Judith Kooiman

Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis

Our aim was to study the safety of outpatient treatment in low risk patients with acute pulmonary embolism compared with inpatient treatment, the current clinical standard. We searched Medline, Web of Science, Cochrane and EMBASE databases and included studies on outpatient treatment of pulmonary embolism. The outcomes were 3-month recurrent venous thromboembolism, major bleeding and all-cause mortality. We identified 13 studies (1657 patients) with outpatients (discharge <24 h), three studies (256 patients) with early discharge patients (discharged within 72 h) and five studies (383 patients) with inpatients. The pooled incidence of recurrent venous thromboembolism was 1.7% (95% CI 0.92–3.1%) in outpatients, 1.1% (0.22–5.4%) in patients discharged early and 1.2% (0.16–8.1%) in inpatients. The pooled incidence of major bleeding was 0.97% (0.58–1.6%) in outpatients, 0.78% (0.16–3.7%) in early discharge patients and 1.0% (0.39–2.8%) in inpatients. The pooled incidence of mortality was 1.9% (0.79–4.6%) in outpatients, 2.3% (1.1–5.1%) in early discharge patients and 0.74% (0.04–11%) in inpatients. Incidences of recurrent venous thromboembolism, major bleeding and, after correction for malignancies, mortality were comparable between outpatients, patients discharged early and inpatients. We conclude that home treatment or early discharge of selected low-risk patients with pulmonary embolism is as safe as inpatient treatment.

Meta-analysis: Serum creatinine changes following contrast enhanced CT imaging

PURPOSE Contrast induced nephropathy (CIN) is defined as a decrease in renal function following administration of contrast media. The aim of this meta-analysis was to asses the overall risk of CIN, chronic loss of kidney function and the need for renal replacement therapy (RRT) after intravenous contrast enhanced CT-scan. Secondly, we aimed to identify subgroups at increased risk for CIN. MATERIALS AND METHODS A literature search in Pubmed, Medline, Embase and Cochrane databases was performed. Data extraction was carried out independently by two reviewers. Meta-analysis and meta-regression were performed using an exact likelihood approach. RESULTS Forty studies evaluating the incidence of CIN after CT were included. The pooled incidence of CIN was 6.4% (95% CI 5.0-8.1). The risk of RRT after CIN was low, 0.06% (95% CI 0.01-0.4). The decline in renal function persisted in 1.1% of patients (95% CI 0.6-2.1%). Patients with chronic kidney disease (odds ratio 2.26, p<0.001) or diabetes mellitus (odds ratio 3.10, p<0.001) were at increased risk for the development of CIN. CONCLUSION CIN occurred in 6% of patients after contrast enhanced CT. In 1% of all patients undergoing contrast enhanced CT the decline in renal function persisted.

Incidence and predictors of contrast-induced nephropathy following CT-angiography for clinically suspected acute pulmonary embolism

1 Buller HR, Cohen AT, Davidson B, Decousus H, Gallus AS, Gent M, Pillion G, Piovella F, Prins MH, Raskob GE. Idraparinux versus standard therapy for venous thromboembolic disease. N Engl J Med 2007; 357: 1094–104. 2 Belle VA, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295: 172–9. 3 Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann O, Nonent M, Cornuz J, Thys F, Le Manach CP, Revel MP, Poletti PA, Meyer G, Mottier D, Perneger T, Bounameaux H, Perrier A. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet 2008; 371: 1343–52. 4 Douketis JD, Gu CS, Schulman S, Ghirarduzzi A, Pengo V, Prandoni P. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med 2007; 147: 766–74. 5 Vartak S, Ward MM, Vaughn TE. Do postoperative complications vary by hospital teaching status? Med Care 2008; 46: 25–32. 6 Hyers TM, Agnelli G, Hull RD, Morris TA, Samama M, Tapson V, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest 2001; 119: 176S–93S. 7 Nijkeuter M, Sohne M, Tick LW, Kamphuisen PW, Kramer MH, Laterveer L, van Houten AA, Kruip MJ, Leebeek FW, Buller HR, Huisman MV. The natural course of hemodynamically stable pulmonary embolism: clinical outcome and risk factors in a large prospective cohort study. Chest 2007; 131: 517–23. 8 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386–9. 9 Prandoni P, LensingAW, Piciolli A, Bernardi E, Simioni P, Girolami B, Marchiori A, Sabbion P, PrinsMH,Noventa F, Girolami A. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.Blood 2002; 100: 3484–8.

