The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency

The Association of Intraindividual Difference Between Cystatin- and Creatinine-Based Estimated GFR and Contrast-Associated Acute Kidney Injury

Purpose

The estimated glomerular filtration rate (eGFR) based on creatinine is crucial for the risk assessment of contrast-associated acute kidney injury (CA-AKI). In recent, the difference between cystatin C-based eGFR (eGFRcys) and creatinine-based eGFR (eGFRcr) has been widely documented. We aimed to explore whether intraindividual differences between eGFRcys and eGFRcr had potential value for CA-AKI risk assessment in patients undergoing elective percutaneous coronary intervention (PCI).

Patients and Methods

From January 2012 to December 2018, we retrospectively observed 5049 patients receiving elective PCI. To determine eGFR, serum creatinine and cystatin C levels were measured. CA-AKI was defined as serum creatinine being increased ≥ 50% or 0.3 mg/dL within 48 h after contrast agents exposure. Chronic kidney disease (CKD) was defined as the eGFR < 60 mL/min/1.73 m2.

Results

Approximately half of the participants (2479, 49.1%) had a baseline eGFRdiff (eGFRcys-eGFRcr) between -15 and 15 mL/min/1.73 m2. Restricted cubic splines analysis revealed a nonlinear relationship between eGFRdiff and CA-AKI. Multivariable logistic regression analysis indicated that compared with the reference group (-15 to 15 mL/min/1.73 m2), the negative-eGFRdiff group (less than -15 mL/min/1.73 m2) had a higher risk of CA-AKI (OR, 3.44; 95% CI, 2.57-4.64). Furthermore, patients were divided into four groups based on CKD identified by eGFRcys or eGFRcr. Multivariable logistic analysis revealed that patients with either CKDcys (OR, 2.94; 95% CI, 2.19-3.95, P < 0.001) or CKDcr (OR, 2.44; 95% CI, 1.19-4.63, P < 0.001) had an elevated risk of CA-AKI compared to those without CKDcys and CKDcr.

Conclusion

There are frequent intraindividual differences between eGFRcys and eGFRcr, and these differences can be used to forecast the risk of CA-AKI.

Acute Kidney Injury After Percutaneous Coronary Intervention Guided by Intravascular Ultrasound

Purpose We investigated the impact of intravascular ultrasound guidance on reducing the incidence of contrast-induced acute kidney injury (CI-AKI) in patients undergoing percutaneous coronary intervention (PCI). Methods Ninety-nine patients were enrolled in this prospective cohort who were not randomly assigned to angiography-guided percutaneous coronary intervention or intravascular ultrasound-guided percutaneous coronary intervention. The patients were hospitalized at the Vietnam National Heart Institute - Bach Mai Hospital between 2019 and 2020. Acute kidney injury incidence during hospitalization was the primary endpoint. Results A total of 99 patients were divided into two groups: the intravascular ultrasound-guided group (33 participants) and the angiography-guided group (66 participants). The mean ± SD contrast volume of each group was 95.2 ± 37.1 mL and 133.0 ± 36.0 mL for the ultrasound-guided and angiography-guided groups, with P < 0.0001. Intravascular imaging-guided percutaneous coronary intervention (IVUS-guided PCI) was associated with reduced acute kidney injury incidence during hospitalization: 0.0% vs. 12.12% and P = 0.049. Conclusions Intravascular ultrasound is a safe imaging tool that guides percutaneous coronary intervention and significantly reduces the rate of acute kidney injury compared to angiography alone. Patients who have a high chance of experiencing acute kidney injury benefit from using intravascular ultrasound.

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.

Development and Validation of a Risk Model for Predicting Contrast-Associated Acute Kidney Injury in Patients With Cancer: Evaluation in Over 46,000 CT Examinations

BACKGROUND. Patients with cancer undergo frequent CT examinations with iodinated contrast media and may be uniquely predisposed to contrast-associated acute kidney injury (CA-AKI). OBJECTIVE. The purpose of this study was to develop and validate a model for predicting the risk of CA-AKI after contrast-enhanced CT in patients with cancer. METHODS. This retrospective study included 25,184 adult patients (12,153 men, 13,031 women; mean age, 62.3 ± 13.7 [SD] years) with cancer who underwent 46,593 contrast-enhanced CT examinations between January 1, 2016, and June 20, 2020, at one of three academic medical centers. Information was recorded regarding demographics, malignancy type, medication use, baseline laboratory values, and comorbid conditions. CA-AKI was defined as a 0.3-mg/dL or greater increase in serum creatinine level from baseline within 48 hours after CT or a 1.5-fold or greater increase in the peak measurement within 14 days after CT. Multivariable models accounting for correlated data were used to identify risk factors for CA-AKI. A risk score for predicting CA-AKI was generated in a development set (n = 30,926) and tested in a validation set (n = 15,667). RESULTS. CA-AKI occurred after 5.8% (2682/46,593) of CT examinations. The final multivariable model for predicting CA-AKI included hematologic malignancy, diuretic use, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, chronic kidney disease (CKD) stage 3a, CKD stage 3b, CKD stage 4 or 5, serum albumin level less than 3.0 g/dL, platelet count less than 150 × 103/μL, 1+ or greater proteinuria on baseline urinalysis, diabetes mellitus, heart failure, and contrast medium volume 100 mL or greater. A risk score (range, 0-53 points) was generated with these variables. The most points (13) were for CKD stage 4 or 5 and for albumin level less than 3 g/dL. The frequency of CA-AKI progressively increased in higher risk categories. For example, in the validation set, CA-AKI occurred after 2.2% of CT examinations in the lowest risk category (score ≤ 4) and after 32.7% of CT examinations in the highest risk category (score ≥ 30). The Hosmer-Lemeshow test result indicated that the risk score was a good fit (p = .40). CONCLUSION. A risk model in which readily available clinical data are used to predict the likelihood of CA-AKI after contrast-enhanced CT in patients with cancer was developed and validated. CLINICAL IMPACT. The model may help facilitate appropriate implementation of preventive measures in the care of patients at high risk of CA-AKI.

Contrast-Associated Acute Kidney Injury: Definitions, Epidemiology, Pathophysiology, and Implications

Acute kidney injury (AKI) is a common occurrence after contrast media administration. Hemodynamic changes, direct tubular injury, and reactive oxygen species are the proposed mechanisms involved in AKI. However, in most scenarios, it is not possible to establish causality despite extensive clinical evaluation, therefore, contrast-associated AKI (CA-AKI) has become a widely accepted term to define AKI postcontrast. CA-AKI is associated with worse clinical outcomes including cardiovascular events and mortality; however, discussions are ongoing whether CA-AKI is a marker of an increased risk of adverse outcomes or a mediator of such outcomes.

A Simple Strategy to Reduce Contrast Media Use and Risk of Contrast-Induced Renal Injury during PCI: Introduction of an "Optimal Contrast Volume Protocol" to Daily Clinical Practice

Contrast-induced acute kidney injury is the leading cause of iatrogenic acute nephropathy. Development of contrast-induced nephropathy (CIN) increases the risk of adverse long- and short-term patients outcomes, the hospital costs, and length of hospitalization. There are a couple of methods described for CIN prevention (statin prescription, prehydration, contrast media (CM) clearance from the blood system, and decrease amounts of contrast volume). The CM volume to patient's creatinine clearance ratio is the main factor to predict the risk of CIN development. The safe CM to creatinine clearance ratio limits have been established. The usage of CM amount depends on personal operators habits and inside center regulations. There is no standardized contrast usage protocol worldwide. The aim of this study was to establish an easy to use, cheap, and efficient protocol to estimate a personalized safe CM dose limit for every patient based on their kidney function. These limits are announced during the "Time Out" before the procedure. Our study included 519 patients undergoing interventional coronary procedures: 207 patients into the "Optimal Contrast Volume" arm and 312 into the control group. Applying the protocol into a daily clinical practice leads to a significant reduction in CM volume used for all type of procedures and the development of CIN in comparison with a control group.

