Incidence of contrast-induced nephropathy with volume supplementation--insights from a large cohort.

OBJECTIVE: The present study was performed to determine the effect of combined intravenous and oral volume supplementation on the incidence of contrast-induced nephropathy (CIN) in patients undergoing percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: Consecutive patients (n = 958) receiving iomeprol 350 during PCI were evaluated prospectively for the development of CIN. All patients received protocol-defined intravenous and oral volume supplementation. CIN was defined as an increase in serum creatinine of at least 44 micromol/l within 48 h. RESULTS: Of the 958 patients enrolled in the study, 147 (15%) were diabetic and 107 (11%) had stage III renal disease. The average baseline glomerular filtration rate was 88 +/- 25 ml/min/1.73 m(2). During the intervention an average of 238 +/- 86 ml of contrast medium was administered. CIN developed in 13 of 958 (1.4%; 95% confidence interval 0.6-2.1%) patients. The incidence of CIN was low even in predefined risk subgroups (women: 2.4%, diabetics: 2.7%, patients with stage III kidney disease: 6.5%). CONCLUSIONS: The incidence of CIN is low when preprocedural fluid volume supplementation is used.

Pulmonary edema after extensive radiofrequency ablation for atrial fibrillation.

BACKGROUND: More extensive ablation strategies for the treatment of atrial fibrillation (AF) have increased success rates but are associated with new and sometimes serious complications. We describe a new complication after extensive radiofrequency (RF) ablation in the left atrium (LA) for persistent AF. METHODS AND RESULTS: Electroanatomic guided circumferential ablation around both ipsilateral pulmonary veins (PV) was performed with the endpoint of complete conduction block. When necessary, supplementary RF applications were added, including ablation of complex fractionated potentials and/or isolation of other thoracic veins and/or linear left atrial lesions. RF energy was delivered via an irrigated tip catheter with a maximum power of 30-35 W. Four out of 120 patients undergoing extensive RF ablation for persistent AF (including two patients with additional LA substrate modification) developed dyspnea, bilateral pulmonary edema, and signs of a systemic inflammatory response syndrome (SIRS) (rise in body temperature, leukocyte count, and C-reactive protein (CRP levels) 18-48 hours after the procedure. There were no signs of PV stenosis, focal lung injury, left ventricular dysfunction, circulatory failure, or infection. All patients had complete recovery with supportive therapy within 3-4 days after the onset of symptoms. CONCLUSIONS: Extensive LA radiofrequency ablation bears the risk of a severe pulmonary edema. Although the precise mechanism is elusive, clinical features point toward a systemic inflammatory response.

Hypertension is an independent risk factor for contrast nephropathy after percutaneous coronary intervention.

BACKGROUND: The administration of radiographic contrast agents is an important cause of acute renal failure. We hypothesised that hypertension is an independent risk factor for the development of contrast nephropathy in patients undergoing percutaneous coronary intervention. METHODS: 1383 consecutive patients scheduled for elective or emergency percutaneous coronary intervention were randomly assigned to receive isotonic or half-isotonic hydration. Contrast nephropathy was defined as a rise in serum creatinine of at least 44 micromol/l (0.5 mg/dl) within 48 h of the procedure. Hypertension was defined as self-reported history of treated or untreated diagnosed high blood pressure. RESULTS: The prevalence of hypertension was 63%. Patients with hypertension were significantly older, were more often female, smoked less and had a higher incidence of 3-vessel disease than patients without hypertension. The estimated glomerular filtration rate was slightly lower in hypertensive patients. There was no difference in preventive hydration regimen, type and quantity of contrast medium used, or quantity of intravenous fluids given. Contrast nephropathy developed in 17 of 874 hypertensive patients (2%) compared to 2 of 509 patients (0.4%) without hypertension (p = 0.016). When contrast nephropathy was defined as a 25% rise in baseline creatinine, the disease developed in 103 patients (12%) with and 36 patients (7%) without hypertension (p = 0.005). After adjustment for confounders, arterial hypertension remained an independent predictor of contrast nephropathy (odds ratio 4.6, 95% CI 1.0-20.5, p = 0.046). CONCLUSION: Hypertension is an independent risk factor for the development of contrast nephropathy. Further preventive strategies to lower the incidence of contrast nephropathy in hypertensive patients are warranted.

Incidence of contrast nephropathy in patients receiving comprehensive intravenous and oral hydration.

