Patients with Different Stages of Chronic Kidney Disease Undergoing Intravenous Contrast-Enhanced Computed Tomography-The Incidence of Contrast-Associated Acute Kidney Injury

Ming-Ju Wu, Shang-Feng Tsai, Ming-Ju Wu, Shang-Feng Tsai

Abstract

Introduction: Iodinated contrast medium (CM) is the third most common cause of acute kidney injury (AKI). However, the association is poorly known between the definitions of AKI between different stages of chronic kidney disease after intravenous CM administration. Methods: The dataset, covering a period of ~15 years (1 June 2008 to 31 March 2015), consisted of 20,018 non-dialytic adult patients who had received intravenous injections of non-ionic iso-osmolar CM, iodixanol, for enhanced computed tomography imaging. Contrast-associated AKI (CA-AKI), dialysis-required AKI, and mortality were analyzed. Results: A total of 12,271 participants were enrolled. CA-AKI increased significantly starting from stage 3A onward (p < 0.001). In summary, incidences of CA-AKI against different levels of chronic kidney disease were as follows: stage 1 (8.3%) = stage 2 (6.7%) < stage 3A (9.9%) < stage 3B (14.3%) < stage 4 (20.5%) = stage 5 (20.4%). The incidences of dialysis within 30 days were as follows: stage 1 (1%) = stage 2 (1.4%) = stage 3A (2.7%) < stage 3B (5.7%) < stage 4 (18%) < stage 5 (54.1%). The prediction of dialysis was good based on the baseline serum creatinine > 1.5 mg/dL (72.78% of sensitivity, 86.07% of specificity, 0.851 of area under curve) or baseline estimated glomerular filtration rate ≤ 38.49 mL/min/1.732 m2 (70.19% of sensitivity, 89.08% of specificity, 0.853 of area under curve). In multivariate Cox regression analysis model for CA-AKI, independent risk factors were stage 4 chronic kidney disease (p = 0.001) and shock (p = 0.001). Conclusion: Baseline serum creatinine and estimated glomerular filtration rate were good predictors for dialysis-required AKI. CA-AKI increased significantly since stage 3A chronic kidney disease. Stage 4 and 5 chronic kidney disease have the same risk for CA-AKI, but stage 5 chronic kidney disease has markedly higher risk for dialysis.

