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.METHODS AND FINDINGS: 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

Network of treatment comparisons for prevention of contrast-induced acute kidney injury in patients undergoing cardiovascular invasive procedures.

<p>The size of the nodes corresponds to the number of trials that studied the treatments. Directly compared treatments are linked with a line, the thickness of which corresponds to the number of trials that assessed the comparison. LVEDP = left ventricular end-diastolic pressure; NAC = N-acetyl cysteine; n = number of patients allocated to a specific treatment.</p

Flow diagram of network meta-analysis.

<p>Flow diagram of network meta-analysis.</p

Forest plots for effect sizes of treatment strategies compared with saline, for mortality, dialysis, myocardial infarction and heart failure.

<p>Estimates are presented as odds ratios and 95% credible intervals (95% CrI). LVEDP = left ventricular end-diastolic pressure; NAC = N-acetylcysteine; *in severe chronic kidney disease.</p

Overall and GFR stratified analysis for CIAKI prevention, with NNT.

<p>Overall and GFR stratified analysis for CIAKI prevention, with NNT.</p

Network meta-analysis odds ratios and 95% credible intervals for contrast-induced acute kidney injury.

<p>Comparisons between treatments should be read from left to right. Estimates of treatment effects in the cell in common between the row-defining treatment and the column-defining treatment. Odds ratios lower than 1 favour the row-defining treatment. To obtain odds ratios for comparisons in the opposite direction, reciprocals should be taken. Significant results are in bold and underlined. ER = event rate; LVEDP = left ventricular end-diastolic pressure; NAC = N-acetylcysteine.</p