Association of contrast-induced acute kidney injury with long-term cardiovascular events in acute coronary syndrome patients with chronic kidney disease undergoing emergent percutaneous coronary intervention

Background

The association between contrast-induced acute kidney injury (CI-AKI) and chronic kidney disease (CKD) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) has not been fully reported. We evaluated the association of CI-AKI on cardiovascular events in ACS patients with CKD.

Methods

A total of 1059 ACS patients who underwent emergent PCI in our multicenter registry were enrolled (69 ± 12 years, 804 men, 604 STEMI patients). CKD was defined as at least stage 3 CKD, and CI-AKI was defined as an increase of at least 0.5 mg/dL and/or an increase of at least 25% of pre-PCI to post-PCI serum creatinine levels within 1 week after the procedure. Primary endpoints included cardiovascular death, myocardial infarction, and cerebrovascular disorder (stroke or transient ischemic attack).

Results

In our study, 368 (34.7%) patients had CKD. During follow-up periods (435 ± 330 days), CI-AKI and primary endpoints occurred in 164 (15.5%) patients and 106 (10.0%) patients, respectively. Multivariate Cox proportional hazards model revealed that age, female gender, peak creatinine kinase > 4000, IABP use, CI-AKI (hazard ratio [HR], 2.17; 95% confidential interval [CI], 1.52 to 4.00; P < 0.001), and CKD (HR, 1.66; 95% CI, 1.01 to 2.72; P = 0.046) were independent predictors of primary endpoints. Kaplan–Meier analysis showed that occurrence of primary endpoints increased significantly with an increase in CKD stage, and CI-AKI yielded worse long-term prognosis at every stage of CKD (P < 0.001).

Conclusions

CI-AKI was revealed to be a significant incremental predictor of cardiovascular events at each stage of CKD in ACS patients.     

Prevention of contrast-induced nephropathy by bolus injection of sodium bicarbonate in patients with chronic kidney disease undergoing emergent coronary procedures

We conducted a prospective study to determine whether a bolus injection of sodium bicarbonate before emergent coronary procedures in patients with chronic kidney disease (CKD) might prevent contrast-induced nephropathy (CIN). We enrolled 59 patients with CKD, defined by a serum creatinine concentration of >1.1 mg/dl or an estimated glomerular filtration rate of <60 ml/min, who were scheduled at admission to undergo an emergent coronary procedure. The patients were randomized to receive a bolus intravenous injection of 154 mEq/L of sodium bicarbonate (n = 30) or sodium chloride (n = 29) at the dose of 0.5 ml/kg, before contrast administration, followed by infusion of 154 mEq/L sodium bicarbonate at 1 ml/kg/hour for 6 hours in both groups. The primary end point was the occurrence of CIN, defined as an increase by > 25% or > 0.5 mg/dl of the serum creatinine level within 2 days after the procedure. In the sodium bicarbonate group, the serum creatinine concentration remained unchanged within 2 days of contrast administration (from 1.32 ± 0.46 to 1.38 ± 0.60 mg/dl, p = 0.33). In contrast, it had increased in the sodium chloride group (1.51 ± 0.59 to 1.91 ± 1.19 mg/dl, p = 0.006). The incidence of CIN was significantly lower in the sodium bicarbonate group than in the sodium chloride group (3.3% vs 27.6%, p = 0.01). In conclusion, rapid alkalization by bolus injection of sodium bicarbonate was effective for the prevention of CIN in patients with CKD undergoing emergent procedures.     

Prevention of contrast-induced acute kidney injury by theophylline in elderly patients with chronic kidney disease

Although the optimal strategy for preventing contrast-induced acute kidney injury (CI-AKI) has not yet been established, the current strategy focuses on adequate periprocedural hydration, the use of a low amount of low or iso-osmolar contrast medium, and the application of adjunctive therapies, including hemofiltration, hemodialysis and drugs. Previous trials and meta-analyses concerning the use of the adenosine antagonist theophylline have revealed contradictory results. We sought to evaluate the effect of theophylline in CI-AKI prevention in well-hydrated elderly patients with chronic kidney disease. We therefore conducted a randomized, double-blind, placebo-controlled trial involving 56 patients who had been referred for cardiac coronary angiography and/or angioplasty. 31 of these patients were randomly assigned to 200 mg theophylline IV before the procedure, and 25 to a placebo. The iso-osmolar contrast medium iodixanol was used. The primary endpoint was an increase in serum creatinine at study termination 48 h after contrast medium administration. Baseline characteristics in the placebo and theophylline groups were similar in terms of median age (75 years), estimated glomerular filtration rate (33 ± 10 vs. 33 ± 10 ml/min/1.73 m²; p = 0.87), diabetes mellitus (80 vs. 71%; p = 0.54), and amount of contrast used (94 ± 35 vs. 95 ± 38 ml; p = 0.89). There was no difference in serum creatinine at baseline (2.06 ± 0.59 vs. 2.02 ± 0.45 mg/dl; p = 0.62) or study termination (2.06 ± 0.68 vs. 2.10 ± 0.53; p = 0.79). A prophylactic effect of theophylline was not observed. The incidence of renal impairment following exposure to the contrast medium was low. This fact can be attributed to adequate parenteral hydratation and the use of the minimum amount of contrast medium necessary.     

