Clinical Study Of Contrast-induced Nephropathy In Patients Undergoing Coronary Intervention

Contrast-induced nephropathy(CIN) is a complex syndrome of acute renal failure occurring after the administration of iodinated contrast media.CIN is one of the most common sources of acute renal failure among hospitalized patients.It is associated with prolonged in-hospital stay and increased mortality and costs.Through this prospective study,we evaluate the incidence of CIN in general patients undergoing coronary angiographically diagnostic and therapeutic procedures and the clinic risk factors of CIN.We also evaluate the renal safety of isosmolar iodixanol in renal insufficiency patients.Part 1 Incidence and risk factors of contrast-induced nephropathy in patients undergoing coronary intervention:a prospective studyObjective:To evaluate the incidence of contrast-induced nephropathy(CIN) in general patients undergoing coronary angiographically diagnostic and therapeutic procedures and the clinic risk factors of CIN.Method:This is a single center,prospective study.Between January 2007 and December 2007,in patients underwent coronary intervention in Zhongshan Hospital, Fudan University,a total of 532 patients with complete data and good compliance were enrolled.Age,sex,body weight,co-morbidities(including diabetes mellitus, hypertension,heart failure,anemia and proteinuria),use of drugs(including metformin,angiotensin converting enzyme inhibitors(ACEI),diuretics),the result of renal arteriography,type of contrast media,and volume of contrast-meida used were documented.Serum creatinine(Scr) was measured at any time a week before the angiography and 2 days(48 hours) post procedure to judge if CIN occurred or not. The definition of CIN is the increase of the serum creatinine of 44.2μmol/l (0.5mg/dl) or 25%of the baseline at 48 hours after the use of contrast media. Creatinine clearance(Ccr) is calculated by C-G formula.Incidence of CIN in real world patients undergoing coronary intervention was investigated and multivariate predictors of CIN was determined using logistic regression.Results:1)Among the all 532 patients,408(76.7%) were male and 124 (23.3%) were female.The average age was 63.7±10.3 years old.Among the patients enrolled,138(25.9%) had diabetes mellitus,356(66.9%) had hypertension, 12(2.3%) had heart failure(NYHAⅢ-Ⅳ),and anemia and proteinuria existed in 2 (0.4%) cases and 31(5.8%) cases respectively.Fifty-three(10.0%) patients took metformins,while 258(48.5%) and 64(12.0%) patients took ACEI and diuretics respectively.The average Scr before procedure was 85.5±30.1μmol/L and the average Ccr before procedure was 77.7±27.8ml/min.Renal arteriography showed that 48(9.0%) patients had renal artery stenosis.Iodixanol was used in 105(19.7%) patients.Iopamidol was used in 216(40.6%) patients.While Iohexol and Iopromide was used in 171(32.2%) and 40(7.5%) patients respectively.The average volume of contrast media was 219±106.5ml.Among the 532 patients,CIN occurred in 29 patients with the incidence of CIN in gerenal patients of 5.5%.The increase of Scr of 25%of the baseline after procedure occurred in all the 29 patients but the increase of Scr of 44.2μmol/l of the baseline occurred in only two patients and the incidence was 0.4%.2) In 52 patients with Scr＞115μmol/l before procedure,4 patients experienced CIN and the incidence was 7.7%.There was no significant difference concerning the incidence of CIN in patients with Scr＞115μmol/l compared with those with Scr≤115μmol/l(7.7%vs.5.2%,p=0.669).Taking Scr of 130μmol/l as cut point,there was no insignificant difference in patients with baseline Scr＞130μmol/l compared with that in those with baseline Scr≤130μmol/l(11.4%vs. 5.0%,p=0.220),either.In 138 patients with Ccr＜60ml/min before procedure,10 patients experienced CIN and the incidence was 7.2%.There was no significant difference regarding the incidence of CIN in patients with Ccr＜60ml/min compared with those with Ccr≥60ml/min(7.2%vs.4.8%,p=0.280).Taking Ccr of 45ml/min as cut point,there was insignificantly higher of CIN(11.4%) in patients with baseline Ccr＜45ml/min compared with that in those with baseline Ccr≥45ml/min(17.5%vs. 4.5%,p=0.002).In 348 patients with 45≤Ccr＜90ml/min,11 patients experienced CIN,and in 144 patients with Ccr≥90ml/min,11 patients experienced CIN.There was no significant difference regarding the incidence of CIN between the two groups (3.2%vs.7.6%,p=0.052).3) No significant difference existed between the incidence of CIN in patients with DM and that in patients without DM.