Intra-Arterial versus Intravenous Contrast and Renal Injury in Chronic Kidney Disease: A Propensity-Matched Analysis

Abstract

Background/Aims: contrast-induced nephropathy (CIN) is well described following an administration of intraarterial contrast, but its occurrence after intravenous (IV) contrast is being questioned. We evaluated the incidence of acute kidney injury (AKI), post-contrast AKI (PC-AKI), CIN, dialysis and mortality in patients with chronic kidney disease (CKD) undergoing non-contrast computed tomography (NCCT) or contrast CT (CCT) or coronary angiography (CoA). Methods: We identified individuals who had CoA or CCT or NCCT between 2010 and 2015 in the Cleveland Clinic CKD registry. We used propensity scores to match patients in the 3 groups. We evaluated the proportion of patients that developed AKI and CIN across the groups with chi-square tests. We generated Kaplan-Meier plots comparing mortality and ESRD among patients who developed AKI (in the NCCT group), PC (multifactorial AKI, CIN) AKI and no AKI. Results: Out of 251 eligible patients, 200 who had CoA were matched to each of the other CT scan groups. The incidence of AKI was 27% in CoA, 24% in CCT and 24% in NCCT (p = 0.72). The incidence of CIN AKI was 16.5% in CoA and 12.5% in CCT (p = 0.26). The Kaplan-Meier survival at 2 years was 74.8 (95% CI 63.8–87.7) for those with CIN and 53.2 (95% CI 39.7–71.4) for those with multifactorial AKI and 56.5 (95% CI 43.4–73.6) for those with AKI-NCCT and 71.4 (95% CI 67.2–76.0) for those without AKI. The Kaplan-Meier ESRD-free estimates at 2 years were 89.9 (95% CI 80.8–100) for those with CIN and 89.4 (95% CI 78.7–100) for those with multifactorial AKI and 77.4 (95% CI 63.6–94.3) for those with AKI-NCCT and 94.4 (95% CI 91.9–97.1) for those without AKI. Conclusion: The administration of both IV and intra-arterial contrast is associated with a risk of AKI. Multifactorial AKI was associated with worse outcomes, while CIN was associated with better outcomes.

Contrast media in patients with kidney disease: An update

“…In our aforementioned study, 19 cases adjudicated to be CI-AKI carried no mortality risk, with an overall survival rate similar to that in patients who did not have acute kidney injury. Adjudication is key.…”

“…A recent meta-analysis with more than 1,500 patients undergoing peripheral angiography found a higher incidence of acute kidney injury with iodinated contrast media than with carbon dioxide contrast (11% vs 4%, respectively. 18 In addition, our group recently published a propensity-matched study evaluating rates of acute kidney injury in patients with stage 3 or 4 chronic kidney disease undergoing coronary angiography, contrast-enhanced CT, or nonenhanced CT. 19 Postcontrast acute kidney injury was noted in 27%, 24%, and 24% of patients, respectively. All cases of acute kidney injury were then adjudicated by 2 nephrologists through chart review to ascertain the cause.…”

Risk of acute kidney injury after contrast-enhanced computerized tomography: a systematic review and meta-analysis of 21 propensity score–matched cohort studies

“…Two studies focused on critically ill [28,29] and two on pediatric patients [30,31]. Four studies consisted of patients admitted via emergency department [32][33][34][35]; one study examined nephrotic syndrome patients [36]; two focused on patients with chronic kidney disease (CKD) [37,38]; and two on patients hospitalized with AKI [39,40]. Two groups studied septic [38,41] and one cancer patients [42].…”

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Association with Contrast Media Dosage and Contrast Media Based Risk Predication Models

“…These results were echoed in the most recent update of the American College of Radiology consensus statement in which it was declared that the risk of AKI developing following exposure to intravenous iodinated CM has been exaggerated and that the true risk of AKI, related to CM administration, remains uncertain even for patients with severe kidney disease [ 31 ]. It has been suggested that intravenous administration of CM, like with CT angiography, may impose a different risk of AKI than the one associated with arterial administration of CM, like with PCI and TAVI; however, the data is inconclusive [ 32 , 33 , 34 , 35 , 36 , 37 ].…”