS V.1.4.3. We finally analyzed 60 eligible RCTs, which examined 21,293 patients and 2232 CI-AKI events. Compared to intravenous 0.9% sodium chloride (reference), intravenous sodium bicarbonate (OR [95% CI]: 0.74 [0.57, 0.93]), hemodynamic guided hydration (0.41 [0.18, 0.93]), and RenalGuard guided hydration (0.32 [0.14, 0.70]) significantly reduced the occurrence of CI-AKI. Oral hydration and intravenous 0.9% sodium chloride were each noninferior to no hydration in preventing CI-AKI. Intravenous 0.9% sodium chloride, sodium bicarbonate, and hemodynamic guided hydration were each noninferior to oral hydration in preventing CI-AKI. Based on surface under the cumulative ranking curve values, the RenalGuard system was best (0.974) and hemodynamic guided hydration was second best (0.849).

Conclusion

There was substantial evidence to support the use of RenalGuard or hemodynamic guided hydration for preventing CI-AKI in high-risk patients, especially those with chronic kidney disease or cardiac dysfunction.

Practical guide to prevention of contrast-induced acute kidney injury after percutaneous coronary intervention

Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.

High-Sensitivity C-Reactive Protein and Acute Kidney Injury in Patients with Acute Myocardial Infarction: A Prospective Observational Study

Background. Accumulating evidence suggests that inflammation plays a key role in acute kidney injury (AKI) pathogenesis. We explored the relationship between high-sensitivity C-reactive protein (hs-CRP) and AKI in acute myocardial infarction (AMI). Methods. We prospectively included 2,063 AMI patients in whom hs-CRP was measured at admission. AKI incidence and a clinical composite of in-hospital death, cardiogenic shock, and acute pulmonary edema were the study endpoints. Results. Two-hundred-thirty-four (11%) patients developed AKI. hs-CRP levels were higher in AKI patients (45 ± 87 vs. 16 ± 41 mg/L; p < 0.0001). The incidence and severity of AKI, as well as the rate of the composite endpoint, increased in parallel with hs-CRP quartiles (p for trend <0.0001 for all comparisons). A significant correlation was found between hs-CRP and the maximal increase of serum creatinine (R = 0.23; p < 0.0001). The AUC of hs-CRP for AKI prediction was 0.69 (p < 0.001). At reclassification analysis, addition of hs-CRP allowed to properly reclassify 14% of patients when added to creatinine and 8% of patients when added to a clinical model. Conclusions. In AMI, admission hs-CRP is closely associated with AKI development and severity, and with in-hospital outcomes. Future research should focus on whether prophylactic renal strategies in patients with high hs-CRP might prevent AKI and improve outcome.

Incidence, Predictors, and Prognostic Value of Acute Kidney Injury Among Patients Undergoing Left Atrial Appendage Closure

OBJECTIVES

The aims of this registry were to determine the incidence, predictors, and prognostic value of periprocedural acute kidney injury (AKI) after left atrial appendage closure (LAAC).

BACKGROUND

No data exist on the occurrence of AKI after LAAC.

METHODS

A total of 355 patients undergoing LAAC were included in the study. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or ≥50%, respectively, after the procedure or the need for hemodialysis during index hospitalization.

RESULTS

The incidence of AKI was 9%, and patients with worse baseline renal function were at higher risk for developing AKI (odds ratio: 1.32; 95% confidence interval [CI]: 1.09 to 1.61; p = 0.004 for each 10 ml/min decrease in glomerular filtration rate). In-hospital bleeding events occurred more frequently in the AKI group (5.3% vs. 15.6%; p = 0.037). After a median follow-up period of 18 months, patients in the AKI group had higher mortality (hazard ratio [HR]: 2.59; 95% CI: 1.36 to 4.92; p = 0.004), more embolic events (HR: 6.14; 95% CI: 2.23 to 16.92; p = 0.001) and major bleeding events (HR: 2.36; 95% CI: 0.89 to 6.24; p = 0.083). The occurrence of AKI was an independent predictor of midterm mortality (HR: 2.00; 95% CI: 1.02 to 3.91; p = 0.044).