Contrast-induced acute kidney injury and clinical outcomes after intra-arterial and intravenous contrast administration: risk comparison adjusted for patient characteristics by design.

BACKGROUND Direct comparisons between risk of contrast induced acute kidney injury (CI-AKI) after intra-arterial versus intravenous contrast administration are scarce. We estimated and compared the risk of CI-AKI and its clinical course after both modes of contrast administration in patients who underwent both. METHODS One hundred seventy patients who received both intra-arterial and intravenous contrast injections within one year between 2001 and 2010 were included. Primary outcome was occurrence of CI-AKI. Secondary outcomes were duration of hospital stay, the need for dialysis, recovery of renal function, and mortality. RESULTS The risk of CI-AKI was 24/170 (14.0%, 95% CI 9.6-20.2) after intra-arterial contrast injection versus 20/170 (11.7%, 95% CI 7.7-17.5) after intravenous contrast administration, which led to a relative risk of 1.2 (95% CI 0.7-2.1). None of the patients had a need for dialysis. Median duration of hospital stay in CI-AKI patients was 15.0 days (2.5-97.5, percentile 1-92) after intra-arterial and 15.5 days (2.5-97.5, percentile 0-38) after intravenous contrast procedures. Renal function recovered after CI-AKI in 13/24 after intra-arterial and in 10/20 patients after intravenous contrast administration. Mortality risks in CI-AKI patients were slightly higher than in non-CI-AKI patients, hazard ratios 1.6 (95% CI 0.7-3.7) for intra-arterial and 1.7 (95% CI 0.7-4.4) for intravenous contrast administration, adjusted for confounders. CONCLUSION The risk of CI-AKI, and its clinical course was similar after intra-arterial and intravenous contrast media administration, after adjustment by design for patient-related risk factors.

Randomized trial of one-hour sodium bicarbonate vs standard periprocedural saline hydration in chronic kidney disease patients undergoing cardiovascular contrast procedures

Background Guidelines advise periprocedural saline hydration for prevention of contrast induced-acute kidney injury (CI-AKI). We analysed whether 1-hour sodium bicarbonate hydration administered solely prior to intra-arterial contrast exposure is non-inferior to standard periprocedural saline hydration in chronic kidney disease (CKD) patients undergoing elective cardiovascular diagnostic or interventional contrast procedures. Methods We performed an open-label multicentre non-inferiority trial between 2011–2014. Patients were randomized to 1 hour pre-procedure sodium bicarbonate hydration (250 ml 1.4%, N = 168) or 4–12 hours saline hydration (1000 ml 0.9%, N = 165) prior to and following contrast administration (2000 ml of saline total). Primary outcome was the relative serum creatinine increase (%) 48–96 hours post contrast exposure. Secondary outcomes were: incidence of CI-AKI (serum creatinine increase>25% or >44μmol/L), recovery of renal function, the need for dialysis, and hospital costs within two months follow-up. Results Mean relative creatinine increase was 3.1% (95%CI 0.9 to 5.2%) in the bicarbonate and 1.1% (95%CI -1.2 to 3.5%) in the saline arm, mean difference 1.9% (95%CI -1.2 to 5.1%, p-non-inferiority <0.001). CI-AKI occurred in 11 (6.7%) patients randomized to sodium bicarbonate and 12 (7.5%) to saline (p = 0.79). Renal function did not fully recover in 40.0% and 44.4% of CI-AKI patients, respectively (p = 0.84). No patient required dialysis. Mean costs for preventive hydration and clinical preparation for the contrast procedure were

Pharmacokinetics and Pharmacodynamics of Dabigatran 75 mg b.i.d. in Patients With Severe Chronic Kidney Disease.

1158 for sodium bicarbonate vs.

Abstract 15644: Does Radial Access Reduce the Risk of Contrast Induced Nephropathy in Patients undergoing Percutaneous Coronary Interventions: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

1561 for saline (p < 0.001). Conclusion Short hydration with sodium bicarbonate prior to elective cardiovascular diagnostic or therapeutic contrast procedures is non-inferior to standard periprocedural saline hydration in CKD patients with respect to renal safety and results in considerable healthcare savings. Trial registration Netherlands Trial Register (http://www.trialregister.nl/trialreg/index.asp), Nr NTR2699