Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis

Ehrmann, Stéphan; Quartin, Andrew A.; Hobbs, Brian P.; Robert-Edan, Vincent; Cely, Cynthia; Bell, Cynthia; Lyons, Genevieve; Pham, Tài; Schein, Roland M. H.; Geng, Yimin; Lakhal, Karim; Ng, Chaan S.

doi:10.1007/s00134-017-4700-9

Cited by 63 publications

(37 citation statements)

References 39 publications

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“…The concept of CI-AKI arose from observation and assumed causality, and despite a lack of rigorous hypothesis testing, has driven clinical practice for more than five decades. While a randomized controlled trial has not been conducted, there is now substantial evidence suggesting that CM contributes minimally, if at all, to the development of AKI [6,7,9,11,13,[15][16][17]. Despite the existence of such evidence, a pervasive preoccupation with what should be referred to as contrast-associated AKI (CA-AKI) persists in clinical practice, medical texts, and even among clinical researchers.…”

Section: Resultsmentioning

confidence: 99%

Section: Contrast Media and Acute Kidney Injury In The Critically Illmentioning

confidence: 99%

“…A recent systematic review revealed that this belief has been driven by a large body of uncontrolled data [15]. Meta-analysis of three propensity-matched controlled studies showed a lack of significant difference in AKI incidence among 560 critically ill patients who were exposed or unexposed to CM [15]. Those data were reinforced by a large monocentric database analysis showing a lack of significant association between CM and AKI, renal replacement therapy, and mortality among 6877 propensity-matched intensive care unit patients [16].…”

Section: Contrast Media and Acute Kidney Injury In The Critically Illmentioning

confidence: 99%

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Contrast-associated acute kidney injury is a myth: Yes

2017

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Section: Resultsmentioning

confidence: 99%

Section: Contrast Media and Acute Kidney Injury In The Critically Illmentioning

confidence: 99%

Section: Contrast Media and Acute Kidney Injury In The Critically Illmentioning

confidence: 99%

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Contrast-associated acute kidney injury is a myth: Yes

2017

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“…From the 291 titles and abstracts retrieved, five potentially relevant reviews were identified. However, the results from three reviews had limited applicability to the outpatient population considered in this assessment, as they were of kidney transplant patients, 84 critically ill patients, 85 and a mixture of emergency, ICU and inpatients. 86 In the two remaining reviews, the quality of included studies was limited because the studies lacked non-contrast agent control groups.…”

Section: Pragmatic Reviews Of Further Evidence To Inform the Economicmentioning

confidence: 99%

Point-of-care creatinine tests to assess kidney function for outpatients requiring contrast-enhanced CT imaging: systematic reviews and economic evaluation

