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KALAYCI S, HAMAMCIOGLU AC, KALAYCI B. The usefulness of arylesterase in predicting contrast-induced nephropathy in ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1221793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: Oxidative stress is one of the causes of contrast-induced nephropathy (CIN). Paraoxonase1 (PON1), is one of the oxidative stress markers. The most sensitive method that has been in use to measure PON1 enzyme activity is the measurement of arylesterase (AREase) activity. To explore relationship between AREase activity and CIN development.
Material and Method: A total of 58 STEMI patients were included in our study. The patients were divided into two groups as CIN (+) and CIN (-). The success of AREase activity level in predicting the development of CIN was also examined by using ROC analysis.
Results: Out of the study patients, 13 were CIN (+) and 45 were CIN (-). AREase activity was found to be statistically significantly lower in the CIN (+) group (875 U/L vs 819 U/L, p= 0.004). In the regression analysis, diabetes mellitus, contrast volume and AREase activity were determined as independent risk factors in the development of CIN. As a result of the ROC analysis, we concluded that the AREase activity level
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Caracciolo A, Scalise RFM, Ceresa F, Bagnato G, Versace AG, Licordari R, Perfetti S, Lofrumento F, Irrera N, Santoro D, Patanè F, Di Bella G, Costa F, Micari A. Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease. J Clin Med 2022; 11:2380. [PMID: 35566504 PMCID: PMC9100167 DOI: 10.3390/jcm11092380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/16/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
Percutaneous coronary intervention (PCI) is one of the most common procedures performed in medicine. However, its net benefit among patients with chronic kidney disease (CKD) is less well established than in the general population. The prevalence of patients suffering from both CAD and CKD is high, and is likely to increase in the coming years. Planning the adequate management of this group of patients is crucial to improve their outcome after PCI. This starts with proper preparation before the procedure, the use of all available means to reduce contrast during the procedure, and the implementation of modern strategies such as radial access and drug-eluting stents. At the end of the procedure, personalized antithrombotic therapy for the patient's specific characteristics is advisable to account for the elevated ischemic and bleeding risk of these patients.
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Affiliation(s)
- Alessandro Caracciolo
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Renato Francesco Maria Scalise
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Fabrizio Ceresa
- Department of Cardio-Thoraco-Vascular Surgery, Division of Cardiac Surgery, Papardo Hospital, 98158 Messina, Italy; (F.C.); (F.P.)
| | - Gianluca Bagnato
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Antonio Giovanni Versace
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Roberto Licordari
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Silvia Perfetti
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Francesca Lofrumento
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Francesco Patanè
- Department of Cardio-Thoraco-Vascular Surgery, Division of Cardiac Surgery, Papardo Hospital, 98158 Messina, Italy; (F.C.); (F.P.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic “Gaetano Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (R.F.M.S.); (G.B.); (A.G.V.); (R.L.); (S.P.); (F.L.); (N.I.); (D.S.); (G.D.B.)
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy
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Bafna AA, Shah HC. Remote ischemic preconditioning for prevention of contrast-induced nephropathy - A randomized control trial. Indian Heart J 2020; 72:244-247. [PMID: 32861377 PMCID: PMC7474124 DOI: 10.1016/j.ihj.2020.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 12/01/2022] Open
Abstract
Background There is a lack of sufficient data regarding the protective effects of remote ischemic preconditioning (RIPC) in patients at risk of developing contrast-induced nephropathy (CIN). Thus, this study was conducted to determine whether RIPC as an adjunct to standard therapy prevents CIN in high-risk patients undergoing coronary intervention. Methods In a single-center, double-blinded, randomized controlled trial, 162 patients who were at risk of CIN received standard hydration combined with RIPC or hydration with sham preconditioning. RIPC was accomplished by four cycles of 5 min ischemia and 5 min reperfusion of the forearm. The primary endpoint was a rise in serum creatinine (>0.5 mg/dL or >25%) from baseline to serum creatinine 48–72 h after contrast administration. Results Of the 162 patients, 81 were randomly allocated to receive sham preconditioning and 81 to receive RIPC. Significantly reduced serum creatinine levels were observed in patients with a Mehran moderate risk allocated to sham group compared to the RIPC group (0.070 ± 0.16 mg/dL vs. 0.107 ± 0.13 mg/dL, p = 0.001). With regards to the primary endpoint, a significantly higher change in serum creatinine from baseline to 48–72 h was observed in the sham group compared to the RIPC group (0.023 ± 0.2 μmol/L vs −0.064 ± 0.1 μmol/L, p < 0.001). Conclusion RIPC as an alternative to standard therapy, improved serum creatinine levels after contrast administration in patients at risk of CIN. However, present data indicate that RIPC might have beneficial effects in patients with a moderate or high risk of CIN.
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Affiliation(s)
- Akshay Ashok Bafna
- Department of Cardiology, Rajarshee Chhatrapati Shahu Maharaj Government Medical College and CPR Hospital, Kolhapur, India.
| | - Hetan C Shah
- Department of Cardiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
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Sharp AJ, Patel N, Reeves BC, Angelini GD, Fiorentino F. Pharmacological interventions for the prevention of contrast-induced acute kidney injury in high-risk adult patients undergoing coronary angiography: a systematic review and meta-analysis of randomised controlled trials. Open Heart 2019; 6:e000864. [PMID: 30774964 PMCID: PMC6350720 DOI: 10.1136/openhrt-2018-000864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/04/2018] [Accepted: 11/10/2018] [Indexed: 12/19/2022] Open
Abstract
Objective Quantify the efficacy of strategies to prevent contrast-induced acute kidney injury (CI-AKI) in high-risk patients undergoing coronary angiography (CAG) with or without percutaneous coronary intervention (PCI). Background CI-AKI remains a common problem. The renoprotective efficacy of existing pharmacological agents remains uncertain in high-risk populations. Methods Systematic review and meta-analysis of randomised controlled trials (RCTs) to compare different strategies versus hydration in patients with chronic kidney disease (CKD) undergoing CAG±PCI. Primary outcome was incident CI-AKI. Fixed-effects meta-analyses estimated ORs, 95% CIs and heterogeneity. Results Forty-eight RCTs were included. Seven pharmacological strategies were evaluated by multiple RCTs and 10 by one RCT each. These had varying risk of bias; >25% of trials were at high risk of performance bias. Five strategies significantly reduced the odds of CI-AKI: N-acetylcysteine (NAC) (27 trials, 5694 participants; OR=0.77, 95% CI 0.65 to 0.91, p=0.002, I2=36%), ascorbic acid (four trials, 759 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.01, I2=0%), statin (two trials, 3234 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.75, I2=0%), trimetazidine (two trials, 214 participants; OR=0.27, 95% CI 0.10 to 0.71, p=0.01, I2=0%) and nicorandil (two trials, 389 participants; OR=0.47, 95% CI 0.23 to 0.94, p=0.03, I2=52%). Theophylline had a similar, but non-significant, effect. A subgroup analysis found that the benefit of NAC was highest in patients requiring a high-contrast dose. Conclusions Several drugs are renoprotective in patients with CKD undergoing CAG±PCI. The evidence is strongest for NAC. We recommend that NAC should be used when a high dose of contrast is anticipated. Trial registration number PROSPERO registration CRD42014014704. Open Science Framework link: https://osf.io/vxg7d/?view_only=62bad0404b18405abd39ff2ead2575a8
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Affiliation(s)
| | | | - Barney C Reeves
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Gianni D Angelini
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Francesca Fiorentino
- Imperial College Trial Unit and Division of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
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Gellis L, Gauvreau K, Ferguson M, Bergersen L, Shafer K, Porras D. Contrast volume to estimated glomerular filtration rate ratio for prediction of contrast-induced acute kidney injury after cardiac catheterization in adults with congenital heart disease. Catheter Cardiovasc Interv 2018; 92:1301-1308. [PMID: 30196559 DOI: 10.1002/ccd.27798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) are vulnerable to contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization. The aim of this study was to identify risk factors for clinically significant CI-AKI and evaluate the predictive value of contrast volume to estimated glomerular filtration rate ratio (V/eGFR) for the risk of CI-AKI following catheterization in the ACHD population. METHODS ACHD patients who underwent catheterization at Boston Children's hospital between 1/2011 and 1/2017 were retrospectively analyzed. CI-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hr or ≥1.5 times baseline within 7 days of procedure. Controls without CI-AKI were matched for calendar year of catheterization with cases using a 3:1 ratio. RESULTS Of 453 catheterizations meeting inclusion criteria, 27 catheterizations (5.9%) were complicated by CI-AKI, with dialysis being used to manage renal dysfunction in five of these events. Older age, male gender, admission prior to catheterization, and V/eGFR ratio were found to be related to risk of CI-AKI. Patients with a V/eGFR ≥ 2.6 had a significantly higher risk of CI-AKI (OR = 6.4; 95% CI = 2.0-20.4; P = 0.002). Survival at 3 years post-catheterization, was significantly shorter for CI-AKI cases compared to controls (49% versus 97%; P < 0.001) even in those with return to baseline renal function prior to discharge (60% versus 97%, P < 0.001). CONCLUSION In ACHD patients undergoing cardiac catheterization, a higher V/eGFR ratio is a strong predictor of clinically significant CI-AKI. Development of CI-AKI is a poor prognostic indicator and is associated with decreased survival in this population.
