Reddan, Donal

Abstract Introduction: Contrast-induced acute kidney injury, also referred to as contrast-induced nephropathy (CIN), is a potentially serious renal complication asso ciated with the use of iodinated contrast media (CM) in patients at risk. With the dramatic growth in contrast enhanced imaging services worldwide, including pro cedures involving exposure to iodinated CM, efforts to reduce the occurrence of CIN have received consider able attention in recent years. To date, these efforts have met with little success since the 12% prevalence of CIN today remains unchanged from 2 decades ago. Methods:We conducted a systematic literature review of the most recent evidence available from published reports of contemporary (2000-2008) prospective, randomized, controlled trials that have investigated CIN either by comparing CM or by comparing pre ventive strategies. The objective was to critically re view the findings in light of several aspects of study design and then to establish a set of parameters for consideration in the planning of future CIN trials so as to optimize the strength of evidence obtained. Results:Whether future CIN trials are investigat ing comparative CM nephrotoxicity or dealing with prophylactic strategies for risk reduction, the com plexities that must be addressed include a stan dardized definition of CIN, appropriate timing of SCr measurements with timing standardized for all subjects in a given study population, awareness of study population risk profile, hydration proto cols, and pharmacological prophylactic strategies. Conclusions: Large, well-designed trials (ideally with hard clinical outcome measures) that consider all the complexities involved in CIN and its preven tion are needed before the clinical community has the evidence-based direction required for optimized patient care.

Background— Outcomes in patients with mild to moderate renal function (RF) abnormalities presenting with acute coronary syndromes (ACS) are not well defined. Methods and Results— A convenience sample of 4 ACS trial databases including all enrolled patients was assessed to determine 30- and 180-day outcomes. The 4 trials were Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb, GUSTO-III, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), and Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A). Patients were stratified into ST-segment elevation (STE) and non–ST-segment elevation (NSE) groups and by the presence or absence of abnormal RF (creatinine clearance <70 mL/min). In the STE group, 7670 of 18 621 patients (41%) had abnormal RF. In the NSE group, 8152 of 19 304 (42%) had abnormal RF. Patients with abnormal RF were older, more often female, and more likely to have adverse baseline characteristics. They had higher mortality and higher mortality/nonfatal myocardial infarction (MI) at both 30 and 180 days, regardless of ST-segment status. Creatinine clearance was independently associated with risk of mortality (hazard ratio 0.79 in the STE group and 0.81 in the NSE group) and with risk of mortality/MI (hazard ratio 0.93) in the NSE group at 180 days. Conclusions— Patients presenting with ACS frequently have abnormal RF. Abnormal RF is a marker of adverse baseline clinical characteristics and is independently associated with increased risk of death and death/MI.