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