Contrast-associated Nephropathy Research Articles

Transplant Renal Artery Stenosis with Varied Clinical Presentations

Renal vascular complications constitute a clinically significant cause of morbidity following renal transplantation. Transplant renal artery stenosis (TRAS) is a well-recognized complication accounting for ~75% of posttransplant vascular complications. Early recognition and prompt correction of TRAS can prevent adverse outcomes, including graft loss. This series is a summary of four renal transplant recipients who developed TRAS at varied time periods and with varied clinical presentations. A 23-year-old male who presented after 1½ months of renal transplantation with accelerated hypertension was diagnosed with TRAS and was treated successfully with percutaneous transluminal angioplasty with stenting. A 26-year-old male with acute allograft dysfunction after 1 month of transplantation without worsening hypertension was diagnosed with TRAS, which was treated successfully with angioplasty and stenting. A 49-year-old male who presented to the emergency with pulmonary edema secondary to accelerated hypertension (Pickering syndrome) after 2 months of transplantation was diagnosed to have TRAS, which was treated successfully with angioplasty with stenting. A 44-year-old male with an incidentally detected TRAS-like clinical picture secondary to kinking in the transplant renal artery in the immediate posttransplant period was successfully treated with re-exploration and repair. All the patients were screened with Doppler ultrasonogram and computed tomogram-angiography supported the diagnosis in three of the cases. None of the cases developed procedure-related complications including contrast-associated nephropathy. All the patients on follow-up after 6 months of the intervention are normotensive with normal renal function. A high index of suspicion is required in the early identification of TRAS, which is a reversible cause of hypertension and graft dysfunction. The risk of contrast-associated nephropathy cannot hinder or delay the diagnosis especially, in emerging transplant centers. The endovascular procedures used today for the treatment of TRAS are safe with high technical success rates.

Transitioning from Contrast-induced Nephropathy and Contrast-associated Nephropathy to Contrast-associated Acute Kidney Injury

Transitioning from Contrast-induced Nephropathy and Contrast-associated Nephropathy to Contrast-associated Acute Kidney Injury

Investigating the Prevalence of Contrast-associated Nephropathy and the Related Risk Factors in Patients Undergoing Elective Angioplasty.

Contrast-associated nephropathy (CAN) is a sudden decrease in kidney function following contrast media administration. Considering the importance of CAN in the patient's outcome and the high prevalence of this complication in cardiac catheterizing centers, this study was designed to investigate the prevalence and the related risk factors of CAN in patients undergoing angioplasty in Chamran Heart Hospital, Isfahan, Iran, from January 2022 to June 2022. The inclusion criteria were adult patients above 18 admitted for elective percutaneous coronary intervention (PCI). Patient demographic information, underlying diseases and medications, dehydration state, type and amount of contrast media, and serum levels of blood urea nitrogen (BUN) and serum creatinine (SrCr) at 24 and 72 h after contrast injection were all recorded. Out of 340, 128 patients developed CAN after PCI, giving an incidence of 37.64%. Adjusted analysis showed a significant relation between age over 65, the amount of contrast media administered, and the use of furosemide with the incidence of CAN. However, adjusted logistic regression analysis failed to show any significant relationship between the risk of CAN and the hydration status of the patients at 24 and 48 h after receiving contrast media as diagnosed by BUN/SrCr >20. The prevalence of CAN in this study was higher than in other studies since this high-risk population was under risk factors such as arterial injection of contrast material and a higher amount of contrast material administration. In addition, advanced age, volume of contrast material, and previous or concurrent furosemide administration were associated with an increased risk of CAN.