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Affiliation(s)
- Laura Gellis
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | - Keri Shafer
- Boston Children's Hospital, Boston, Massachusetts
| | - Diego Porras
- Boston Children's Hospital, Boston, Massachusetts
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Valappil SP, Kunjukrishnapillai S, Iype M, Koshy AG, Viswanathan S, Gupta PN, Velayudhan RV, Ali FM. Predictors of contrast induced nephropathy and the applicability of the Mehran risk score in high risk patients undergoing coronary angioplasty-A study from a tertiary care center in South India. Indian Heart J 2018; 70:399-404. [PMID: 29961457 PMCID: PMC6034029 DOI: 10.1016/j.ihj.2017.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/08/2017] [Accepted: 08/22/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To study the incidence and predictors of Contrast induced nephropathy (CIN) in high risk patients undergoing coronary angioplasty. To study the applicability of the Mehran Risk Score (MRS) in the prediction of CIN in our population. Methods This was a prospective observational study where patients with an estimated glomerular filtration rate (eGFR) between 30 and 60 ml/mt undergoing elective percutaneous coronary intervention (PCI) over a period of 15 months were evaluated prospectively for the development of CIN. The patients who developed CIN were then analysed for the presence of specific risk factors. The patients were categorized into the 4 risk groups based on the MRS. Results 100 high risk patients underwent PCI during the study period. The incidence of CIN was 29%. On multivariate analysis, the presence of anemia (p = 0.007), increased contrast volume usage (as defined by >5* B.Wt/S.cr) (p = 0.012) and usage of loop diuretics (p = 0.033) were independently found to confer a significant risk of CIN. In patients belonging to the high Mehran risk group (MRS10- 15) and very high risk group (MRS >15) the risk of CIN was 3 fold (OR: 3.055, 95% CI: 1.18–7.94, p = 0.022) and 24 fold (OR: 24, 95% CI: 2.53–228.28, p = 0.006) higher respectively when compared to intermediate and low risk patients (MRS <10). Conclusion The incidence of CIN in high risk patients undergoing PCI is substantially higher in our population compared to similar studies in the west. The MRS risk prediction is pertinent even in an Indian population.
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Affiliation(s)
- Sanjai Pattu Valappil
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India.
| | | | - Mathew Iype
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
| | | | - Sunitha Viswanathan
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
| | - Prabha Nini Gupta
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
| | | | - Faeez Mohamad Ali
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
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Karadeniz M, Kandemir H, Sarak T, Alp Ç. The prevalence of contrast nephropathy in patients undergoing percutaneous coronary intervention in acute coronary syndrome. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2018. [DOI: 10.32322/jhsm.410522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Valappil SP, Kunjukrishnapillai S, Viswanathan S, Koshy AG, Gupta PN, Velayudhan RV, Iype M. Remote ischemic preconditioning for prevention of contrast induced nephropathy-Insights from an Indian study. Indian Heart J 2017; 70:857-863. [PMID: 30580857 PMCID: PMC6306307 DOI: 10.1016/j.ihj.2017.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/26/2017] [Accepted: 11/15/2017] [Indexed: 01/18/2023] Open
Abstract
Objectives To study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI). Methods This was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI. Results Eleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p = 0.123). There was a statistically significant improvement in the post procedure creatinine values at 24 h (p = 0.013), 48 h (p = 0.015), 2 weeks (p = 0.003), 6 weeks (p = 0.003) and post procedure glomerular filtration rate (eGFR) values at 24 h (p = 0.026), 48 h (p = 0.044), 2 weeks (p = 0.015) and 6 weeks (p = 0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646). Conclusion RIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks.
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Affiliation(s)
- Sanjai Pattu Valappil
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India.
| | | | - Sunitha Viswanathan
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
| | | | - Prabha Nini Gupta
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
| | | | - Mathew Iype
- Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, Ostermann M, Oudemans-van Straaten HM, Schetz M. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730-749. [PMID: 28577069 PMCID: PMC5487598 DOI: 10.1007/s00134-017-4832-y] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. METHOD A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. RESULTS We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. CONCLUSION The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.
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Affiliation(s)
- M Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstasse 35, 6020, Innsbruck, Austria.
| | - W Druml
- Department of Internal Medicine III, University Hospital Vienna, Vienna, Austria
| | - L G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey and Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group (SPACeR), Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | | | - P M Honore
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - E Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - M Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - H M Oudemans-van Straaten
- Department of Adult Intensive Care, VU University Medical Centre, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - M Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
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Abstract
Acute kidney injury (AKI) is a common condition with multiple etiologies and variable clinical findings and pathologic manifestations. AKI is associated with serious adverse clinical outcomes, including the development of de novo chronic kidney disease, accelerated progression of pre-existing chronic kidney disease, end-stage kidney disease, and increased mortality. Past research has advanced our understanding of the pathophysiology, epidemiology, and outcomes of AKI significantly, however, little progress has been made in the development of evidence-based interventions for its prevention and treatment. In this review, we discuss key considerations in the design of clinical trials in AKI and highlight significant methodologic limitations that precluded many past studies from determining the effectiveness of preventive and therapeutic strategies for this common and serious condition.
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Ichai C, Vinsonneau C, Souweine B, Armando F, Canet E, Clec’h C, Constantin JM, Darmon M, Duranteau J, Gaillot T, Garnier A, Jacob L, Joannes-Boyau O, Juillard L, Journois D, Lautrette A, Muller L, Legrand M, Lerolle N, Rimmelé T, Rondeau E, Tamion F, Walrave Y, Velly L, Société française d’anesthésie et de réanimation (Sfar), Société de réanimation de langue française (SRLF), Groupe francophone de réanimation et urgences pédiatriques (GFRUP), Société française de néphrologie (SFN). Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Ann Intensive Care 2016; 6:48. [PMID: 27230984 PMCID: PMC4882312 DOI: 10.1186/s13613-016-0145-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/19/2016] [Indexed: 12/17/2022] Open
Abstract
Acute kidney injury (AKI) is a syndrome that has progressed a great deal over the last 20 years. The decrease in urine output and the increase in classical renal biomarkers, such as blood urea nitrogen and serum creatinine, have largely been used as surrogate markers for decreased glomerular filtration rate (GFR), which defines AKI. However, using such markers of GFR as criteria for diagnosing AKI has several limits including the difficult diagnosis of non-organic AKI, also called "functional renal insufficiency" or "pre-renal insufficiency". This situation is characterized by an oliguria and an increase in creatininemia as a consequence of a reduction in renal blood flow related to systemic haemodynamic abnormalities. In this situation, "renal insufficiency" seems rather inappropriate as kidney function is not impaired. On the contrary, the kidney delivers an appropriate response aiming to recover optimal systemic physiological haemodynamic conditions. Considering the kidney as insufficient is erroneous because this suggests that it does not work correctly, whereas the opposite is occurring, because the kidney is healthy even in a threatening situation. With current definitions of AKI, normalization of volaemia is needed before defining AKI in order to avoid this pitfall.
