|Year : 2021 | Volume
| Issue : 4 | Page : 347-350
Contrast-induced nephropathy following peripheral endovascular intervention and its long-term morbidity
V Vishal Hudgi, B Nishan, K Sivakrishna, I Surya Kiran, Roshan Rodney, Vishnu Motukuru
Department of Vascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
|Date of Submission||06-Nov-2020|
|Date of Acceptance||07-Dec-2020|
|Date of Web Publication||9-Dec-2021|
V Vishal Hudgi
Department of Vascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objectives: Contrast-induced nephropathy (CIN) is an acute deterioration of renal function seen following the administration of iodinated contrast media for various diagnostic procedures. Although extensive study has been done in various fields, the data on CIN are lacking in peripheral endovascular procedures. This study was conducted to analyze the incidence, risk factors, and long-term renal morbidity of CIN after endovascular procedure for critical limb ischemia (CLI) of lower limbs. Methods: This was a prospective, observational study and the patients undergoing peripheral endovascular procedure for CLI in a referral center were included. The patients were followed up for the development of CIN with serum creatinine levels on the 5th day postprocedure and till 6 months. Results: A total of 211 patients with various comorbidities were included. The incidence of CIN was found to be 7.5%. The risk factors and multiple comorbidities were compared between CIN and non CIN patients. The higher preprocedure creatinine (mean 1.03 mg/dl vs. 0.92 mg/dl, P < 0.045), higher contrast volume (mean 73.8 ml vs. 52.1 ml, P < 0.001), and lower hemoglobin (mean 10.5 g/dl vs. 11.8 g/dl, P < 0.008) were significantly associated with CIN. The follow-up at 6 months showed CIN patients had increased serum creatinine and reduced estimated glomerular filtration rate as compared to non-CIN patients. Conclusion: CIN is a substantial problem in peripheral endovascular procedures with long-term renal morbidity. The strategies to prevent CIN should be included in all patients undergoing endovascular procedures irrespective of risk profile and long-term renal function monitoring of CIN patients is warranted.
Keywords: Contrast-induced nephropathy, peripheral endovascular procedures, renal morbidity
|How to cite this article:|
Hudgi V V, Nishan B, Sivakrishna K, Kiran I S, Rodney R, Motukuru V. Contrast-induced nephropathy following peripheral endovascular intervention and its long-term morbidity. Indian J Vasc Endovasc Surg 2021;8:347-50
|How to cite this URL:|
Hudgi V V, Nishan B, Sivakrishna K, Kiran I S, Rodney R, Motukuru V. Contrast-induced nephropathy following peripheral endovascular intervention and its long-term morbidity. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 25];8:347-50. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/347/332043
| Introduction|| |
It has been >60 years since contrast-induced nephropathy (CIN) was first described in the medical literature. Variety of studies has been conducted to investigate its incidence and various mechanisms examined to explain its pathophysiology. However, CIN remains a controversial topic with a widely variable and often questionable incidence derived from various studies. The contrast agents are used extensively in vascular imaging and interventions. CIN is defined as an absolute increase of 0.5 mg/dL in serum creatinine concentration or a relative increase in 25% from the baseline value, as measured 48–72 h after exposure to contrast medium., CIN characteristically manifests 3 days after the administration of the contrast medium, with a peak in renal function decline 3–5 days after contrast exposure. The prevalence of CIN reported in literature varies between 1% and 45% and depends largely on comorbidities of the study population. An increase in use of invasive catheter-based diagnostic and therapeutic interventions has led to rise in the amount of intra-arterial contrast medium administered to patients. Although peripheral endovascular interventions are well established as limb salvage treatments for critical limb ischemia (CLI), few studies have analyzed the incidence of CIN and associated long-term morbidity in this group. The prompt identification and prevention of CIN is important because it is the third most common cause of acute kidney injury in patients admitted to hospital. This study was conducted to analyze the incidence of CIN, risk factors, and long-term renal morbidity associated with it in the patients undergoing endovascular interventions for CLI of lower limbs.
| Methods|| |
This was a prospective observational study conducted at a tertiary care unit JIVAS, Bangalore. All the patients admitted in JIVAS, Bhagwan Mahaveer Jain Hospital with CLI (Rutherford class IV, V, VI) requiring endovascular revascularization for iliac/infrainguinal diseases during June 2018 to October 2019 were included. The present study was approved by the Institutional Ethics Committee. Patient with end-stage renal disease who were on dialysis, patients who received additional iodinated contrast media during the follow-up period, patients with preoperative serum creatinine of >1.5 mg/dl, and patients who underwent intervention with CO2 angiogram were excluded. The serum creatinine level was measured before intervention, on the 5th day after intervention and at 1 month, 3 months, and 6 months (±3 days) during follow-up. The modification of diet in renal disease formula was used for estimated glomerular filtration rat (eGFR) calculation. The included patients were grouped as CIN and no CIN and the associated risk factors and renal outcome were analyzed.
