Ning Tan

Contrast medium volume to creatinine clearance ratio: a predictor of contrast-induced nephropathy in the first 72 hours following percutaneous coronary intervention.

Objectives: To investigate the predictive value of the contrast media volume to creatinine clearance (V/CrCl) ratio for the risk of contrast‐induced nephropathy (CIN) (i.e., within 48–72 hr) and to determine a relatively safe V/CrCl cut‐off value to avoid CIN in patients following percutaneous coronary intervention (PCI). Background: The V/CrCl ratio is a pharmacokinetic risk factor for an early abnormal increase in serum creatinine (i.e., within 24 hr) after PCI. Methods: V/CrCl ratios were obtained from 1,140 consecutive consenting patients after unselective PCI. Receiver‐operator characteristic (ROC) curves were used to identify the optimal sensitivity for the observed range of V/CrCl. The predictive value of V/CrCl for the risk of CIN was assessed using multivariate logistic regression. Results: Fifty‐five (4.8%) patients out of 1,140 developed CIN. There was a significant association between higher V/CrCl ratio values and risk of CIN in the overall population: 1.4%, 1.4%, 5.7%, and 10.9% for quartile 1 (Q1) of the V/CrCl value (<1.56, n = 283), Q2 (1.56–2.27, n = 289), Q3 (2.28–3.42, n = 282), and Q4 (>3.42, n = 285) of contrast, respectively (P < 0.001). ROC curve analysis indicated that a V/CrCl ratio of 2.62 was a fair discriminator for CIN (C‐statistic 0.73). After adjusting for other known predictors of CIN, V/CrCl ratios > 2.62 remained significantly associated with CIN (odds ratio: 2.20; 95% confidence interval: 1.00–4.81, P < 0.05). Conclusion: A V/CrCl ratio > 2.62 was a significant and independent predictor of CIN after PCI in unselected patients.

The contrast medium volume to estimated glomerular filtration rate ratio as a predictor of contrast-induced nephropathy after primary percutaneous coronary intervention

BackgroundContrast-induced nephropathy (CIN) is a serious complication in percutaneous coronary intervention (PCI) patients, which may be related to the contrast dose used during cardiac catheterization.MethodsWe prospectively investigated 277 consecutive consenting patients with acute ST-segment elevation myocardial infarction (STEMI) who were given primary PCI, and we calculated their ratio of volume of contrast media to estimated glomerular filtration rate (V/eGFR). Receiver–operator characteristic methods were used to identify the optimal sensitivity for the observed range of V/eGFR for CIN (i.e., within 48–72xa0h). The predictive value of V/eGFR for the risk of CIN was assessed using multivariable logistic regression.ResultsTwenty-five (9%) patients developed CIN. The baseline mean and median V/eGFR values were significantly greater among patients with CIN (mean 3.22xa0±xa01.53, median 2.97, and interquartile range 1.90–4.17) than among those without CIN (mean 1.80xa0±xa01.00, median 1.52, and interquartile range 1.12–2.21, Pxa0<xa00.001). The receiver–operator characteristic curve analysis indicated that a V/eGFR ratio of 2.39 was a fair discriminator for CIN (C statistic 0.81). After adjusting for other known predictors of CIN, a V/eGFR ratioxa0≥xa02.39 remained significantly associated with CIN (odds ratio 4.24, 95% confidence interval 1.23–14.66, Pxa0<xa00.05).ConclusionA V/eGFR ratioxa0≥xa02.39 was a significant and independent predictor of CIN after primary PCI in patients with STEMI.