A Simplified Risk Score to Estimate the Risk of Contrast-Induced Nephropathy after Contrast Exposure

Introduction

Scores are available to predict the probability of contrast-induced nephropathy (CIN) after cardiac interventions, but not many scores are available for non-cardiac interventions and there are none for intravenous exposure to contrast. We designed this study to develop a simplified score to determine the probability of developing CIN in patients exposed to the parenteral contrast medium.

Methods

This was a prospective study of patients who received parenteral contrast. Of 1300 patients, the first 1000 comprised the derivation cohort and the next 300 comprised the validation cohort. The patient variables in the development cohort were studied using univariate analysis. Statistically significant individual variables were used as independent variables, and CIN was used as the dependent variable in the final multivariate logistic regression model. Then, the risk score was obtained and validated.

Results

The incidence of CIN was 3.8%. The risk factors, namely the presence of diabetes mellitus, e-GFR, and route and volume of contrast material were significantly associated with the risk of CIN (P < 0.05). The developed risk score had a sensitivity of 90.4% and specificity of 98.78%. The overall accuracy was 97.8%. The values of AUC of ROC in the development and validation datasets were high. This indicated that the predicted CIN risk score correlated well with the calibration and discriminative characteristics.

Conclusions

The route and volume of contrast administered, low e-GFR, and diabetes mellitus were the significant risk factors. The developed risk score exhibited very good sensitivity and specificity and excellent accuracy in predicting the probability of CIN.

Impact of SGLT2-inhibitors on contrast-induced acute kidney injury in Diabetic patients with Acute Myocardial Infarction with and without chronic kidney disease: Insight from SGLT2-I AMI PROTECT Registry

AIMS

To analyze the association between chronic SGLT2-I treatment and development of contrast-induced acute kidney injury (CI-AKI) in diabetic patients with acute myocardial infarction (AMI) undergoing PCI.

METHODS

Multicenter international registry of consecutive patients with type 2 diabetes mellitus (T2DM) and AMI undergoing PCI between 2018-2021. The study population was stratified by the presence of chronic kidney disease (CKD) and anti-diabetic therapy at admission (SGLT2-I versus non-SGLT2-I users).

RESULTS

The study population consisted of 646 patients: 111 SGLT2-I users [28 (25.2%) with CKD] and 535 non-SGLT2-I users [221 (41.3%) with CKD]. The median age was 70 [61-79] years. SGLT2-I users exhibited significantly lower creatinine values at 72h after PCI, both in the non-CKD and CKD stratum. The rate of CI-AKI was 76 (11.8%), significantly lower in SGLT2-I users compared to non-SGLT2-I patients (5.4% vs 13.1%, p=0.022). This finding was also confirmed in patients without CKD (p=0.040). In the CKD cohort, SGLT2-I users maintained significantly lower creatinine values at discharge. The use of SGLT2-I was an independent predictor of reduced rate of CI-AKI (OR 0.356; 95%CI 0.134-0.943, p=0.038).

CONCLUSION

In T2DM patients with AMI, the use of SGLT2-I was associated with a lower risk of CI-AKI, mostly in patients without CKD.

Incidence, Determinants, and Outcome of Contrast-induced Acute Kidney Injury following Percutaneous Coronary Intervention at a Tertiary Care Hospital

Contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) is the common cause of in-hospital acquired AKI and is associated with in-hospital mortality and prolonged hospital stay. We studied the incidence of CI-AKI after PCI, determinants of CI-AKI, and also assessed their length of hospital stay, in-hospital mortality, and need for dialysis. This was a hospital-based prospective observational study done on 204 adult subjects, who were candidates for PCI, at a tertiary care center in North India. Various clinical and biochemical parameters were monitored. Renal function was estimated at admission and 48 and 72 h after PCI. The incidence of CI-AKI post-PCI was 12.7%. Factors predicting the CI-AKI post-PCI on multiple logistic regression analysis are as follows: age ≥70 years, chronic kidney disease (CKD), hypotension, acute decompensated heart failure (ADHF), severe left ventricular systolic dysfunction (LVSD), and intra-aortic balloon pump (IABP) support. Contrast medium volume ≥200 mL and baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 were significantly found to increase the risk of CI-AKI. Patients developing CI-AKI had significantly longer duration of hospital stay (6.4 ± 1.8 days vs. 3.1 ± 0.9 days; P <0.001). 15.4% of CI-AKI patients needed dialysis. In-hospital mortality was significantly higher in patients with CI-AKI (P <0.001). CI-AKI is a common complication following PCI, especially if the patient is elderly, has impaired renal function, hypotension, ADHF, severe LVSD and requires IABP support. The incidence of CI-AKI increases with the increases in contrast volume above 200 mL. The development of CI-AKI leads to a longer duration of hospital stay and increases in-hospital mortality.

Contrast-Induced Acute Kidney Injury and Endothelial Dysfunction: The Role of Vascular and Biochemical Parameters

INTRODUCTION

Contrast-induced acute kidney injury (CIAKI) is one of the main causes of acute renal failure in hospitalized patients, following the administration of iodinated contrast medium used for CT scans and angiographic procedures. CIAKI determines a high cardiovascular risk and appears to be one of the most feared complications of coronary angiography, causing a notable worsening of the prognosis with high morbidity and mortality.

AIM

To evaluate a possible association between the renal resistive index (RRI) and the development of CIAKI, as well as an association with the main subclinical markers of atherosclerosis and the main cardiovascular risk factors.

MATERIALS AND METHODS

We enrolled 101 patients with an indication for coronary angiography. Patients underwent an assessment of renal function (serum nitrogen and basal creatinine, 48 and 72 h after administration of contrast medium), inflammation (C reactive protein (CRP), serum calcium and phosphorus, intact parathormone (iPTH), 25-hydroxyvitaminD (25-OH-VitD), serum uric acid (SUA), total cholesterol, serum triglycerides, serum glucose and insulin). All patients also carried out an evaluation of RRI, intima-media thickness (IMT), interventricular septum (IVS) and the ankle-brachial index (ABI).

RESULTS

101 patients (68 male), with a mean age of 73.0 ± 15.0 years, were enrolled for the study; 35 are affected by type 2 diabetes mellitus. A total of 19 cases of CIAKI were reported (19%), while among diabetic patients we reported an incidence of 23% (8 patients). In our study, patients with CIAKI had significantly higher RRI (p < 0.001) and IMT (p < 0.001) with respect to the patients who did not develop CIAKI. Furthermore, patients with CIAKI had significantly higher CRP (p < 0.001) and SUA (p < 0.006).

CONCLUSIONS

We showed a significant difference in RRI, IMT, SUA and CRP values between the population developing CIAKI and patients without CIAKI. This data appears relevant considering that RRI and IMT are low-cost, non-invasive and easily reproducible markers of endothelial dysfunction and atherosclerosis.

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.

Deep learning reconstruction allows for usage of contrast agent of lower concentration for coronary CTA than filtered back projection and hybrid iterative reconstruction

BACKGROUND

The demand for homogeneous and higher vascular contrast enhancement is critical to provide an appropriate interpretation of abnormal vascular findings in coronary computed tomography angiography (CTA).

PURPOSE

To evaluate the effect of various contrast media concentrations (Iohexol-370, Iohexol-300, Iohexol-240) and image reconstructions (filtered back projection [FBP], hybrid iterative reconstruction [IR], and deep learning reconstruction [DLR]) on coronary CTA.

