Impact on clinical practice of updated guidelines on iodinated contrast material: CINART

Abstract

Objective: Guidelines on safe use of iodinated contrast material recommend intravenous prophylactic hydration to prevent post-contrast adverse (renal) effects. Recently, guidelines have been updated and standard prophylaxis is no longer recommended for the majority of patients. The current study aims to evaluate the consequences for clinical practice of the updated guidelines in terms of complications, hospitalisations, and costs.

Methods: The Contrast-Induced Nephropathy After Reduction of the prophylaxis Threshold (CINART) project is a retrospective observational study. All elective procedures with intravascular iodinated contrast administration at Maastricht University Medical Centre (UMC+) in patients aged > 18 years, formerly eligible for prophylaxis (eGFR 30-44 ml/min/1.73 m2 or eGFR 45-59 ml/min/1.73 m2 in combination with diabetes or > 1 predefined risk factor), and currently eligible for prophylaxis (eGFR < 30 ml/min/1.73 m2) were included. Data were used to calculate relative reductions in complications, hospitalisations, and costs associated with standard prophylactic intravenous hydration. CINART is registered with Clinicaltrials.gov: NCT03227835.

Results: Between July 1, 2017, and July 1, 2018, 1992 elective procedures with intravascular iodinated contrast in patients formerly and currently eligible for prophylaxis were identified: 1808 in patients formerly eligible for prophylaxis and 184 in patients currently eligible for prophylaxis. At Maastricht UMC+, guideline updates led to large relative reductions in numbers of complications of prophylaxis (e.g. symptomatic heart failure; - 89%), extra hospitalisations (- 93%), and costs (- 91%).

Conclusion: Guideline updates have had a demonstrable impact on daily clinical practice benefiting patient, hospital, and health care budgets. Clinical practice varies between institutions and countries; therefore, a local estimation model is provided with which local impact on costs, hospitalisations, and complications can be calculated.

Key points: • Clinical practice guidelines recommend prophylactic intravenous hydration to prevent post-contrast adverse outcomes such as contrast-induced acute kidney injury. • Clinical practice guidelines have recently been updated, and standard prophylaxis is no longer recommended for the majority of patients. • The guideline updates have a large impact on daily clinical practice: relative reductions at Maastricht UMC+ were - 89% prophylaxis complications, - 93% hospitalisations, and - 91% costs, and similar reductions are expected for Dutch and adherent European medical centres.

Keywords: Acute kidney injury; Clinical practice guideline; Contrast media; Costs and cost analysis; Preventive measures.

Conflict of interest statement

Dr. Wildberger declares the following institutional grants to the Department of Radiology and Nuclear Medicine, Maastricht UMC+ (via Clinical Trial Center Maastricht): Agfa Healthcare, Bayer Healthcare, General Electric, Optimed, Philips Healthcare, Siemens Healthcare. Speakers bureau (JEW/ Clincial Trial Center Maastricht): Bayer, Siemens. These grants and fees are not related to the contents of this manuscript.

The other authors declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Figures

Fig. 1

Screening and inclusion profile. CECT, contrast-enhanced computed tomography; CAG, coronary angiography; PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation. *i.e. patients with eGFR 30–59 ml/min/1.73 m2 combined with risk factors; $ i.e. patients with eGFR < 30 ml/min/1.73 m2

Fig. 2

Complications, hospitalisations, and costs associated with standard prophylaxis at Maastricht UMC+ before and after guideline updates