Role of Hydration in Contrast-Induced Nephropathy_2

Role of Hydration in Contrast-Induced Nephropathyin Patients Who Underwent Primary Percutaneous

Coronary Intervention

Annis Rakhmawati

Identitas Jurnal

• Judul : Role of Hydration in Contrast-Induced Nephropathy in Patients Who Underwent Primary Percutaneous Coronary Intervention

• Penulis : Alfonso Jurado-Román et al

• Publikasi : Am J Cardiol 2015;115:1174-1178

INTRODUCTION

• The incidence of CIN in Primary PCI (PPCI) for STEMI patient is higher than in elective procedures.

• There is no preventive strategy has been recommended by current guidelines for STEMI who underwent PPCI

• The aim to evaluate the possible beneficial role of periprocedural i.v isotonic saline in STEMI patient who underwent PPCI

Subjects

• Inclusion Criteria– All STEMI patients who underwent PPCI– July 2012 to November 2013 at their institution

(Cardiology Department, Madrid, Spain)

• Exclusion Criteria:– end-stage renal failure requiring dialysis– cardiac arrest– severe heart failure (Killip III to IV)

Methods

• Prospective, single-center, randomized study to investigate the role of hydration to prevent CIN in STEMI patient who underwent PPCI.

• All patients received an iso-osmolar nonionic contrast medium (iodixanol).

• Primary end point the development of CIN ≥ 25% or ≥ 0.5 mg/dl increase in serum creatinine within 3 days post procedural.

• Categorical variables were analyzed by the chi-square analysis or Fisher’s exact test.

• Independent t test and Wilcoxon tests were used to determine differences between normal and non-normally distributed quantitative variables

• Multivariate logistic regression analysis to identify independent predictors of CIN.

• Significant crossover rate was expected exploratory analysis & an intention-to-treat analysis.

• All analyses were performed with SPSS 20.0

Baseline Characteristics

Procedural Characteristics

RESULT

Discussion

• In STEMI with elective PCI, i.v hydration is simple & effective to prevent CIN.

• Not only patients with CKD have CIN variety of other risk factors facilitate CIN in patients with normal renal function

• Current guidelines haven’t still suggested definite recommendations about CIN prevention in PPCI

• Marenzi et al the use of postprocedural hydration with saline solution in STEMI underwent PPCI.

• Merten et al rapid preprocedural infusion of sodium bicarbonate in elective PCI.

• Maioli et al hydrated patients had higher reductions of creatinine. The sooner the better results. – This study use 2 different hydration sodium

bicarbonate and saline solution. – Important finding 960 ml of fluids in CIN

prevention

Prevention of Contrast-Induced Nephropathy With N-Acetylcysteine or Sodium Bicarbonate in Patients With ST-SegmenteMyocardial Infarction (CINSTEMI) trial

• Thayssen et al Prevention with NAC, NaHCO3, or the combined NAC+NaHCO3 didn’t reduce the rate of CIN significantly compared with hydration with i.v NaCl infusion alone

Study limitation

• Single-center study without blinding & small sample size

• The significant crossover rate between both treatment groups expected limitation an intention-to-treat analysis was performed

• Standard of GFR formula can be over-ridden by the acute conditions fluctuation in creatinine values.

• The simple laboratory definition of CIN can’t exclude acute tubular necrosis & cardiorenal syndrome.

Conclusion

• i.v saline hydration during PPCI reduced the risk of CIN to 48%.

• Patients with CIN had increased mortality and need for dialysis.

• Preventive hydration should be given to STEMI patients underwent PPCI.

Critical AppraisalAre the results Valid

1. Was the assignment of patients to treatments randomized? And was the

randomization list concealed? yes

2. Was follow-up of patients sufficiently long and complete? yes

3. Were patients analyzed in the groups which they were randomized? yes

4. Were patients and clinicians kept “blind” to treatment? no

5. Were the groups treated equally, apart from the experimental treatment? yes

6. Were the groups similar at the start of the trial? yes

Are the valid results of this randomized study important?

What is the magnitude of the treatment effect?

RRR = 48,8%

Are these valid, important results applicable to our patient?

1. Is our patient so different from those in the study that its

results cannot apply? No

2. Is the treatment feasible in our setting? Yes

3. What are our patient’s potential benefits and harms form the

therapy?

Benefit: reduce the risk of CIN in patients with STEMI

underwent PPCI with an easy, cheap, and safe preventive

strategy.

Harm : Has not been proved as gold standard therapy

Thank you