MATERIAL AND METHODS

A total of 63 patients referred for coronary CTA between July and October 2021 were enrolled in this prospective study, and they randomly received one of three contrast media. CTA images were reconstructed with FBP, hybrid IR, and DLR. The CT attenuation, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated for all three images. The images were subjectively evaluated by two radiologists in terms of overall image quality, artifacts, image noise, and vessel wall delineation on a 5-point Likert scale.

RESULTS

The application of DLR resulted in significantly lower image noise; higher CT attenuation, SNR, and CNR; and better subjective analysis among the three different concentrations of contrast media groups (P < 0.001). There was no significant difference in the CT attenuation of the left ventricle (P = 0.089) and coronary arteries (P = 0.072) between hybrid IR at Iohexol-300 and DLR at Iohexol-240. Furthermore, application of DLR to the Iohexol-240 significantly improved SNR and CNR; it achieved higher subjective scores compared with hybrid IR at Iohexol-300 (P < 0.001).

CONCLUSION

We suggest that using DLR with Iohexol-240 contrast media is preferable to hybrid IR with Iohexol-300 contrast media in coronary CTA.

Ultra-low CONtraSt PCI vs conVEntional PCI in patients of ACS with increased risk of CI-AKI (CONSaVE-AKI)

Objectives

This prospective, randomized study assessed short-term outcomes and safety of ultra-low contrast percutaneous coronary intervention(ULC-PCI) vs conventional PCI in high risk for contrast induced acute kidney injury(CI-AKI) patients presenting with acute coronary syndrome(ACS).

Background

Patients at an increased risk of developing CI-AKI can be identified prior to PCI based on their pre-procedural risk scores. ULC-PCI is a novel contrast conservation strategy in such high risk patients for prevention of CI-AKI.

Methods

82 patients undergoing PCI for ACS were enrolled having estimated glomerular filtration rate(eGFR) < 60 ml/min/1.73 m² and moderate to very high pre-procedural risk of developing CI-AKI as calculated by Maioli risk calculator. They were randomized into two groups of 41 patients each of ULC-PCI (contrast volume ≤ patient's eGFR) and conventional PCI (contrast volume ≤ 3xpatient's eGFR). Primary end point was development of CI-AKI.

Results

Baseline clinical and angiographic characteristics were similar between groups. Primary outcome of CI-AKI occurred more in patients of the conventional PCI group [7 (17.1%)] than in the ULC PCI group [(0 patients), p = 0.012]. Contrast volume (41.02 (±9.8) ml vs 112.54 (±25.18) ml; P < 0.0001) was markedly lower in the ULC-PCI group. No significant difference in secondary safety outcomes between two study arms at 30 days. IVUS was used in 17% patients in ULC PCI.

Conclusion

ULC-PCI in patients with increased risk of developing CI-AKI is feasible, appears safe, and has the potential to decrease the incidence of CI-AKI specially in resource limited setting such as ours where coronary imaging by IVUS is not possible in every patient.

Influence of concomitant percutaneous transluminal angioplasty with percutaneous coronary intervention on clinical outcomes of stable lower extremity artery diseases

Concomitant percutaneous transluminal angioplasty (PTA) at the time of percutaneous coronary intervention (PCI) is often performed because lower extremity artery disease (LEAD) commonly coincides with coronary artery disease. We investigated the impact of concomitant PTA on both cardiovascular and limb outcomes in the Korean National Health Insurance Service registry. Among 78,185 patients undergoing PCI, 6563 patients with stable LEAD without limb ischemia were included. After 1:5 propensity score matching was conducted, 279 patients in the PTA + PCI group and 1385 patients in the PCI group were compared. Multivariate Cox proportional hazard models showed that the risk of all-cause death was higher in the PTA + PCI group than in the PCI group, whereas the risks of myocardial infarction, repeat revascularization, stroke, cardiovascular death and bleeding events were not different between the 2 groups. In contrast, the risks of end-stage renal disease and unfavorable limb outcomes were higher in the PTA + PCI group. Mediation analyses revealed that amputation and PTA after discharge significantly mediated the association between concomitant PTA and all-cause death. Concomitant PTA was not associated with an increased risk of cardiovascular events but may increase the risk of all-cause death mediated by unfavorable renal and limb outcomes in patients with stable LEAD.

A simple proteinuria-based risk score predicts contrast-associated acute kidney injury after percutaneous coronary intervention

Contrast-associated acute kidney injury (CA-AKI) is a complication of percutaneous coronary intervention (PCI). Because proteinuria is a sentinel marker of renal dysfunction, we assessed its role in predicting CA-AKI in patients undergoing PCI. A total of 1,254 patients undergoing PCI were randomly assigned to a derivation (n = 840) and validation (n = 414) dataset. We identified the independent predictors of CA-AKI where CA-AKI was defined by the new criteria issued in 2020, by a multivariate logistic regression in the derivation dataset. We created a risk score from the remaining predictors. The discrimination and calibration of the risk score in the validation dataset were assessed by the area under the receiver-operating characteristic curves (AUC) and Hosmer–Lemeshow test, respectively. A total of 64 (5.1%) patients developed CA-AKI. The 3 variables of the risk score were emergency procedures, serum creatinine, and proteinuria, which were assigned 1 point each based on the correlation coefficient. The risk score demonstrated a good discriminative power (AUC 0.789, 95% CI 0.766–0.912) and significant calibration. It was strongly associated with the onset of CA-AKI (Cochran-Armitage test, p < 0.0001). Our risk score that included proteinuria was simple to obtain and calculate, and may be useful in assessing the CA-AKI risk before PCI.

Radiographic Contrast Media and the Kidney

AKI is a potential complication of intravascular iodinated contrast exposure. Contrast-associated AKI, which typically manifests as small and transient decrements in kidney function that develop within several days of contrast administration, is associated with serious adverse outcomes, including progressive kidney dysfunction and death. However, a causal link between the small increases in serum creatinine that characteristically occur with contrast-associated AKI and serious adverse outcomes remains unproven. This is important given mounting evidence that clinically indicated, potentially lifesaving radiographic procedures are underutilized in patients with CKD. This has been hypothesized to be related to provider concern about precipitating contrast-associated AKI. Intravascular gadolinium-based contrast, an alternative to iodinated contrast that is administered with magnetic resonance imaging, has also been linked with potential serious adverse events, notably the development of nephrogenic systemic fibrosis in patients with severe impairment in kidney function. Patients hospitalized in the intensive care unit frequently have clinical indications for diagnostic and therapeutic procedures that involve the intravascular administration of contrast media. Accordingly, critical care providers and others treating critically ill patients should possess a sound understanding of the risk factors for and incidence of such outcomes, the ability to perform evidence-based risk-benefit assessments regarding intravascular contrast administration, and knowledge of empirical data on the prevention of these iatrogenic complications.

Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease

Percutaneous coronary intervention (PCI) is one of the most common procedures performed in medicine. However, its net benefit among patients with chronic kidney disease (CKD) is less well established than in the general population. The prevalence of patients suffering from both CAD and CKD is high, and is likely to increase in the coming years. Planning the adequate management of this group of patients is crucial to improve their outcome after PCI. This starts with proper preparation before the procedure, the use of all available means to reduce contrast during the procedure, and the implementation of modern strategies such as radial access and drug-eluting stents. At the end of the procedure, personalized antithrombotic therapy for the patient’s specific characteristics is advisable to account for the elevated ischemic and bleeding risk of these patients.