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Affiliation(s)
- Carole Ichai
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
| | | | - Bertrand Souweine
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Fabien Armando
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Canet
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Christophe Clec’h
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
| | - Jean-Michel Constantin
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
| | - Michaël Darmon
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
| | - Jacques Duranteau
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Théophille Gaillot
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
| | - Arnaud Garnier
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
| | - Laurent Jacob
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Olivier Joannes-Boyau
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Laurent Juillard
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Didier Journois
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
| | - Alexandre Lautrette
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
| | - Laurent Muller
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
| | - Matthieu Legrand
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Nicolas Lerolle
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
| | - Thomas Rimmelé
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Eric Rondeau
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
| | - Fabienne Tamion
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Yannick Walrave
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Lionel Velly
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française d’anesthésie et de réanimation (Sfar)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société de réanimation de langue française (SRLF)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Groupe francophone de réanimation et urgences pédiatriques (GFRUP)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française de néphrologie (SFN)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
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12
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Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Anaesth Crit Care Pain Med 2016; 35:151-65. [PMID: 27235292 DOI: 10.1016/j.accpm.2016.03.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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13
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Najafi A, Mojtahedzadeh M, Ahmadi KH, Abdollahi M, Mousavi M, Chelkeba L, Najmeddin F, Ahmadi A. The immunological benefit of higher dose N-acetyl cysteine following mechanical ventilation in critically ill patients. ACTA ACUST UNITED AC 2014; 22:57. [PMID: 25027749 PMCID: PMC4223415 DOI: 10.1186/2008-2231-22-57] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 07/08/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Sepsis complication is a major cause of death in multiple trauma critically ill patients. Defensin (cysteine rich anti-microbial peptides), as an important component of immune system, might play an important role in this process. There is also rising data on immunological effects of N-acetyl-cysteine (NAC), a commonly used anti-oxidant in oxidative stress conditions and glutathione (GSH) deficiencies. The aim of the present study was to evaluate the potential beneficial effects of NAC administration on multiple trauma patients with sepsis. METHODS In a prospective, randomized controlled study, 44 multiple trauma critically ill patients who were mechanically ventilated and met the criteria of sepsis and admitted to the intensive care unit (ICU) were randomized into two groups . Control group received all standard ICU therapies and NAC group received intravenous NAC 3 gr every 6 hours for 72 hours in addition to standard therapies. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, length of ICU stay, ICU mortality were recorded. Levels of serum Immunoglobulin M (IgM), Human β-Defensin 2 (HβD2) and GSH were assessed at baseline and 24, 72, 120 hours after intervention. RESULTS During a period of 13-month screening, 44 patients underwent randomization but 5 patients had to be excluded. 21 patients in NAC group and 18 patients in control group completed the study. For both groups the length of ICU stay, SOFA score and systemic oxygenation were similar. Mortality rate (40% vs. 22% respectively, p = 0.209) and ventilator days (Mean ± SD 19.82 ± 19.55 days vs. 13.82 ± 11.89 days respectively, p = 0.266) were slightly higher for NAC group. IgM and GSH levels were similar between two groups (p = 0.325, 0.125 respectively), HβD2 levels were higher for NAC group (at day 3). CONCLUSION High dose of NAC administration not only did not improve patients' outcome, but also raised the risk of inflammation and was associated with increased serum creatinine.
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Affiliation(s)
| | | | | | | | | | | | | | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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14
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Börekçi A, Gür M, Türkoğlu C, Çaylı M, Selek Ş, Kaypaklı O, Uçar H, Coşkun M, Şeker T, Koç M, Gökdeniz T, Gözükara MY. Oxidative Stress and Paraoxonase 1 Activity Predict Contrast-Induced Nephropathy in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Angiology 2014; 66:339-45. [DOI: 10.1177/0003319714533588] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Reactive oxygen species have been implicated in the pathogenesis of contrast-induced nephropathy (CIN). We investigated the relationship between CIN with paraoxonase 1 (PON-1) activity and oxidative stress markers (total antioxidant status [TAS], total oxidant status [TOS], and oxidative stress index [OSI]) in patients with anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention; 289 consecutive patients with STEMI were prospectively included. The patients were divided into 2 groups: CIN (n = 69) and non-CIN (n = 220). Activity of PON-1 and TAS levels were significantly lower and OSI and TOS levels were significantly higher in patients with CIN compared to the non-CIN group ( P < .05, for all). On multivariate logistic regression analysis, PON-1 activity and OSI as well as the amount of contrast medium and diabetes were independent predictors for CIN in patients with anterior STEMI. Activity of PON-1 and oxidative stress may play a role in the pathogenesis of CIN.
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Affiliation(s)
- Abdurrezzak Börekçi
- Department of Cardiology, School of Medicine, Kafkas University, Kars, Turkey
| | - Mustafa Gür
- Department of Cardiology, School of Medicine, Kafkas University, Kars, Turkey
| | - Caner Türkoğlu
- Department of Cardiology, Yenimahalle State Hospital, Ankara, Turkey
| | - Murat Çaylı
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Şahbettin Selek
- Department of Biochemistry, School of Medicine, Harran University, Şanlıurfa, Turkey
| | - Onur Kaypaklı
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Hakan Uçar
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Mehmet Coşkun
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Taner Şeker
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Mevlüt Koç
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Teyyar Gökdeniz
- Department of Cardiology, School of Medicine, Kafkas University, Kars, Turkey
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15
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Narula A, Mehran R, Weisz G, Dangas GD, Yu J, Genereux P, Nikolsky E, Brener SJ, Witzenbichler B, Guagliumi G, Clark AE, Fahy M, Xu K, Brodie BR, Stone GW. Contrast-induced acute kidney injury after primary percutaneous coronary intervention: results from the HORIZONS-AMI substudy. Eur Heart J 2014; 35:1533-40. [DOI: 10.1093/eurheartj/ehu063] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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16
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Pharmacological strategies to prevent contrast-induced acute kidney injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:236930. [PMID: 24719848 PMCID: PMC3955653 DOI: 10.1155/2014/236930] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 01/03/2014] [Accepted: 01/07/2014] [Indexed: 02/01/2023]
Abstract
Contrast-induced acute kidney injury (CI-AKI) is the most common iatrogenic cause of acute kidney injury after intravenous contrast media administration. In general, the incidence of CI-AKI is low in patients with normal renal function. However, the rate is remarkably elevated in patients with preexisting chronic kidney disease, diabetes mellitus, old age, high volume of contrast agent, congestive heart failure, hypotension, anemia, use of nephrotoxic drug, and volume depletion. Consequently, CI-AKI particularly in high risk patients contributes to extended hospitalizations and increases long-term morbidity and mortality. The pathogenesis of CI-AKI involves at least three mechanisms; contrast agents induce renal vasoconstriction, increase of oxygen free radicals through oxidative stress, and direct tubular toxicity. Several strategies to prevent CI-AKI have been evaluated in experimental studies and clinical trials. At present, intravascular volume expansion with either isotonic saline or sodium bicarbonate solutions has provided more consistent positive results and was recommended in the prevention of CI-AKI. However, the proportion of patients with risk still develops CI-AKI. This review critically evaluated the current evidence for pharmacological strategies to prevent CI-AKI in patients with a risk of developing CI-AKI.
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17
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Su MW, Chang SS, Chen CH, Huang CC, Chang SW, Tsai YC, Lam CF. Preconditioning renoprotective effect of isoflurane in a rat model of virtual renal transplant. J Surg Res 2014; 189:135-42. [PMID: 24674838 DOI: 10.1016/j.jss.2014.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The development of warm-cold ischemia-reperfusion (IR) injury of the kidney grafts is inevitable during renal transplantation. However, there is currently no definite renoprotective strategy available in the protection of the graft tissue. In the present study, we compared the renal protection of preconditioning isoflurane with N-acetylcysteine (NAC) in a novel rat model of warm-cold renal IR injury. MATERIALS AND METHODS Adult Sprague-Dawley rats were randomly assigned to receive inhaled isoflurane (1.5% for 2 h), NAC (1 g/kg, intra-arterial injection) or placebo before the induction of brief warm ischemia (10 min) followed by cold ischemia (45 min) periods. Plasma levels of creatinine and tissue inflammatory reaction in the kidney were analyzed 72 h after reperfusion. RESULTS Elevated plasma level of creatinine and urea indicated the development of acute renal injury secondary to IR injury. The creatinine levels were reduced in animals pretreated with inhaled isoflurane and NAC, and the level was more significantly decreased in the isoflurane-treated group. Preconditioning with volatile isoflurane also significantly suppressed the tissue myeloperoxidase activity and expression of the inducible nitric oxide synthase. Immunostaining confirmed that myeloperoxidase expression was most significantly attenuated in the glomerulus and peritubular capillaries of rats pre-exposed to isoflurane. CONCLUSIONS We present the first study demonstrating that the administration of volatile isoflurane before induction of experimental warm-cold renal IR injury provides preconditioning renoprotective effect, which is superior to the treatment with NAC. The beneficial renoprotective effect of isoflurane is most likely mediated by attenuation of proinflammatory reaction in the injured kidney.
