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Author Spotlight: Developing a Bedside Protocol for Kidney and Genitourinary Ultrasonography
Published on: June 21, 2024
Patient-centered contrast thresholds to reduce acute kidney injury in high-risk patients undergoing percutaneous
Ali O Malik1, Amit Amin2, Kevin Kennedy3
1University of Missouri-Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO.
Insights
A new model personalizes contrast dye limits to reduce contrast-associated acute kidney injury (CA-AKI) risk during PCI. Meeting these personalized thresholds significantly lowered CA-AKI rates compared to exceeding them.
Area of Science:
- Cardiology
- Nephrology
- Medical Imaging
Background:
- Contrast volume in percutaneous coronary intervention (PCI) correlates with contrast-associated acute kidney injury (CA-AKI).
- Existing risk models for CA-AKI lack actionable, personalized contrast dose guidance.
- The 3x estimated glomerular filtration rate (eGFR) rule is actionable but doesn't account for individual patient risk factors like diabetes or heart failure.
Purpose of the Study:
- To develop a patient-centered strategy for personalized contrast volume thresholds to mitigate CA-AKI risk.
- To assess the impact of meeting these novel thresholds on CA-AKI rates in a large patient cohort.
Main Methods:
- Utilized the National Cardiovascular Data Registry (NCVD) acute kidney injury risk model, incorporating a contrast term to define safe limits for specific relative risk reductions (e.g., 10%).
- Analyzed data from CathPCI version 5 (April 2018-June 2019) to compare CA-AKI rates when patient-centered model-derived thresholds were met versus exceeded.
- Performed a subset analysis on patients receiving contrast volume ≤3x eGFR.
Main Results:
- In a high-risk cohort (n=141,133), CA-AKI rates were 10.0% when thresholds were met vs. 18.2% when exceeded (P < .001).
- In the subset receiving ≤3x eGFR contrast (n=82,318), CA-AKI rates were 9.8% when thresholds were met vs. 14.5% when exceeded (P < .001).
Conclusions:
- A novel, personalized contrast volume threshold strategy offers actionable guidance to potentially decrease CA-AKI rates.
- Prospective validation is required to confirm the efficacy of this strategy in improving patient outcomes.
Background:
Contrast volume used during percutaneous coronary intervention has a direct relationship with contrast-associated acute kidney injury. While several models estimate the risk of contrast-associated acute kidney injury, only the strategy of limiting contrast volume to 3 × estimated glomerular filtration rate (eGFR) gives actionable estimates of safe contrast volume doses. However, this method does not consider other patient characteristics associated with risk, such as age, diabetes or heart failure.
Methods:
Using the National Cardiovascular Data Registry acute kidney injury risk model, we developed a novel strategy to define safe contrast limits by entering a contrast term into the model and using it to meet specific (eg, 10%) relative risk reductions. We then estimated acute kidney injury rates when our patient-centered model-derived thresholds were and were not exceeded using data from CathPCI version 5 between April 2018 and June 2019. We repeated the same analysis in a sub-set of patients who received ≤3 × eGFR contrast.
Results:
After excluding patients on hemodialysis, below average risk (<7%), missing data and multiple percutaneous coronary interventions, our final analytical cohort included 141,133 patients at high risk for acute kidney injury. The rate of acute kidney injury was 10.0% when the contrast thresholds derived from our patient-centered model were met and 18.2% when they were exceeded (P < .001). In patients who received contrast ≤3 × eGFR (n = 82,318), contrast-associated acute kidney injury rate was 9.8% when the contrast thresholds derived from our patient centered model were met and 14.5% when they were exceeded (P < .001).
Conclusions:
A novel strategy for developing personalized contrast volume thresholds, provides actionable information for providers that could decrease rates of contrast-associated acute kidney injury. This strategy needs further prospective testing to assess efficacy in improving patient outcomes.
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