Serum Uric Acid to Albumin Ratio Can Predict Contrast-Induced Nephropathy in ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) is one of the common complication of ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI). Serum uric acid to albumin ratio (UAR) is a novel marker, which is associated with acute kidney injury in intensive care unit patients. We investigated the predictive value of UAR for the development of CIN in STEMI patients (n = 1379) after pPCI. The diagnosis of CIN was made based on an increase of basal creatinine levels >.5 mg/dL or 25% within 72 h after pPCI; 128 patients were in the CIN (+) group and 1251 patients were in the CIN (-) group. CIN (+) patients had higher serum uric acid (SUA), UAR, and lower albumin levels than CIN (-) patients. Age, diabetes, hypertension, hemoglobin, glucose at admission, basal creatinine, peak troponin I, total bilirubin, contrast volume/glomerular filtration rate, and UAR were independent predictors of CIN. A cutoff value of 1.62 for UAR detected CIN development with a sensitivity of 54% and specificity of 87.4%, and the discrimination ability of UAR was better than that of SUA or albumin. In conclusion, UAR was an independent predictor of the development of CIN.

Prevalence and Risk Factors for Acute Kidney Injury Among Adults Undergoing Cardiac Interventions in King Abdulaziz University Hospital: A Retrospective Review

Background

Acute kidney injury (AKI) is a syndrome that has been receiving considerable attention as a common risk in cardiac surgeries, which has consequences for short- and long-term survival implications, even for those who do not progress to renal failure. There have been limited studies in the Middle East, and specifically in the Kingdom of Saudi Arabia (KSA). Therefore, our study aimed to identify the prevalence of and risk factors for AKIs following adult cardiac interventions during 2010-2020 at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Methods

Setting and Design: A retrospective medical record review was conducted among all the adult patients who underwent cardiac interventions and developed AKIs between 2010 and 2020. Google forms were used to extract the data from the hospital records. About statistical analysis binary logistic regression analyses, relative risks (RRs), and confidence intervals (CI) were used to determine the associations among the variables.

Results

After applying the inclusion and exclusion criteria, 564 patients were included. Their baseline demographic, clinical, biological, and operative characteristics were analyzed. AKIs developed in 110 (19.5%) patients and patients with diabetes were more likely to develop AKIs (P < 0.012, RR = 2.280, CI = 1.198-4.339). Hypertension showed a strong effect in the development of AKIs (P < 0.004, RR = 2.865, CI = 1.391-5.900). Moreover, patients who suffered from chronic heart failure were more prone to the development of AKIs (P < 0.008, RR = 4.189, CI =1.452-12.087). Furthermore, anemia with significant P-values (<0.002), and CIs of 1.509-6.822, indicated that these patients were more likely to develop AKIs (3.209 times).

Conclusion

We demonstrated that AKIs are frequent complications in adults after cardiac interventions and were associated with poor outcomes. Risk factors for the development of AKIs were identified to be diabetes mellitus, hypertension, chronic heart failure, and anemia. Further investigation of this cohort is necessary to better understand the problem of kidney injuries.

Association Between Non-Recovered Contrast-Associated Acute Kidney Injury and Poor Prognosis in Patients Undergoing Coronary Angiography

Background

Previous studies have shown that renal function recovery after acute kidney injury (AKI) was associated with decreased risk of all-cause mortality. However, little is known about the correlation between renal function recovery and long-term prognosis in patients with contrast-associated acute kidney injury (CA-AKI) undergoing coronary angiography (CAG).

Methods

We retrospectively enrolled 5,865 patients who underwent CAG. CA-AKI was defined as an increase in serum creatinine (SCr) ≥ 50% or ≥ 0.3 mg/dl from baseline within 72 h post procedure. Recovered CA-AKI was defined as a decrease in SCr to baseline or no CA-AKI level. The first endpoint was long-term all-cause mortality. Kaplan–Meier analysis and Cox regression analysis were used to investigate the association between kidney function recovery and long-term mortality.

Results

During the median follow-up period of 5.25 years, the overall long-term mortality was 20.07%, and the long-term mortality in patients with recovered CA-AKI and non-recovered CA-AKI was 17.46 and 27.44%, respectively. After multivariate Cox hazard regression, non-recovered CA-AKI was significantly associated with long-term mortality, while recovered CA-AKI was not [recovered CA-AKI vs. no CA-AKI, hazard ratio (HR) = 1.06, 95% confidence interval (CI): 0.81–1.39, p = 0.661; non-recovered CA-AKI vs. no CA-AKI, HR = 1.39, 95% CI: 1.21–1.60, p &lt; 0.001]. In the subgroup of CAD, both recovered CA-AKI and non-recovered CA-AKI were associated with increased risk of long-term all-cause mortality. However, in other subgroup analyses, only non-recovered CA-AKI was associated with increased risk of long-term all-cause mortality.

Conclusion

Our results found that non-recovered CA-AKI is significantly associated with long-term mortality. In patients with CAD, recovered CA-AKI can still increase the risk of all-cause mortality. Clinicians need to pay more attention to patients suffering from CA-AKI, whose kidney function has not recovered. In addition, active prevention treatments should be taken by patients with CAD.

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

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

Risk of acute kidney injury requiring hemodialysis after contrast-enhanced imaging after traumatic injury: A National Trauma Databank analysis

BACKGROUND

Trauma patients undergo routine contrast administration for diagnostic and therapeutic purposes. The aim of this study is to investigate the incidence and predictors of contrast-induced nephropathy requiring acute hemodialysis in the trauma population.

METHODS

Adult patients (age ≥16) were identified from the National Trauma Databank (2017-2018) and were grouped based on contrast received. The defined groups included no contrast, computed tomography intravascular contrast only, and angiography contrast. Patient demographic and clinical variables collected included vital signs (systolic blood pressure, pulse rate) recorded upon arrival to the emergency room, injury severity score, shock index, Glasgow Coma Scale, and mechanism. Outcome measures included mortality, hospital discharge disposition, intensive care unit and hospital length of stay, and need for hemodialysis. We performed a Poisson regression to assess relative risk for undergoing hemodialysis during hospital admission.

RESULTS

In total, 1,850,460 patients were included in the analysis (no contrast: 1,189,209; computed tomography intravascular contrast only: 621,846; angiography: 39,405); 3,135 patients required hemodialysis during the admission. Patients with reduced Glasgow Coma Scale, higher injury severity score, higher shock index, and preexisting diabetes mellitus and hypertension were more likely to require hemodialysis. Poisson regression revealed the relative risk of requiring hemodialysis as 1.49 with computed tomography intravascular contrast only, 4.33 with angiography only, and 5.35 with consecutive computed tomography intravascular and angiography.

CONCLUSION

Intravascular contrast administration through computed tomography and or angiography is independently associated with increased risk of requiring hemodialysis after a traumatic injury. Trauma surgeons should consider the necessity of contrast for each clinical situation and understand the potential for contrast-induced nephropathy.

Is intravenous iodinated contrast medium administration really harmful in hospitalized acute kidney injury patients: a propensity score-matched study

OBJECTIVES

To evaluate the effects of intravenous iodinated contrast medium (ICM) administration on the deterioration of renal function (DRF), new renal replacement therapy (RRT) induction and mortality of hospitalized acute kidney injury (AKI) patients.

METHODS

Adult hospitalized patients undergoing a contrast-enhanced or unenhanced CT scan within 7 days after AKI diagnosis from January 2015 to December 2019 were identified in this retrospective study. Propensity score matching was performed. Outcomes in 7 and 30 days after CT scan were compared between the contrast and non-contrast groups. Additional analyses were also performed in patients stratified by SCr levels at AKI diagnosis, times and time of CT scan, and in patients without chronic kidney disease or RRT requirement prior to CT scan.

