Abstract
BackgroundContrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization.MethodsWe assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio ≤ 3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis.ResultsFrom 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5–56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8–36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6–53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56–2.08) for periprocedural hydration, 1.95 (CI 1.66–2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23–3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n = 5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38–1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65–2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N = 1059), 6.2% of cases in 2015 (N = 128, p = < 0.0001)) and no significant change in contrast-minimization (p = 0.3907).ConclusionsAmong patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.
Highlights
Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI)
Among patients with chronic kidney disease (CKD) undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, was present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed
He is currently employed as a cardiologist and director of the Healthcare Innovation Lab at BJC HealthCare/Washington University School of Medicine
Summary
Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization. Major society guidelines on CA-AKI prophylaxis in CKD patients are currently lacking or contradictory [12, 13] We hypothesized that such variability in the literature and guidelines would result in significant site-level practice variation independent of patient-specific factors. We hypothesized there would be less variability in well-established interventions, such as contrast minimization With this in mind, we sought to assess the prevalence and variation of CA-AKI prophylactic measures utilized in CKD patients undergoing PCI throughout the largest integrated healthcare system in the United States, the Veterans Affairs (VA) Healthcare System, with hopes of identifying opportunities to improve the use of prophylactic measures and reduce the incidence of CA-AKI
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