高敏C-反应蛋白对经皮冠状动脉介入术后对比剂肾病风险预测价值

目的:探讨经皮冠状动脉介入治疗术前高敏C反应蛋白(hs-CRP)水平与患者术后对比剂急性肾损伤(CI-AKI)的发生率及远期预后的关系。方法:连续入选1 820例于我院行择期经皮冠状动脉介入治疗患者,排除急性心肌梗死、近期手术或创伤的患者。根据术前hs-CRP值分为3组:hs-CRP升高组(hs-CRP>3 mg/L,n=546)、hs-CRP轻度升高组(hs-CRP 1～3 mg/L,n=650)和hs-CRP正常组(hs-CRP<1 mg/L,n=624)。结果:中位随访时间为26个月。与hs-CRP正常组相比,hs-CRP升高组术后CI-AKI发生率显著增加(10.9%vs.14.8%vs.23.1%,P<0.0001)。经过Logistic回归校正临床基线资料后,术前hs-CRP水平仍然是对比剂急性肾损伤发生率的独立预测因素。此外,男性OR=0.61;95%CI=0.45～0.82;P=0.001),糖尿病(OR=2.21,95%CI=1.67～2.93;P<0.0001),围手术期水化治疗(OR=0.50,95%CI=0.38～0.65,P<0.0001)也是患者对比剂肾病风险的独立预测因素。结论:术前hs-CRP水平与经皮冠状动脉介入治疗术后CI-AKI发生率显著相关。hs-CRP水平可以为患者术前危险分层提供帮助。     

Fibrinogen-to-albumin ratio is related to the severity of coronary artery disease in chronic kidney disease patients undergoing coronary angiography

ObjectivesThis study was to explore the potential relationship between the fibrinogen-to-albumin ratio (FAR) and the presence and severity of coronary artery disease (CAD) in stage 3–5 predialysis chronic kidney disease (CKD) patients.DesignThis study included 978 patients undergoing coronary angiography (CAG). CAD was defined as the presence of obstructive stenosis > 50% of the lumen diameter in any of the four main coronary arteries. Gensini scores (GSs), left main coronary artery (LMCA) and three-vessel coronary artery disease (TVD) were used to elevate the severity of CAD.ResultsThe adjusted odds ratios of CAD were 3.059 (95% CI: 1.859–5.032) and 2.670 (95% CI: 1.605–4.441) in the third and fourth quartiles of FAR compared with the first quartile, respectively. Among 759 patients diagnosed with CAD, multivariate logistic regression analysis showed that FAR (at the 0.01 level) was significantly positively associated with the presence of LMCA (adjusted OR = 1.177, 95% CI 1.067–1.299, P = 0.001) or TVD (adjusted OR = 1.154, 95% CI 1.076–1.238, P < 0.001), and a higher GS (adjusted OR = 1.152, 95% CI 1.073–1.238, P < 0.001).ConclusionsFAR levels were independently associated with the presence and severity of CAD in stage 3–5 predialysis CKD patients.     