RESULTS

In total, 1172 pairs were generated after 1:1 propensity score matching from 1336 cases exposed to ICM and 2724 unexposed. No significant differences were found in the outcomes between the two groups: DRF, 7.8% vs 9.0% (odds ratio (OR) 0.83, 95% confidence interval (CI) 0.62-1.11) in 7 days, 5.1% vs 5.4% (OR 0.93, 95%CI 0.64-1.34) in 30 days; new RRT induction, 2.3% vs 3.3% (OR 0.72,95%CI 0.43-1.18) in 7 days, 4.2% vs 4.5% (OR 0.95,95%CI 0.64-1.41) in 30 days; and mortality, 3.9% vs 4.8% (OR 0.83,95%CI 0.56-1.22) in 7 days, 9.0% vs 10.2% (OR 0.88,95%CI 0.68-1.15) in 30 days. Subset analyses showed similar results.

CONCLUSION

Intravenous ICM administration during AKI duration did not increase the risks of DRF, new RRT induction, and mortality in 7 and 30 days after CT scan.

KEY POINTS

• Intravenous ICM administration in hospitalized AKI patients does not increase the risks of deterioration of renal function, RRT induction, and mortality in 7 and 30 days after CT scan. • The effects of intravenous ICM on adverse outcomes are minimal even in AKI patients with high level of SCr values or multiple CT scans.

Combined evaluation of plasma B-type natriuretic peptide and urinary liver-type fatty acid-binding protein/creatinine ratio is related to worsening renal function in patients undergoing elective percutaneous coronary intervention

BACKGROUND

There are few reports on the significance for the combined evaluation of blood humoral factors and urinary biomarkers in terms of worsening renal function (WRF) after coronary angiography (CAG)/percutaneous coronary arterial intervention (PCI).

METHOD AND RESULTS

Urinary liver type-fatty acid-binding protein (L-FABP), neutrophil gelatinase associated lipocalin (NGAL), and adrenomedullin (AM) were measured less than 24 h before and 3 h, 6 h, 1 day, and 2 days after CAG/PCI. WRF was defined as a > 20% decrease in the estimated GFR. WRF occurred in seven of 100 patients and the increase in L-FABP/creatinine (Cr) at 1 day after CAG/PCI was significantly higher in the WRF group than in the non-WRF group. Plasma B-type natriuretic peptide (BNP) before CAG/PCI and L-FABP/Cr at 1 day after CAG/PCI were independent predictors for WRF. The areas under the receiver-operating characteristic curves were as follows: 0.760 for BNP before CAG/PCI, 0.731 for L-FABP/Cr at 1 day after CAG/PCI, and 0.892 for BNP and L-FABP/Cr. Urinary AM levels after PCI/CAG were negatively correlated only to serum potassium levels. Gene expressions of AM and AM-receptor were detectable in renal tubule epithelial cells. AM increased intracellular second messenger levels in a dose-dependent manner.

CONCLUSIONS

Our results suggest that combined evaluation of plasma BNP and urinary L-FABP/Cr is useful as a predictor of renal dysfunction in CAG/PCI patients.

Impact of RAAS Blockers on Contrast-Induced Nephropathy in Patients With Renal Insufficiency: A Meta-Analysis

The effect of renin-angiotensin-aldosterone system (RAAS) blockers [angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers] on Contrast-induced nephropathy (CIN) is unclear in patients with renal insufficiency. Thus, we conduct a meta-analysis to evaluate the association between the administration of RAAS blockers and CIN in patients with renal insufficiency. We searched PubMed, EMBASE, and Cochrane Library for relevant studies published before September 2019. The primary outcome was the incidence of CIN, and the secondary outcome was the changes in serum creatinine (SCr) from baseline to postprocedure (ΔSCr). Pooled odds ratio (OR) or weighted mean difference (WMD) with their 95% confidence interval (CIs) for the CIN incidence, ΔSCr were used to calculate original data. A total of 8 studies were included in the meta-analysis. Compared with controls, ACEI/angiotensin receptor blocker increased the risk of CIN (OR = 1.61, 95% CI 1.14-2.28, I = 30%; P = 0.007), whereas this association was not significant in Chinese patients (OR = 1.07, 95% CI 0.65-1.77, I = 19%, P = 0.79). The total weighted mean differences of the ΔSCr were 0.06 mg/dL (95% CI: 0.01-0.11, I = 82%; P = 0.03). Administration of RAAS blockers in patients with renal insufficiency was associated with a significantly higher incidence of CIN, whereas it did not show a significant effect on Chinese patients.

Renal artery embolization for spontaneous hemorrhage in patients with acquired cystic kidney disease: A 20-year single-center experience

Objectives

To evaluate the safety and effectiveness of transcatheter arterial embolization for controlling spontaneous hemorrhage in patients with acquired cystic kidney disease (ACKD).

Methods

This retrospective study included 18 patients with ACKD (M:F=13:5; mean age, 56 years) who underwent renal artery embolization to control spontaneous hemorrhage between January 2001 and September 2020. The underlying etiology and clinical presentations were reviewed and previous computed tomography (CT) findings were analyzed. Furthermore, angiographic and embolization details, technical and clinical successes, and complications were assessed.

Results

Subcapsular, perirenal, and pararenal hematomas were observed on CT scans for all patients. Contrast extravasation was observed in 15 / 17 patients (88%) on contrast-enhanced CT scans. Angiography showed active bleeding in 14 patients (78%; contrast extravasation [n=6], pseudoaneurysm [n=3], and both [n=5]), suspicious bleeding in 1 (5%), and no bleeding in 3 (17%). The technical and clinical success rates were 100% and 94% (17/18), respectively. Total and partial embolization was performed in 14 (78%) and 4 (22%) cases, respectively. Subsequent surgical nephrectomy was required for one patient with clinical failure due to recurrent bleeding despite total embolization. Procedure-related complications included mild post-embolization syndrome in one patient and contrast-induced nephropathy in five patients (28%) without long-term complications.

Conclusions

Renal artery embolization is safe and effective for controlling spontaneous renal hemorrhage in patients with ACKD.

Effect of contrast medium versus low-molecular-weight dextran for intracoronary optical coherence tomography in renal insufficiency

Low-molecular-weight dextran (LMWD) is considered a safe alternative to contrast media to displace blood during optical coherence tomography (OCT) imaging, but concerns remain. The purpose of this study was to investigate whether using LMWD for OCT protects against kidney injury in patients with renal insufficiency compared with contrast media. We retrospectively identified 474 patients with renal insufficiency (estimated glomerular filtration rate < 60 ml/min/1.73 m²) who underwent OCT during coronary angiography or percutaneous coronary intervention; 110 patients with LMWD plus contrast medium (LMWD group) and 364 patients with contrast medium exclusively (Contrast group). We evaluated differences between the two groups and performed propensity score-matched subgroup comparisons. Compared with the Contrast group, the LMWD group had worse baseline renal function, higher prevalence of diabetes mellitus and percutaneous coronary intervention history, higher C-reactive protein and N-terminal pro B-type natriuretic peptide levels, lower hemoglobin levels, and lower left ventricular ejection fraction. The median total volume of contrast medium in the Contrast group was 230.0 ml vs. 61.8 ml of LMWD in addition to 164.0 ml of contrast medium in the LMWD group. Renal function was consistently impaired in the LMWD group within 5 days, at 1-month, and 1-year follow-up (P < 0.001). Two propensity score-matched analyses adjusted for either total volume used or contrast media volume consistently indicated a trend toward worsening renal function in the LMWD group at the 1-year follow-up. No protective benefit for renal function from using LMWD instead of contrast media for OCT was observed in patients with renal insufficiency.