Impact of chronic total occlusion in a non-infarct-related coronary artery on contrast-associated nephropathy in acute ST-elevation myocardial infarction

Objectives Co-existing chronic total occlusion (CTO) in a non-infarct-related artery (IRA) might serve as an important trigger of adverse outcomes in ST-segment elevation myocardial infarction (STEMI). Therefore, we planned to analyse the potential impact of non-IRA CTO on the evolution of contrast-associated nephropathy (CAN) in STEMI patients managed with primary percutaneous coronary intervention (P-PCI). Methods A total of 537 subjects with STEMI undergoing P-PCI during the first 12 h after the onset of their symptoms were enrolled in this retrospective study. The subjects were categorised based on the angiographic presence of non-IRA CTO. Moreover, the subjects were also divided into 2 groups based on their CAN status following P-PCI (CAN (+) and CAN (−)). Results Co-existing non-IRA CTO was demonstrated in 86 subjects (16%). During the hospitalisation period, we identified 81 (15.1%) subjects with CAN. Subjects with non-IRA CTO had a significantly higher incidence of CAN compared with those without (56 [12.4%] vs 25 [29.1%], respectively, p < 0.001). In a logistic regression analysis, an existing non-IRA CTO (odds ratio: 2.840, 95%CI: 1.451–5.558, p = 0.002), as well as age, haemoglobin, diabetes mellitus, creatinine, and white blood cell count, were independent of predictors of CAN. Conclusion In STEMI patients managed with P-PCI, a co-existing non-IRA CTO had an independent association with the evolution of CAN.

Acute kidney injury rates during a single hospitalization undergoing tavr with or without pci in high-risk surgical candidates. a study using the national inpatient sample: 2011–2014

Abstract Introduction Aortic valve stenosis (AS) and atherosclerosis share similar risk factors, therefore patients referred for replacement have incidental obstructive coronary lesions in 40–70% of the cases. Using the surgical approach of replacement, guidelines from observational studies give a class IIa recommendation for revascularization through CABG of major coronary arteries with &amp;gt;70% luminal stenosis or left main artery with &amp;gt;50% luminal stenosis at the time of valve replacement. In the event of high-risk surgical patients, TAVR is prompted and current recommendations support combined TAVR and percutaneous coronary intervention (PCI) for treatment of ostial/proximal lesions, or in unstable patients. Further characterization of complications is needed to allow experts to make a supported decision. Purpose One of the biggest concerns when performing both procedures without a washing period is the increased renal burden. In the present study, we evaluated the outcomes and complications in patients undergoing TAVR and PCI during the same hospitalization. Methods The patient population was obtained from the Nation Inpatient Sample database in the U.S. ICD-9 billing codes were used to identify all patients with severe AS undergoing PCI and TAVR during the same admission between 2011:2014. At this timeframe, only high-risk surgical patients were candidates for TAVR. Multivariate logistic regression was used to adjust for patient and procedural confounders. Results Between 2011 and 2014, 31945 patients underwent TAVR out of which 1069 had a PCI during the same hospital admission. The adjusted odds ratio (OR) of an AKI was 2.44 (95% CI: 0.85–7.00) times greater in those who underwent a TAVR+PCI during the same admission compared to TAVR alone; however, this was not statistically significant (p=0.097). Mean length of stay was 10.6 days in the TAVR+PCI group, compared to 7.1 days in those who underwent a TAVR alone, p-value &amp;lt;0.05. In-hospital, all-cause mortality was 4.4 times greater in those receiving TAVR+PCI than TAVR alone (95% CI: 2.81–7.14). A multivariate regression model controlling for potential confounders was used to evaluate the likelihood of developing an AKI in the setting of CKD: the adjusted OR of stage I was 0.51 (95% CI: 0.09–2.92), stage II was 1.36 (95% CI: 0.52–3.51), stage III was 3.24 (95% CI: 1.10–9.58), stage IV was 0.96 (95% CI: 0.16–5.73), and stage V was 1.58 (95% CI: 0.59–4.24) when compared to normal renal function. Conclusion Periprocedural PCI and TAVR during the same hospitalization have increased length of stay and in-hospital mortality compared to TAVR alone. However, the likelihood of an AKI in the setting of a concurrent PCI with TAVR was not statistically significant compared to a TAVR alone. Those with CKD Stage III were noted to have an increased likelihood of developing an AKI during their admission. This might give new insight for operators on the so feared contrast-associated nephropathy. Funding Acknowledgement Type of funding source: None

The place of hydration using intravenous fluid in patients at risk of developing contrast-associated nephropathy.

