Post-contrast acute kidney injury in patients with chronic kidney disease grade IV receiving iodinated contrast for elective computed tomography following new ESUR guidelines prophylaxis
Post-contrast acute kidney injury in patients with chronic kidney disease grade IV receiving iodinated contrast for elective computed tomography following new ESUR guidelines prophylaxis
C. Sebastia Cerqueda, A. Gil Ordóñez, A. Jareño, E. Guillen, LL. Cabedo, E. Poch, C. Nicolau; Barcelona/ES
In 2018, guidelines from the European Society of Urogenital Radiology on contrast agents were updated (ESUR 10.0). These new guidelines define post-contrast acute kidney injury (PC-AKI) as an increase in serum creatinine >0.3 mg/dl (or >26.5 µmol/l), or >1.5 times baseline, that occurs within 48-72 hours of intravascular administration of a contrast agent. ESUR 10.0 reduced the indications for PC-AKI prophylaxis, establishing an eGFR lower than 30 ml/min/1,73m2 as the main risk factor for PC-AKI in patients receiving intravenous (i.v.) iodinated contrast media. Several prophylaxis regimens were proposed for such high-risk patients, including a short i.v. hydration option (3 ml/kg/h one hour before the administration of the contrast agent). The aim of this study is to estimate the PC-AKI rate in our hospital in patients with chronic kidney disease (CKD) grade IV who undergo elective contrast-enhanced CT (CECT) following the ESUR 10.0 short prophylaxis guidelines.
Patients with CKD grade IV (GFR 30-15 ml/min/1.73m2) who attended the out-department's nurse office to evaluate PC-AKI prophylaxis before an elective CECT during 2022 were reviewed. Patients received i.v. prophylaxis one hour before the CECT (sodium bicarbonate/saline 3mL/kg/hour), following ESUR new guidelines. An increase in serum creatinine ≥0.3 mg/dL within 48-72h after the i.v. contrast administration was considered PC-AKI. Serum creatinine levels before the CECT and 48-72 hours and 15 days after CECT were analysed. When PC-AKI was detected, patients who had returned to their baseline eGFR 15 days after the CECT were classified as reversible and those who did not were considered irreversible cases of PC-AKI. Basic epidemiological data such as gender, age and indication for the CECT were also registered.
Three hundred fifty-two patients attended our department's nurse's office during 2022 for evaluation of PC-AKI prophylaxis before an elective CECT after an automatic alert detected GFR between 30 and 15mL/min/1.73m2. Two hundred and six patients were excluded from the study due to the following: - eGFR 30ml/min/1.73m2 previously to the CECT (38) - patients already in dialysis (18) - CT not performed (26) - non-contrast CT performed (52) - lack of post-CECT serum creatinine levels (42). - Multiple CECTs (30) One hundred forty-six patients were finally included in this study. 29 patients experienced AKI 48-72 hours after CECT; in 12 cases other concomitant causes of AKI were found. - Prerenal AKI (2) - Dilated urinary tract (3) - Kidney or urinary tract surgery or procedure (6) - Diarrea (1) PC-AKI rate was 17 (11,6%), of which 12 were reversible (8,2%) and in 5 cases were irreversible (3,4%).
Although the pathophysiological mechanisms behind PC-AKI are not completely understood and there is controversy in the literature about the causative association of contrast agents and AKI, efforts have been made in recent years to identify which types of patients are most at risk of developing PC-AKI. The ESUR 10.0 guidelines on safety in contrast agents represented a relevant change from previous practice, reducing the indications for PC-AKI prophylaxis and omitting most of the patient-related risk factors considered in previous guidelines. Under ESUR 10.0 guidelines, risk factors may be divided into two groups: Those related to the patient: - eGFR < 30ml/min/1.73m2 - Confirmed or suspected acute renal failure. Those related to the procedure: - Intra-arterial contrast medium administration with first-pass renal exposure. - High-osmolality contrast media. - Multiple contrast medium injections within 48-72 hours. Some studies have evaluated the usefulness of i.v. and oral hydration as prophylaxis for PC-AKI in patients with eGFR 30-60 ml/min/1.73m2 showing PC-AKI rates of 4.6 to 9.5 %. In this context and given that new guidelines limit the indication of prophylaxis to patients with eGFR <30ml/min/1.73m2, we aimed to estimate the rate of PC-AKI in patients with CKD grade IV in a real-life environment with very short schemes of hydration. Our results show a PC-AKI rate of 11,6% in a high-risk population (CDK grade IV) who received prophylaxis following ESUR new guidelines. We observed that in most cases, PC-AKI were reversible and previous renal function were restored in 15 days or less (8,2%). These oscillations of creatinine levels are even minor to that Newhouse et al observed in patients with CDK grade IV in which unenhanced CT was performed (https://doi.org/10.2214/AJR.07.3280 ) The rate of irreversible PC-AKI was 3,8% in our sample. Even though risk factors such as diabetic nephropathy, hypertension or oncological disease are now considered to be nonspecific and do not indicate the necessity of prophylaxis, PC-AKI is multifactorial, and they might play a significant role. All cases of irreversible PC-AKI in our series occurred in old patients (70 years old and older) with concurrent abdominal metastatic oncological disease. Therefore, caution must be taken in this specific group of patients in order to prevent persistent PC-AKI, avoiding multiple contrast medium injections and performing a more extended hydration scheme. In conclusion, although the PC-AKI rate in patients with CKD grade IV was high (11,6%), most cases were reversible, with the restoration of previous renal function in 15 days. Oncological patients older than 70 years old with abdominal metastatic disease seem to be the group more at risk for irreversible PC-AKI. In conclusion, although PC-AKI rate in patients with CKD grade IV is high (11,6 %), most cases are reversible with restoration of previous renal function in 15 days ( 8,2%). All patients with irreversible PC-AKI (3,4%) were older than 70 years and had oncological abdominal metastatic disease. In these cases, a more intense hydration prophylaxis regime should be performed.
