Effect Of Iso-osmolar Contrast Media Versus Lowosmolar Contrast Medium On Contrast-induced Acute Kidney Injury In Patients With Acute Myocardial Infarction Undergoing Emergent Percutaneous Coronary Intervention

ObjectiveContrast-induced acute kidney injury(CI-AKI)is a complication associated with the use of intravascular injection of contrast agents,which has risk of acute renal failure,inhospital dialysis and mortality,impacting short-term and long-term outcomes.The main cause of CI-AKI in cardiovascular intervention is percutaneous coronary intervention(PCI),and the incidence of CI-AKI is higher among patients with ST-segment elevation acute myocardial infarction(STEMI)who undergo primary PCI than those patients undergoing coronary angiography or elective PCI,ranging from 16.1% to 28%.Physico-chemical properties of various contrast media,such as viscosity and osmolality,might play a role in the development of CI-AKI,but the selection of the least-toxic iodinated contrast agent in high-risk patients in clinical practice is controversial.NEPHRIC study showed that the incidence of CI-AKI in diabetic patients with chronic kidney failure is higher in using lowosmolar contrast medium(LOCM)iohexol than an iso-osmolar contrast medium(IOCM)iodixanol.But recent randomized trials failed to find any statistical difference between IOCM or LOCM in high-risk patients.Furthermore,whether LOCM iohexol is suitable for patients with STEMI who undergo emergent PCI has not been reported in the previous study.This study aimed to compare the incidence of CI-AKI following IOCM iodixanol or LOCM iohexol administration in patients with acute myocardial infarction(AMI)undergoing primary PCI and to evaluate the potential clinical impact of them on CI-AKI.MethodsThe trial was a prospective,randomized controlled study,including consecutive patients from July 2015 to November 2016 admitted to our chest pain center with STEMI who underwent emergent PCI.Inclusion criteria: Men or women aged >18 years;Patients with STEMI presenting within 12 hours after the onset of symptoms(18 hours in case of cardiogenic shock,or within 24 hours after thrombolysis).Exclusion criteria: A: Women in pregnancy or lactation.B: Severe renal function failure with CKD staged 4 or 5 or long-term dialysis.C: Intra-arterial or intravenous administration of iodinated contrast medium within 7 days before included.D: Intake of any nephrotoxic medications within 24 hours before included.Rejection criteria: The following patients will be rejected.A: Underwent only coronary angiography but not PCI procedure..B: Died peri-procedure of PCI or 2 days after PCI.C: Re-administration of iodinated contrast within 2 days after PCI.D: Serum creatinine(sCr)of pre-procedure was not detected.The patients were randomized to the IOCM iodixanol group or the LOCM iohexol group according to the infarcted walls(inferior and anterior infarction)indicated by electrocardiogram and sCr was measured at admission,days 2,and day 3.Clinical characteristics and major adverse events were recorded.The primary end point was incidence of CI-AKI,which is defined as sCr increase>25% or >0.5mg/d L(44?mol/L)from baseline to 72 hours.ResultsA total of 310 patients were randomized to receive iodixanol or iohexol,and 13 patients were eliminated from the group for matching with the rejection criteria.Two hundred ninetyseven patients were allocated to iodixanol group(n=149)or iohexol group(n=148).1.No significant differences were detected in general clinical characteristics between the iodixanol group and iohexol groups(P>0.05).The primary end point occurred in 22.1% of the iodixanol group and 16.9% of the iohexol group(95% confidence interval-14.2% to 3.8%,P value for noninferiority <0.002).At 1-month follow-up,the incidence of Major Adverse Renal and Cardiac events(MARCE)in total of the population was 5.4%,in which the incidence of iohexol group was statistically higher than that of iodixanol group(8.1% vs 2.7%,P=0.038).However,there were no statistical differences in Major Adverse Cardiac events(MACE)(2.7% vs 6.8%,P=0.098)and In-hospital dialysis(0% vs 1.4%,P=0.247)between two groups.2.The total incidence of CI-AKI in block analysis was higher in anterior infarction group than in inferior infarction group(21.4% vs.11.6%,P<0.01).The incidences of CI-AKI in iodixanol group were 30% and 13% in patients with inferior and anterior infarction respectively(P=0.013).Among iohexol group,the incidences of CI-AKI were 22.8% in subgroup of anterior wall infarction and 10.1% in sub-group of inferior wall infarction respectively(P=0.041).Univariate analysis was performed between inferior and anterior infarction groups and statistical differences were detected in diabetes mellitus,hyperlipidemia,hypotension before admission,Killip classification,contrast agent volume>100ml,the use of intra-aortic balloon pump(IABP),the average value and classification of left ventricular ejection fraction,the use of dopamine or diuretics,volume expansion therapy.Logistic regression analysis revealed the use of diuretics was identified as independent predictors of CI-AKI(OR=2.322,P=0.007,95%CI:1.262-4.272).ConclusionsThe major finding of the study is that there were no significant differences between LOCM iohexol and IOCM iodixanol on the incidence of CI-AKI in STEMI patients who underwent emergent PCI.Secondly,the incidence of CI-AKI is different between groups according to the infarcted walls,which is higher in anterior infarction group than inferior infarction group.Finally,the use of diuretics is independent predictors of CI-AKI development after emergent PCI for STEMI.