As low as reasonably achievable (ALARA) is a widely accepted approach to contrast use in PCI due to contrast induced acute kidney injury (CI-AKI).
Contrast medium has a "two-hit" model of direct contrast-induced renal tubular epithelial cell toxicity and vasoconstriction within the renal arteries that can last up to several hours, which results in the kidneys becoming ischemic and a decreased glomerular filtration rate (GFR), this in-turn causes a rise in creatinine. This complication adds to the patient’s length of stay and cost accrual to the hospital.
CI-AKI (also referred to as contrast induced nephropathy, CIN) is one of the major causes of hospital-acquired AKI:
Stage | Estimated GFR (ml/min/1.73 m2) | Cardiovascular risk (odds ratio) |
1 | >90† | Dependent on degree of proteinuria |
2 | 30–89† | 1.5 |
3 | 30–59 | 2-4 |
4 | 15–29 | 4-10 |
5 | <15 | 10-50 |
ESRD | Dialysis | 20-1000 |
Authors12 | Clinical presentation | Patients (N) | CKD | CKD invasive | No CKD invasive |
Chertow et al | MI | 57,284 | 26% | 25% | 47% |
Han et al | NSTE ACS | 45,343 | 14% | 48% | 74% |
Goldenberg et al | NSTE ACS | 13,141 | 32% | 50% | 68% |
Szummer et al | MI | 57,477 | 33% | 33% | 58%a |
Nauta et al | MI | 12,087 | 25%b | NS | NS |
LVDEP | Rate |
<13 | 5.0 ml/kg/hr |
13-18 | 3.0 ml/kg/hr |
>18 | 1.5 ml/kg/hr |
Philips PCI guidance solutions incorporate non-invasive and adjunctive IVUS and iFR modalities, requiring less contrast for proper diagnosis.
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7. Manjunath G, et al. Level of Kidney Function as a Risk Factor for Atherosclerotic Cardiovascular Outcomes in the CommunityJACC 2003; 41:47–55.
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10. Dangas G, et al. Contrast-Induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. AJC 2005.
11. Chertow et al. “Renalism”: Inappropriately Low Rates of Coronary Angiography in Elderly Individuals with Renal Insufficiency. J Am Soc Nephrol 15: 2462-2468, 2004.
12. Weisbord S. AKI and Medical Care after Coronary Angiography: Renalism Revisited. CJASN November 2014, 9 (11) 1823-1825; DOI: https://doi.org/10.2215/CJN.09430914.
13. Brar et al. Hemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomized controlled trial. Lancet 2014. DOI: https://doi.org/10.1016/S0140-6736(14)60689-9.
14. Brown et al. Does Safe Dosing of Iodinated Contrast Prevent Contrast-Induced Acute Kidney Injury? Circ Interv 2010;3:346-350.
15. Amin, A. P., Bach, R. G., Caruso, M. L., Kennedy, K. F., and Spertus, J. A. (2017). Association of Variation in Contrast Volume With Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention. JAMA cardiology, 2(9), 1007–1012. https://doi.org/10.1001/jamacardio.2017.2156.
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