Arteriography in chronic renal failure: a case for carbon dioxide

The aim of this study was to assess the utilisation of carbon dioxide arteriography, performed with a simple injection system, as the imaging technique of choice in patients with chronic renal failure. Patients with chronic renal impairment who required arterial imaging or intervention were recruited for carbon dioxide angiography. Demographic data were prospectively recorded and pre- and post-arteriogram renal function was quantified. Radiographic images were graded by an independent radiologist. Twenty-eight patients underwent renal or aorto-femoral studies with only one failure. There were no cases of contrast-induced nephropathy. Twenty-two of the films (79%) were graded as excellent or good, four as acceptable and two were considered to be poor (non-diagnostic). This study has demonstrated that carbon dioxide angiography is a safe and clinically effective procedure in patients with chronic renal failure.

Carbon dioxide (Co2) Angiography in Diabetic Patients with Peripheral Arterial Disease and Chronic Renal Insufficiency as a Standard Procedure

Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies

Carbon dioxide angiography during peripheral vascular interventions is associated with decreased cardiac and renal complications in patients with chronic kidney disease

BackgroundIodinated contrast media are amongst the most frequently prescribed medications, however, their use is not without complications. With contrast-induced nephropathy constituting a major concern, alternative non-iodine based approaches have been explored such as carbon dioxide angiography. The purpose of this study is to report the incidence of contrast-induced nephropathy following carbon dioxide angiography in patients with impaired renal function that underwent peripheral angioplasty compared with a historical cohort of patients that underwent angioplasty with use of solely iodine contrast medium. The historical cohort of patients treated with iodinated contrast was used as control. Baseline demographics and renal function tests were recorded. Primary outcome was incidence of contrast-induced nephropathy within 48–72 h post intervention. Receiver-Operating-Characteristic curve analysis was used to correlate the volume of iodinated contrast with the risk of contrast-induced nephropathy.ResultsCarbon Dioxide was used as an alternative to iodinated contrast media in patients with impaired renal function (eGFR<60mls/min/1.73 m2) undergoing peripheral angioplasty procedures. Fifty, consecutive patients (baseline eGFR = 38.6 ± 13.2mls/min/1.73 m2) were included in a prospective clinical audit. These were matched (1:2) with a historical cohort of patients (baseline eGFR = 43.3 ± 12.2mls/min/1.73 m2) treated with Iodinated contrast media. The incidence of contrast-induced nephropathy was 14% (n = 7/50) in case of carbon dioxide vs. 29% (n = 29/100) in the matched cohort group (p = 0.045). Receiver-Operating-Characteristic analysis showed that use of >25mls of contrast was 94.4% (95% CI:81–99%) sensitive in predicting contrast-induced nephropathy.ConclusionCarbon dioxide imaging during peripheral angioplasty procedures protects against contrast-induced nephropathy. Use of >25mls of iodinated contrast media in high-risk patients is a predictor of contrast-induced nephropathy.

Cardiac Biomarkers and Prediction of ESRD

Prevention of contrast-induced nephropathy with sodium bicarbonate: A randomized controlled trial

BackgroundValidated prediction scores are required to assess the risks of end-stage renal disease (ESRD) and death in individuals with chronic kidney disease (CKD).Study DesignProspective cohort study with validation in a separate cohort.Setting & ParticipantsCox regression was used to assess the relevance of baseline characteristics to risk of ESRD (mean follow-up, 4.1 years) and death (mean follow-up, 6.0 years) in 382 patients with stages 3-5 CKD not initially on dialysis therapy in the Chronic Renal Impairment in Birmingham (CRIB) Study. Resultant risk prediction equations were tested in a separate cohort of 213 patients with CKD (the East Kent cohort).Factors44 baseline characteristics (including 30 blood and urine assays).OutcomesESRD and all-cause mortality.ResultsIn the CRIB cohort, 190 patients reached ESRD (12.1%/y) and 150 died (6.5%/y). Each 30% lower baseline estimated glomerular filtration rate was associated with a 3-fold higher ESRD rate and a 1.3-fold higher death rate. After adjustment for each other, only baseline creatinine level, serum phosphate level, urinary albumin-creatinine ratio, and female sex remained strongly (P < 0.01) predictive of ESRD. For death, age, N-terminal pro-brain natriuretic peptide, troponin T level, and cigarette smoking remained strongly predictive of risk. Using these factors to predict outcomes in the East Kent cohort yielded an area under the receiver operating characteristic curve (ie, C statistic) of 0.91 (95% CI, 0.87-0.96) for ESRD and 0.82 (95% CI, 0.75-0.89) for death.LimitationsOther important factors may have been missed because of limited study power.ConclusionsSimple laboratory measures of kidney and cardiac function plus age, sex, and smoking history can be used to help identify patients with CKD at highest risk of ESRD and death. Larger cohort studies are required to further validate these results.

