Prevention of Contrast‐Induced Nephropathy in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: A Systematic Review

Abstract

Objective:To evaluate the current prophylactic strategies against CIN in patients with STEMI treated by primary percutaneous coronary intervention. Background: Contrast-induced nephropathy (CIN) is the third leading course of acute renal failure and a recognized complication to cardiac catheterization. CIN is associated with increased risk of cardiac adverse events and mortality, and recent studies point at the risk of developing a transient or persistent renal dysfunction. Patients with ST-elevation myocardial infarction treated by primary percutaneous coronary intervention have a markedly increased risk of developing CIN. At present no strategy is universally accepted in the prevention of CIN in the acute setting of primary percutaneous coronary intervention. Method: We performed a systematic search in Pubmed and EMBASE and ended up including nine randomised clinical trials; six studies of N-acetylcysteine, one study of early and late hydration regimens, one study of recombinant human brain natriuretic peptide and one study comparing a low-osmolar contrast agent with an iso-osmolar contrast agent. Results: Recombinant human brain natriuretic peptide and the regimens of hydration significantly reduced the incidence of CIN and administration of N-acetylcysteine in one of the six studies significantly reduced the occurrence of CIN. The iso-osmolar contrast agent was not proven to be superior to the low-osmolar contrast agent in terms of preventing CIN. Conclusion: Preliminary studies are promising but further studies are needed before any prevention strategy against CIN can be recommended in routine care of patients undergoing primary percutaneous coronary intervention for STEMI. (J Interven Cardiol 2013;26:97-105) Address for reprints: Sarah Busch, Ved Kløvermarken 9, 2.th, events, prolonged hospitalization, and short-and longterm mortality. 1-3 Patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) have an increased risk of developing CIN when compared with patients undergoing elective PCI. 4,5 Conditions such as hemodynamic instability and impaired systemic perfusion caused by left ventricular dysfunction, large volume of contrast medium, renal hypotension and lack of hydration or other effective prophylactic measures may contribute to the development of renal dysfunction. 4,5 CIN was previously considered a reversible form of acute kidney injury. However, a recent study showed An increase in serum cystatin C concentration of >25% from baseline within 72 hours after PCI.

Heart failure is the strongest predictor of acute kidney injury in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

“…Four potential preventive strategies against AKI have been evaluated in STEMI patients undergoing primary PCI; however, the data are too sparse to make a clinical recommendation [4,19]. This paper reflects our daily practice.…”

“…Patients with acute myocardial infarction undergoing primary PCI are at increased risk of acute kidney injury (AKI) [3,4]. This fact suggests that mechanisms other than direct contrast nephrotoxicity are involved in AKI in this clinical setting.…”

Role of Hydration in Contrast-Induced Nephropathy in Patients Who Underwent Primary Percutaneous Coronary Intervention

“…10) Similarly, conditions such as hemodynamic instability and impaired systemic perfusion caused by left ventricular dysfunction, large volume of contrast medium, renal hypotension, and lack of hydration or other effective prophylactic measures may contribute to the development of renal dysfunction in patients with STEMI undergoing PPCI. 1) At present, since no feasible, effective therapeutic strategy for CIN has been identified, certain preventive measures against CIN can be adopted in a timely manner in patients with STEMI undergoing PPCI to improve renal and cardiac outcomes. 9) Routine administration of hydration protocols before contrast exposure is an established preventive measure for preventing CIN in patients with chronic renal failure undergoing elective PCI.…”

“…atients with ST-segment elevation myocardial infarction (STEMI) who are treated by primary percutaneous coronary intervention (PPCI) have an increased risk of developing contrast-induced nephropathy (CIN) when compared with patients undergoing elective percutaneous coronary intervention (PCI). 1) However, CIN prevention measures are less frequently applied in PPCI than in elective PCI. 2) Although several specific pharmacological interventions have been proposed for the protection of the renal function, compared with intravenous volume expansion with isotonic saline, hydration with Nacetylcysteine (NAC), sodium bicarbonate (NaHCO3), or combined NAC and NaHCO3 does not significantly reduce the incidence of CIN.…”

Contrast-induced Acute Kidney Injury: A Contemporary Review

“…To date, intravenous loading with a 0.9% NaCl solution is the only proved efficient CIAKI prophylactic measure [9,41,42,45,[73][74][75][76]. Despite the aforesaid superiority of using intravenous sodium bicarbonate, its role in nephropathy prophylaxis is comparable to 0.9% NaCl, based on the findings of some randomized studies [66,73,75,77].…”