CONCLUSIONS

The occurrence of AKI was relatively frequent following LAAC, and patients with lower renal glomerular filtration rates were at high risk for developing this complication. AKI identified a group of patients with worse midterm outcomes, highlighting the importance of further preventive strategies in this population.

[Contrast medium-induced renal failure : Useful protective measures prior to contrast medium administration]

BACKGROUND

Iodinated contrast is essential for diagnosis and treatment in contemporary interventional cardiology. An important complication of percutaneous intervention is contrast-induced nephropathy, which is associated with increased morbidity and mortality, while prolonged hospitalization is responsible for economic consequences.

OBJECTIVES

This article reviews the definition of contrast-induced nephropathy, the role of biomarkers in early diagnosis to identify high-risk patients and potential therapeutic options for preventing acute nephropathy.

CURRENT DATA

The optimization of patients' circulating volume remains the main aspect for preventing contrast-induced nephropathy, as recent studies confirm. Several medications are known to be nephrotoxic, whereas several are nephroprotective and the subject of recent research.

CONCLUSION

Interventions to improve outcomes of established acute kidney injury have not been developed as yet. Prevention and early diagnosis are relevant factors in clinical management. It is important to identify patients at risk and to treat them preemptively.

Controlled decongestion by Reprieve therapy in acute heart failure: results of the TARGET-1 and TARGET-2 studies

AIMS

Safe and effective decongestion is the main goal of therapy in acute heart failure (AHF). In the non-randomized, prospective TARGET-1 and TARGET-2 studies (NCT03897842), we investigated whether adding the Reprieve System® (which continuously monitors urine output and delivers a matched volume of hydration fluid sufficient to maintain the set fluid balance rate) to standard diuretic-based regimen improves decongestion in AHF.

METHODS AND RESULTS

The population consisted of 19 patients hospitalized with AHF (mean age 67 ± 10 years, 18 male, ejection fraction 34 ± 15%, median N-terminal pro-B-type natriuretic peptide 4492 pg/mL). Patients served as their own controls: each patient underwent 24 h of standard diuretic therapy followed by 24 h of diuretics with Reprieve therapy (with normal saline used for matched volume replacement). The primary efficacy endpoint of actual fluid loss not exceeding the target fluid loss at the end of therapy was met in all 19 (100%) patients. The mean diuresis during Reprieve therapy was 6284 ± 2679 mL (vs. 1966 ± 1057 mL 24 h before therapy) and 2053 ± 888 mL (24 h after therapy) (both P < 0.0001). At the end of therapy, patient global assessment improved from 7.7 ± 1.1 to 3.0 ± 1.3 points (P < 0.001), central venous pressure decreased from 15.5 ± 5.3 mmHg to 12.8 ± 4.8 mmHg (P < 0.05) and the median urine sodium loss was 9.7 [3-13] mmol/h. The Reprieve therapy was safe, systolic blood pressure remained stable, mean creatinine dropped from 1.45 ± 0.4 mg/dL to 1.26 ± 0.4 mg/dL (P < 0.001) and biomarkers of renal injury did not change during treatment.

CONCLUSIONS

The Reprieve System in conjunction with diuretic therapy supports safe and controlled decongestion in AHF.

Bioimpedance-Guided Hydration for the Prevention of Contrast-Induced Kidney Injury: The HYDRA Study

BACKGROUND

Intravascular volume expansion plays a major role in the prevention of contrast-induced acute kidney injury (CI-AKI). Recommended standard amounts of fluid infusion before procedures do not produce homogeneous responses in subjects with different initial hydration status.

OBJECTIVES

The goal of this study was to compare the effect of standard and double intravenous (IV) infusion volumes in patients with low body fluid level, assessed by using bioimpedance vector analysis (BIVA), on the incidence of CI-AKI after elective coronary angiographic procedures.