There has been a significant rise in the incidence of contrast-associated nephropathy caused by administration of contrast media during cardiac interventions. This is one of the major complications of percutaneous coronary interventions, which may proceed to acute renal failure. Risk factors, including pre-existing renal dysfunction, older age and use of high osmolar contrast media, predispose patients to the development of contrast-associated nephropathy. Different risk-reduction strategies have been used to prevent contrast-associated nephropathy, including use of low osmolar contrast media, N-acetylcysteine, alkalisation of tubular fluid with intravenous sodium bicarbonate, and oral and intravenous hydration with isotonic solution. Hydration using intravenous saline is one of the main treatments used to prevent the development of nephropathy in patients receiving contrast media during cardiac interventions. Prehydration, before administering contrast media, seems to be crucial. The results of studies of the relative efficacy of sodium bicarbonate and/or N-acetylcysteine in reducing the development of contrast-associated nephropathy are not consistent and any beneficial effects may depend on the pre-existing state of the kidney. This review discusses hydration of patients who are at risk of developing contrast-associated nephropathy using intravenous fluid.

The Relationship Between Contrast Associated Nephropathy and Coronary Collateral Circulation in very Old Patients.

Background: The aim of this study was to investigate whether there is a relationship between coronary collateral circulation (CCC) and contrast associated nephropathy (CAN) in very elderly patients. Methods: Patients aged 90 years or older with at least one major occlusion of the coronary artery proximal or mid-section were included in the study. CCC was graded according to the Rentrop classification. CAN was defined as an increase in blood creatinine value of 25% or more on the second day after coronary angiography. Results: Thirty-six patients who met the study criteria were included in the study. In the study group, CAN developed in 12 patients (CAN (+) group), 24 patients did not develop CAN (CAN (−) group). The creatinine levels before coronary angiography were 1.05 ± 0.12 in the CAN (−) group and 1.22 ± 0.14 in the CAN (+) group. Baseline creatinine values were significantly higher in the CAN (+) group (p = 0.001). The contrast agent used in the CAN (+) group was significantly higher (p = 0.001). In the CAN (+) group, nine patients (43%) had poor collateral circulation, whereas only three patients (20%) had well-developed collateral circulation. In a logistic regression analysis, the collateral class was not a risk factor for CAN, whereas contrast agent volume and basal creatinine were independent predictors of CAN. Conclusion: We found that CCC grade was not associated with the development of CAN in very old patients, but the amount of contrast agent and pre-procedure creatinine values were independent variables in the development of CAN.

Incidence, Risk Factors, and Outcomes of Contrast Associated Nephropathy following Percutaneous Coronary Intervention

Introduction: Contrast-associated acute kidney injury (CA-AKI) is a prevalent but underdiagnosed complication of percutaneous coronary intervention (PCI) that is associated with increased inhospital morbidity and mortality. Aims and Objectives: The aims and objectives were to study the incidence, risk factors, and outcome of CA-KI following PCI. Materials and Methods: This was a single-center prospective observational study. Five hundred patients who were admitted in ward and medical intensive care unit with chronic stable angina and acute coronary syndrome (unstable angina, non-ST-elevation myocardial infarction [STEMI], and STEMI) for PCI (intracoronary stent implantation) were included in the present study. All baseline demographic and clinical characteristics including pre- and postprocedure kidney function test (24 h, 48 h) were noted. Hospital stay, need for dialysis, and mortality were recorded. Results: In this study, 500 patients were enrolled. The mean age of presentation was 61.83 ± 13.17 years. Three hundred and sixty-six patients (73.2%) were male. Of 500 patients, 52 (10.4%) patients developed AKI. AKI was significantly higher in those with diabetes (27.2% vs. 5.4% P 1.2 (18.5% vs. 5.9% P 60 min (20.2% vs. 7.3% P

Use of Urinary Cell-Cycle Arrest Biomarkers in Contrast-Associated Nephropathy After Coronary Angiography

Use of Urinary Cell-Cycle Arrest Biomarkers in Contrast-Associated Nephropathy After Coronary Angiography

Contrast-associated nephropathy: Does the route of administration matter? .