(4.3%vs. 5.8%,p=0.187).4) Old age of more than 75 years old,diuretics intake before procedure,baseline Ccr＜45ml/min,and volume of contrast-meida more than 500ml were the univariated risk factors of CIN.Using logistic regression,diuretics intake before procedure,basic Ccr＜45ml/min,and volume of contrast-meida more than 500ml were the independent risk factors of CIN.Conclusions:The incidence of contrast-induced nephropathy(CIN) in real world patients undergoing coronary intervention is 5.5%.In patients with low baseline Scr, the incidence of CIN may be lower if the definition of CIN is the increase of the serum creatinine of 44.2μmol/l(0.5mg/dl) of the baseline at 48 hours after the use of contrast media.The incidence of CIN is significant higher in the patients with Ccr＜45ml/min than that in patients with Ccr≥45ml/min.And Ccr is a better predictor of CIN than Scr.The incidence of CIN is no significant increase in those with diabetes mellitus.Age may be a risk factor of CIN,but not independent.The independent risk factors of CIN are diuretics intake before procedure,basic Ccr＜45ml/min,and volume of contrast-meida more than 500ml.Part 2 The renal safety of isosmolar iodixanol in renal insufficiency patientsObjective:To evaluate the renal safety of isosmolar iodixanol in renal insufficiency patients.Method:This is a single center,prospective study.Between January 2007 and December 2007,in patients underwent coronary intervention in Zhongshan Hospital, Fudan University,a total of 532 patients with complete data and good compliance were enrolled.Age,sex,weight,co-morbidities(including diabetes mellitus, hypertension,heart failure,anemia and proteinuria),the use of drugs(including metformin,Angiotensin converting enzyme inhibitors(ACEI),diuretics),the result of renal arteriography,type of contrast media,and volume of contrast-meida were documented.Serum creatinine was measured at any time a week before the angiography and 2 days(48 hours) post procedure to judge if CIN occured or not. Creatinine clearance(Ccr) was calculated by C-G formula.The definition of renal insufficiency was Ccr＜45ml/min.We compared the incidence of CIN in patients with Ccr＜45ml/min and Ccr≥45ml/min used different types of contrast-media to evaluate the renal safety of isosmolar iodixanol in renal insufficiency patients. Results:1) Among the all 40 patients with Ccr＜45ml/min,LOCM was used in 21 patients and IOCM was used in 19 patients.There was no significant difference regarding the incidence of CIN between the two groups(19.0%vs.15.8%,p=1.000). 2) In a total of 427 patients used LOCM,21 patients was with Ccr＜45ml/min.The incidence of CIN in patients with Ccr＜45ml/min was significantly higher than that in patients with Ccr≥45ml/min(19.0%vs.4.9%,p=0.024).3) In 19 patients with Ccr＜45ml/min and used IOCM,3 patients experienced CIN.The incidence of CIN in patients with Ccr＜45ml/min and used IOCM was significantly higher than that in patients used with Ccr≥45ml/min and IOCM(15.8%vs.2.3%,p=0.040).4) Among 19 patients with Ccr＜45ml/min and used IOCM,3 patients experienced CIN.And in 406 patients with Ccr≥45ml/min and used LOCM,20 patients experienced CIN. There was no significant difference between the two groups(15.8%vs.4.9%, p=0.127).Conclusions:Both IOCM and LOCM can induce a higher incidence of CIN in renal insufficiency patients.But it is likely that the renal safety of IOCM might be a little better than LOCM.