Safety and Efficacy of Tolvaptan for the Prevention of Contrast-Induced Acute Kidney Injury in Patients with Heart Failure and Chronic Kidney Disease

Abstract

Background: Tolvaptan is a promising drug for the prevention of contrast-induced acute kidney injury (CI-AKI) because it induces aquaresis without adversely affecting renal hemodynamics. CI-AKI is a major cause of acute renal failure associated with increased morbidity and mortality. Objective: To investigate the effectiveness of different doses of tolvaptan for the prevention of CI-AKI. Method: Ninety-one consecutive patients with congestive heart failure (CHF) and chronic kidney disease (CKD) were prospectively enrolled as the tolvaptan group in this study (T-group; 7.5-mg: n = 42, 15-mg: n = 49). In addition, 91 consecutive patients with CHF and CKD were collected retrospectively as a control group (C-group, n = 91). All patients received continuous intravenous infusion of isotonic saline, and tolvaptan was administered to the T-group. Results: One patient developed CI-AKI in the T-group versus 3 in the C-group (1.1 vs. 3.3%, p = 0.61). On the other hand, the change of serum creatinine in the T-group was lower than that in the C-group. Additionally, in the 7.5-mg group, serum creatinine was unchanged up to 72 h after contrast administration, showing a significant difference from the 15-mg group (–0.00 ± 0.09 vs. 0.05 ± 0.12 mg/dL, p = 0.009). Similarly, the change of eGFR was significantly smaller in the 7.5-mg group than that in the 15-mg group (0.7 ± 5.4 vs. –2.8 ± 5.1 mL/min/1.73 m², p = 0.002). No patient required hemodialysis and there was no prolongation of hospitalization due to exacerbation of heart failure. Conclusions: Compared to hydration alone, tolvaptan combined with hydration could be a safer method for preventing CI-AKI while avoiding exacerbation of heart failure, and a dosage of 7.5-mg might be safer than 15-mg.

Influence of vasopressin receptor antagonists on triple‐whammy acute kidney injury: A VigiBase analysis

“…The results of disproportionality analysis and multiple logistic regression analysis consistently showed that vasopressin receptor antagonists did not increase the risk of AKI in patients who received NSAIDs and RASi; thus, the findings suggest that vasopressin receptor antagonists may not increase the risk of triple‐whammy AKI. Indeed, tolvaptan decreases the risk of AKI in patients with heart failure, hepatic ascites or polycystic kidney disease or in those who have received contrast agent, 9–12 and these previous findings support the results of the present study. Although the mechanism underlying the reduction in the risk of triple‐whammy AKI with vasopressin receptor antagonists was not evaluated in this study, loop and thiazide diuretics increase the risk of AKI via not only hypovolaemia, but also electrolyte disturbances including hypokalaemia, hypomagnesaemia or hypochloraemic metabolic alkalosis 16–18 .…”

“…5,7,8 In particular, tolvaptan, a vasopressin receptor antagonist, has been reported to decrease the risk of AKI in patients with certain comorbidities. [9][10][11][12] AKI compared with other diuretics. The aim of this study was to evaluate whether vasopressin receptor antagonists affect triplewhammy AKI.…”

“…Previous research has focused on loop diuretics alone or did not discriminate by type of diuretic 5,7,8 . In particular, tolvaptan, a vasopressin receptor antagonist, has been reported to decrease the risk of AKI in patients with certain comorbidities 9–12 . Thus, vasopressin receptor antagonists might not increase the risk of triple‐whammy AKI compared with other diuretics.…”

Tolvaptan Improves Contrast-Induced Acute Kidney Injury

“…A case reported by Lee et al [16] also showed that TOL could rescue CI-AKI patients and prevent hemodialysis. And it is also reported that TOL was effective in preventing AKI in patients with contrast-induced heart failure and chronic kidney disease [17]. All of the above studies have confirmed that TOL is effective in preventing and treating patients with CI-AKI.…”

Imaging for Risk Stratification in Atrial Fibrillation with Heart Failure

“…It is less invasive than coronary angiography but higher level of X-ray exposure is an issue but that seems to be getting better with improvement in technology 10 . Also, the iodinated contrast medium may induce acute kidney injury so one has to be careful when using this on a routine basis 11,12 .…”