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Affiliation(s)
- Min-Wen Su
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Shen-Shin Chang
- Department of Surgery, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Chung-Hao Chen
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Chien-Chi Huang
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Shih-Wei Chang
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Yu-Chuan Tsai
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan; Department of Anesthesiology, Buddhist Tzu-Chi General Hospital and Tzu-Chi University School of Medicine, Hualien, Taiwan.
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Sadat U. Radiographic contrast-media-induced acute kidney injury: pathophysiology and prophylactic strategies. ISRN RADIOLOGY 2013; 2013:496438. [PMID: 24967281 PMCID: PMC4045530 DOI: 10.5402/2013/496438] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 07/14/2013] [Indexed: 12/17/2022]
Abstract
Contrast-induced acute kidney injury (CI-AKI) is one of the most widely discussed and debated topics in cardiovascular medicine. With increasing number of contrast-media- (CM-) enhanced imaging studies being performed and growing octogenarian population with significant comorbidities, incidence of CI-AKI remains high. In this review, pathophysiology of CI-AKI, its relationship with different types of CM, role of serum and urinary biomarkers for diagnosing CI-AKI, and various prophylactic strategies used for nephroprotection against CI-AKI are discussed in detail.
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Affiliation(s)
- Umar Sadat
- Department of Surgery, Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Box 201, Cambridge CB2 0QQ, UK
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Weisbord SD, Gallagher M, Kaufman J, Cass A, Parikh CR, Chertow GM, Shunk KA, McCullough PA, Fine MJ, Mor MK, Lew RA, Huang GD, Conner TA, Brophy MT, Lee J, Soliva S, Palevsky PM. Prevention of contrast-induced AKI: a review of published trials and the design of the prevention of serious adverse events following angiography (PRESERVE) trial. Clin J Am Soc Nephrol 2013; 8:1618-31. [PMID: 23660180 DOI: 10.2215/cjn.11161012] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Contrast-induced AKI (CI-AKI) is a common condition associated with serious, adverse outcomes. CI-AKI may be preventable because its risk factors are well characterized and the timing of renal insult is commonly known in advance. Intravenous (IV) fluids and N-acetylcysteine (NAC) are two of the most widely studied preventive measures for CI-AKI. Despite a multitude of clinical trials and meta-analyses, the most effective type of IV fluid (sodium bicarbonate versus sodium chloride) and the benefit of NAC remain unclear. Careful review of published trials of these interventions reveals design limitations that contributed to their inconclusive findings. Such design limitations include the enrollment of small numbers of patients, increasing the risk for type I and type II statistical errors; the use of surrogate primary endpoints defined by small increments in serum creatinine, which are associated with, but not necessarily causally related to serious, adverse, patient-centered outcomes; and the inclusion of low-risk patients with intact baseline kidney function, yielding low event rates and reduced generalizability to a higher-risk population. The Prevention of Serious Adverse Events following Angiography (PRESERVE) trial is a randomized, double-blind, multicenter trial that will enroll 8680 high-risk patients undergoing coronary or noncoronary angiography to compare the effectiveness of IV isotonic sodium bicarbonate versus IV isotonic sodium chloride and oral NAC versus oral placebo for the prevention of serious, adverse outcomes associated with CI-AKI. This article discusses key methodological issues of past trials investigating IV fluids and NAC and how they informed the design of the PRESERVE trial.
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Affiliation(s)
- Steven D Weisbord
- Renal Section, VeteransAffairs PittsburghHealthcare System, Pittsburgh, PA 15240, USA.
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Bhandari S, Seth A, Sethi KK, Tyagi S, Gupta R, Tiwari SC, Mehrotra S, Seth A, Guha S, Deb PK, Dasbiswas A, Mohanan PP, Venugopal K, Sinha N, Pinto B, Banerjee A, Sengottuvelu G, Mehran R, Mc Collough P. Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction. Indian Heart J 2012. [PMID: 23186627 DOI: 10.1016/j.ihj.2012.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.
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Albabtain MA, Almasood A, Alshurafah H, Alamri H, Tamim H. Efficacy of ascorbic acid, N-acetylcysteine, or combination of both on top of saline hydration versus saline hydration alone on prevention of contrast-Induced nephropathy: a prospective randomized study. J Interv Cardiol 2012; 26:90-6. [PMID: 22994682 DOI: 10.1111/j.1540-8183.2012.00767.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Antioxidant drugs such as N-acetylcysteine (NAC) and ascorbic acid have been evaluated in interventional studies to prevent contrast-induced nephropathy (CIN), however, there are limited data on comparing either or both, with background of standard intravenous saline hydration versus the standard intravenous saline hydration alone in preventing CIN. METHODS We conducted a single-center randomized trial among patients undergoing coronary angiography or percutaneous coronary intervention who had serum creatinine ≥ 1.3 mg/dL or were on diabetes mellitus medication. Eligible patients were randomly assigned to one of the following 4 groups: (1) NAC, (2) ascorbic acid, (3) combination of both drugs, and (4) control group. Additionally, all the groups received the standard intravenous saline hydration. Creatinine was measured 4-5 days after procedure. RESULTS A total of 243 patients were randomized; 62 to NAC, 57 to ascorbic acid, 58 to both drugs, and 66 to placebo. The development of 0.5 mg/dL absolute increase of serum creatinine, 25% relative decrease of creatinine clearance, or either (CIN) were measured in the ascorbic acid group (3.6% for all), NAC group (6.8%, 3.4%, 8.5%, respectively), combined group (5.5%, 5.5%, 9.1%, respectively), and control group (6.2%, 6.2%, 7.7%, respectively). None of these differences were significant (P = 0.896 for serum creatinine, P = 0.863 for creatinine clearance, and P = 0.684 for CIN). CONCLUSIONS In a cohort of patients at risk of developing CIN, we could not detect any significant benefit of the use of ascorbic acid, NAC, or a combination of both drugs over the standard hydration regimen in preventing CIN.
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Affiliation(s)
- Monirah A Albabtain
- Adult Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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22
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WYLIE SJ, WONG GTC, CHAN YC, IRWIN MG. Endovascular aneurysm repair: a perioperative perspective. Acta Anaesthesiol Scand 2012; 56:941-9. [PMID: 22621365 DOI: 10.1111/j.1399-6576.2012.02681.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2012] [Indexed: 11/28/2022]
Abstract
Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.
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Affiliation(s)
- S. J. WYLIE
- Barts and the Royal London NHS Trust; London
| | - G. T. C. WONG
- Department of Anaesthesiology; University of Hong Kong; Hong Kong
| | - Y. C. CHAN
- Department of Surgery; University of Hong Kong; Hong Kong
| | - M. G. IRWIN
- Department of Anaesthesiology; University of Hong Kong; Hong Kong
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Hung YM, Lin SL, Hung SY, Huang WC, Wang PYP. Preventing radiocontrast-induced nephropathy in chronic kidney disease patients undergoing coronary angiography. World J Cardiol 2012; 4:157-72. [PMID: 22655164 PMCID: PMC3364502 DOI: 10.4330/wjc.v4.i5.157] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 03/16/2012] [Accepted: 03/23/2012] [Indexed: 02/06/2023] Open
Abstract
Radiocontrast-induced nephropathy (RCIN) is an acute and severe complication after coronary angiography, particularly for patients with pre-existing chronic kidney disease (CKD). It has been associated with both short- and long-term adverse outcomes, including the need for renal replacement therapy, increased length of hospital stay, major cardiac adverse events, and mortality. RCIN is generally defined as an increase in serum creatinine concentration of 0.5 mg/dL or 25% above baseline within 48 h after contrast administration. There is no effective therapy once injury has occurred, therefore, prevention is the cornerstone for all patients at risk for acute kidney injury (AKI). There is a small but growing body of evidence that prevention of AKI is associated with a reduction in later adverse outcomes. The optimal strategy for preventing RCIN has not yet been established. This review discusses the principal risk factors for RCIN, evaluates and summarizes the evidence for RCIN prophylaxis, and proposes recommendations for preventing RCIN in CKD patients undergoing coronary angiography.