Contrast-associated nephropathy (CAN) is an extensively studied but equally controversial sequela of intravascular contrast use. Despite this, there is still significant debate about its definition and thus incidence, the impact of route of contrast administration, and ultimately, what constitutes appropriate clinical practice in light of risks. While guidelines cannot replace clinical judgment, without consensus either enthusiastic withholding of contrast from necessary procedures or its administration despite increased risk may be deleterious to patient outcomes. This article reviews current literature on route-dependent risk and other interplaying factors impacting incidence of CAN. .

Meta-Analysis of Individual Patient Data of Sodium Bicarbonate and Sodium Chloride for All-Cause Mortality After Coronary Angiography

We sought to examine the relation between sodium bicarbonate prophylaxis for contrast-associated nephropathy (CAN) and mortality. We conducted an individual patient data meta-analysis from multiple randomized controlled trials. We obtained individual patient data sets for 7 of 10 eligible trials (2,292 of 2,764 participants). For the remaining 3 trials, time-to-event data were imputed based on follow-up periods described in their original reports. We included all trials that compared periprocedural intravenous sodium bicarbonate to periprocedural intravenous sodium chloride in patients undergoing coronary angiography or other intra-arterial interventions. Included trials were determined by consensus according to predefined eligibility criteria. The primary outcome was all-cause mortality hazard, defined as time from randomization to death. In 10 trials with a total of 2,764 participants, sodium bicarbonate was associated with lower mortality hazard than sodium chloride at 1year (hazard ratio 0.61, 95% confidence interval [CI] 0.41 to 0.89, p=0.011). Although periprocedural sodium bicarbonate was associated with a reduction in the incidence of CAN (relative risk 0.75, 95% CI 0.62 to 0.91, p= 0.003), there exists a statistically significant interaction between the effect on mortality and the occurrence of CAN (hazard ratio 5.65, 95% CI 3.58 to 8.92, p <0.001) for up to 1-year mortality. Periprocedural intravenous sodium bicarbonate seems to be associated with a reduction in long-term mortality in patients undergoing coronary angiography or other intra-arterial interventions.

Blood oxygenation level-dependent MRI for assessment of renal oxygenation.

Blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) has recently emerged as an important noninvasive technique to assess intrarenal oxygenation under physiologic and pathophysiologic conditions. Although this tool represents a major addition to our armamentarium of methodologies to investigate the role of hypoxia in the pathogenesis of acute kidney injury and progressive chronic kidney disease, numerous technical limitations confound interpretation of data derived from this approach. BOLD MRI has been utilized to assess intrarenal oxygenation in numerous experimental models of kidney disease and in human subjects with diabetic and nondiabetic chronic kidney disease, acute kidney injury, renal allograft rejection, contrast-associated nephropathy, and obstructive uropathy. However, confidence in conclusions based on data derived from BOLD MRI measurements will require continuing advances and technical refinements in the use of this technique.

Prevention and treatment of contrast-associated nephropathy in interventional cardiology

Contrast-induced nephropathy (CIN) is a common complication after diagnostic and therapeutic cardiovascular procedures that is associated with significant mortality and morbidity. CIN is highly prevalent in patients with well-known risk factors, including older age, chronic renal insufficiency, congestive heart failure, and diabetes. Thus far, no strategies have been shown to be effective in preventing CIN beyond thorough patient selection, minimizing the amount of contrast agent, and meticulous hydration of the patient. The role of various drugs in preventing CIN is still controversial and warrants future studies. Despite the remaining uncertainty regarding the degree of nephrotoxicity produced by various contrast agents, nonionic low-osmolar contrast media may be preferred in patients at high risk for CIN.

Cardiac computed tomography with gadolinium: An alternative to iodinated contrast agents?

