Major Adverse Renal and Cardiovascular Events following Intra-Arterial Contrast Media Administration in Hospitalized Patients with Comorbid Conditions

Abstract

<b><i>Introduction:</i></b> Several clinical studies and meta-analyses have demonstrated lower incidence of adverse renal and cardiovascular outcomes associated with the use of iso-osmolar contrast media (IOCM) than low-osmolar contrast media (LOCM) in patients with variable risk profiles undergoing intra-arterial interventional procedures. However, the association of contrast-type and major adverse renal and cardiovascular events (MARCE) has not been studied via comprehensive and robust real-world data analyses in patients with comorbid conditions considered at risk for post-procedural acute kidney injury (AKI). The objective of this study was therefore to retrospectively assess the MARCE rates comparing IOCM with LOCM in at-risk patients receiving iodinated intra-arterial contrast media using a real-world inpatient data source. <b><i>Methods:</i></b> Patients who underwent a diagnostic or treatment procedure with intra-arterial IOCM or LOCM administration were identified using the Premier Healthcare Database. Patient subgroups including those with diabetes, heart failure, chronic kidney disease (CKD) stages 1–4, CKD 3–4, or diagnosis of chronic total occlusion (CTO) were formed. Subgroups with combinations of diabetes and CKD 3–4 with and without CTO were also investigated. We compared the primary endpoint of MARCE (composite of AKI, AKI requiring dialysis, acute myocardial infarction, stroke/transient ischemic attack, stent occlusion/thrombosis, or death) after IOCM versus LOCM administration via adjusted multivariable regression analyses. <b><i>Results:</i></b> A total of 536,013 inpatient visits met the primary inclusion and exclusion criteria (IOCM = 133,192; LOCM = 402,821). After multivariable modeling, the use of IOCM was associated with a significantly lower incidence of MARCE than LOCM in patients with CKD 1–4, CKD 3–4, diabetes, or heart failure, with greatest absolute risk reduction (ARR) of 2.4% (<i>p</i> < 0.0001) in CKD 3–4 patients (relative risk reduction [RRR] = 13.8%, number needed to treat [NNT] = 43). Additionally, ARR associated with IOCM increased to 3.5% (<i>p</i> < 0.0001) in patients with combined comorbidities of diabetes and CKD 3–4 (RRR = 19.1%, NNT = 29). Statistically significant risk reduction was also found for the use of IOCM among patients who underwent revascularization for CTO (ARR = 1.6% [<i>p</i> < 0.0001], RRR = 22.3%, NNT = 62). <b><i>Conclusion:</i></b> Intra-arterial administration using IOCM in at-risk patients is associated with lower rates of MARCE than the use of LOCM. This difference is especially apparent in patients with a combination of CKD 3–4 and diabetes and in patients with CTO, providing real-world data validation with meaningful NNT in favor of IOCM.

Iso‐osmolar versus low‐osmolar contrast media and outcomes after percutaneous coronary intervention: Insights from the VA CART Program

“…This is consistent with data from a recently published retrospective report describing outcomes with IOCM in over 9400 patients undergoing elective PCI. 36 While a recently published secondary analysis of the PREMIER database data showed a statistically significant lowering in MARCE associated with the use of IOCM in patients with multiple risk factors or undergoing high-risk procedures, 22 our subgroup analyses showed that neither patients' characteristics or comorbidities nor procedural characteristics, such as indications and urgency, were significantly associated with a lower incidence of MARCE after adjustment for procedure site when patients were given IOCM for the PCI with the exception of patients with CKD and of outpatients. Whether the significant association between contrast media type and MARCE in patients with CKD and in outpatients is real or is the result of the play of chance is unclear but there is no good biological explanation why this association would appear in these subgroups but not in any other subgroups.…”

“…A study directly comparing IOCM with several LOCM found no differences between the various contrast media 18 and the results of meta‐analyses have been conflicting 19,20 . A study of administrative data in several hundred thousand patients undergoing PCI found an association of IOCM with a lower risk of adverse renal and cardiovascular outcomes compared with LOCM 21 which was more evident in high‐risk patients 22 . We evaluated the association between contrast type and adverse renal outcomes using data from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) Program.…”

Key Considerations regarding the Renal Risks of Iodinated Contrast Media: The Nephrologist’s Role

“…The different studies considered those undergoing intra-arterial diagnostic or treatment procedures, those undergoing endovascular aneurysm repair (EVAR), and those undergoing peripheral vascular procedures. In each scenario, isoosmolar iodixanol was associated with a significant reduction in major adverse renal and cardiovascular events versus low-osmolar contrast media [41–43].…”

Contrast-Induced Encephalopathy: A Rare Complication in a Patient on Peritoneal Dialysis with Several Risk Factors

“…Iodinated contrast media (CM) are widely used for diagnostic and interventional procedures. It is well known that their use is associated with an increased risk of major adverse renal and cardiovascular events (MARCE) [1,2]. MARCE includes both major adverse kidney events including post-contrast-induced acute kidney injury (PC-AKI), with or without need of dialysis treatment, and death [2], and major adverse cardiovascular events, including acute myocardial infarction, stroke/transient ischemic attack, stent occlusion/ thrombosis, heart failure, and death [3].…”

“…It is well known that their use is associated with an increased risk of major adverse renal and cardiovascular events (MARCE) [1,2]. MARCE includes both major adverse kidney events including post-contrast-induced acute kidney injury (PC-AKI), with or without need of dialysis treatment, and death [2], and major adverse cardiovascular events, including acute myocardial infarction, stroke/transient ischemic attack, stent occlusion/ thrombosis, heart failure, and death [3]. Cardiovascular and renal adverse events are rare, but their incidence increases in high-risk patients, mainly affected by hypertension, diabetes mellitus, chronic heart failure, chronic kidney disease (CKD) [4].…”