Predictors for contrast media-induced nephropathy and long-term survival: Prospectively assessed data from the randomized controlled Dialysis-Versus-Diuresis (DVD) trial

Abstract

T he development of radiographic contrast media originated from the use of sodium iodide in radiography in 1918 (1), when Walter Dandy directly injected contrast media into the cerebral ventricles for visualizing the outline of the brain and the ventricular system. Since then, many different types of contrast media have been synthesized, and many improvements in terms of side effects, such as hypersensitivity reactions, have been made. Moreover, associated acute renal failure, currently classified as contrast media-induced nephropathy (CIN), remains a major complication in hospitalized patients undergoing diagnostic or therapeutic interventional procedures using CLINICAL STUDIES ©2008 Pulsus Group Inc. All rights reserved BACKGROUND: Among the numerous studies concerning contrast media-induced nephropathy (CIN), there was no prospective trial that provided data on the long-term outcomes. OBJECTIVES: To prospectively assess predictors of CIN and long-term outcomes of affected patients. METHODS: Four hundred twelve consecutive patients with serum creatinine levels of 115 μmol/L to 309 μmol/L (1.3 mg/dL to 3.5 mg/dL) undergoing elective coronary angiography were included. Patients were randomly assigned to periprocedural hydration alone, hydration plus onetime hemodialysis or hydration plus N-acetylcysteine. RESULTS: Multivariate logistic regression identified the following as predictors of CIN within 72 h (equivalent to an increase in creatinine 44.2 μmol/L [0.5 mg/dL] or more) : prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast media given (OR 1.01, 95% CI 1.00 to 1.01). With regard to long-term outcome (mean follow-up 649 days), multivariate Cox regression models found elevated creatinine levels at 30 days (hazard rate ratio [HRR] 5.48, 95% CI 2.85 to 10.53), but not CIN within 72 h (HRR 1.12, 95% CI 0.63 to 2.02), to be associated with increased mortality. In addition, independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96). CONCLUSION: From the present prospective trial, performance of postprocedural hemodialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after catheterization. Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients' long-term survival.

Contrast Induced Nephropathy in Patients with Acute Coronary Syndrome

“…They speculated that abnormalities of renal perfusion possibly mediated by RAS were responsible for development of CIN and administration of captopril offers protection against development of CIN. Holscher et al [11] prospectively assessed predictors of CIN within 72 h and long-term outcomes of 412 consecutive patients with serum creatinine levels of 1.3 mg/dL to 3.5 mg/dL undergoing elective CAG. In their study, patients were randomly assigned to periprocedural hydration alone, hydration plus one-time hemodialysis or hydration plus N-acetylcysteine [11].…”

“…Holscher et al [11] prospectively assessed predictors of CIN within 72 h and long-term outcomes of 412 consecutive patients with serum creatinine levels of 1.3 mg/dL to 3.5 mg/dL undergoing elective CAG. In their study, patients were randomly assigned to periprocedural hydration alone, hydration plus one-time hemodialysis or hydration plus N-acetylcysteine [11]. Multivariate logistic regression identified the predictors of CIN as prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast material (OR 1.01, 95% CI 1.00 to 1.01).…”

“…Multivariate logistic regression identified the predictors of CIN as prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast material (OR 1.01, 95% CI 1.00 to 1.01). In addition, they found that independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96) [11]. From their prospective trial, Holscher et al [11] concluded that postprocedural heUnauthenticated Download Date | 5/11/18 1:21 AM modialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after coronary procedure Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients' long-term survival.…”

“…In addition, they found that independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96) [11]. From their prospective trial, Holscher et al [11] concluded that postprocedural heUnauthenticated Download Date | 5/11/18 1:21 AM modialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after coronary procedure Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients' long-term survival. Treatment with RAAS blockers does not usually cause renal dysfunction or hyperkalemia in patients with normal renal function.…”

Using the Mehran Risk Scoring Tool to Predict Risk for Contrast Medium-Induced Nephropathy in Patients Undergoing Percutaneous Angiography

“…15 Because the study was retrospective, medication use was according to the prescribing preferences of individual physicians irrespective of the controversial role of ACE inhibitors in the development of CIN. Some investigators have reported that ACE inhibitors can prevent CIN in patients with diabetes mellitus 16 or chronic kidney disease, 17 and other researchers 18,19 have recommended that administration of ACE inhibitors be discontinued before cardiac catheterization.…”