Magnitude and associated factors of contrast induced nephropathy among patients undergoing coronary angiography and interventions at a cardiac referral hospital in Tanzania - a cross-sectional study

Introduction

contrast media are increasingly used in diagnostic and interventional procedures but are also known causes of acute kidney injury - a condition known as contrast induced nephropathy (CIN). We aimed to determine the magnitude and associated factors of CIN among patients undergoing coronary angiography and percutaneous coronary intervention at a cardiac referral hospital in Tanzania.

Methods

all adult patients undergoing elective coronary angiography and percutaneous coronary intervention at Jakaya Kikwete Cardiac Institute were consecutively enrolled between August 2017 and January 2018, if they fulfilled the inclusion criteria. Pre-procedure, 24- and 72-hours' post procedure serum creatinine was measured. CIN was defined as increase of ≥25% or absolute increase of ≥44μmol/L of serum creatinine within 72 hours following exposure to contrast media. Data analysis were done using SPSS Version 20. P-value of <0.05 was considered statistically significant.

Results

in total, 210 (94.6%) out of 222 patients seen during the study period fulfilled the inclusion criteria and were enrolled. Their mean (SD) age was 61.3 (10.9) years and 64.3% were men. Hypertension, diabetes, smoking and alcohol consumption was present in 86.7%, 37.7%, 12.4% and 37.6% respectively. The incidence of CIN was 19% within 72 hours post procedure. On multivariate logistic regression analysis, independent factors for developing CIN were history of heart failure (aOR=7.34), central obesity (aOR=3.12), triple vessel disease (aOR=10.14) and post procedure stay of ≥3 days (aOR=4.1), all p<0.05.

Conclusion

the incidence of CIN found in this population is high (19%) and is associated with heart failure, obesity, multi-vessel disease and longer post-procedure hospital stay.

Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population

Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.

Low-molecular-weight dextran for optical coherence tomography may not be protective against kidney injury in patients with renal insufficiency

BACKGROUND

Low-molecular-weight dextran (LMWD) is considered a safe alternative to contrast media for blood displacement during optical coherence tomography (OCT) imaging.

AIM

To investigate whether the use of LMWD for OCT is protective against kidney injury in patients with advanced renal insufficiency.

METHODS

In this retrospective cohort study, we identified 421 patients with advanced renal insufficiency (estimated glomerular filtration rate < 45 mL/min/1.73 m²) who underwent coronary angiography or percutaneous coronary intervention; 79 patients who used additional LMWD for OCT imaging (LMWD group) and 342 patients who used contrast medium exclusively (control group). We evaluated the differences between these two groups and performed a propensity score-matched subgroup comparison.

RESULTS

The median total volume of contrast medium was 133.0 mL in the control group vs 140.0 mL in the LMWD group. Although baseline renal function was not statistically different between these two groups, the LMWD group demonstrated a strong trend toward the progression of renal insufficiency as indicated by the greater change in serum creatinine level during the 1-year follow-up compared with the control group. Patients in the LMWD group experienced worsening renal function more frequently than patients in the control group. Propensity score matching adjusted for total contrast media volume consistently indicated a trend toward worsening renal function in the LMWD group at the 1-year follow-up. Delta serum creatinine at 1-year follow-up was significantly greater in the LMWD group than that in the control group [0.06 (-0.06, 0.29) vs -0.04 (-0.23, 0.08) mg/dL, P = 0.001], despite using similar contrast volume.

CONCLUSION

OCT using LMWD may not be protective against worsening renal function in patients with advanced renal insufficiency.

Effect of Calcium Dobesilate in Preventing Contrast-Induced Nephropathy in Patients with Diabetes and Chronic Kidney Disease

OBJECTIVES

This study assessed the protective effect of calcium dobesilate against contrast-induced nephropathy (CIN) after coronary angiography (CAG) or percutaneous coronary intervention (PCI) in patients with diabetes and chronic kidney disease (CKD).

METHODS

A total of 130 patients with diabetes and CKD estimated glomerular filtration rate: 30-90 mL/min/1.73m2 were enrolled and included in the analysis. They were divided into experimental (n=65) and control groups (n=65). Patients in the experimental group were administered oral calcium dobesilate (500 mg) three times daily for 2 days before and 3 days after the procedure. The serum creatinine (SCr), cystatin C (Cys C), and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured before and after the procedure.

RESULTS

The mean SCr level at 24h after the procedure was found to be significantly lower in the experimental group than in the control group (79.1±19.6 μmol/L vs. 87.0±19.3 μmol/L, p=0.023). However, the Cys C and NGAL levels were not significantly different between the two groups at all measurement time points (all p>0.05). The incidence of CIN defined by the SCr level was significantly lower in the experimental group than in the control group (3 [4.6%] vs. 13 [20.0%], p=0.017). However, the incidence of CIN defined by the Cys C level was not statistically different between the two groups (7 [10.8%] vs. 7 [10.8%], p=1.000).

CONCLUSIONS

This study revealed that calcium dobesilate has no preventive effect against CIN in patients with diabetes and CKD.

Percutaneous transluminal angioplasty with carbon dioxide for peripheral arterial disease after kidney transplantation: a case report with literature review

Background

Arteriosclerosis may progress and lead to peripheral arterial disease (PAD) during the waiting period until kidney transplantation in end-stage kidney disease (ESKD) patients. Additionally, contrast-induced nephropathy (CIN) of a kidney allograft after the examination and treatment for PAD is problematic. Here, we report the case of a kidney transplant recipient with PAD in the lower extremities who underwent percutaneous transluminal angioplasty (PTA) with carbon dioxide to prevent CIN incidence.

Case presentation

A 57-year-old woman underwent a cadaveric kidney transplant when she was 49 years old. Immunosuppression was maintained with tacrolimus, methylprednisolone, and mycophenolate mofetil. Her post-transplant course was uneventful, and serum creatinine level was maintained at 1.1–1.3 mg/dL. Intermittent claudication of the lower legs began 3 years after transplantation. Under saline intravenous rehydration, computed tomographic angiographies were performed, and the patient was diagnosed with PAD in the bilateral lower extremities. Total PTA was performed thrice for PAD in the lower extremities via a combination of carbon dioxide and iodinated contrast medium to prevent CIN incidence at 3, 4, and 7 years after kidney transplantation. The patient’s recoveries were uneventful. One year later, the serum creatinine level was maintained at 0.9–1.1 mg/dL, and since then, the patient has shown no evidence of recurrence.

Conclusions

In a kidney transplant recipient with PAD, PTA with carbon dioxide was effective to minimize the volumes of iodinated contrast medium and prevent CIN incidence.

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.

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT

OBJECTIVES

This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

BACKGROUND

The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

METHODS

This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

RESULTS

Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

CONCLUSIONS

Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.

Exploring Triaging and Short-Term Outcomes of Early Invasive Strategy in Non-ST Segment Elevation Acute Coronary Syndrome: A Report from Japanese Multicenter Registry

This observational study aimed to examine the extent of early invasive strategy (EIS) utilization in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) according to the National Cardiovascular Data Registry (NCDR) CathPCI risk score, and its association with clinical outcomes. Using a prospective multicenter Japanese registry, 2968 patients with NSTE-ACS undergoing percutaneous coronary intervention within 72 hours of hospital arrival were analyzed. Multivariable logistic regression analyses were performed to determine predictors of EIS utilization. Additionally, adverse outcomes were compared between patients treated with and without EIS. Overall, 82.1% of the cohort (n = 2436) were treated with EIS, and the median NCDR CathPCI risk score was 22 (interquartile range: 14-32) with an expected 0.3-0.6% in-hospital mortality. Advanced age, peripheral artery disease, chronic kidney disease or patients without elevation of cardiac biomarkers were less likely to be treated with EIS. EIS utilization was not associated with a risk of in-hospital mortality; yet, it was associated with an increased risk of acute kidney injury (AKI) (adjusted odds ratio: 1.42; 95% confidence interval: 1.02-2.01) regardless of patients' in-hospital mortality risk. Broader use of EIS utilization comes at the cost of increased AKI development risk; thus, the pre-procedural risk-benefit profile of EIS should be reassessed appropriately in patients with lower mortality risk.

