Original Article

Intravascular Iodinated Contrast Is an Independent Cause of Acute Kidney Injury Following Coronary Angiography

Authors: Srijan Tandukar, MD, Helbert Rondon-Berrios, MD, MS, Steven D. Weisbord, MD, MSc

Abstract

Objectives: Recent studies have questioned whether intravascular iodinated contrast remains an independent cause of acute kidney injury (AKI). We sought to assess whether iodinated contrast administered during coronary angiography is an independent cause of AKI.

Methods: We identified all of the patients who underwent coronary angiography between July 1, 2015 and June 30, 2017 with a discharge diagnosis of AKI that developed within 7 days following angiography. Using chart review, we categorized patients as having multifactorial AKI if ≥1 insults other than intravascular contrast potentially contributed to kidney injury or contrast-induced AKI (CI-AKI) if the only insult was contrast administration. We compared the severity of AKI and renal function upon discharge between patients with CI-AKI and multifactorial AKI.

Results: We identified 78 patients who experienced AKI within 7 days following angiography, 10 (13%) of whom had CI-AKI and 68 of whom (87%) experienced multifactorial AKI. Nine (90%) patients with CI-AKI manifested stage 1 disease, 1 (10%) had stage 2 disease, and 9 (90%) experienced full recovery of kidney function. More patients with multifactorial AKI developed stage 2 or 3 disease (42% vs 10%, χ2 = 3.73, P = 0.05) and experienced either partial recovery of kidney function or persistent kidney impairment compared with patients with CI-AKI (25% vs 10%, χ2 = 1.9, P = 0.17), although the latter comparison was not statistically significant.

Conclusions: The intravascular administration of iodinated contrast remains an independent cause of AKI. Compared with those with multifactorial AKI, patients with CI-AKI appear to be more likely to experience mild decrements in kidney function that recover completely.
Posted in: Nephrology and Urology3

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References

1. Berlyne N, Berlyne GM. Acute renal failure following intravenous pyelography with hypaque. Acta Med Scand 1962;171:39-41.
2. Heyman SN, Reichman J, Brezis M. Pathophysiology of radiocontrast nephropathy: a role for medullary hypoxia. Invest Radiol 1999;34:685-91.
3. Heyman SN, Rosen S, Khamaisi M, et al. Reactive oxygen species and the pathogenesis of radiocontrast-induced nephropathy. Invest Radiol 2010;45:188-195.
4. Cacoub P, Deray G, Baumelou A, et al. Nephrotoxicity of low osmolar radiocontrast agents in patients with chronic renal failure. Nephron 1988;48:324-325.
5. Solomon R, Gordon P, Manoukian SV, et al. Randomized trial of bicarbonate or saline study for the prevention of contrast-induced nephropathy in patients with CKD. Clin J Am Soc Nephrol 2015;10:1519-1524.
6. Weisbord SD, Gallagher M, Jneid H, et al. Outcomes after angiography with sodium bicarbonate and acetylcysteine. N Engl J Med 2018;378:603-614.
7. McCullough PA, Adam A, Becker CR, et al. Epidemiology and prognostic implications of contrast-induced nephropathy. Am J Cardiol 2006;98:5K-13K.
8. McCullough PA, Chinnaiyan KM. Hazards of contrast-induced acute kidney injury in elderly women. Womens Health (Lond) 2009;5:123-125.
9. McCullough PA, Wolyn R, Rocher LL, et al. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997;103:368-375.
10. Bruce RJ, Djamali A, Shinki K, et al. Background fluctuation of kidney function versus contrast-induced nephrotoxicity. AJR Am J Roentgenol 2009;192:711-718.
11. McDonald JS, Leake CB, McDonald RJ, et al. Acute kidney injury after intravenous versus intra-arterial contrast material administration in a paired cohort. Invest Radiol 2016;51:804-809.
12. McDonald JS, McDonald RJ, Carter RE, et al. Risk of intravenous contrast material-mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate. Radiology 2014;271:65-73.
13. McDonald JS, McDonald RJ, Comin J, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology 2013;267:119-128.
14. McDonald JS, McDonald RJ, Lieske JC, et al. Risk of acute kidney injury, dialysis, and mortality in patients with chronic kidney disease after intravenous contrast material exposure. Mayo Clin Proc 2015;90:1046-1053.
15. McDonald JS, McDonald RJ, Williamson EE, et al. Post-contrast acute kidney injury in intensive care unit patients: a propensity score-adjusted study. Intensive Care Med 2017;43:774-784.
16. Hinson JS, Ehmann MR, Fine DM, et al. Risk of acute kidney injury after intravenous contrast media administration. Ann Emerg Med 2017;69:577-586.e4.
17. Caspi O, Habib M, Cohen Y, et al. Acute kidney injury after primary angioplasty: is contrast-induced nephropathy the culprit? J Am Heart Assoc 2017;6:e005715.
18. Wilhelm-Leen E, Montez-Rath ME, Chertow G. Estimating the risk of radiocontrast-associated nephropathy. J Am Soc Nephrol 2017;28:653-659.
19. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
20. Brinjikji W, Demchuk AM, Murad MH, et al. Neurons over nephrons: systematic review and meta-analysis of contrast-induced nephropathy in patients with acute stroke. Stroke 2017;48:1862-1868.
21. Mehran R, Dangas GD, Weisbord SD. Contrast-associated acute kidney injury. N Engl J Med 2019;380:2146-2155.
22. Chertow GM, Normand SL, McNeil BJ."Renalism": inappropriately low rates of coronary angiography in elderly individuals with renal insufficiency. J Am Soc Nephrol 2004;15:2462-2468.
23. Szummer K, Lundman P, Jacobson SH, et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Circulation 2009;120:851-858.
24. Wong JA, Goodman SG, Yan RT, et al. Temporal management patterns and outcomes of non-ST elevation acute coronary syndromes in patients with kidney dysfunction. Eur Heart J 2009;30:549-557.
25. Bhatt DL, Roe MT, Peterson ED, et al. Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 2004;292:2096-2104.
26. Goldenberg I, Subirana I, Boyko V, et al. Relation between renal function and outcomes in patients with non-ST-segment elevation acute coronary syndrome: real-world data from the European Public Health Outcome Research and Indicators Collection Project. Arch Intern Med 2010;170:888-895.
27. Fox CS, Muntner P, Chen AY, et al. Use of evidence-based therapies in short-term outcomes of ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction in patients with chronic kidney disease: a report from the National Cardiovascular Data Acute Coronary Treatment and Intervention Outcomes Network registry. Circulation 2010;121:357-365.
28. Keeley EC, Kadakia R, Soman S, et al. Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with acute coronary syndromes. Am J Cardiol 2003;92:509-514.
29. Lau JK, Anastasius MO, Hyun KK, et al. Evidence-based care in a population with chronic kidney disease and acute coronary syndrome. Findings from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Am Heart J 2015;170:566-572.e1.
30. Reddan DN, Szczech LA, Tuttle RH, et al. Chronic kidney disease, mortality, and treatment strategies among patients with clinically significant coronary artery disease. J Am Soc Nephrol 2003;14:2373-2380.
31. Wright RS, Reeder GS, Herzog CA, et al. Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med 2002;137:563-570.
32. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;2:1-126.