Use of the contrast volume or grams of iodine–to–creatinine clearance ratio to predict mortality after percutaneous coronary intervention

BACKGROUNDnFew studies have assessed the predictive value of the ratio of the contrast media volume or grams of iodine to the creatinine clearance (V/CrCl or g-I/CrCl, respectively) for the risk of contrast-induced nephropathy (CIN) and mortality after percutaneous coronary intervention (PCI).nnnMETHODSnThe association between V/CrCl and mortality was prospectively evaluated in 1,135 consecutive patients undergoing PCI. Cox regression models were used to adjust for the V/CrCl ratio and other confounding factors for risk of death within 1 year.nnnRESULTSnFifty-five patients (4.84%) developed CIN. The 1-year mortality was higher in patients with a V/CrCl ratio >2.62 (g-I/CrCl >0.97) than in others (4.44% vs 0.40%; P < .001). After adjusting for other risk factors, the 1-year mortality risk remained associated with increased V/CrCl ratio. The risk of death was significant for V/CrCl >2.62 (adjusted risk ratio [RR] for death 2.605, 95% CI 1.040-6.529, P = .041), V/CrCl >3.0 (g-I/CrCl >1.11) (adjusted RR 4.338, 95% CI 1.689-11.142, P = .002), and V/CrCl >3.7 (g-I/CrCl >1.37) (adjusted RR 2.557, 95% CI 1.162-5.627, P = .002).nnnCONCLUSIONnThe data further support the prognostic significance of calculating the V/CrCl ratio to predict the relative maximum contrast volume during PCI. Use of a contrast dose determined based on the estimated renal function with a planned V/CrCl ratio <3.7 (g-I/CrCl <1.37) and preferably <2.62 (g-I/CrCl <0.97) might be valuable in reducing the risks of CIN and even death after PCI.

The relationship between hyperuricemia and the risk of contrast-induced acute kidney injury after percutaneous coronary intervention in patients with relatively normal serum creatinine

OBJECTIVES: Hyperuricemia is a risk factor for contrast-induced acute kidney injury in patients with chronic kidney disease. This study evaluated the value of hyperuricemia for predicting the risk of contrast-induced acute kidney injury in patients with relatively normal serum creatinine who were undergoing percutaneous coronary interventions. METHODS AND RESULTS: A total of 788 patients with relatively normal baseline serum creatinine (<1.5 mg/dL) undergoing percutaneous coronary intervention were prospectively enrolled and divided into a hyperuricemic group (nu200a=u200a211) and a normouricemic group (nu200a=u200a577). Hyperuricemia is defined as a serum uric acid level>7 mg/dL in males and >6 mg/dL in females. The incidence of contrast-induced acute kidney injury was significantly higher in the hyperuricemic group than in the normouricemic group (8.1% vs. 1.4%, p<0.001). In-hospital mortality and the need for renal replacement therapy were significantly higher in the hyperuricemic group. According to a multivariate analysis (adjusting for potential confounding factors) the odds ratio for contrast-induced acute kidney injury in the hyperuricemic group was 5.38 (95% confidence interval, 1.99-14.58; pu200a=u200a0.001) compared with the normouricemic group. The other risk factors for contrast-induced acute kidney injury included age >75 years, emergent percutaneous coronary intervention, diuretic usage and the need for an intra-aortic balloon pump. CONCLUSION: Hyperuricemia was significantly associated with the risk of contrast-induced acute kidney injury in patients with relatively normal serum creatinine after percutaneous coronary interventions. This observation will help to generate hypotheses for further prospective trials examining the effect of uric acid-lowering therapies for preventing contrast-induced acute kidney injury.

Comparison of combination therapy of high-dose oral N-acetylcysteine and intravenous sodium bicarbonate hydration with individual therapies in the reduction of Contrast-induced Nephropathy during Cardiac Catheterisation and Percutaneous Coronary Intervention (CONTRAST): A multi-centre, randomised, controlled trial.

