Abstract
IntroductionAcute kidney injury (AKI) after intravenous contrast administration for computed tomography (CT) occurs infrequently, but certain patients may be susceptible. This study evaluated AKI incidence among emergency department (ED) patients with pre-existing chronic kidney disease (CKD) undergoing CT exams.MethodsThis retrospective cohort study in an integrated healthcare system included ED patients previously diagnosed with CKD stages 3–5 (estimated glomerular filtration rate <60 milliliters per minute per 1.73 meters squared over at least three months), undergoing CT exams with or without intravenous contrast, from January 1, 2013–December 31, 2017. We excluded patients with CT prior to (30 days) or following (14 days) index CT and missing serum creatinine (sCr) measurements. We applied propensity score matching, and then multivariable regression adjustment for post-CT ED disposition and ED diagnosis, to calculate adjusted risk of AKI. Secondary patient-centered outcomes included 30-day mortality, end-stage renal disease (ESRD) diagnosis, and dialysis initiation.ResultsAmong 103,573 eligible ED patients undergoing CT, propensity score matching yielded 5,589 pairs. Adjusted risk ratio (ARR) for AKI was higher overall for contrast-enhanced CT (1.60; 95% confidence interval [CI], 1.43–1.79). However, secondary outcomes were infrequent: 19/5,589 non-contrast vs 40/5,589 contrast patients with new dialysis initiation at 30 days (adjusted risk 0.3% vs 0.7%; adjusted risk reduction 0.4%; 95% CI, 0.1%–0.7%).ConclusionIn ED patients with chronic kidney disease undergoing CT, intravenous contrast was associated with higher overall adjusted risk of AKI, but patient-centered secondary outcomes were rare. The clinical significance of transient kidney injury after CT is unclear, although patients with advanced chronic kidney disease appear to have elevated risk.
Highlights
Acute kidney injury (AKI) after intravenous contrast administration for computed tomography (CT) occurs infrequently, but certain patients may be susceptible
In emergency department (ED) patients with chronic kidney disease undergoing CT, intravenous contrast was associated with higher overall adjusted risk of AKI, but patient-centered secondary outcomes were rare
Meta-analyses concluding that intravenous (IV) contrast is not associated with AKI were not focused on ED patients or chronic kidney disease (CKD), and where CKD patients were included, definitions were inconsistent.[13,14,15]
Summary
Acute kidney injury (AKI) after intravenous contrast administration for computed tomography (CT) occurs infrequently, but certain patients may be susceptible. This study evaluated AKI incidence among emergency department (ED) patients with pre-existing chronic kidney disease (CKD) undergoing CT exams. Studies overestimated CA-AKI incidence, while recent work casts doubt on the phenomenon of CA-AKI altogether.[8,10,11,12] Meta-analyses concluding that intravenous (IV) contrast is not associated with AKI were not focused on ED patients or chronic kidney disease (CKD), and where CKD patients were included, definitions were inconsistent.[13,14,15]. States emergency departments (ED) brings controversy over contrast-associated acute kidney injury (CA-AKI) in focus for ED patients, where a subset may be vulnerable even if overall risk is low.[1,2,3,4,5,6,7,8] The recent American College of Radiology and National Kidney Foundation joint consensus statement suggests for patients with “severe kidney disease,” risks of contrast media are uncertain, and existing evidence may be underpowered to estimate risk of injury.[9]
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