Corbett

Duarte

Llewellyn

et al. 2020

Health Technol Assess

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Background Patients with low estimated glomerular filtration rates may be at higher risk of post-contrast acute kidney injury following contrast-enhanced computed tomography imaging. Point-of-care devices allow rapid measurement of estimated glomerular filtration rates for patients referred without a recent estimated glomerular filtration rate result. Objectives To assess the clinical effectiveness and cost-effectiveness of point-of-care creatinine tests for outpatients without a recent estimated glomerular filtration rate measurement who need contrast-enhanced computed tomography imaging. Methods Three systematic reviews of test accuracy, implementation and clinical outcomes, and economic analyses were carried out. Bibliographic databases were searched from inception to November 2018. Studies comparing the accuracy of point-of-care creatinine tests with laboratory reference tests to assess kidney function in adults in a non-emergency setting and studies reporting implementation and clinical outcomes were included. Risk of bias of diagnostic accuracy studies was assessed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Probabilities of individuals having their estimated glomerular filtration rates correctly classified were estimated within a Bayesian framework and pooled using a fixed-effects model. A de novo probabilistic decision tree cohort model was developed to characterise the decision problem from an NHS and a Personal Social Services perspective. A range of alternative point-of-care testing approaches were considered. Scenario analyses were conducted. Results Fifty-four studies were included in the clinical reviews. Twelve studies reported diagnostic accuracy for estimated glomerular filtration rates; half were rated as being at low risk of bias, but there were applicability concerns for most. i-STAT (Abbott Point of Care, Inc., Princeton, NJ, USA) and ABL (Radiometer Ltd, Crawley, UK) devices had higher probabilities of correctly classifying individuals in the same estimated glomerular filtration rate categories as the reference laboratory test than StatSensor® devices (Nova Biomedical, Runcorn, UK). There was limited evidence for epoc® (Siemens Healthineers AG, Erlangen, Germany) and Piccolo Xpress® (Abaxis, Inc., Union City, CA, USA) devices and no studies of DRI-CHEM NX 500 (Fujifilm Corporation, Tokyo, Japan). The review of implementation and clinical outcomes included six studies showing practice variation in the management decisions when a point-of-care device indicated an abnormal estimated glomerular filtration rate. The review of cost-effectiveness evidence identified no relevant studies. The de novo decision model that was developed included a total of 14 strategies. Owing to limited data, the model included only i-STAT, ABL800 FLEX and StatSensor. In the base-case analysis, the cost-effective strategy appeared to be a three-step testing sequence involving initially screening all individuals for risk factors, point-of-care testing for those individuals with at least one risk factor, and including a final confirmatory laboratory test for individuals with a point-of-care-positive test result. Within this testing approach, the specific point-of-care device with the highest net benefit was i-STAT, although differences in net benefit with StatSensor were very small. Limitations There was insufficient evidence for patients with estimated glomerular filtration rates < 30 ml/minute/1.73 m2, and on the full potential health impact of delayed or rescheduled computed tomography scans or the use of alternative imaging modalities. Conclusions A three-step testing sequence combining a risk factor questionnaire with a point-of-care test and confirmatory laboratory testing appears to be a cost-effective use of NHS resources compared with current practice. The risk of contrast causing acute kidney injury to patients with an estimated glomerular filtration rate of < 30 ml/minute/1.73 m2 is uncertain. Cost-effectiveness of point-of-care testing appears largely driven by the potential of point-of-care tests to minimise delays within the current computed tomography pathway. Future work Studies evaluating the impact of risk-stratifying questionnaires on workflow outcomes in computed tomography patients without recent estimated glomerular filtration rate results are needed. Study registration This study is registered as PROSPERO CRD42018115818. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 39. See the NIHR Journals Library website for further project information.

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“…-У пациентов с наличием факторов риска контрастиндуцированного ОПП (КИ-ОПП) следует проводить профилактику путем инфузии изотонического раствора хлорида или бикарбоната натрия [85,86]. Уровень достоверности (доказательности) A. Уровень убедительности рекомендации I.…”

Section: нефротоксические препараты в периоперационном периодеunclassified

Perioperative management of patients with renal insufficiency

Zabolotskikh¹,

Afonchikov²,

Bayalieva³

et al. 2018

Anesteziologiya I Reanimatologiya

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В обзоре представлены современные подходы по ведению пациентов с острым повреждением почек на различных этапах периоперационного периода. Послеоперационное острое повреждение почек является одним из самых серьезных осложнений во время госпитализации и увеличивает заболеваемость, смертность и продолжительность пребывания в стационаре. Частота встречаемости периоперационного острого повреждения почек зависит от характера оперативного вмешательства и колеблется в широком диапазоне-от 0,8 до 94%. В обзоре представлены диагностические критерии и классификация острого повреждения почек согласно рекомендациям Kidney Disease Improving Global Outcomes (KDIGO). Дано этиологическое и патогенетическое обоснование развития различных форм острого повреждения почек. Представлены рекомендации по профилактике и лечению острого повреждения почек на дооперационном, интраоперационном и послеоперационном периоде, сформулированные с позиции доказательной медицины. В частности, даны рекомендации по инфузионной терапии, контролю волемического статуса, гемодинамической и нутритивной поддержке, использованию диуретиков, профилактике контраст-индуцированного повреждения почек и коррекции режима введения нефротоксических препаратов. Обсуждены подходы к началу проведения и режимы заместительной почечной терапии. Ключевые слова: острое повреждение почек, периоперационный период, заместительная почечная терапия.

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Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis

Abstract: Meta-analysis of matched cohort studies of iodinated contrast medium exposure does not support a significant incidence of acute kidney injury attributable to iodinated contrast media in critically ill patients.

Cited by 63 publications

References 39 publications

Contrast-associated acute kidney injury is a myth: Yes

Contrast-associated acute kidney injury is a myth: Yes

Point-of-care creatinine tests to assess kidney function for outpatients requiring contrast-enhanced CT imaging: systematic reviews and economic evaluation

Perioperative management of patients with renal insufficiency

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