INTRODUCTIONnN-acetylcysteine (NAC) and sodium bicarbonate (SOB) therapies may prevent contrast-induced nephropathy (CIN). However, the efficacy of using combination over individual therapies was not established, and there was no large randomised study comparing abbreviated SOB therapy with conventional sustained saline pre-hydration with oral NAC.nnnMETHODSnIn a multi-centre, open-label, randomised, controlled trial (NCT00497328), we prospectively enrolled 548 patients with at least moderate renal impairment undergoing cardiac catheterisation with or without percutaneous coronary intervention. Patients were randomly assigned to 3 groups: 1) NAC: 154 mEq/L sustained sodium chloride regime (1 mL/kg/h 12 h before, during and 6h after the procedure) with oral NAC at 1.2g bid for 3 days (n=185); 2) SOB: 154 mEq/L abbreviated SOB regime at 3 mL/kg/h 1h before the procedure, and 1 mL/kg/h during and 6h after the procedure (n=182); and 3) COM: combination of abbreviated SOB regime and oral NAC (n=181). The primary end point was incidence of CIN. The secondary end points were rise in serum creatinine, hospitalisation duration, haemodialysis, morbidity and mortality within 30 days.nnnRESULTSnThe 3 groups had similar baseline characteristics: age 68 ± 10 years, 76% male, 48% diabetic and baseline glomerular filtration rate (GFR) 47.7 ± 13.0 mL/min. There were 41 (8.8%) patients with GFR<30. The CIN incidences were NAC 6.5%, SOB 12.8% and COM 10.6%. The COM regimen was not superior to either the NAC (relative risk (RR)=1.61, 95% confidence interval (CI): 0.76 to 3.45, p=0.225) or SOB (RR=0.83, 95% CI: 0.44 to 1.56, p=0.593) regimens. The CIN incidence was lower in the NAC group than the SOB group (adjusted odds ratio (OR)=0.40, 95% CI: 0.17 to 0.92; p=0.032). Multivariate analysis showed contrast volume (OR=1.99, 95% CI: 1.33 to 2.96, p<0.001 per 100mL), female (OR=2.47, 95% CI: 1.22 to 5.00, p=0.012) and diabetes (OR=2.03, 95% CI: 1.03 to 3.99, p=0.041) were independent risk predictors. There were no differences in the secondary outcomes among the 3 groups.nnnCONCLUSIONnThe combination regimen was not superior to individual regimens in preventing CIN in patients with baseline renal impairment. There was a trend suggesting that the 12-hour sustained sodium chloride pre-hydration regimen was more protective than the 1-hour abbreviated SOB regimen.

A novel risk score model for prediction of contrast-induced nephropathy after emergent percutaneous coronary intervention.

BACKGROUNDnA few studies developed simple risk model for predicting CIN with poor prognosis after emergent PCI. The study aimed to develop and validate a novel tool for predicting the risk of contrast-induced nephropathy (CIN) in patients undergoing emergent percutaneous coronary intervention (PCI).nnnMETHODSn692 consecutive patients undergoing emergent PCI between January 2010 and December 2013 were randomly (2:1) assigned to a development dataset (n=461) and a validation dataset (n=231). Multivariate logistic regression was applied to identify independent predictors of CIN, and established CIN predicting model, whose prognostic accuracy was assessed using the c-statistic for discrimination and the Hosmere Lemeshow test for calibration.nnnRESULTSnThe overall incidence of CIN was 55(7.9%). A total of 11 variables were analyzed, including age >75years old, baseline serum creatinine (SCr)>1.5mg/dl, hypotension and the use of intra-aortic balloon pump(IABP), which were identified to enter risk score model (Chen). The incidence of CIN was 32(6.9%) in the development dataset (in low risk (score=0), 1.0%, moderate risk (score:1-2), 13.4%, high risk (score≥3), 90.0%). Compared to the classical Mehrans and ACEF CIN risk score models, the risk score (Chen) across the subgroup of the study population exhibited similar discrimination and predictive ability on CIN (c-statistic:0.828, 0.776, 0.853, respectively), in-hospital mortality, 2, 3-years mortality (c-statistic:0.738.0.750, 0.845, respectively) in the validation population.nnnCONCLUSIONSnOur data showed that this simple risk model exhibited good discrimination and predictive ability on CIN, similar to Mehrans and ACEF score, and even on long-term mortality after emergent PCI.

