Acute Kidney Injury – ABC CARDIOL

ABC

Original Article

Ultra-Low Contrast versus Conventional Percutaneous Coronary Intervention for Patients with Baseline Renal Impairment: A Systematic Review and Meta-Analysis of Clinical Outcomes

Marcos Danillo Oliveira et al. Ricardo Fonseca Oliveira Suruagy-Motta Leonardo Dexheimer da Silva Karlos Daniell Araújo dos Santos Adriano Caixeta

Abstract

Background

Contrast-associated acute kidney injury (CA-AKI) results in increased morbidity and mortality, prolonged hospitalization, and worse clinical outcomes. Prior studies have shown that limiting contrast volume (CV) to less than 3 times the estimated glomerular filtration rate (eGFR) implies a lower risk of CA-AKI, and both efficacy and superior outcomes are associated with ultra-low contrast (ULC) volume coronary procedures (total CV ≤ eGFR).

Objectives

This systematic review and meta-analysis aimed to compare clinical outcomes of ULC versus conventional percutaneous coronary intervention (PCI) in patients with chronic kidney disease.

Methods

The search was conducted in the databases PubMed/MEDLINE, Cochrane, Embase, Scopus, and Web of Science, including all studies reporting clinical outcomes of ULC PCI. The primary efficacy endpoint was the incidence of CA-AKI, and secondary endpoints were need for dialysis, all-cause mortality, and major adverse cardiovascular events (MACE), defined as the composite endpoint of all-cause mortality, non-fatal myocardial infarction, and clinically driven target lesion revascularization.

Results

Six studies met the inclusion criteria and were included in the final analysis, encompassing a total of 274,102 patients. ULC PCI was associated with a statistically significant reduction of CA-AKI (risk ratio=0.27; 95% CI=0.13–0.56; p=0.0004). In turn, ULC PCI did not result in statistically significant reduction of need for dialysis (risk ratio=0.33; 95% CI=0.06–1.72; p=0.186), all-cause mortality (risk ratio=0.48; 95% CI=0.17–1.39; p=0.18), and MACE (risk ratio=0.52; 95% CI= 0.21–1.30; p=0.16).

Conclusions

ULC, as compared to conventional PCI, in patients with chronic kidney disease, was found to be safe, feasible, and associated with a statistically significant reduction of CA-AKI. Further, larger, well-powered, randomized, and controlled trials are warranted in order to reassure these findings.

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Letter to the Editor

Volume-Independent Renal Injury: Why Contrast-Induced Nephropathy Can Occur Even at Ultra-Low Contrast Doses

Fahri Çakan

Dear Editor,

I reviewed with great interest the article titled “Impact of Contrast Volume Used After Percutaneous Coronary Procedures in Patients at Risk for Contrast-Induced Nephropathy,” authored by Freitas et al. This post-hoc subgroup analysis, designed to assess contrast-induced nephropathy (CIN) risk management, provides clinically valuable data on the interaction between contrast type and volume, particularly in high-risk patient populations (n=2,268).

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ABC

Original Article

Association between Glucose/lymphocytes Ratio and Contrast-Induced Acute Kidney Injury in Patients with Myocardial Infarction without Diabetes Mellitus

Murat Gök et al. Alparslan Kurtul Orçun Demir Kenan Yalta

Abstract

Background

Glucose metabolism and systemic inflammation appears to be strongly related to many cardiovascular diseases. Glucose to lymphocyte ratio (GLR), a novel promising marker, has been recognized as a reliable predictor of prognosis in various cancers. However, there are still no studies on the association of cardiovascular disease with GLR.

Objectives

This analysis aimed to uncover the potential association between GLR and the risk for contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention (PPCI) in a ST-elevation acute myocardial infarction (STEMI) population.

Methods

Clinical data of 592 nondiabetic STEMI patients managed with PPCI from February 2021 to February 2023 were retrospectively analyzed. Patients with end-stage kidney disease, missing laboratory data, cancers, inflammatory/infectious diseases, or died during the procedure or within 24 hours after the procedure were excluded. The receiver operating characteristic curve was used to determine the optimal cutoff of GLR in CI-AKI. Based on the cutoff value, the study population was categorized into high-GLR (≥4.16) and low-GLR (<4.16) groups. The level of significance adopted in the statistical analysis was 5%.

Results

The overall CI-AKI incidence was 7.4%. The high-GLR group showed a higher CI-AKI incidence in comparison to the low-GLR group (30.9%vs1.3%, p<0.001). Following adjustment for potential confounders, high-GLR still served as an independent predictor for CI-AKI (odds ratio [OR] 45.100, 95% confidence interval [CI] 7.312-278.174, p<0.001), as well as creatinine at admission (OR:10.459, 95%CI 1.169-93.583, p=0.036).