All the patients admitted with CLI in the unit during the study period underwent detailed history taking, physical examination, and laboratory evaluation. The demographic data, comorbidities, medications, and vitals (within 24 h before the intervention) of the included patients were noted. Diabetes mellitus (DM) was defined by the criteria of fasting blood glucose levels of >126 mg/dl and/or HbA1c (>6.5%) and/or on medication for the same. Hypertension was considered when the recorded systolic blood pressure was >140 mg Hg and/or diastolic blood pressure >90 mm Hg and/or receiving antihypertensive medications. Dyslipidemia was defined as serum low-density lipoprotein cholesterol >100 mg/dl or total cholesterol >200 mg/dl, or on medication for dyslipidemia.
All the included patients underwent detailed evaluation with ankle brachial index, toe brachial index, pulse volume recording and transcutaneous oximetry, arterial duplex scan, contrast-enhanced magnetic resonance angiography. All patients were evaluated by vascular surgeons' team. Patients who were planned for the endovascular procedure with iodinated contrast material were given intravenous hydration with 0.9% NaCl at 1 ml/kg/h (0.5 ml/kg/h if ejection fraction was <40%) 12 h preprocedure and for a minimum of 12 h postprocedure based on the urine output. Infusion of 150 mEq/L sodium bicarbonate as a bolus of 3 ml/kg/h for 1 h before the administration of contrast, followed by 1 mL/kg/h for 6 h during and after the procedure. N-acetyl cysteine of 1200 mg twice daily was started 1 day before the procedure and continued for 2 days post procedure. All DM patients who were on oral hypoglycemic agents were switched over to regular insulin and strict glycemic control was ensured perioperatively. Nonsteroidal anti-inflammatory drugs use was restricted for 2 days before the procedure. All patients received statin and antiplatelet therapy as per unit protocol.
Nonionic contrast media Iohexol (Omnipaque 300 mg per ml) was used for imaging in all patients. Most of the procedures were carried out under local anesthesia with monitored anesthesia care unless patient opted for general anesthesia. All cases were done by consultant vascular and endovascular surgeons.
The Excel and SPSS version 18.5 (SPSS Inc, Chicago) software packages were used for data entry and analysis, respectively. The results were averaged (mean ± standard deviation) for each parameter for continuous data and percentage for categorical data. Student's t-test was used to compare the two groups for continuous variables. Proportions were compared using the Chi-square test. P < 0.05 was accepted as statistically significant.
| Results|| |
A total of 211 patients were included in the study. Patients with chronic kidney disease (on dialysis), revascularization within the last 6 months of inclusion into the study, and who underwent CO2 angiogram were excluded. [Figure 1] shows the flow chart for the inclusion of the patients.
|Figure 1: Flow chart of patient enrolment. Note: CKD – chronic kidney disease, CO2 – carbon dioxide|
Click here to view
The general characteristics of the study population are presented in [Table 1]. None of the observed comorbidities for CLI posed a significant risk for CIN. The significant risk factors for CIN are presented in [Table 2]. The incidence of CIN in our study was 7.5%. The factors associated with CIN were higher baseline creatinine value 1.03 mg/dl (95th confidence interval [CI] 0.53–1.53, P < 0.045) versus 0.92 mg/dl, higher contrast volume 73.8 ml (95th CI 11.8–135.8 ml, P < 0.001) versus 52.1 ml. The patients who developed CIN also had a lower mean hemoglobin 10.5 g/dl versus 11.8 g/dl (P < 0.008). The baseline low eGFR and high creatinine were associated with long-term renal function decline in CIN.
|Table 2: Significant risk factors for developing contrast-induced nephropathy|
Click here to view
Long-term renal outcome in patients with contrast-induced nephropathy
At 6 months follow-up, lower mean eGFR was seen in CIN patients (50.9 ml/min/1.73 m2 95th CI 35.9–65.9 ml/min/1.73 m2, P < 0.001) versus 74.6 ml/min/1.73 m2 in non CIN patients. The mean creatinine was also found to be high in CIN patients (1.49 mg/dl vs. 1.07 mg/dl).
| Discussion|| |
The incidence of CIN varies greatly depending on the population age, comorbidities, type and volume of contrast used, preventive measures implemented, and time of measuring postprocedure creatinine. In our study, the incidence of CIN was found to be 7.5% which is in agreement with the documented incidence between 5.4% and 13.5% in the literature in peripheral vascular interventions.