普罗布考联合阿托伐他汀对冠心病并发糖尿病介入治疗患者对比剂急性肾损害的影响

目的探讨普罗布考联合阿托伐他汀对冠状动脉粥样硬化性心脏病(冠心病)并发糖尿病介入治疗患者对比剂急性肾损害(contrast-induced acute kidney injury,CIAKI)的影响。方法选取2018年1月至2019年3月廊坊市第四人民医院行择期介入治疗的冠心病并发糖尿病患者260例,随机分为对照组和观察组各130例。对照组患者在水化预防基础上给予口服阿托伐他汀,观察组患者在对照组基础上加用普罗布考。比较两组患者介入治疗前后高敏C-反应蛋白(high sensitivity C-reactive protein,hs-CRP)、细胞间黏附分子-1(intercellular cell adhesion molecule-1,ICAM-1)、总抗氧化能力(total antioxidant capacity,T-AOC)、一氧化氮(nitric oxide,NO)、内皮素(endothelin-1,ET-1)、几丁质酶3样蛋白1(chitinase-3-like protein,CHI3L1)、肌酐、尿素氮、估算的肾小球滤过率(estimated glomerular filtration rate,eGFR)及CIAKI的发病率。结果(1)两组患者术前hs-CRP、ICAM-1、T-AOC、NO、ET-1、CHI3L1比较,差异无统计学意义(P>0.05);术后3 d,观察组患者hs-CRP、ICAM-1、ET-1、CHI3L1低于对照组,而T-AOC、NO高于对照组,差异有统计学意义(P<0.05)。(2)两组患者术前肌酐、尿素氮、eGFR比较,差异无统计学意义(P>0.05);术后3 d,观察组患者的肌酐、尿素氮浓度低于对照组,eGFR高于对照组,差异有统计学意义(P<0.05)。(3)介入治疗后,观察组和对照组分别有4例(3.08%)和19例(14.62%)患者发生CIAKI,两组CIAKI发病率比较,差异有统计学意义(χ2=10.73,P<0.05)。(4)多因素Logistic回归分析结果显示,普罗布考联合阿托伐他汀使用是CIAKI的保护因素。结论普罗布考联合阿托伐他汀可有效预防冠心病并发糖尿病介入治疗患者CIAKI的发生,其机制可能与二者联合用药的强力抗炎、抗氧化、改善血管内皮功能有关.     

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

Background: Low 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. Methods: We 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. Results: CI-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. Conclusions: Measurement 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.     

Neutrophil gelatinase-associated lipocalin as a biomarker for acute kidney injury in patients undergoing coronary artery bypass grafting

BACKGROUND/OBJECTIVE:

The development of acute renal injury (ARI) is an important indicator of clinical outcomes after cardiac surgery. Neutrophil gelatinase-associated lipocalin (NGAL) has been certified as a predictive biomarker of hypoxic ARI. The present study aimed to determine the predictive role of NGAL in coronary bypass graft (CABG) surgery.

METHOD:

A total of 72 consecutive patients undergoing elective CABG were enrolled in the study. NGAL levels were determined preoperatively and postoperatively after 6 h, 24 h and 72 h for all participants. The participants were then divided into two groups according to their preoperative creatinine levels (group I, creatinine 111.38 μmol/L to 361.55 μmol/L; group II, creatinine <111.38 μmol/L).

RESULTS:

There was no statistically significant difference between the groups according to their NGAL values (P>0.05), except at 6 h (P=0.045). Three patients required continuous hemodialysis. Comparison of the NGAL levels of these three patients with those of the other participants did not reveal any correlation with serum creatinine levels. In contrast, the NGAL levels were significantly lower in the continuous hemodialysis patients (1.9±1 ng/mL) compared with those of the other participants (22.6±12.8 ng/mL; P=0.001).

CONCLUSION:

NGAL is one of the most frequently used biomarkers for ARI after cardiac operations, especially in younger patients. The participants in the present study were coronary artery disease patients and were, therefore, older than patients in previous reports. These results support the view that NGAL is not a relevant predictive factor for ARI in patients with CABG, including older patients.     

尼可地尔对急性ST段抬高型心肌梗死患者介入治疗后发生对比剂诱导急性肾损伤的疗效观察

目的探讨急性ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PPCI)术前及术后24 h内使用尼可地尔对对比剂诱导的急性肾损伤(CI-AKI)发病率的影响。方法采用前瞻性单盲随机对照设计,纳入行PPCI的STEMI患者397例。随机分为尼可地尔组(n=199)和对照组(n=198)。主要观察指标为术后CI-AKI的发病率,次要观察指标为术后住院期间主要不良心血管事件(MACE)及需要肾脏替代治疗等情况。结果 STEMI患者心肌总缺血时间为(6.1±2.1) h。尼可地尔组、对照组术前Mehran风险评分差异无统计学意义(P0.05)。术后采血时间的中位数为28.5(25.3,29.6)h,397例患者中53例(13.4%)发生CI-AKI,其中尼可地尔组17例(8.5%)、对照组36例(18.2%)(P0.05)。多因素Logistic回归分析显示,与对照组比较,尼可地尔可以降低术后血肌酐(SCr)增幅或血肌酐差值(ΔSCr)(OR=0.38,95%CI 0.20～0.72,P=0.003),提示其可能为术后发生CI-AKI的独立保护因素;碘对比剂(CM)剂量(OR=1.03,95%CI 1.01～1.04,P0.001)是发生CI-AKI的独立危险因素。尼可地尔组术后24 h内心绞痛发生率更低(P0.05),其他MACE及需要肾脏替代治疗事件方面,两组之间差异无显著性(P0.05)。结论 STEMI患者PPCI术前及术后24 h内使用尼可地尔,可以预防CI-AKI的发生,但并不改善短期预后。