Noninvasive cardiac imaging using multislice computed tomography (MSCT) has become a real alternative to invasive angiography in selected patient populations with rising procedural volume because of its noninvasive character and ease of use. Although computed tomography angiography (CTA) is in general a safe procedure, risks of the test include X-ray exposure and the need to administer iodinated contrast agents. Although radiation remains the most important current point of critique, 1 Einstein A.J. Henzlova M.J. Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007; 298: 317-323 Crossref PubMed Scopus (1217) Google Scholar contrast media complications are also of potential concern. Typically, cardiac CTA requires approximately 80 to 100 mL of iodinated contrast medium, 2 Leber A.W. Becker A. Knez A. von Ziegler F. Sirol M. Nikolaou K. Ohnesorge B. Fayad Z.A. Becker C.R. Reiser M. Steinbeck G. Boekstegers P. Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: a comparative study using intravascular ultrasound. J Am Coll Cardiol. 2006; 47: 672-677 Abstract Full Text Full Text PDF PubMed Scopus (661) Google Scholar , 3 Kopp A.F. Heuschmid M. Reimann A. Kuettner A. Beck T. Ohmer M. Burgstahler C. Brodoefel H. Claussen C.D. Schroeder S. Evaluation of cardiac function and myocardial viability with 16- and 64-slice multidetector computed tomography. Eur Radiol. 2005; 15: D15-D20 Crossref PubMed Scopus (24) Google Scholar with possible side effects including allergic reactions, hyperthyroidism, and acute renal failure. In particular, contrast-induced nephropathy is a feared complication that is associated with substantial rates of morbidity and mortality and furthermore may limit the application of CTA to otherwise eligible patients with abnormal renal function. Risk factors for contrast-associated nephropathy include contrast volume, contrast osmolality, chronic kidney disease, diabetes, and congestive heart failure. 4 Barrett B.J. Parfrey P.S. Clinical practice Preventing nephropathy induced by contrast medium. N Engl J Med. 2006; 354: 379-386 Crossref PubMed Scopus (513) Google Scholar

Patients at high risk of adverse events from intravenous contrast media after computed tomography examination

Adverse reactions to iodinated contrast media (CM) may occur and require prompt recognition and treatment. Although adverse reactions to radiocontrast agents cannot be eliminated, an important first step toward reducing their incidence is to identify patients at greatest risk. Prior to examinations using CM, patients should be adequately assessed by obtaining thorough medical histories and using simple screening tests. Studies have demonstrated that patients with a history of asthma, allergy, hyperthyroidism, and previous reaction to CM are at risk for severe reactions to iodinated CM. Renal adverse reactions reportedly occur more frequently in patients with pre-existing chronic kidney disease, especially those with diabetic nephropathy. Patients with congestive heart failure, dehydration, older age, and those who use nephrotoxic medications are also at risk for developing contrast-associated nephropathy. The occurrence of adverse events may be further increased in patients with multiple risk factors. As the number of patients undergoing computed tomography procedures continues to increase, it is essential for physicians to be able to identify patients at risk for adverse events of CM. Patient-related risk factors are discussed and simple tools for risk stratification presented.

Acetylcysteine In Diabetes (AID): A randomized study of acetylcysteine for the prevention of contrast nephropathy in diabetics

Patients with diabetes mellitus (DM) are at increased risk of contrast-associated nephropathy irrespective of their baseline creatinine (Cr). We tested the efficacy of N-acetylcysteine (NAC) relative to hydration in unselected patients (irrespective of baseline Cr) with DM. We conducted a randomized open-label study comparing hydration alone (combined oral and rapid intravenous hydration, n = 69) to NAC plus hydration (similar hydration protocol plus NAC 600 mg BID x 4 doses, n = 68) in diabetic patients (mean age 65 +/- 10 years, 65% men) undergoing elective coronary angiography. The primary end point was the mean change in serum Cr measured up to 96 hours postangiography. Baseline Cr was 1.14 +/- 0.43 mg/dL (Cr > or = 1.3 mg/dL in 37 subjects). Baseline characteristics including blood urea nitrogen, Cr, and contrast volume were similar between the 2 groups. The mean Cr change in the NAC group was 0.14 +/- 0.47 versus 0.08 +/- 0.11 mg/dL in the hydration only group (P = NS). Contrast-associated nephropathy, defined as a > or = 0.5 mg/dL increase in Cr, was significantly more common in the NAC group, 9.2% versus 1.4%, P = .043. Similar results were found in the subgroup of participants with either an increased baseline serum Cr (> or = 1.3 mg/dL) or in those receiving high contrast volumes (> 100 mL). N-Acetylcysteine provides no benefit over an aggressive hydration protocol in patients with DM undergoing coronary angiography.

