Elsevier

International Journal of Cardiology

Volume 228, 1 February 2017, Pages 137-144
International Journal of Cardiology

Contrast media use in patients with chronic kidney disease undergoing coronary angiography: A systematic review and meta-analysis of randomized trials

https://doi.org/10.1016/j.ijcard.2016.11.170Get rights and content

Abstract

Background

Patients with chronic kidney disease (CKD) undergoing coronary angiography (CA), adequate hydration and minimizing volume of contrast media (CM) are class 1b recommendations for preventing contrast induced nephropathy (CIN). Current data are insufficient to justify specific recommendations about isoosmolar vs. low-osmolar contrast media by the ACCF/AHA/SCAI guidelines.

Methods

Randomized trials comparing IOCM to LOCM in CKD stage 3 and above patients undergoing CA, and reporting incidence of CIN (defined by a rise in creatinine of 25% from baseline) were included in the analysis. The secondary outcome of the study was the incidence of serum creatinine increase by > 1 mg/dl.

Results

A total of 2839 patients were included in 10 trials, in which 1430 patients received IOCM and 1393 received LOCM. When compared to LOCM, IOCM was not associated with significant benefit in preventing CIN (OR = 0.72, [CI: 0.50–1.04], P = 0.08, I2 = 59%). Subgroup analysis revealed non-significant difference in incidence of CIN based on baseline use of N-acetylcystine (NAC), diabetes status, ejection fraction, and whether percutaneous coronary intervention vs coronary angiography alone was performed. The difference between IOCM and LOCM was further attenuated when restricted to studies with larger sample size (> 250 patients) (OR = 0.93; [CI: 0.66–1.30]) or when compared with non-ionic LOCM (OR = 0.79, [CI: 0.52–1.21]).

Conclusion

In patients with CKD stage 3 and above undergoing coronary angiography, use of IOCM showed overall non-significant difference in incidence of CIN compared to LOCM. The difference was further attenuated when IOCM was compared with non-ionic LOCM.

Introduction

Contrast-induced nephropathy (CIN) is one of the most common cause of hospital acquired kidney injury, which accounts for increase in morbidity, mortality, length of stay and hospitalization cost [1], [2]. Chronic kidney disease (CKD) patients have higher risk of developing cardiovascular disease requiring coronary interventions compared to general populations [3], placing them at higher risk of developing CIN [4]. Risk factors for CIN are type and amount of contrast media (CM), older age, intra-arterial administration of CM, dehydration and use of nephrotoxic agents [5], [6], [7]. Adequate hydration and minimizing volume of contrast media administered are class 1b recommendations for preventing CIN [8], [9], [10], [11]. It is also well recognized that high osmolar contrast media (HOCM) are more nephrotoxic than low (LOCM) or isoosmolar contrast media (IOCM) [12], [13], [14]. Trial done by Netti et al. [15] showed a significant benefit of IOCM over LOCM but other trials have failed to show this [16], [17], [18], [19]. Current data are insufficient to justify specific recommendations about IOCM and LOCM, and specific guidelines on use of different CM especially in patients with higher stages of CKD have been lacking [20].

The aim of the current meta-analysis is to compare the renal safety of IOCM to LOCM in patients with advanced CKD and to assess the incidence of CIN in patients undergoing coronary angiography. To our best knowledge this is the first meta-analysis reporting difference in CIN between two types of CM among advanced CKD patients undergoing coronary angiography.

Section snippets

Data sources and search strategy

A literature review on published RCTs was performed using Pubmed, Medline (via OVID), Scopus, and Web of science up till January 2016 without any language restrictions. Search keywords included “contrast media”, “contrast-induced nephropathy”, “chronic kidney disease” and “coronary angiography” as MeSH and free text terms. Additionally, root variations of the mentioned keywords were used in an attempt to improve search outcomes. Abstracts from the annual meetings of the American Heart

Identification of studies

As shown in Fig. 1, initial search yielded 198 potential studies. Out of these 71 were excluded based on the titles. Remaining articles were scanned through abstracts and excluded based on the type of contrast media used. Ten RCTs that compared IOCM to LOCM fulfilled our inclusion criteria. The major reasons for exclusion were either that selected studies were not randomized, not exclusively assessing contrast media use in patients undergoing coronary angiography, or were not restricted to

Discussion

There has been a long debate regarding the prevention of CIN after coronary artery catheterization. Although the overall incidence of CIN in the general healthy population is low [30], the consequences of such an event can have significant health detriments such as increased morbidity, longer hospital stays, and the potential for renal replacement therapy. Individuals at high risk for CIN include those with renal impairment and DM, CIN incidence rises from 2% to 12–50% in these patients

Strength and limitations

To the best of our knowledge this is the first systematic review and meta-analysis comparing the renal safety in terms of contrast induced nephropathy among two types of contrast media in patients undergoing coronary angiography with or without intervention in CKD patients. All included studies are randomized control trials, which accounts for very low risk of selection bias. Our meta-analysis also has few limitations. First CIN was defined differently in each study, CIN definitions varied

Conclusion

In CKD patients with stage 3 and above undergoing coronary angiography, use of IOCM showed non-significant benefit in terms of preventing CIN compared to LOCM. More randomized controlled trials are needed to better assess the effects of contrast media in CKD patients undergoing coronary angiography.

Conflict of interest

The authors have no conflict of interest to declare.

References (35)

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    Another meta-analysis suggested that the relative safety of iodixanol may vary depending on the specific low-osmolar CM used as comparator, but overall, iodixanol was not considered superior to low-osmolar CM (34). A more recent meta-analysis including only patients with CKD undergoing PCI included 2,839 subjects from 10 randomized trials, and showed no significant benefit of iodixanol in preventing CI-AKI (OR: 0.72; 95% confidence interval: 0.50 to 1.04; p = 0.08) (35). Finally, a recent large observational study compared the risk of CI-AKI across 4 different low-osmolar CM and iodixanol and found no differences between low-osmolar CM and iodixanol (17).

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