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Affiliation(s)
- Yao-Min Hung
- Yao-Min Hung, Division of Nephrology, Jiannren Hospital, Kaohsiung 813, Taiwan, China
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Chow SL, Ng TM, Litwinski RA, Kangavari S, Weiss M. Effect of iodixanol and ioxilan on QT interval and renal function in patients with systolic heart failure. Int J Cardiol 2012; 154:17-21. [DOI: 10.1016/j.ijcard.2010.08.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 08/10/2010] [Accepted: 08/19/2010] [Indexed: 11/28/2022]
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Hafiz AM, Jan MF, Mori N, Shaikh F, Wallach J, Bajwa T, Allaqaband S. Prevention of contrast-induced acute kidney injury in patients with stable chronic renal disease undergoing elective percutaneous coronary and peripheral interventions: Randomized comparison of two preventive strategies. Catheter Cardiovasc Interv 2011; 79:929-37. [DOI: 10.1002/ccd.23148] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/02/2011] [Accepted: 03/19/2011] [Indexed: 01/05/2023]
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Care of the critically ill emergency department patient with acute kidney injury. Emerg Med Int 2011; 2012:760623. [PMID: 22145079 PMCID: PMC3226299 DOI: 10.1155/2012/760623] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/14/2011] [Indexed: 01/13/2023] Open
Abstract
Introduction. Acute Kidney Injury (AKI) is common and associated with significant mortality and complications. Exact data on the epidemiology of AKI in the Emergency Department (ED) are sparse. This review aims to summarise the key principles for managing AKI patients in the ED. Principal Findings. Timely resuscitation, goal-directed correction of fluid depletion and hypotension, and appropriate management of the underlying illness are essential in preventing or limiting AKI. There is no specific curative therapy for AKI. Key principles of secondary prevention are identification of patients with early AKI, discontinuation of nephrotoxic medication where possible, attention to fluid resuscitation, and awareness of the risks of contrast-induced nephropathy. In patients with advanced AKI, arrangements for renal replacement therapy need to be made before the onset of life-threatening uraemic complications. Conclusions. Research and guidelines regarding AKI in the ED are lacking and AKI practice from critical care departments should be adopted.
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Brown JR, McCullough PA, Splaine ME, Davies L, Ross CS, Dauerman HL, Robb JF, Boss R, Goldberg DJ, Fedele FA, Kellett MA, Phillips WJ, Ver Lee PN, Nelson EC, MacKenzie TA, O'Connor GT, Sarnak MJ, Malenka DJ. How do centres begin the process to prevent contrast-induced acute kidney injury: a report from a new regional collaborative. BMJ Qual Saf 2011; 21:54-62. [PMID: 21890755 DOI: 10.1136/bmjqs-2011-000041] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI. Background CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged hospitalisation, end-stage renal disease, and all-cause mortality. Reducing the risk of CI-AKI is a patient safety objective set by the National Quality Forum. METHODS This study prospectively collected quantitative and qualitative data from 10 centres, which participate in the Northern New England Cardiovascular Disease Study Group PCI Registry. Quantitative data were collected from the PCI Registry. Qualitative data were obtained through clinical team meetings to map care processes related to CI-AKI and focus groups to understand attitudes towards CI-AKI prophylaxis. Fixed and random effects modelling were conducted to test the differences across centres. RESULTS Significant variation in rates of CI-AKI were found across 10 medical centres. Both fixed effects and mixed effects logistic regression demonstrated significant variability across centres, even after adjustment for baseline covariates (p<0.001 for both modelling approaches). Patterns were found in reported processes and clinical leadership that were attributable to centres with lower rates of CI-AKI. These included reducing nil by mouth (NPO) time to 4 h prior to case, and standardising volume administration protocols in combination with administering three to four high doses of N-acetylcysteine (1200 mg) for each patient. CONCLUSIONS These data suggest that clinical leadership and institution-focused efforts to standardise preventive practices can help reduce the incidence of CI-AKI.
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Affiliation(s)
- Jeremiah R Brown
- Dartmouth-Hitchcock Medical Center, HB 7505, One Medical Center Drive, Lebanon, NH 03756, USA.
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Abstract
The intravascular administration of iodine-based contrast media remains a common cause of acute kidney injury and a leading cause of iatrogenic renal disease. Past research has elucidated the principal risk factors for contrast-induced acute kidney injury (CIAKI) and helped to establish the efficacy of various interventions for the prevention of this condition. The importance of preventing CIAKI has been underscored by a growing number of studies showing strong associations of CIAKI with serious adverse short- and long-term outcomes. However, it remains unclear whether these associations are causal. This is important because considerable health care resources are used to prevent CIAKI. If CIAKI is a marker, but not a mediator, of serious adverse downstream outcomes, more judicious and selective use of preventive care may be appropriate. Moreover, with an increasing number of studies reporting the underuse of coronary angiography in patients with acute coronary syndrome and underlying chronic kidney disease, presumably in part because of a fear of CIAKI, a clear understanding of whether this condition directly results in adverse downstream outcomes is essential. Careful inspection of past studies that investigated the association of CIAKI with adverse short- and long-term events sheds light on their strengths and weaknesses and provides insight into how future research may be better able to characterize the short- and long-term implications of this iatrogenic condition.
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Affiliation(s)
- Steven D Weisbord
- Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
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Zhang T, Shen LH, Hu LH, He B. Statins for the prevention of contrast-induced nephropathy: a systematic review and meta-analysis. Am J Nephrol 2011; 33:344-51. [PMID: 21430372 DOI: 10.1159/000326269] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 02/17/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Retrospective and prospective studies have demonstrated that statins have a protective effect in preventing contrast-induced nephropathy (CIN), but there are currently no established guidelines for statin timing or dosage. A systematic review and meta-analysis was performed to determine whether statin administration is protective and the magnitude of their effect. METHODS We searched MEDLINE, EMBASE, Cochrane Library, CNKI and ISI Proceedings for cohort studies comparing the CIN incidence in a chronic statin pretreatment group and a statin-naïve group, as well as for randomized controlled trials (RCTs) comparing short-term high-dose to short-term low-dose statin treatment or placebo. CIN was defined as an increase in serum creatinine >25% or 0.5 mg/dl (44.2 μmol/l). Qualitative analysis of cohort studies and quantitative analysis of RCTs to estimate pooled risk ratios were performed. RESULTS Among 6 cohort studies, 4 showed chronic statin pretreatment had a preventive effect against CIN. From 6 RCTs, 1,194 patients were included in the meta-analysis. Under the fixed-effects model, a nonsignificant protective trend toward decreased incidence of CIN with periprocedural short-term high-dose statin treatment was seen (RR: 0.70; 95% CI: 0.48-1.02). CONCLUSION Current data are not conclusive to whether statins are protective for CIN due to the inherent limitations of the included studies. In the future, large well-designed studies are needed to address the effect of this drug and its longer-term clinical outcomes.
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Affiliation(s)
- Tuo Zhang
- Department of Cardiology, Ren Ji Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, PR China
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Ozhan H, Erden I, Ordu S, Aydin M, Caglar O, Basar C, Yalcin S, Alemdar R. Efficacy of short-term high-dose atorvastatin for prevention of contrast-induced nephropathy in patients undergoing coronary angiography. Angiology 2010; 61:711-4. [PMID: 20395226 DOI: 10.1177/0003319710364216] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Contrast-induced nephropathy (CIN) is associated with increased morbidity, extended hospital stay, and higher costs. We compared an atorvastatin plus N-acetylcysteine (NAC) regimen with NAC alone in patients undergoing coronary angiography. A total of 130 patients (mean age 54 +/- 10; 77 men) undergoing coronary angiography were studied. Seven CIN cases occurred in the NAC group and 2 in the atorvastatin + NAC group; this difference was not significant. Baseline mean creatinine and estimated glomerular filtration rate (eGFR) were similar between the 2 groups, whereas after the procedure there was a significant creatinine decrease and eGFR increase in the atorvastatin + NAC group. Change in creatinine (baseline creatinine-creatinine after the procedure) was also significantly higher in patients taking statin plus NAC. Atorvastatin may be effective in protecting patients undergoing coronary angiography from CIN.
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Affiliation(s)
- Hakan Ozhan
- Department of Cardiology, Duzce University Düzce Medical School, Konuralp Düzce, Turkey.