Keywords: acute kidney injury; chronic kidney disease; computed tomography; dialysis; intravenous contrast medium; mortality.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Patients selection flow chart.
Figure 2
Figure 2
Outcomes of renal function outcomes according to baseline stages of CKD. All the three renal outcomes are significantly worse beyond the baseline renal function of stage IIIA. (A) Incidences of acute kidney injury after CCT according to baseline stages of CKD. Incidences are significant (p < 0.001) between stages I and IIIB–V; between stages II and IIIA to V; between stages IIIA and IIIB to V; and between stages IIIB and V. The increases in incidence are statistically significant starting from stage IIIA onward. Acute kidney injury after contrast computed tomography shown according to baseline stages of CKD; post hoc analysis showed p < 0.001 in I vs. IIIB, I vs. IV, I vs. V, II vs. IIIA, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IIIB, IIIA vs. IV, IIIA vs. V, and IIIB vs. IV. (B) Incidences of dialysis within 30 days after CCT shown according to baseline stages of CKD. The incidence was significantly different (p < 0.001) between stages I and IIIA to V; between stages II and IIIB to V; between stages IIIA and IIIB to V; between stages IIIB and IV to V; between stages IV and V. The incidence significantly increased from stage IIIA onward. Dialysis within 30 days after contrast computed tomography shown according to baseline stages of CKD, Post hoc analysis showed p < 0.001 in I vs. IIIA, I vs. IIIB, I vs. IV, I vs. V, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IIIB, IIIA vs. IV, IIIA vs. V, IIIB vs. IV, IIIB vs. V, and IV vs. V. (C) Incidences of death within 30 days after CCT shown according to baseline stages of CKD. The incidence was significantly different (p < 0.001) between stages I and IIIA to V; between stages II and s IIIA to V; between stages IIIA and IV to V; and between stages IIIB and IV. The incidence significantly increased from stage IIIA onward. Deaths within 30 days after contrast computed tomography shown according to baseline stages of CKD. Post hoc analysis showed p < 0.001 in I vs. IIIA, I vs. IIIB, I vs. IV, I vs. V, II vs. IIIA, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IV, IIIA vs. V, and IIIB vs. IV; chi-square test, ** p < 0.01.
Figure 2
Figure 2
Outcomes of renal function outcomes according to baseline stages of CKD. All the three renal outcomes are significantly worse beyond the baseline renal function of stage IIIA. (A) Incidences of acute kidney injury after CCT according to baseline stages of CKD. Incidences are significant (p < 0.001) between stages I and IIIB–V; between stages II and IIIA to V; between stages IIIA and IIIB to V; and between stages IIIB and V. The increases in incidence are statistically significant starting from stage IIIA onward. Acute kidney injury after contrast computed tomography shown according to baseline stages of CKD; post hoc analysis showed p < 0.001 in I vs. IIIB, I vs. IV, I vs. V, II vs. IIIA, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IIIB, IIIA vs. IV, IIIA vs. V, and IIIB vs. IV. (B) Incidences of dialysis within 30 days after CCT shown according to baseline stages of CKD. The incidence was significantly different (p < 0.001) between stages I and IIIA to V; between stages II and IIIB to V; between stages IIIA and IIIB to V; between stages IIIB and IV to V; between stages IV and V. The incidence significantly increased from stage IIIA onward. Dialysis within 30 days after contrast computed tomography shown according to baseline stages of CKD, Post hoc analysis showed p < 0.001 in I vs. IIIA, I vs. IIIB, I vs. IV, I vs. V, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IIIB, IIIA vs. IV, IIIA vs. V, IIIB vs. IV, IIIB vs. V, and IV vs. V. (C) Incidences of death within 30 days after CCT shown according to baseline stages of CKD. The incidence was significantly different (p < 0.001) between stages I and IIIA to V; between stages II and s IIIA to V; between stages IIIA and IV to V; and between stages IIIB and IV. The incidence significantly increased from stage IIIA onward. Deaths within 30 days after contrast computed tomography shown according to baseline stages of CKD. Post hoc analysis showed p < 0.001 in I vs. IIIA, I vs. IIIB, I vs. IV, I vs. V, II vs. IIIA, II vs. IIIB, II vs. IV, II vs. V, IIIA vs. IV, IIIA vs. V, and IIIB vs. IV; chi-square test, ** p < 0.01.
Figure 3
Figure 3