LDL cholesterol as a novel risk factor for contrast-induced acute kidney injury in patients undergoing percutaneous coronary intervention

BACKGROUNDnLow density lipoprotein cholesterol (LDL-C) is associated with endothelial dysfunction, inflammation and increased vasoconstriction, which are involved in the development of contrast-induced acute kidney injury (CI-AKI). However, whether LDL-C is an independent risk factor of CI-AKI in patients undergoing percutaneous coronary intervention (PCI) is unknown.nnnMETHODSnWe prospectively enrolled 3236 consecutive patients undergoing PCI between January 2010 and September 2012. Multivariate logistic regression analysis was used to determine whether LDL-C is an independent risk factor of CI-AKI. CI-AKI was defined as an absolute increase in serum creatinine of ≥ 0.5 mg/dL or ≥ 25% over the baseline value within 48-72 h after contrast exposure.nnnRESULTSnCI-AKI was observed in 338 patients (10.4%). Patients with CI-AKI had a significantly higher rate of in hospital mortality (4.4% vs. 0.5%, p < 0.001), and significantly higher rates of other in hospital complications compared with those without CI-AKI. The LDL-C quartiles were as follows: Q1 (<2.04 mmol/L), Q2 (2.04-2.61 mmol/L), Q3 (2.61-3.21 mmol/L) and Q4 (>3.21 mmol/L). Patients with high baseline LDL-C levels were more likely to develop CI-AKI and composite end points including all-cause mortality, renal replacement therapy, non-fatal myocardial infarction, acute heart failure, target vessel revascularization or cerebrovascular accident during the observation period of hospitalization (8.9%, 9.9%, 10.5%, 12.6%, p = 0.001, and 5.0%, 5.2%, 6.1%, 8.1%, respectively; p = 0.007). Univariate logistic analysis showed that LDL-C levels (increment 1 mmol/L) were significantly associated with CI-AKI (odds ratio = 1.25, 95% confidence interval (CI), 1.11-1.39, p < 0.001). Furthermore, LDL-C remained a significant risk factor of CI-AKI (odds ratio = 1.23, 95% CI, 1.04-1.45, p = 0.014), even after adjusting for potential confounding risk factors.nnnCONCLUSIONSnMeasurement of plasma LDL-C concentrations in patients undergoing PCI may be helpful to identify those who are at risk of CI-AKI and poor in hospital outcomes.

Association of left ventricular ejection fraction with contrast-induced nephropathy and mortality following coronary angiography or intervention in patients with heart failure.

Background Left ventricular ejection fraction (LVEF) is the most widely used parameter to evaluate the cardiac function in patients with heart failure (HF). However, the association between LVEF and contrast-induced nephropathy (CIN) is still controversial. Therefore, the aim of this study is to evaluate the association of LVEF with CIN and long-term mortality following coronary angiography (CAG) or intervention in patients with HF. Methods We analyzed 1,647 patients with HF (New York Heart Association [NYHA] or Killip class >1) undergoing CAG or intervention, including 207 (12.57%) patients with reduced LVEF (HFrEF), 238 (14.45%) with mid-range LVEF (HFmrEF) and 1,202 (72.98%) with preserved LVEF (HFpEF). CIN was defined as an absolute increase of ≥0.5 mg/dL or a relative increase of ≥25% from baseline serum creatinine within 48–72 h after contrast medium exposure. Multivariable logistic regression and Cox proportional hazards regression analyses were performed to identify the association between LVEF, CIN and long-term mortality, respectively. Results Overall, 225 patients (13.7%) developed CIN. Individuals with lower LVEF were more likely to develop CIN (HFrEF, HFmrEF and HFpEF: 18.4%, 21.8% and 11.2%, respectively; P<0.001), but without a significant trend after adjusting for the confounding factors (HFrEF vs HFpEF: odds ratio [OR] =1.01; HFmrEF vs HFpEF: OR =1.31; all P>0.05). However, advanced HF (NYHA class >2 or Killip class >1) was an independent predictor of CIN (adjusted OR =1.54, 95% confidence interval [CI], 1.07–2.22; P=0.019). During the mean follow-up of 2.3 years, reduced LVEF (HFrEF group) was significantly associated with increased mortality (HFrEF vs HFpEF: adjusted hazard ratio =2.88, 95% CI, 1.77–4.69; P<0.001). Conclusion In patients with HF undergoing CAG or intervention, not worsened LVEF but advanced HF was associated with an increased risk of CIN. In addition, reduced LVEF was an independent predictor of long-term mortality following cardiac catheterization.