Although various risk factors have been found to be associated with the development of CIN, no single factor is known to be causative. The reviewed literature showed variable risk factors. In our study, preintervention creatinine, contrast volume, and anemia were significantly associated with CIN, whereas age, metabolic syndrome, and stages of CLI were not found to be significant. Our findings are in line with the published data on CIN risk factors.,,,
CIN is known to cause acute adverse effects, longer hospital stay, and long-term renal function decline. Lower eGFR in CIN patients at 6 months follow-up in our study is consistent with the current available literature in peripheral endovascular interventions. However, further large studies are required to assess renal and other long-term morbidities.
CIN is variable by its definition and risk factors. Still, there is a large knowledge gap in the risk factors, preventive measures and causality of long-term morbidities. However, the present study was a prospective study and included patients undergoing single peripheral vascular intervention and identified the risk factors and long-term renal morbidity in CIN patients. This warrants the vascular surgeons to monitor all patients undergoing the intervention for CIN and also follow them up for long-term morbidities.
However, the study has some limitations. The study excluded patients with CKD on dialysis and those who had higher creatinine (>1.5 mg/dl), who are at increased risk of CIN with low renal function. The risk factors were not matched in CIN and non-CIN groups as in randomized studies. The cardiovascular events were not assessed on follow-up. The CIN effect on patients undergoing revascularization during the follow-up period was not assessed. Hence, the study recommends further research with randomized trials in peripheral vascular interventions.
| Conclusion|| |
The study adds to the current limited literature available on CIN after peripheral vascular interventions. With the protocolized preventive measures, CIN incidence was high with long-term renal function decline. Hence, the study warrants further research on CIN to improve patients' outcome after peripheral vascular interventions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, et al
. CIN consensus working panel. Epidemiology and prognostic implications of contrast-induced nephropathy. Am J Cardiol 2006;98:5K-13.
Solomon R. Contrast-induced acute kidney injury (CIAKI). Radiol Clin North Am 2009;47:783-8, v.
Gleeson TG, Bulugahapitiya S. Contrast-induced nephropathy. AJR Am J Roentgenol 2004;183:1673-89.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 2000;23 Suppl 1:S4-19.
Verdecchia P, Angeli F. The seventh report of the joint national committee on the prevention, detection, evaluation and treatment of high blood pressure: The weapons are ready. Rev Esp Cardiol 2003;56:843-7.
Das SK, Yuan YF, Li MQ. Predictors of delayed wound healing after successful isolated below-the-knee endovascular intervention in patients with ischemic foot ulcers. J Vasc Surg 2018;67:1181-90.
Karlsberg RP, Dohad SY, Sheng R, Iodixanol Peripheral CTA Study Investigator Panel. Contrast-induced acute kidney injury (CI-AKI) following intra-arterial administration of iodinated contrast media. J Nephrol 2010;23:658-66.
Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, et al.
The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000;36:1542-8.
Kumar S, Nair RK, Aggarwal N, Abbot AK, Muthukrishnan J, Kumar KV, et al.
Risk factors for contrast-induced nephropathy after coronary angiography. Saudi J Kidney Dis Transpl 2017;28:318-24.
] [Full text]
Grossman PM, Ali SS, Aronow HD, Boros M, Nypaver TJ, Schreiber TL, et al
. Contrast-induced nephropathy in patients undergoing endovascular peripheral vascular intervention: Incidence, risk factors, and outcomes as observed in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. J Intervent Cardiol 2017;30:274-80.
Nyman U, Björk J, Aspelin P, Marenzi G. Contrast medium dose-to-GFR ratio: A measure of systemic exposure to predict contrast-induced nephropathy after percutaneous coronary intervention. Acta Radiol 2008;49:658-67.
Sigterman TA, Krasznai AG, Snoeijs MG, Heijboer R, Schurink GW, Bouwman LH, et al.
Contrast induced nephropathy and long-term renal decline after percutaneous transluminal angioplasty for symptomatic peripheral arterial disease. Eur J Vasc Endovasc Surg 2016;51:386-93.
[Table 1], [Table 2]