Once patients had developed post-CCT AKI, they more likely died (33.3% vs. 7.9%, p < 0.001). Similarly, once patients started with dialysis after CCT, they more likely died (32.7% vs. 9.3%, p < 0.001). The association between mortality within 30 days and AKI or dialysis within 30 days. Chi-square test, ** p < 0.01.
Figure 4
Figure 4
The predictive value of baseline serum creatinine (SCr) and eGFR to acute kidney injury and dialysis within 30 days after CCT. (A) The baseline serum creatinine (SCr) (>1.3 mg/dL) to predicting post-CCT AKI showed rather low sensitivity (36.73%) and high specificity (78.92%). The AUC was only 0.555. (B) The baseline eGFR (≤57.18 mL/min/1.732 m2) in predicting post-CCT AKI showed rather low sensitivity (43.17%) and high specificity (73.69%). The AUC was only 0.563. The baseline eGFR in predicting post-CCT AKI. (C) The baseline serum creatinine (SCr) (>1.5 mg/dL) in predicting dialysis within 30 days after CCT showed high sensitivity (72.78%) and high specificity (86.07%). The AUC was up to 0.851. The baseline serum creatinine (Scr) in predicting dialysis within 30 days after CCT. (D) The baseline eGFR (≤38.49 mL/min/1.732 m2) in predicting dialysis within 30 days after CCT showed high sensitivity (70.19%) and high specificity (89.08%). The AUC was up to 0.853. The baseline eGFR in predicting dialysis within 30 days after CCT.
Figure 4
Figure 4
The predictive value of baseline serum creatinine (SCr) and eGFR to acute kidney injury and dialysis within 30 days after CCT. (A) The baseline serum creatinine (SCr) (>1.3 mg/dL) to predicting post-CCT AKI showed rather low sensitivity (36.73%) and high specificity (78.92%). The AUC was only 0.555. (B) The baseline eGFR (≤57.18 mL/min/1.732 m2) in predicting post-CCT AKI showed rather low sensitivity (43.17%) and high specificity (73.69%). The AUC was only 0.563. The baseline eGFR in predicting post-CCT AKI. (C) The baseline serum creatinine (SCr) (>1.5 mg/dL) in predicting dialysis within 30 days after CCT showed high sensitivity (72.78%) and high specificity (86.07%). The AUC was up to 0.851. The baseline serum creatinine (Scr) in predicting dialysis within 30 days after CCT. (D) The baseline eGFR (≤38.49 mL/min/1.732 m2) in predicting dialysis within 30 days after CCT showed high sensitivity (70.19%) and high specificity (89.08%). The AUC was up to 0.853. The baseline eGFR in predicting dialysis within 30 days after CCT.
Figure 4
Figure 4
The predictive value of baseline serum creatinine (SCr) and eGFR to acute kidney injury and dialysis within 30 days after CCT. (A) The baseline serum creatinine (SCr) (>1.3 mg/dL) to predicting post-CCT AKI showed rather low sensitivity (36.73%) and high specificity (78.92%). The AUC was only 0.555. (B) The baseline eGFR (≤57.18 mL/min/1.732 m2) in predicting post-CCT AKI showed rather low sensitivity (43.17%) and high specificity (73.69%). The AUC was only 0.563. The baseline eGFR in predicting post-CCT AKI. (C) The baseline serum creatinine (SCr) (>1.5 mg/dL) in predicting dialysis within 30 days after CCT showed high sensitivity (72.78%) and high specificity (86.07%). The AUC was up to 0.851. The baseline serum creatinine (Scr) in predicting dialysis within 30 days after CCT. (D) The baseline eGFR (≤38.49 mL/min/1.732 m2) in predicting dialysis within 30 days after CCT showed high sensitivity (70.19%) and high specificity (89.08%). The AUC was up to 0.853. The baseline eGFR in predicting dialysis within 30 days after CCT.
Figure 4
Figure 4
The predictive value of baseline serum creatinine (SCr) and eGFR to acute kidney injury and dialysis within 30 days after CCT. (A) The baseline serum creatinine (SCr) (>1.3 mg/dL) to predicting post-CCT AKI showed rather low sensitivity (36.73%) and high specificity (78.92%). The AUC was only 0.555. (B) The baseline eGFR (≤57.18 mL/min/1.732 m2) in predicting post-CCT AKI showed rather low sensitivity (43.17%) and high specificity (73.69%). The AUC was only 0.563. The baseline eGFR in predicting post-CCT AKI. (C) The baseline serum creatinine (SCr) (>1.5 mg/dL) in predicting dialysis within 30 days after CCT showed high sensitivity (72.78%) and high specificity (86.07%). The AUC was up to 0.851. The baseline serum creatinine (Scr) in predicting dialysis within 30 days after CCT. (D) The baseline eGFR (≤38.49 mL/min/1.732 m2) in predicting dialysis within 30 days after CCT showed high sensitivity (70.19%) and high specificity (89.08%). The AUC was up to 0.853. The baseline eGFR in predicting dialysis within 30 days after CCT.

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