The conundrum of contrast-induced acute kidney injury

More than sixty years have elapsed since contrast induced nephropathy (CIN) was first described in the medical literature. This term has since been extensively explored, with a variety of studies conducted to investigate its incidence and various mechanisms examined to explain its pathophysiology. However, the topic of CIN remains one of controversy with a widely variable and often questionable incidence derived from various studies. The past two decades have seen a surge in reports questioning the existing of CIN altogether and if more harm is actually being caused to patients out of fear of this potential complication. We have attempted to review relevant studies regarding CIN and highlight the key points of its surmised understanding. The review has a higher focus on more recent literature and updates, in order to determine if an accurate estimate can be made on the incidence of CIN. While there was certainly no lack of material available, practically all the studies reviewed were limited by one or more significant drawbacks that limited the reliability of their conclusions regarding CIN. Based on the information reviewed, the strengths and the flaws encountered in other studies can be used to design a randomized control trial that may help in concluding the longstanding debate on this topic. However due to time, financial, and perhaps even ethical constraints such a trial will be difficult to arrange, and so a definitive answer on CI-AKI, and whether it really exist, may continue to elude clinicians.

Carbon dioxide-angiography for patients with peripheral arterial disease at risk of contrast-induced nephropathy

Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO₂) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO₂ angiography has been underutilized due to concerns regarding safety and image quality. Modern CO₂ delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO₂ angiography. This review aims to highlight current technological advances in the delivery of CO₂ in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.

Post-contrast acute kidney injury in a hospitalized population: short-, mid-, and long-term outcome and risk factors for adverse events

Objectives

To investigate the prognosis including major adverse kidney events within 30 days (MAKE30) and 90-day and 1-year adverse outcome in hospitalized patients with post-contrast acute kidney injury (PC-AKI) to identify high-risk factors.

Methods

This retrospective observational study included 288 PC-AKI patients selected from 277,898 patients admitted to hospitals from January 2015 to December 2015. PC-AKI was defined according to the 2018 guideline of European Society of Urogenital Radiology. Multivariable Cox regression and logistic regression analyses were used to analyze main outcome and risk factors.

Results

PC-AKI patients with AKI stage ≥ 2 had much higher incidence of MAKE30 than those with AKI stage 1 (RR = 7.027, 95% CI 4.918–10.039). Persistent renal dysfunction, heart failure, central nervous system failure, baseline eGFR < 60 mL/min/1.73 m², oliguria or anuria, blood urea nitrogen ≥ 7.14 mmol/L, respiratory failure, and shock were independent risk factors of 90-day or 1-year adverse prognosis (p < 0.05). Compared with transient renal dysfunction, PC-AKI patients with persistent renal dysfunction had a higher all-cause mortality rate (RR = 3.768, 95% CI 1.612–8.810; RR = 4.106, 95% CI 1.765–9.551) as well as combined endpoints of death, chronic kidney disease, or end-stage renal disease (OR = 3.685, 95% CI 1.628–8.340; OR = 5.209, 95% CI 1.730–15.681) within 90 days or 1 year.

Conclusions

PC-AKI is not always a transient, benign creatininopathy, but can result in adverse outcome. AKI stage is independently correlated to MAKE30 and persistent renal dysfunction may exaggerate the risk of long-term adverse events.

Key Points

• PC-AKI can result in adverse outcome such as persistent renal dysfunction, dialysis, chronic kidney disease (CKD), end-stage renal disease (ESRD), or death.

• AKI stage is independently correlated to MAKE30.

• Persistent renal dysfunction may exaggerate the risk of long-term adverse events.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06690-3) contains supplementary material, which is available to authorized users.

Impact of One-Catheter Strategy with TIG I Catheter on Coronary Catheterization Performance and Economic Costs

BACKGROUND

Coronary angiography with two catheters is the traditional strategy for diagnostic coronary procedures. TIG I catheter permits to cannulate both coronary arteries, avoiding exchanging catheters during coronary angiography by transradial access.

OBJECTIVE

The aim of this study is to evaluate the impact of one-catheter strategy, by avoiding catheter exchange, on coronary catheterization performance and economic costs.

METHODS

Transradial coronary diagnostic procedures conducted from January 2013 to June 2017 were collected. One-catheter strategy (TIG I catheter) and two-catheter strategy (left and right Judkins catheters) were compared. The volume of iodinated contrast administered was the primary endpoint. Secondary endpoints included radial spasm, procedural duration (fluoroscopy time) and exposure to ionizing radiation (dose-area product and air kerma). Direct economic costs were also evaluated. For statistical analyses, two-tailed p-values < 0.05 were considered statistically significant.

RESULTS

From a total of 1,953 procedures in 1,829 patients, 252 procedures were assigned to one-catheter strategy and 1,701 procedures to two-catheter strategy. There were no differences in baseline characteristics between the groups. One-catheter strategy required less iodinated contrast [primary endpoint; (60-105)-mL vs. 92 (64-120)-mL; p < 0.001] than the two-catheter strategy. Also, the one-catheter group presented less radial spasm (5.2% vs. 9.3%, p = 0.022) and shorter fluoroscopy time [3.9 (2.2-8.0)-min vs. 4.8 (2.9-8.3)-min, p = 0.001] and saved costs [149 (140-160)-€/procedure vs. 171 (160-183)-€/procedure; p < 0.001]. No differences in dose-area product and air kerma were detected between the groups.

CONCLUSIONS

One-catheter strategy, with TIG I catheter, improves coronary catheterization performance and reduces economic costs compared to traditional two-catheter strategy in patients referred for coronary angiography.

A prospective study of contrast preservation using ultra-low contrast delivery technique versus standard automated contrast injector system in coronary procedures

Background

We aimed to assess the decrease in contrast media volume (CMV) with ultra-low contrast delivery technique (ULCD) developed at our institution versus the usual automated contrast injector system (ACIS) contrast delivery in coronary procedures.

Methods

We analyzed the amount of contrast given in the consecutive 204 patients of the operators who use ULCD technique versus consecutive 200 patients of the other operators who use ACIS without ULCD technique for coronary angiograms and/or percutaneous coronary interventions (PCIs) from May 2017 to July 2018 at our center. We calculated the mean CMV between these groups.

Results

We observed a significant reduction in mean CMV with ULCD technique versus standard ACIS, respectively: angiogram 24.8 ± 15.8 mL (n = 194) vs 42.3 ± 25.1 mL (n = 200) (p < 0.0001); PCI 23.5 ± 19.7 mL (n = 52) vs 48.2 ± 30.8 mL (n = 16) (p < 0.0070); angiogram with ad hoc PCI 53.4 ± 32.1 mL (n = 23) vs 89.7 ± 35.6 mL (n = 16) (p < 0.0024); and overall angiogram and PCI 27.4 ± 20.5 mL (n = 204) vs 44.9 ± 28.0 mL (n = 181) (p < 0.0001).

Conclusion

Our study showed a highly significant reduction in CMV using ULCD technique compared to standard ACIS contrast delivery in coronary invasive procedures. Even in the standard ACIS arm, CMV was significantly lower than values reported in literature, possibly due to operators' bias toward contrast preservation.