Conclusions

In conclusion, a high GLR level served as an independent risk factor for CI-AKI evolution after PPCI in subjects with STEMI without diabetes mellitus.

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Research Letter

Venous Excess Ultrasound (VExUS) Score in Patients with ST-Elevation Myocardial Infarction to Predict In-Hospital Mortality

Guilherme Pinheiro Machado et al. Guilherme Heiden Telo João Pedro da Rosa Barbato Marina Petersen Saadi … Gustavo Neves de Araujo Angelo Chies Julia Carvalho da Silva Rodrigo Wainstein Marco Wainstein

Key points

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ABCHF

Review Article

Hypertonic Saline Solution: How, Why, and for Whom?

Ciro Mancilha Murad et al. Fabiana Goulart Marcondes-Braga

Abstract

The administration of hypertonic saline (HS) in decompensated heart failure (HF) seems counterintuitive, given the concept that sodium is universally harmful for these patients. However, increasingly, strict sodium restrictions have been questioned due to the lack of proven benefits. On the other hand, we know that in acute HF complicated with diuretic resistance, there is hyperactivation of the renin-angiotensin-aldosterone system (RAAS), resulting in a state of excessive increase in renal avidity for sodium, hindering the action of loop diuretics. In this sense, HS would have the potential to attenuate the hyperactivation of RAAS and provide a supply of sodium to the renal tubules, enabling the action of loop diuretics. Several studies have consistently demonstrated that the association of HS with loop diuretics results in greater diuresis, weight loss, and possibly improved renal function. Therefore, despite being underused, we believe that HS is an effective, low-cost, and widely available strategy whose mechanism of action addresses one of the central points in the pathophysiology of diuretic resistance.

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Original Article

Effectiveness of Oral Hydration in Preventing Contrast-Induced Nephropathy in Individuals Undergoing Elective Coronary Interventions

Mariana Rodrigues Pioli et al. Renata Muller Couto José de Arimatéia Francisco Diego Quilles Antoniassi … Célia Regina de Souza Matheus Ynada de Olivio Gabriel Forato Anhê Silvio Giopatto Andrei C. Sposito Wilson Nadruz Otavio Rizzi Coelho-Filho Rodrigo Modolo

Abstract

Background

Contrast-induced nephropathy (CIN) is defined as worsening renal function, represented by an increase in serum creatinine of ≥ 25% or ≥ 0.5 mg/dL up to 72 h after exposure to iodinated contrast medium (ICM). The most effective preventive measure to date is intravenous hydration (IVH). Little is known about the effectiveness of outpatient oral hydration (OH).

Objetive

To investigate whether outpatient OH with water is as effective as IVH with 0.9% saline solution in preventing CIN in elective coronary procedures.

Methods

In this retrospective observational study, we analyzed the medical records and laboratory data of individuals undergoing percutaneous coronary procedures with ICM. Data collected between 2012 and 2015 refer to individuals who underwent IVH and those collected between 2016 and 2020 (after implementation of an OH protocol) correspond to individuals who underwent OH at home before and after coronary procedures as instructed by the nursing team. Statistical significance was established at α = 0.05.

Results

In total, 116 patients were included in this study: 58 in the IVH group and 58 in the OH group. An incidence of CIN of 15% (9/58) was observed in the group that received IVH and an incidence of 12% (7/58) was seen in the group that received OH (p = 0.68).

Conclusion

The OH protocol, performed by the patient, appears to be as effective as the in-hospital IVH protocol for the renal protection of individuals susceptible to CIN in elective coronary interventions. These findings should be put to test in larger trials.

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Editorial

What Is the Role of Kidney Injury Biomarkers in Contrast-Induced Nephropaty?

Pedro Pimenta de Mello Spineti

Contrast-induced acute kidney injury (CI-AKI) is a potential severe complication in the use of iodinated radiological contrast media and is associated with higher rates of morbidity and mortality and increased length of hospital stay in patients undergoing cardiac catheterization. Its incidence is variable in the literature according to the criteria used for its diagnosis. The CI-AKI definition most often used in clinical trials is an increase in serum creatinine (Cr) levels of 0.5 mg/dl or 25% over baseline within 72 h after exposure to contrast medium.

However, Cr has a number of limitations as a marker of renal function. Its serum level is influenced by external factors such as sex, age, skin color, weight and muscle mass. It underestimates renal function in women, in the elderly or in underweight individuals. Its variation overestimates renal damage in individuals with previous kidney failure. Another important limitation is the fact that Cr rises only after 24 h of an acute kidney injury, being considered a “slow marker” of acute kidney injury.^,

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