&lt;p&gt;&lt;strong&gt;Abstract&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;Contrast-induced renal dysfunction and hemostatic imbalance remain major concerns during angiographic procedures in patients with chronic kidney disease (CKD). Carboxyangiography, using carbon dioxide (CO₂) as a contrast medium, offers a potentially safer alternative to iodinated agents, especially in patients with advanced vascular disease. This study aimed to evaluate the effect of carboxyangiography on renal hemostatic parameters and systemic blood biomarkers in retired military patients with critical limb ischemia (CLI) and CKD.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Methods&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;A total of 130 retired military patients (mean age 67.3 &plusmn; 6.1 years; 84% male) with CLI and stage II&ndash;IV CKD were prospectively enrolled. Participants underwent either CO₂-based carboxyangiography or standard iodinated contrast angiography. Renal function (serum creatinine, estimated glomerular filtration rate [eGFR]) and hemostatic parameters (platelet count, fibrinogen, D-dimer, prothrombin time [PT], activated partial thromboplastin time [aPTT]) were assessed at baseline and 24 hours post-procedure. Inflammatory and oxidative stress biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], malondialdehyde [MDA]) were also analyzed.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;Compared with the iodinated contrast group, patients undergoing carboxyangiography showed a significantly smaller post-procedural rise in serum creatinine (0.08 &plusmn; 0.12 vs 0.31 &plusmn; 0.15 mg/dL, p &lt; 0.001) and a smaller decline in eGFR (&minus;1.9 &plusmn; 3.4 vs &minus;6.7 &plusmn; 4.5 mL/min/1.73 m&sup2;, p &lt; 0.001). Carboxyangiography was associated with attenuated increases in D-dimer and fibrinogen levels, suggesting reduced coagulation activation. Moreover, systemic inflammation markers (CRP, IL-6) and oxidative stress indices were lower post-procedure in the CO₂ group.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Conclusion&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;Carboxyangiography demonstrates a favorable renal and hemostatic safety profile compared with iodinated contrast angiography in retired military patients with CLI and CKD. The findings support its wider clinical adoption in high-risk populations to minimize procedure-related nephrotoxicity and hemostatic disturbances.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Keywords:&lt;/strong&gt; carboxyangiography, carbon dioxide angiography, chronic kidney disease, critical limb ischemia, hemostasis, renal biomarkers, contrast-induced nephropathy&lt;/p&gt;

Carbon dioxide angiography with addition of optical coherence tomography imaging may improve procedural success and clinical outcomes in patients with peripheral artery disease and chronic kidney disease. Single-center, retrospective analysis of patients with chronic kidney disease who underwent carbon dioxide angiography and optical coherence tomography-guided chronic total occlusion crossing and/or optical coherence tomography-guided directional atherectomy was performed. Patient and procedure-related characteristics, along with peri- and one-year post-procedural major adverse events, were analyzed. A total of 18 vessels in 11 patients, with mean age 70 years were treated. All had co-morbidities such as hypertension, hyperlipidemia, had history or were current smokers with baseline peripheral artery disease. Majority were diabetic with coronary disease (82%); 55% baseline chronic kidney disease IV, 55% Rutherford class III and 45% class IV. Contrast was used in only two patients. Mean total fluoroscopy time and radiation dose was 24.1 min and 249.2 mGY, respectively. Half of the lesions were femoro-popliteal chronic total occlusions, and Ocelot catheter was used to cross seven of nine chronic total occlusions and was successful in six. Adjunctive optical coherence tomography-guided directional atherectomy was performed in 8 of 11 patients. Only two adverse events occurred: one clinically significant event of slow-flow intra-procedurally and one target limb revascularization within one year of index procedure in a vessel different than prior treated. Optical coherence tomography imaging in both chronic total occlusion-crossing and atherectomy resulted in 10-min mean fluoroscopy reduction time and 32 mGY reduction in radiation dose. Carbon dioxide angiography with the addition of optical coherence tomography imaging for chronic total occlusion crossing and/or optical coherence tomography-guided directional atherectomy reduced the need for contrast agents, total fluoroscopy time, and radiation exposure in patients with peripheral artery disease and baseline chronic kidney disease.

Background and ObjectiveVascular calcification (VC) and resulting vascular disease is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). CKD itself is increasingly recognized as a risk factor for cardiac and peripheral arterial disease (PAD). This paper examines the atherosclerotic plaque composition and specific endovascular considerations in the end stage renal disease (ESRD) patients. The literature was reviewed regarding the current status of medical and interventional management arteriosclerotic disease in patients with CKD. Lastly, three representative cases displaying typical endovascular treatment options are provided.MethodsA literature search was performed in PubMed covering publications up to September 2021 as well as discussion with experts in the field.Key Content and FindingsThe high prevalence of atherosclerotic lesions in patients with chronic renal failure and high (re-)stenosis cause problems in the medium and long term as vascular calcium load represents one of the most widely encountered predictors of failure of endovascular treatment of PAD and future cardiovascular events (e.g., coronary calcium score). Patients with CKD also suffer from a greater risk for major vascular adverse events in general and worse revascularization outcomes following peripheral vascular intervention. A correlation between calcium burden and drug-coated balloon (DCB) performance has been established for PAD necessitating the need for different tools to cope with vascular calcium such as endoprosthesis or braided stents. Patients with CKD are at a higher risk of developing contrast-induced nephropathy (CIN). In addition to recommendations such as the administration of intravenous fluids, carbon dioxide (CO2) angiography is one option to potentially provide an effective and safe alternative both to iodine-based contrast media allergy and to the use of iodine-based contrast media in patients with CKD.ConclusionsManagement and endovascular procedures of patients with ESRD are complex. In the course of time, new endovascular therapy methods have been developed such as directional atherectomy (DA) and the so-called “pave-and-crack” technique to deal with high vascular calcium burden. Besides interventional therapy, vascular patients with CKD benefit from aggressive medical management.