Contrast-induced nephropathy: Pharmacological prophylaxis

Contrast media-associated acute renal failure represents the third most common cause of in-hospital renal function deterioration after decreased renal perfusion and post-operative renal insufficiency. Although generally benign, this complication is associated with a mortality rate ranging from 3.8 to 64%, depending on the increase of creatinine concentration. Multiple drugs have been tested in an attempt to prevent this complication. Central to the pathophysiology of contrast-induced nephrotoxicity (CIN) is an alteration in renal hemodynamics. In an effort to reverse these hemodynamic changes, vasodilators and diuretics have been tested as prophylactic drugs. However, their effectiveness has not been confirmed. Recently, considerable interest has resulted from the initial positive data on the effectiveness of prophylactic administration of antioxidant compounds, such as acetylcysteine and ascorbic acid. In this review, we focus on the effectiveness of pharmacologic therapies for preventing CIN.

Optimal Timing of Hydration to Erase Contrast-Associated Nephropathy: The OTHER CAN Study

Optimal Timing of Hydration to Erase Contrast-Associated Nephropathy: The OTHER CAN Study

N-acetylcysteine reduces contrast-associated nephropathy but not clinical events during long-term follow-up

Background Contrast-associated nephropathy (CAN) is associated with increased morbidity and mortality following percutaneous coronary intervention (PCI). N-acetylcysteine (NAC) has been shown to reduce the risk of nephropathy; however, the impact of NAC on long-term clinical outcomes has not been assessed. Methods This randomized, double-blind, placebo-controlled trial enrolled 180 patients with moderate renal dysfunction undergoing PCI or coronary angiography with a high likelihood of ad hoc PCI; 171 patients completed the clinical follow-up. Patients received oral NAC (2000 mg/dose, n = 95) or placebo (n = 85) twice a day for 3 doses if randomized the night prior to the procedure, and 2 doses if randomized the day of the procedure. The primary end point was the incidence of a ≥25% increase in serum creatinine level 48 to 72 hours after PCI. Secondary end points were the inhospital incidence of death, nonfatal myocardial infarction, or urgent dialysis, and the 9-month incidence of death, nonfatal myocardial infarction, need for dialysis, or repeat hospitalization for cardiac reasons. Results CAN occurred in 9.6% of patients assigned to NAC and 22.2% of patients assigned to placebo ( P = .04); 1 patient receiving NAC required urgent dialysis. The inhospital composite end point occurred in 7 (7.4%) NAC-treated and 3 (3.5%) placebo-treated patients, P = NS. At 9 months, the composite end point occurred in 23 (24.2%) NAC-treated patients and 18 (21.2%) placebo-treated, P = NS. Conclusion Although high-dose NAC prevented periprocedural CAN, this benefit did not translate into a decrease in adverse outcomes over 9 months. Further studies to determine the clinical utility of this drug are required.

Cardiovascular risk in stage 4 and 5 nephropathy 1,2

Severity of heart disease of almost all types, as well as mortality risk associated with heart disease, increases in step with severity of kidney disease, although not necessarily in a linear fashion. Heart failure is more common and just as lethal as ischemic heart disease in patients with severe chronic kidney disease (CKD). The incidence of nonfatal heart disease in dialysis and transplant populations has now been described in detail. Although standard risk factors for heart disease that are more common among patients with CKD than in the general population do not adequately explain the greatly increased risk of heart disease in patients with severe CKD, neither do as yet identified “nontraditional” risk factors. However, in addition to the factors not common in the general population, such as anemia, hyperphosphatemia, and markers of systemic inflammation, patients with CKD in the modern era may also exhibit excessive thrombotic tendencies. Screening for heart disease in this population relies mainly on dobutamine stress echocardiography or nuclear scintigraphy. The role of electron beam CT (EBCT) scanning is currently controversial. The indications for coronary angiography are the same for patients with CKD as for the general population, but patients with CKD are at greatly increased risk for contrast-associated nephropathy, the least controversial preventive therapy, which consists of isotonic saline and N-acetylcysteine. Finally, patients with CKD do not currently receive adequate medical therapy for prevention and treatment of heart disease.