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore P, Oudemans-van Straaten HM, Ronco C, Schetz MRC, Woittiez AJ. Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM. Intensive Care Med 2010; 36:392-411. [PMID: 19921152 DOI: 10.1007/s00134-009-1678-y] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 08/13/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. METHOD A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system. CONCLUSIONS AND RECOMMENDATIONS Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest specific vasodilators [corrected] under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (doi:10.1007/s00134-009-1678-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Joannidis
- Medical Intensive Care Unit, Department of Internal Medicine I, Medical University Innsbruck, Anichstasse 31, 6020 Innsbruck, Austria.
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Sodium bicarbonate plus N-acetylcysteine prophylaxis: a meta-analysis. JACC Cardiovasc Interv 2010; 2:1116-24. [PMID: 19926054 DOI: 10.1016/j.jcin.2009.07.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 07/25/2009] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We sought to conduct a meta-analysis to compare N-acetylcysteine (NAC) in combination with sodium bicarbonate (NaHCO(3)) for the prevention of contrast-induced acute kidney injury (AKI). BACKGROUND Contrast-induced AKI is a serious consequence of cardiac catheterizations and percutaneous coronary interventions (PCI). Despite recent supporting evidence for combination therapy, not enough has been done to prevent the occurrence of contrast-induced AKI prophylactically. METHODS Published randomized controlled trial data were collected from OVID/PubMed, Web of Science, and conference abstracts. The outcome of interest was contrast-induced AKI, defined as a >or=25% or >or=0.5 mg/dl increase in serum creatinine from baseline. Secondary outcome was renal failure requiring dialysis. RESULTS Ten randomized controlled trials met our criteria. Combination treatment of NAC with intravenous NaHCO(3) reduced contrast-induced AKI by 35% (relative risk: 0.65; 95% confidence interval: 0.40 to 1.05). However, the combination of N-acetylcysteine plus NaHCO(3) did not significantly reduce renal failure requiring dialysis (relative risk: 0.47; 95% confidence interval: 0.16 to 1.41). CONCLUSIONS Combination prophylaxis with NAC and NaHCO(3) substantially reduced the occurrence of contrast-induced AKI overall but not dialysis-dependent renal failure. Combination prophylaxis should be incorporated for all high-risk patients (emergent cases or patients with chronic kidney disease) and should be strongly considered for all interventional radio-contrast procedures.
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Abu Jawdeh BG, Kanso AA, Schelling JR. Evidence-based approach for prevention of radiocontrast-induced nephropathy. J Hosp Med 2009; 4:500-6. [PMID: 19824094 DOI: 10.1002/jhm.477] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The frequency of radiocontrast administration is dramatically increasing, with over 80 million doses delivered annually worldwide. Although recently developed radiocontrast agents are relatively safe in most patients, contrast nephropathy (CN) is still a major source of in-hospital and long-term morbidity and mortality, particularly in patients with preexisting kidney disease. Multiple protocols for CN prevention have been studied; however, strict guidelines have not been established, in part because of conflicting efficacy data for most prevention approaches. In this work, we critically review the major trials that have addressed common CN prophylaxis strategies, including type of radiocontrast media, N-acetylcysteine administration, extracellular fluid volume expansion, and hemofiltration/hemodialysis. We conclude with evidence-based recommendations for CN prevention, which emphasize concurrent NaHCO3 infusion and N-acetylcysteine administration. These guidelines should be helpful to hospitalists, who frequently order radiocontrast studies, and could therefore have a significant impact on prevention of CN.
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Affiliation(s)
- Bassam G Abu Jawdeh
- Department of Medicine, Case Western Reserve University School of Medicine, Rammelkamp Center for Research, Cleveland, Ohio 44109-1998, USA.
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Baskurt M, Okcun B, Abaci O, Dogan GM, Kilickesmez K, Ozkan AA, Ersanli M, Gurmen T. N-acetylcysteine versus N-acetylcysteine + theophylline for the prevention of contrast nephropathy. Eur J Clin Invest 2009; 39:793-9. [PMID: 19500141 DOI: 10.1111/j.1365-2362.2009.02173.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of N-acetylcysteine or theophylline in specific subgroups of patients has been suggested to reduce the incidence of contrast-induced nephropathy (CIN) in patients undergoing angiographic procedures. Our purpose was to compare the use of N-acetylcysteine versus N-acetylcysteine + theophylline for the prevention of CIN. MATERIALS AND METHODS We randomized 217 patients with estimated glomerular filtration rate (eGFR) (calculated by Modification of Diet in Renal Disease formula) between 30 and 60 mL min(-1) 1.73 m(-2) who were undergoing coronary angiography to three prophylactic treatment groups: Group 1: Intravenous hydration with isotonic saline (1 mL kg(-1) h(-1) for 12 h before and after contrast, n = 72). Group 2: Intravenous hydration with isotonic saline (1 mL kg(-1) h(-1) for 12 h before and after contrast)+ N-acetylcysteine (600 mg p.o. twice daily the preceding day and the day of angiography, n = 73). Group 3: Intravenous hydration with isotonic saline (1 mL kg(-1) h(-1) for 12 h before and after contrast)+ N-acetylcysteine + theophylline (600 mg N-acetylcysteine p.o. and 200 mg theophylline p.o. twice daily for the preceding day and the day of angiography, n = 72). The incidence of CIN (0.5 mg dL(-1) increase in serum creatinine from the baseline value 48 h after intravascular injection of contrast) was compared in three groups. RESULTS Of the 217 patients, 12 patients (5.5%) experienced CIN. Five patients (6.9%) in group 1, seven patients (9.6%) in group 2 and zero (0%) patients in group 3 experienced CIN (P < 0.033). CONCLUSION Among patients with eGFR between 30 and 60 mL min(-1) 1.73 m(-2) undergoing coronary angiography, oral administration of N-acetylcysteine + theophylline in addition to saline hydration has a beneficial effect in the prevention of CIN.
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Affiliation(s)
- M Baskurt
- Institute of Cardiology, Istanbul University, Istanbul, Turkey.
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Amini M, Salarifar M, Amirbaigloo A, Masoudkabir F, Esfahani F. N-acetylcysteine does not prevent contrast-induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease: a randomized clinical trial. Trials 2009; 10:45. [PMID: 19563648 PMCID: PMC2714294 DOI: 10.1186/1745-6215-10-45] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2008] [Accepted: 06/29/2009] [Indexed: 12/15/2022] Open
Abstract
Background Patients with diabetes mellitus (DM) and chronic kidney disease (CKD) constitute to be a high-risk population for the development of contrast-induced nephropathy (CIN), in which the incidence of CIN is estimated to be as high as 50%. We performed this trial to assess the efficacy of N-acetylcysteine (NAC) in the prevention of this complication. Methods In a prospective, double-blind, placebo controlled, randomized clinical trial, we studied 90 patients undergoing elective diagnostic coronary angiography with DM and CKD (serum creatinine ≥ 1.5 mg/dL for men and ≥ 1.4 mg/dL for women). The patients were randomly assigned to receive either oral NAC (600 mg BID, starting 24 h before the procedure) or placebo, in adjunct to hydration. Serum creatinine was measured prior to and 48 h after coronary angiography. The primary end-point was the occurrence of CIN, defined as an increase in serum creatinine ≥ 0.5 mg/dL (44.2 μmol/L) or ≥ 25% above baseline at 48 h after exposure to contrast medium. Results Complete data on the outcomes were available on 87 patients, 45 of whom had received NAC. There were no significant differences between the NAC and placebo groups in baseline characteristics, amount of hydration, or type and volume of contrast used, except in gender (male/female, 20/25 and 34/11, respectively; P = 0.005) and the use of statins (62.2% and 37.8%, respectively; P = 0.034). CIN occurred in 5 out of 45 (11.1%) patients in the NAC group and 6 out of 42 (14.3%) patients in the placebo group (P = 0.656). Conclusion There was no detectable benefit for the prophylactic administration of oral NAC over an aggressive hydration protocol in patients with DM and CKD. Trial registration NCT00808795
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Affiliation(s)
- Manouchehr Amini
- Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
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Pleguezuelo M, Marelli L, Misseri M, Germani G, Calvaruso V, Xiruochakis E, Manousou P, Burroughs AK. TACE versus TAE as therapy for hepatocellular carcinoma. Expert Rev Anticancer Ther 2009; 8:1623-41. [PMID: 18925854 DOI: 10.1586/14737140.8.10.1623] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, best anticancer agent and best technique are still unclear. TACE may not be better than transarterial embolization (TAE). HCC is very chemoresistant, thus embolization may be more important than chemotherapy. Lipiodol cannot be considered as an embolic agent and there are no data to show that it can release chemotherapeutic agents slowly. It can mask residual vascularity on CT imaging and its use is not recommended. Both TACE and TAE result in hypoxia, which stimulates angiogenesis, promoting tumor growth; thus combination of TACE with antiangiogenic agents may improve current results. To date, there is no evidence that TACE pre-liver transplantation or resection helps to expand current selection criteria for patients with HCC, nor results in less recurrence after surgery. Combination with other techniques, such as radiofrequency ablation and drugs, may enhance the effect of TACE. New trials are being conducted to clarify these issues.