Fatal Brain Injury Following Carbon Dioxide Angiography

Gadolinium-based Contrast and Carbon Dioxide Angiography to Evaluate Renal Transplants for Vascular Causes of Renal Insufficiency and Accelerated Hypertension

Contrast-induced nephropathy has become increasingly prevalent as the age and prevalence of comorbidities in the general population have increased. Most cases of contrast-induced nephropathy are reversible; however, some may progress to acute kidney disease, and subsequently, to chronic kidney disease. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are known for their renoprotective effects. However, whether the use of these inhibitors affects the risk of contrast-induced kidney injury remains unclear. Data were collected from the Taipei Medical University Clinical Research Database. We included patients with diabetes who had contrast exposure between 2016 and 2020 because of computed tomography or coronary angiography. The primary outcome was the risk of a major adverse kidney event (MAKE), which encompassed acute kidney disease, chronic kidney disease progression, and the need for renal replacement therapy. Overlap weighting was performed to reduce the effects of potential confounders. This study included 12 421 patients, who were divided into two groups: SGLT2i users (n = 920) and nonusers (n = 11 501). The follow-up period after contrast exposure was 6months. The risk of a MAKE was lower in SGLT2i users than in nonusers (incidence, 36.9 vs. 49.9 per 1000 person-months, respectively; P = .0011). Furthermore, the incidence of acute kidney disease or chronic kidney disease progression was significantly lower in the SGLT2i users than in nonusers. However, no significant between-group difference was noted in the incidence of other MAKEs. SGLT2i may be safely used in diabetic patients needing contrast exposure. The risk of a MAKE may be lower in SGLT2i users than in nonusers.

Aim: To identify the predictors of in-hospital mortality in patients with coronavirus disease of 2019 (COVID-19) and acute renal impairment (ARI) or chronic kidney disease (CKD), and to evaluate the performance and inter-reader concordance of chest CT total severity scores (TSSs). Methods: This retrospective single-center study was conducted on symptomatic COVID-19 patients with renal impairment (either acute or chronic) and a serum creatinine of >2 mg/dL at the time of admission. The patients’ demographic characteristics, clinical data, and laboratory data were extracted from the clinical computerized medical records. All chest CT images obtained at the time of hospital admission were analyzed. Two radiologists independently assessed the pulmonary abnormalities and scored the severity using CT chest total severity score (TSS). Univariate logistic regression analysis was used to determine factors associated with in-hospital mortality. A receiver operating characteristic (ROC) curve analysis was performed for the TSS in order to identify the cut-off point that predicts mortality. Bland–Altman plots were used to evaluate agreement between the two radiologists assessing TSS. Results: A total of 100 patients were included, with a mean age of 60 years, 54 were males, 53 had ARI, and 47 had CKD. In terms of in-hospital mortality, 60 patients were classified in the non-survivor group and 40 were classified in the survivor group. The mortality rate was higher for those with ARI compared to those with CKD (p = 0.033). The univariate regression analysis showed an increasing odds of in-hospital mortality associated with higher respiratory rate (OR 1.149, 95% CI 1.057–1.248, p = 0.001), total bilirubin (OR 2.532, 95% CI 1.099–5.836, p = 0.029), lactate dehydrogenase (LDH) (OR 1.001, 95% CI 1.000–1.003, p = 0.018), CRP (OR 1.010, 95% CI 1.002–1.017, p = 0.012), invasive mechanical ventilation (MV) (OR 7.667, 95% CI 2.118–27.755, p = 0.002), a predominant pattern of pulmonary consolidation (OR 21.714, 95% CI 4.799–98.261, p < 0.001), and high TSS (OR 2.082, 95% CI 1.579–2.745, p < 0.001). The optimum cut-off value of TSS used to predict in-hospital mortality was 8.5 with a sensitivity of 86.7% and a specificity of 87.5%. There was excellent interobserver agreement (ICC > 0.9) between the two independent radiologists in their quantitative assessment of pulmonary changes using TSS. Conclusions: In-hospital mortality is high in COVID-19 patients with ARI/CKD, especially for those with ARI. High serum bilirubin, a predominant pattern of pulmonary consolidation, and TSS are the most significant predictors of mortality in these patients. Patients with a higher TSS may require more intensive hospital care. TSS is a reliable and helpful auxiliary tool for risk stratification among COVID-19 patients with ARI/CKD.