Prevention of contrast-induced acute kidney injury in patients undergoing cardiovascular procedures-a systematic review and network meta-analysis.
BACKGROUND
Interventional diagnostic and therapeutic procedures requiring intravascular iodinated contrast steadily increase patient exposure to the risks of contrast-induced acute kidney injury (CIAKI), which is associated with death, nonfatal cardiovascular events, and prolonged hospitalization. The aim of this study was to investigate the efficacy of pharmacological and non-pharmacological treatments for CIAKI prevention in patients undergoing cardiovascular invasive procedures with iodinated contrast.


RESULTS
MEDLINE, Google Scholar, EMBASE and Cochrane databases as well as abstracts and presentations from major cardiovascular and nephrology meetings were searched, up to 22 April 2016. Eligible studies were randomized trials comparing strategies to prevent CIAKI (alone or in combination) when added to saline versus each other, saline, placebo, or no treatment in patients undergoing cardiovascular invasive procedures with administration of iodinated contrast. Two reviewers independently extracted trial-level data including number of patients, duration of follow-up, and outcomes. Eighteen strategies aimed at CIAKI prevention were identified. The primary outcome was the occurrence of CIAKI. Secondary outcomes were mortality, myocardial infarction, dialysis and heart failure. The data were pooled using network meta-analysis. Treatment estimates were calculated as odds ratios (ORs) with 95% credible intervals (CrI). 147 RCTs involving 33,463 patients were eligible. Saline plus N-acetylcysteine (OR 0.72, 95%CrI 0.57-0.88), ascorbic acid (0.59, 0.34-0.95), sodium bicarbonate plus N-acetylcysteine (0.59, 0.36-0.89), probucol (0.42, 0.15-0.91), methylxanthines (0.39, 0.20-0.66), statin (0.36, 0.21-0.59), device-guided matched hydration (0.35, 0.12-0.79), prostaglandins (0.26, 0.08-0.62) and trimetazidine (0.26, 0.09-0.59) were associated with lower odds of CIAKI compared to saline. Methylxanthines (0.12, 0.01-0.94) or left ventricular end-diastolic pressure-guided hydration (0.09, 0.01-0.59) were associated with lower mortality compared to saline.


CONCLUSIONS
Currently recommended treatment with saline as the only measure to prevent CIAKI during cardiovascular procedures may not represent the optimal strategy. Vasodilators, when added to saline, may significantly reduce the odds of CIAKI following cardiovascular procedures.
Department of Cardiology, Multimedica IRCCS, Milan, Italy.|Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.
Eliano P
EP
Navarese
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Inova Heart and Vascular Institute, Fairfax, VA, United States of America.
Paul A
PA
Gurbel
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Institute of Cardiology, Catholic University, Rome, Italy.
Felicita
F
Andreotti
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland.
Michalina Marta
MM
Kołodziejczak
Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
Suetonia C
SC
Palmer
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|University of Bristol, School of Social and Community Medicine, Bristol, United Kingdom.
Sofia
S
Dias
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Institute of Cardiology, Catholic University, Rome, Italy.
Antonino
A
Buffon
Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
Jacek
J
Kubica
Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland.
Mariusz
M
Kowalewski
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland.
Tomasz
T
Jadczyk
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland.
Michał
M
Laskiewicz
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland.
Marek
M
Jędrzejek
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Department of Cardiology, University of Duesseldorf, Duesseldorf, Germany.
Maximillian
M
Brockmeyer
Department of Cardiology, Multimedica IRCCS, Milan, Italy.
Flavio
F
Airoldi
Diaverum Medical Scientific Office, Diaverum Sweden AB, Lund, Sweden.
Marinella
M
Ruospo
Department of Cardiology, Multimedica IRCCS, Milan, Italy.
Stefano
S
De Servi
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland.
Wojciech
W
Wojakowski
Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE research network, Milan, Italy.|Inova Heart and Vascular Institute, Fairfax, VA, United States of America.
Christopher
C
O' Connor
Diaverum Medical Scientific Office, Diaverum Sweden AB, Lund, Sweden.|Sydney School of Public Health, University of Sydney, Sydney, Australia.|Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
Giovanni F M
GF
Strippoli
D006801:Humans; D058186:Acute Kidney Injury / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D003287:Contrast Media / Q000009:adverse effects; D003935:Diagnostic Techniques, Cardiovascular / Q000009:adverse effects; D007677:Kidney Function Tests; D015641:Radiography, Interventional / Q000009:adverse effects; D014665:Vasodilator Agents / Q000008:administration & dosage
D003287:Contrast Media; D014665:Vasodilator Agents