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Affiliation(s)
- Maria Pleguezuelo
- Department of Surgery & Liver Transplantation, The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Hampstead Heath, London, UK.
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Preventing contrast-induced nephropathy in patients with baseline renal dysfunction undergoing coronary angiography. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2009; 11:71-8. [PMID: 19141263 DOI: 10.1007/s11936-009-0008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although contrast-induced nephropathy (CIN) is usually self-limited, it may cause permanent renal injury and even lead to long-term dialysis in patients with preexisting renal impairment. Cardiologists face a dilemma as to whether to alleviate coronary syndromes by coronary intervention or to risk CIN in these patients. Strategies to prevent CIN, including hydration, use of low-osmolal or iso-osmolal contrast media, administration of N-acetylcysteine, and blood purification procedures, were proposed to be effective; however, there are conflicting results. Recently, we found that prophylactic hemodialysis could significantly improve renal survival in patients with advanced renal insufficiency undergoing coronary angiography in a randomized controlled trial. In these patients, fluid supplementation is poorly tolerated and impractical, especially in those with poor heart function. However, the routine use of prophylactic hemodialysis in patients with mild renal insufficiency requires further investigation.
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Massicotte A. Contrast Medium–Induced Nephropathy: Strategies for Prevention. Pharmacotherapy 2008; 28:1140-50. [DOI: 10.1592/phco.28.9.1140] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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El-Hajjar M, Bashir I, Khan M, Min J, Torosoff M, DeLago A. Incidence of contrast-induced nephropathy in patients with chronic renal insufficiency undergoing multidetector computed tomographic angiography treated with preventive measures. Am J Cardiol 2008; 102:353-6. [PMID: 18638601 DOI: 10.1016/j.amjcard.2008.03.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2008] [Revised: 03/17/2008] [Accepted: 03/17/2008] [Indexed: 11/25/2022]
Abstract
Contrast-induced nephropathy (CIN) is associated with adverse outcomes. Strategies for its prevention have been evaluated for patients undergoing invasive coronary and peripheral angiography, including treatment with N-acetylcysteine, sodium bicarbonate, and use of iso-osmolar nonionic contrast. Recently, multidetector computed tomographic angiography (MDCTA) of the coronary and peripheral arteries has been introduced as an accurate method for assessing vascular stenosis and has been widely adopted for assessment of outpatients with suspected coronary artery disease or peripheral arterial disease. To date, the incidence of CIN in outpatients with chronic renal insufficiency (CRI) treated with CIN-preventive strategies undergoing MDCTA remains unknown. Thus, we evaluated the incidence of CIN in outpatients with CRI (creatinine 1.5 to 2.5 mg/dl) undergoing MDCTA using CIN-preventive measures; 400 patients with CRI (78.5% men, mean age 76 years, 41% with diabetes) underwent MDCTA with iodixanol for detection of coronary artery disease or peripheral arterial disease (mean contrast volume 101 cc). CIN was defined as a nonallergic creatinine increase of >0.5 mg/dl. Creatinine levels were obtained before and 3 to 5 days after MDCTA; the average creatinine levels were 1.80 mg/dl and 1.75 mg/dl, respectively (p = NS), with an average change of -0.03 mg/dl. In the study cohort, only 7 patients (1.75%) experienced a creatinine increase >0.5 mg/dl, satisfying the definition of CIN. In conclusion, multivariate analysis, diabetes was the only predictor for CIN (odds ratio 5.9, 95% confidence interval 1.0 to 33.3, p = 0.045). No patient required hemodialysis. In conclusion, in patients with CRI undergoing MDCTA and receiving CIN-preventive measures, the incidence of CIN is low.
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Mrkobrada M, Thiessen-Philbrook H, Haynes RB, Iansavichus AV, Rehman F, Garg AX. Need for quality improvement in renal systematic reviews. Clin J Am Soc Nephrol 2008; 3:1102-14. [PMID: 18400967 PMCID: PMC2440265 DOI: 10.2215/cjn.04401007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 02/11/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Systematic reviews of clinical studies aim to compile best available evidence for various diagnosis and treatment options. This study assessed the methodologic quality of all systematic reviews relevant to the practice of nephrology published in 2005. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched electronic databases (Medline, Embase, American College of Physicians Journal Club, Cochrane) and hand searched Cochrane renal group records. Clinical practice guidelines, case reports, narrative reviews, and pooled individual patient data meta-analyses were excluded. Methodologic quality was measured using a validated questionnaire (Overview Quality Assessment Questionnaire). For reviews of randomized trials, we also evaluated adherence to recommended reporting guidelines (Quality of Reporting of Meta-Analyses). RESULTS Ninety renal systematic reviews were published in year 2005, 60 of which focused on therapy. Many systematic reviews (54%) had major methodologic flaws. The most common review flaws were failure to assess the methodologic quality of included primary studies and failure to minimize bias in study inclusion. Only 2% of reviews of randomized trials fully adhered to reporting guidelines. A minority of journals (four of 48) endorsed adherence to consensus guidelines for review reporting, and these journals published systematic reviews of higher methodologic quality (P < 0.001). CONCLUSIONS The majority of systematic reviews had major methodologic flaws. The majority of journals do not endorse consensus guidelines for review reporting in their instructions to authors; however, journals that recommended such adherence published systemic reviews of higher methodologic quality.
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Affiliation(s)
- Marko Mrkobrada
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada
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Acute renal failure and outcome of children with solitary kidney undergoing cardiac surgery. Pediatr Cardiol 2008; 29:614-8. [PMID: 18084811 DOI: 10.1007/s00246-007-9172-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 10/20/2007] [Accepted: 11/18/2007] [Indexed: 10/22/2022]
Abstract
The aim of this study was to investigate the risk of acute renal failure (ARF), the need for renal replacement therapy, and the outcome of children with a solitary functioning kidney undergoing open heart surgery. The study was performed retrospectively on all children diagnosed with solitary functioning kidney and who required open heart surgery between January 2003 and January 2007. Demographic, perioperative renal function and intensive care course data were documented. Eight patients (six females) fulfilled the study criteria and were included in the study. Their median age and weight were 4.5 months and 3.6 kg, respectively. Their mean +/- standard deviation (SD) preoperative blood urea nitrogen (BUN) and creatinine levels were 3.7 +/- 1.6 mmol/L and 55 +/- 10 micromol/L, respectively. Postoperatively, the mean BUN and creatinine levels peaked on the first postoperative day to reach 7.8 +/- 2.6 mmol/L and 76 +/- 22 micromol/L, respectively, before starting to return to their preoperative values. Two out of eight patients (25%) developed ARF after surgery, but only one of them (12.5%) required renal replacement therapy. Open heart surgery on bypass can be performed safely for children with solitary functioning kidney with a good outcome. ARF requiring renal replacement therapy might occur temporarily after bypass surgery in a minority of cases.