BACKGROUND: Contrast-induced nephropathy (CIN) remains a major complication of percutaneous coronary interventions (PCI) and a common cause of acute renal failure. The most effective preventive strategy is unknown. OBJECTIVES: This study sought to estimate the incidence of CIN in patients receiving comprehensive intravenous and oral volume supplementation for PCI during which iopromide (Ultravist 370, Schering, Berlin, Germany) was used. METHODS: We prospectively studied the development of CIN in 425 consecutive patients undergoing PCI, applying comprehensive intravenous and oral hydration in all patients. Baseline renal function was assessed by calculating the glomerular filtration rate (GFR) with the use of the abbreviated Modification of Diet in Renal Disease Study equation. CIN was defined as an increase in serum creatinine of at least 0.5 mg/dl (44 mmol/l) within 48 hours. RESULTS: Mean patients' age (mean +/- SD) was 64 +/- 10 years. A total of 133/425 patients (31%) were 70 years or older, 107 (25%) were women, 70 (16%) were diabetics, 218 (51%) had prior myocardial infarction, and 43 (10%) underwent PCI for an acute ST-segment elevation myocardial infarction. Mean GFR was 89 ml/min/1.73 m2. Glomerular filtration rate was below 60 ml/min/ 1.73 m2 in 43 patients (10%). During PCI 226 +/- 80 ml of iopromide were used. With the comprehensive hydration strategy used, CIN developed in only 6 of 425 (1.4%; 95% confidence interval 0.5-3.1%) patients. No patient required dialysis. CONCLUSIONS: Applying the combination of intravenous and oral volume supplementation results in a very low incidence of CIN following PCI. Hydration remains the cornerstone for the prevention of CIN.

Female sex and risk of contrast nephropathy after percutaneous coronary intervention.

BACKGROUND: Women undergoing percutaneous coronary intervention (PCI) seem to have a higher in-hospital mortality than men. The reason for this difference in outcome is unknown. Contrast nephropathy (CN) remains a major complication of PCI and a common cause of acute renal failure. OBJECTIVE: To test the hypothesis that women have a higher incidence of CN, which April contribute in part to their increased in-hospital mortality following PCI. METHODS: Sex-based differences in the development of CN were studied in 1383 patients undergoing PCI who were included in a randomized trial of two hydration regimens. Baseline renal function was assessed by calculating the glomerular filtration rate (GFR) using the abbreviated Modification of Diet in Renal Disease Study equation. CN was defined as an increase in serum creatinine of at least 44 micromol/L within 48 h. RESULTS: Women and men differed in several baseline characteristics. Women were older and had a higher incidence of arterial hypertension and diabetes. In addition, baseline GFR was significantly lower in women than in men. The incidence of CN was significantly higher in women. CN developed in 10 of 354 (2.8%) women compared with nine of 1029 (0.9%) men (odds ratio 3.3, 95% CI 1.3 to 8.2, P=0.01). After adjusting for confounders including baseline GFR and incidence of arterial hypertension, female sex was no longer a significant independent predictor of CN (odds ratio 2.2, 95% CI 0.8 to 5.6, P=0.12). CONCLUSIONS: The significantly higher incidence of CN after PCI in women seemed largely due to their less favourable baseline characteristics, including lower GFR and higher incidence of arterial hypertension, rather than to female sex itself.

Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty.

BACKGROUND: The administration of radiographic contrast agents remains an important cause of acute renal failure. The optimal infusion for hydration has not been evaluated. OBJECTIVE: To compare the incidence of contrast media-associated nephrotoxicity with isotonic or half-isotonic hydration. DESIGN: Prospective, randomized, controlled, open-label study. METHODS: Patients scheduled for elective or emergency coronary angioplasty were randomly assigned to receive isotonic (0.9% saline) or half-isotonic (0.45% sodium chloride plus 5% glucose) hydration beginning the morning of the procedure for elective interventions and immediately before emergency interventions. An increase in serum creatinine of at least 0.5 mg/dL (44 micromol/L) within 48 hours was defined as contrast media-associated nephrotoxicity. Secondary end points were cardiac and peripheral vascular complications. RESULTS: A total of 1620 patients were assigned to receive isotonic (n = 809) or half-isotonic (n = 811) hydration. Primary end point analysis was possible in 1383 patients. Baseline characteristics were well matched. Contrast media-associated nephropathy was significantly reduced with isotonic (0.7%, 95% confidence interval, 0.1%-1.4%) vs half-isotonic (2.0%, 95% confidence interval, 1.0%-3.1%) hydration (P =.04). Three predefined subgroups benefited in particular from isotonic hydration: women, persons with diabetes, and patients receiving 250 mL or more of contrast. The incidence of cardiac (isotonic, 5.3% vs half-isotonic, 6.4%; P =.59) and peripheral vascular (isotonic, 1.6% vs half-isotonic, 1.5%, P =.93) complications was similar between the 2 hydration groups. CONCLUSION: Isotonic hydration is superior to half-isotonic hydration in the prevention of contrast media-associated nephropathy.