METHODS

A total of 303 patients with low BIVA level on admission were randomized to receive standard volume saline (1 ml/kg/h for 12 h before and after the procedure) or double volume saline (2 ml/kg/h). Patients (n = 715) with an optimal BIVA level received standard volume saline and were included in a prospective registry. The saline infusion was halved in all patients with an ejection fraction <40%. BIVA was repeated immediately before the angiographic procedure in all patients. CI-AKI was defined as an increase in levels of cystatin C ≥10% above baseline at 24 h after contrast administration.

RESULTS

The incidence of CI-AKI was significantly lower (11.5% vs. 22.3%; p = 0.015) in patients receiving double volume saline than in those receiving standard volume saline, respectively. Before the angiographic procedure, 50% of the double volume patients achieved the optimal BIVA level compared with only 27.7% in the standard group (p = 0.0001). The findings were consistent in all the pre-specified subgroups excluding patients with a left ventricular ejection fraction <40% (p for interaction = 0.01).

CONCLUSIONS

Evaluation of BIVA levels on admission in patients with stable coronary artery disease allows adjustment of intravascular volume expansion, resulting in lower CI-AKI occurrence after angiographic procedures. (Personalized Versus Standard Hydration for Prevention of CI-AKI: A Randomized Trial With Bioimpedance Analysis; NCT02225431).

Loop Diuretics in Acute Kidney Injury Prevention, Therapy, and Risk Stratification

BACKGROUND

Loop diuretics (LD) are widely used in emergency and intensive care medicine.

SUMMARY

The substances increase the clearance of electrolytes and water; thus, they allow us to control hypervolemia and to prevent patients from pulmonary edema. LD are also frequently applied to patients with an acute decrease in glomerular filtration rate, namely, acute kidney injury (AKI). Nevertheless, volume depletion may be associated with reduced renal perfusion and possibly slower restitution or even aggravation of kidney dysfunction. Several trials on the preventive or therapeutic efficacy of LD have been published since the early 1970s. Our review article is intended to summarize the most important references related to this topic. In addition, we discuss the diagnostic value of the so-called furosemide stress test. The currently available data indicate that LD may act in a beneficial manner as long as euvolemia is maintained (matched hydration). Key Massages: LD are not beneficial for AKI treatment if kidney-related endpoints are considered. In certain situations, AKI prevention with LD can be associated with favorable outcomes as long as euvolemia is maintained. LD can help to identify AKI subjects at a higher risk of AKI progression, but the exact clinical consequences need to be determined.

Impact of furosemide on mortality and the requirement for renal replacement therapy in acute kidney injury: a systematic review and meta-analysis of randomised trials

Objective

To examine the impact of furosemide on mortality and the need for renal replacement therapy (RRT) in adult patients with acute kidney injury (AKI) based on current evidence.

Data sources

PubMed (Medline) and Embase were searched from 1998 to October 2018.

Study selection

We retrieved data from randomised controlled trials comparing prevention/treatment with furosemide at any stage of AKI with alternative treatment/standard of care/placebo. The outcome was short-term mortality and the requirement for RRT, when applicable.

Data extraction

Two reviewers independently extracted appropriate data. PRISMA guidelines were followed for data preparation and reporting.

Data synthesis

We identified 20 relevant studies (2608 patients: 1330 in the treatment arm and 1278 in the control arm). Heterogeneity between studies was deemed acceptable, and the publication bias was low. Furosemide had neither an impact on mortality (OR = 1.015; 95% CI 0.825–1.339) nor the need for RRT (OR = 0.947; 95% CI 0.521–1.721). Furosemide had also no effect on the outcomes in strata defined by intervention strategy (prevention/treatment), AKI origin (cardio-renal syndrome, post-cardiopulmonary bypass, critical illness), control arm comparator (RRT, saline/placebo/standard of care) and its dose (< 160/≥ 160 mg) (p > 0.05 for all). Subjects who received furosemide with matched hydration in prevention of contrast-induced nephropathy (CIN) had a less frequent need for RRT (OR = 0.218; 95% CI 0.05–1.04; p = 0.055).

Conclusions

Furosemide administration has neither an impact on mortality nor the requirement for RRT. Patients at risk of CIN may benefit from furosemide administration. Further well-designed RCTs are needed to verify these findings.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0557-0) contains supplementary material, which is available to authorized users.