Effect of no prehydration vs sodium bicarbonate prehydration prior to contrast-enhanced computed tomography in the prevention of postcontrast acute kidney injury in adults with chronic kidney disease the Kompas randomized clinical trial

Importance Prevention of postcontrast acute kidney injury in patients with stage 3 chronic kidney disease (CKD) by means of prehydration has been standard care for years. However, evidence for the need for prehydration in this group is limited. Objective To assess the renal safety of omitting prophylactic prehydration prior to iodine-based contrast media administration in patients with stage 3 CKD. Design, Setting, and Participants The Kompas trial was a multicenter, noninferiority, randomized clinical trial conducted at 6 hospitals in the Netherlands in which 523 patients with stage 3 CKD were randomized in a 1:1 ratio to receive no prehydration or prehydration with 250 mL of 1.4% sodium bicarbonate administered in a 1-hour infusion before undergoing elective contrast-enhanced computed tomography from April 2013 through September 2016. Final follow-up was completed in September 2017. Data were analyzed from January 2018 to June 2019. Interventions In total, 262 patients were allocated to the no prehydration group and 261 were allocated to receive prehydration. Analysis on the primary end point was available in 505 patients (96.6%). Main Outcomes and Measures The primary end point was the mean relative increase in serum creatinine level 2 to 5 days after contrast administration compared with baseline (noninferiority margin of less than 10% increase in serum creatinine level). Secondary outcomes included the incidence of postcontrast acute kidney injury 2 to 5 days after contrast administration, mean relative increase in creatinine level 7 to 14 days after contrast administration, incidences of acute heart failure and renal failure requiring dialysis, and health care costs. Results Of 554 patients randomized, 523 were included in the intention-to-treat analysis. The median (interquartile range) age was 74 (67-79) years; 336 (64.2%) were men and 187 (35.8%) were women. The mean (SD) relative increase in creatinine level 2 to 5 days after contrast administration compared with baseline was 3.0% (10.5) in the no prehydration group vs 3.5% (10.3) in the prehydration group (mean difference, 0.5; 95% CI, -1.3 to 2.3; P < .001 for noninferiority). Postcontrast acute kidney injury occurred in 11 patients (2.1%), including 7 of 262 (2.7%) in the no prehydration group and 4 of 261 (1.5%) in the prehydration group, which resulted in a relative risk of 1.7 (95% CI, 0.5-5.9; P = .36). None of the patients required dialysis or developed acute heart failure. Subgroup analyses showed no evidence of statistical interactions between treatment arms and predefined subgroups. Mean hydration costs were euro119 (US $143.94) per patient in the prehydration group compared with euro0 (US$0) in the no prehydration group (P < .001). Other health care costs were similar. Conclusions and Relevance Among patients with stage 3 CKD undergoing contrast-enhanced computed tomography, withholding prehydration did not compromise patient safety. The findings of this study support the option of not giving prehydration as a safe and cost-efficient measure.Cardiolog

Chronic rejection in renal tranplantation

Immunopathologische aspecten van vaat- en nierziekte

A joint latent class changepoint model to improve the prediction of time to graft failure

The reciprocal of serum creatinine concentration, RC, is often used as a biomarker to monitor renal function. It has been observed that RC trajectories remain relatively stable after transplantation until a certain moment, when an irreversible decrease in the RC levels occurs. This decreasing trend commonly precedes failure of a graft. Two subsets of individuals can be distinguished according to their RC trajectories: a subset of individuals having stable RC levels and a subset of individuals who present an irrevocable decrease in their RC levels. To describe such data, the paper proposes a joint latent class model for longitudinal and survival data with two latent classes. RC trajectories within latent class one are modelled by an intercept-only random-effects model and RC trajectories within latent class two are modelled by a segmented random changepoint model. A Bayesian approach is used to fit this joint model to data from patients who had their first kidney transplantation in the Leiden University Medical Center between 1983 and 2002. The resulting model describes the kidney transplantation data very well and provides better predictions of the time to failure than other joint and survival models. © 2008 Royal Statistical Society

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Cardiovascular Aspects of Radiolog