Does N-terminal pro-brain natriuretic peptide add prognostic value to the Mehran risk score for contrast-induced nephropathy and long-term outcomes after primary percutaneous coronary intervention?

AbstractPurposenTo evaluate the prognostic value of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in relation to Mehran risk score (MRS) for contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).MethodsnWe prospectively enrolled 283 consecutive patients treated with PPCI for STEMI. NT-proBNP was measured, and the MRS was calculated. The primary end point was CIN, defined as an absolute increase in serum creatinine ≥0.5xa0mg/dL from baseline within 48–72xa0h after contrast medium exposure.ResultsThe incidence of CIN was 9.2xa0%. Patients with CIN had higher NT-proBNP and MRS than those without CIN. The value of NT-proBNP was similar to MRS for CIN (C statistics 0.760 vs. 0.793, pxa0=xa00.689). After adjustment for MRS, elevated NT-proBNP (defined as the best cutoff point) was significantly associated with CIN. The addition of elevated NT-proBNP to MRS did not significantly improve the C statistics, over that with the original MRS model (0.833 vs. 0.793, pxa0=xa00.256). In addition, similar results were observed for in-hospital and long-term major adverse clinical events.ConclusionsnAlthough NT-proBNP did not add any prognostic value to the MRS model for CIN, NT-proBNP, as a simple biomarker, was similar to MRS, and may be another useful and rapid screening tool for CIN and death risk assessment, identifying subjects who need therapeutic measures to prevent CIN.

Safe Hydration Volume to Prevent Contrast-induced Acute Kidney Injury and Worsening Heart Failure in Patients With Heart Failure and Preserved Ejection Fraction After Cardiac Catheterization

Abstract: Few studies have investigated the efficacy and safety of hydration to prevent contrast-induced acute kidney injury (CI-AKI) and worsening heart failure (WHF) after cardiac catheterization in heart failure and preserved ejection fraction (HFpEF; HF and EF ≥50%) patients. We recruited 1206 patients with HFpEF undergoing cardiac catheterization with periprocedural hydration volume/weight (HV/W) ratio data and investigated the relationship between hydration volumes and risk of CI-AKI and WHF. Incidence of CI-AKI was not significantly reduced in individuals with higher HV/W [quartile (Q) 1, Q2, Q3, and Q4: 9.7%, 10.2%, 12.7%, and 12.2%, respectively; P = 0.219]. Multivariate analysis indicated that higher HV/W ratios were not associated with decreased CI-AKI risks [Q2 vs. Q1: odds ratio (OR), 0.95; Q3 vs. Q1: OR, 1.07; Q4 vs. Q1: OR, 0.92; all P > 0.05]. According to multivariate analysis, higher HV/W significantly increased the WHF risk (Q4 vs. Q1: adjusted OR, 8.13 and 95% confidence interval, 1.03–64.02; P = 0.047). CI-AKI and WHF were associated with a significantly increased risk of long-term mortality (mean follow-up, 2.33 years). For HFpEF patients, an excessively high hydration volume might not be associated with lower risk of CI-AKI but may increase the risk of postprocedure WHF.