Impact of heart failure on the incidence of contrast-induced nephropathy in patients with chronic kidney disease

Abstract

We randomized patients with chronic kidney disease (serum creatinine ≥ 1.5 mg/dl or glomerular filtration rate (GFR) <60 ml/min/1.73 m²) in a double-blind fashion to receive saline or sodium bicarbonate prior to and after cardiac or vascular angiography. The primary endpoint was contrast-induced nephropathy (CIN), defined as an increase in serum creatinine by 25% or by 0.5 mg/dl from baseline. Patients with congestive heart failure (CHF), cardiac ejection fraction (EF) <30%, or GFR < 20 ml/min/1.73 m² were excluded. The study was discontinued (after 142 patients were randomized) due to a low incidence of CIN (1.5%). We retrospectively identified all cases of CIN (n = 30) at our institution during the same time period to see if these patients differed from our trial sample. There was no difference in serum creatinine (1.7 ± 0.4 vs. 1.7 ± 0.6 mg/dL), GFR (42.7 ± 9.7 vs. 45.3 ± 3.2 ml/min), incidence of diabetes (51.8% vs. 63.3%), contrast volume (121.7 ± 63.8 vs. 122.7 ± 68.3 ml), ACE inhibitor or angiotensin receptor blocker use (54.0% vs 63.3%), and periprocedure diuretic use (33.1% vs 26.7%). On multivariate analysis, only a cardiac ejection fraction (EF) of less than 40% was significantly associated with CIN (odds ratio, 4.52; 95% confidence interval, 1.30-15.71; P = 0.02). In all, 22/30 patients (73.3%) who developed CIN had at least one or more characteristics that would have excluded their enrollment in our randomized trial including evidence of congestive heart failure (17/30 patients), EF less than 30% (9 patients), age greater than 85 years (2 patients), or advanced renal failure with a baseline GFR of less than 20 cc/min (1 patient). In summary, patients with CKD without evidence of CHF who receive adequate hydration appear to have a very low risk of CIN associated with angiography. A low EF (less than 40%) appeared to be the most significant risk factor for CIN in our population.

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

“…Heart failure (i.e., LVEF \ 40%) is another potential indicator of hemodynamic instability, and it is an independent risk factor for CIN [27]; however, it was not observed in our study. To protect renal function, it may be beneficial to perform elective PCI of non-infarct-related arteries for patients with multi-vessel disease, especially in those whose eGFR is somewhat decreased.…”

Pre-Procedural Risk Score of Contrast-Induced Nephropathy in Elderly Patients Undergoing Elective Coronary Angiography

“…As another well-known risk factor for CIN, CHF contributes to the development of CIN, 19) because the renin-angiotensin-aldosterone system (RAAS) increases the level of circulating vasoconstrictive neurohormones and elevates systemic vascular resistance in CHF patients, leading to systemic vasodilation and renal hypoperfusion. Many studies have proven that patients with severe CHF with New York Heart Association (NYHA) class 3-4 have a higher incidence of CIN.…”

Prevention of Contrast-Induced AKI

“…Recent studies focused on the comparative effectiveness of IV sodium bicarbonate (bicarbonate) and IV sodium chloride (saline) based on the hypothesis that alkalinization of tubular fluid with bicarbonate will decrease the generation of injurious reactive oxygen species. Several trials suggested bicarbonate to be more effective than saline (5)(6)(7)(8)(9)(10)(11)(12), whereas others reported no difference (13)(14)(15)(16)(17)(18)(19)(20)(21). A second preventive intervention that has received substantial attention is the administration of N-acetylcysteine (NAC), an antioxidant with vasodilatory properties.…”