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N-Acetylcysteine Use to Prevent Contrast Medium–induced Nephropathy: Premature Phase III Trials. J Vasc Interv Radiol 2008; 19:309-18. [DOI: 10.1016/j.jvir.2007.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 10/31/2007] [Accepted: 11/01/2007] [Indexed: 11/20/2022] Open
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Gonzales DA, Norsworthy KJ, Kern SJ, Banks S, Sieving PC, Star RA, Natanson C, Danner RL. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med 2007; 5:32. [PMID: 18001477 PMCID: PMC2200657 DOI: 10.1186/1741-7015-5-32] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 11/14/2007] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Meta-analyses of N-acetylcysteine (NAC) for preventing contrast-induced nephrotoxicity (CIN) have led to disparate conclusions. Here we examine and attempt to resolve the heterogeneity evident among these trials. METHODS Two reviewers independently extracted and graded the data. Limiting studies to randomized, controlled trials with adequate outcome data yielded 22 reports with 2746 patients. RESULTS Significant heterogeneity was detected among these trials (I2 = 37%; p = 0.04). Meta-regression analysis failed to identify significant sources of heterogeneity. A modified L'Abbé plot that substituted groupwise changes in serum creatinine for nephrotoxicity rates, followed by model-based, unsupervised clustering resolved trials into two distinct, significantly different (p < 0.0001) and homogeneous populations (I2 = 0 and p > 0.5, for both). Cluster 1 studies (n = 18; 2445 patients) showed no benefit (relative risk (RR) = 0.87; 95% confidence interval (CI) 0.68-1.12, p = 0.28), while cluster 2 studies (n = 4; 301 patients) indicated that NAC was highly beneficial (RR = 0.15; 95% CI 0.07-0.33, p < 0.0001). Benefit in cluster 2 was unexpectedly associated with NAC-induced decreases in creatinine from baseline (p = 0.07). Cluster 2 studies were relatively early, small and of lower quality compared with cluster 1 studies (p = 0.01 for the three factors combined). Dialysis use across all studies (five control, eight treatment; p = 0.42) did not suggest that NAC is beneficial. CONCLUSION This meta-analysis does not support the efficacy of NAC to prevent CIN.
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Affiliation(s)
- Denise A Gonzales
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kelly J Norsworthy
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Steven J Kern
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Steve Banks
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Pamela C Sieving
- National Institutes of Health Library, National Institutes of Health, Bethesda, MD, USA
| | - Robert A Star
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Fishbane S. N-acetylcysteine in the prevention of contrast-induced nephropathy. Clin J Am Soc Nephrol 2007; 3:281-7. [PMID: 18003766 DOI: 10.2215/cjn.02590607] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Contrast-induced nephropathy (CIN) is a common clinical problem that is growing in importance as an increasing number of tests and procedures that utilize contrast media are performed. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS The biological and pharmacological properties of n-acetylcysteine (NAC) are reviewed, as well as the current literature relevant to the ability of NAC to prevent CIN. RESULTS After publication of a seminal study by Tepel et al. in 2000, there has been a surge in interest regarding the ability of NAC to reduce the risk for CIN. Since then a large number of studies, mostly with relatively small sample sizes, have been published. CONCLUSIONS The results have been remarkably varied with some studies finding great efficacy with NAC but most finding no significant benefit.
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Abstract
Interventional radiological procedures involving anaesthesia are generally increasing. Contrast-induced nephropathy (CIN), usually defined as an increase in serum creatinine of 44 micromol litre(-1) (0.5 mg dl(-1)) or a 25% increase from the baseline value 48 h after intravascular injection of contrast media, is a common and potentially serious complication of the use of iodinated contrast media in patients at risk of acute renal injury. It is an important cause of hospital-acquired renal failure, may be a difficult differential diagnosis and the incidence does not appear to have changed over the last few decades. In the general population, the incidence of CIN is estimated to be 1-2%. However, the risk for developing CIN may be as high as 50% in some patient subgroups, such as those with diabetes mellitus and pre-existing renal impairment. The impact of CIN on clinical outcomes has been evaluated most extensively in patients undergoing percutaneous coronary intervention where it is associated with increased mortality both in hospital and at 1 yr. As treatment is limited to supportive measures while awaiting the resolution of the renal impairment, emphasis needs to be directed at prevention.
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Affiliation(s)
- G T C Wong
- Department of Anaesthesiology, The University of Hong Kong, Room 424, Block K, Queen Mary Hospital, Pokfulam Road, Hong Kong
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Sayin T, Turhan S, Akyürek O, Kilickap M. Gadolinium:nonionic contrast media (1:1) coronary angiography in patients with impaired renal function. Angiology 2007; 58:561-4. [PMID: 17906283 DOI: 10.1177/0003319707303640] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was to test safety and efficacy of 1:1 mixture of gadolinium:nonionic contrast media in avoiding contrast nephropathy during coronary angiography in patients with renal dysfunction. Although "off label" for x-ray angiography, gadolinium has drawn attention for its potential to avoid contrast nephropathy during coronary angiography. Initial data seem promising. Patients with a baseline creatinine of 1.5 mg/dl or more were included. In order to minimize contrast nephropathy risk, all patients were thoroughly hydrated and treated by N-acetylcysteine. After coronary angiography and/or percutaneous coronary intervention, renal function tests were remeasured on days 1, 2, and 3. A rise of 0.5 mg/dl or more in creatinine value in the following 3 days or the need for dialysis were considered as a contrast nephropathy event. Twenty-six patients were enrolled in this study. Ten were women and 16 were men. The mean age was 65.7 +/- 11. Baseline creatinine value was 2.47 +/- 0.74 mg/dl. The total amount of contrast medium used on 1:1 fashion was 57.1 +/- 27.2 ml. No procedure-related cardiac complication or contrast nephropathy event occurred in this study. Although there was a slight loss in image quality, we felt that the results were adequate for interpretation. Although "off label," using gadolinium contrast media in a 1:1 mixture with standard nonionic low osmolar contrast media seems to be a viable option in decreasing the likelihood of contrast nephropathy. Further evaluation appears to be warranted.
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Affiliation(s)
- Tamer Sayin
- Ankara University Department of Cardiology, Heart Center, Turkey.
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Van Praet JT, De Vriese AS. Prevention of contrast-induced nephropathy: a critical review. Curr Opin Nephrol Hypertens 2007; 16:336-47. [PMID: 17565276 DOI: 10.1097/mnh.0b013e3281ca6fe5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although contrast-induced nephropathy (CIN) is common and portends a significant morbidity and mortality, only few large and well designed trials have assessed the available prophylactic measures and there are no clear evidence-based guidelines that can easily be adopted by the clinician. We critically discuss the evidence for periprocedural hydration, pharmacological agents, periprocedural withdrawal of medication, application of renal replacement therapy and the use of contrast media. RECENT FINDINGS Pending confirmation of the superiority of sodium bicarbonate, NaCl 0.9% remains the fluid of choice for periprocedural hydration. A recent trial found a dose-dependent beneficial effect of acetylcysteine on CIN and mortality, adding to the controversy on the prophylactic use of this agent. Publication bias of acetylcysteine trials may have confounded the results of the meta-analyses, since negative results were more likely to be published as an abstract only. Periprocedural haemofiltration protected against CIN in a high-risk population, but the results require confirmation before the technique can be recommended. SUMMARY Pending randomized controlled trials with rigorous scientific design, we propose practical mixed evidence-based and opinion-based guidelines for the prevention of CIN, using a stratification of patients into three risk groups, based on their renal function and a risk-prediction model.
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Affiliation(s)
- Jens T Van Praet
- Department of Internal Medicine, University of Gent, Gent, Belgium
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Yen HW, Lee HC, Lai WT, Sheu SH. Effects of Acetylcysteine and Probucol on Contrast Medium-induced Depression of Intrinsic Renal Glutathione Peroxidase Activity in Diabetic Rats. Arch Med Res 2007; 38:291-6. [PMID: 17350478 DOI: 10.1016/j.arcmed.2006.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 11/10/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Antioxidants such as N-acetylcysteine and probucol have been used to protect patients from contrast media-induced nephrotoxicity. The mechanisms underlying these protective effects are not well understood. We hypothesized that acetylcysteine and probucol alter the activity of endogenous antioxidant enzyme activity. METHODS Four weeks after induction of diabetes with streptozotocin, diabetic and nondiabetic rats were divided into three groups. Group 1 rats did not receive any antioxidant agents. Group 2 rats were treated with acetylcysteine and group 3 rats with probucol for 1 week before injection of the contrast medium diatrizoate (DTZ). RESULTS We found that diabetic rats had higher renal glutathione peroxidase (GPx) activity than normal rats. DTZ suppressed renal GPx activity significantly in both group 1 diabetic and normal rats. Interestingly, renal GPx activity in both diabetic and normal rats pretreated with acetylcysteine or probucol was not inhibited by DTZ. Renal superoxide dismutase (SOD) increased significantly in normal rats after DTZ injection, but not in diabetic rats. Finally, acetylcysteine or probucol did not significantly influence renal SOD. CONCLUSIONS These findings suggest that the renal protective effects of acetylcysteine and probucol against contrast-induced oxidative stress and nephrotoxicity may be mediated by altering endogenous GPx activity.
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Affiliation(s)
- Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University, Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
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