Strategies to Reduce Acute Kidney Injury and Improve Clinical Outcomes Following Percutaneous Coronary Intervention: A Subgroup Analysis of the PRESERVE Trial

OBJECTIVES

The aim of this study was to compare intravenous (IV) sodium bicarbonate with IV sodium chloride and oral acetylcysteine with placebo for the prevention of contrast-associated acute kidney injury (CAAKI) and intermediate-term adverse outcomes.

BACKGROUND

Data are conflicting on the optimal strategy to reduce CAAKI and related complications after percutaneous coronary intervention (PCI).

METHODS

The PRESERVE (Prevention of Serious Adverse Events Following Angiography) trial used a 2 × 2 factorial design to randomize 5,177 patients with stage III or IV chronic kidney disease undergoing angiography to IV 1.26% sodium bicarbonate or IV 0.9% sodium chloride and 5 days of oral acetylcysteine or placebo. A subgroup analysis was conducted of the efficacy of these interventions in patients who underwent PCI during the study angiographic examination. The primary endpoint was a composite of death, need for dialysis, or persistent kidney impairment at 90 days; CAAKI was a secondary endpoint.

RESULTS

A total of 1,161 PRESERVE patients (mean age 69 ± 8 years) underwent PCI. The median estimated glomerular filtration rate was 50.7 ml/min/1.73 m² (interquartile range: 41.7 to 60.1 ml/min/1.73 m²), and 952 patients (82%) had diabetes mellitus. The primary endpoint occurred in 15 of 568 patients (2.6%) in the IV sodium bicarbonate group and 24 of 593 patients (4.0%) in the IV sodium chloride group (odds ratio: 0.64; 95% confidence interval: 0.33 to 1.24; p for interaction = 0.41) and in 23 of 598 patients (3.8%) in the acetylcysteine group and 16 of 563 patients (2.8%) in the placebo group (odds ratio: 1.37; 95% confidence interval: 0.71 to 2.62; p for interaction = 0.29). There were no significant between-group differences in the rates of CAAKI.

CONCLUSIONS

Among patients with CKD undergoing PCI, there was no benefit of IV sodium bicarbonate over IV sodium chloride or of acetylcysteine over placebo for the prevention of CAAKI or intermediate-term adverse outcomes.

Persistent Renal Dysfunction in Patients Undergoing Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Background The long-term prognosis of patients with acute myocardial infarction who develop persistent renal dysfunction (RD) remains unclear. We investigated risk factors and prognostic implications of persistent RD after contrast-induced nephropathy (CIN) in patients with acute myocardial infarction after primary percutaneous coronary intervention. Methods and Results We enrolled 952 consecutive patients who underwent primary percutaneous coronary intervention for acute myocardial infarction. CIN was defined as an increase in serum creatinine levels ≥0.5 mg/dL or ≥25% from baseline within 72 hours after percutaneous coronary intervention. Persistent RD was defined as residual impairment of renal function over 2 weeks, and transient RD was defined as recovery of renal function within 2 weeks, after CIN. The overall incidence of CIN was 8.8% and that of persistent CIN was 3.1%. A receiver-operator characteristic curve showed that the optimal cutoff value of the contrast volume/baseline estimated glomerular filtration rate ratio for persistent CIN was 3.45. In multivariable logistic analysis, a contrast volume/baseline estimated glomerular filtration rate >3.45 was an independent correlate of persistent RD. At 3 years, the incidence of death was significantly higher in patients with persistent RD than in those with transient RD (P=0.001) and in those without CIN (P<0.001). Cox regression analysis showed that persistent RD (hazard ratio, 4.99; 95% CI, 2.30-10.8; P<0.001) was a significant risk factor for mortality. A similar trend was observed for the combined end points, which included mortality, hemodialysis, stroke, and acute myocardial infarction. Conclusions Persistent RD, but not transient RD, is independently associated with long-term mortality. A contrast volume/baseline estimated glomerular filtration rate >3.45 is an independent predictor of persistent RD.

Development and Validation of a Model for Predicting the Risk of Acute Kidney Injury Associated With Contrast Volume Levels During Percutaneous Coronary Intervention

Importance

Determining the association of contrast volume during percutaneous coronary intervention (PCI) with the risk of acute kidney injury (AKI) is important for optimizing PCI safety.

Objective

To quantify how the risk of AKI is associated with contrast volume, accounting for the possibility of nonlinearity and heterogeneity among different baseline risks.

Design, Setting, and Participants

This prognostic study used data from the American College of Cardiology National Cardiovascular Data Registry CathPCI Registry for 1694 US hospitals. Derivation analysis included 2 076 694 individuals who underwent PCI from July 1, 2011, to June 30, 2015. Validation analysis included 961 863 individuals who underwent PCI from July 1, 2015, to March 31, 2017. Data analysis took place from July 2018 to May 2019.

Exposure

Contrast volume during PCI.

Main Outcomes and Measures

Acute kidney injury was defined using 3 thresholds for preprocedure to postprocedure creatinine level increase (ie, ≥0.3 mg/dL, ≥0.5 mg/dL, and ≥1.0 mg/dL). A model quantifying the association of contrast volume with AKI was developed, and the existence of nonlinearity and heterogeneity were examined by likelihood ratio tests. The model was derived in the training set (a random 50% of the derivation cohort), and performance was evaluated in the test set (the remaining 50% of the derivation cohort) and an independent validation set by area under the receiver operating characteristic curve (AUC) and calibration slope of observed vs predicted risks.

Results

The 2 076 694 patients in the derivation set had a mean (SD) age of 65.1 (12.1) years, and 662 525 (31.9%) were women; 133 306 (6.4%) had creatinine level increases of at least 0.3 mg/dL, 66 626 (3.2%) had creatinine level increases of at least 0.5 mg/dL, and 28 378 (1.4%) had creatinine level increases of at least 1.0 mg/dL. In the validation set of 961 843 patients (mean [SD] age, 65.7 [12.1] years; 305 577 [31.8%] women), these rates were 62 913 (6.5%), 34 229 (3.6%), and 15 555 (1.6%), respectively. The association of contrast volume and AKI risk was nonlinear (χ226 = 1436.2; P < .001) and varied by preprocedural risk (χ220 = 105.6; P < .001). In the test set, the model yielded an AUC of 0.777 (95% CI, 0.775-0.779) for predicting risk of a creatinine level increase of at least 0.3 mg/dL, 0.839 (95% CI, 0.837-0.841) for predicting risk of a creatinine level increase of at least 0.5 mg/dL, and 0.870 (95% CI, 0.867-0.873) for predicting risk of a creatinine level increase of at least 1.0 mg/dL; it achieved a calibration slope of 0.998 (95% CI, 0.989-1.007), 0.999 (95% CI, 0.989-1.008), and 0.986 (95% CI, 0.973-0.998), respectively, for the AKI severity levels. The model had similar performance in the validation set (creatinine level increase of ≥0.3 mg/dL: AUC, 0.794; 95% CI, 0.792-0.795; calibration slope, 1.039; 95% CI, 1.030-1.047; creatinine level increase of ≥0.5 mg/dL: AUC, 0.845; 95% CI, 0.843-0.848; calibration slope, 1.063; 95% CI, 1.054-1.074; creatinine level increase of ≥1.0 mg/dL: AUC, 0.872; 95% CI, 0.869-0.875; calibration slope, 1.103; 95% CI, 1.089-1.117).

Conclusions and Relevance

The association of contrast volume with AKI risk is complex, varies by baseline risk, and can be predicted by a model. Future research to evaluate the effect of the model on AKI is needed.