Predictors for contrast media-induced nephropathy and long-term survival: prospectively assessed data from the randomized controlled Dialysis-Versus-Diuresis (DVD) trial

Abstract

Background: Among the numerous studies concerning contrast media-induced nephropathy (CIN), there was no prospective trial that provided data on the long-term outcomes.

Objectives: To prospectively assess predictors of CIN and long-term outcomes of affected patients.

Methods: Four hundred twelve consecutive patients with serum creatinine levels of 115 micromol/L to 309 micromol/L (1.3 mg/dL to 3.5 mg/dL) undergoing elective coronary angiography were included. Patients were randomly assigned to periprocedural hydration alone, hydration plus one-time hemodialysis or hydration plus N-acetylcysteine.

Results: Multivariate logistic regression identified the following as predictors of CIN within 72 h (equivalent to an increase in creatinine 44.2 micromol/L [0.5 mg/dL] or more) : prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast media given (OR 1.01, 95% CI 1.00 to 1.01). With regard to long-term outcome (mean follow-up 649 days), multivariate Cox regression models found elevated creatinine levels at 30 days (hazard rate ratio [HRR] 5.48, 95% CI 2.85 to 10.53), but not CIN within 72 h (HRR 1.12, 95% CI 0.63 to 2.02), to be associated with increased mortality. In addition, independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96).

Conclusion: From the present prospective trial, performance of postprocedural hemodialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after catheterization. Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients' long-term survival.

Figures

Figure 1)

Adjusted cumulative survival rates deriving from multivariate Cox regression models are shown for those patients who suffered from contrast media-induced nephropathy (CIN) within 72 h (A) and those with elevated creatinine levels at 30 days (B). Adjustment was made for age, baseline glomerular filtration rate, serum phosphate levels, hemoglobin levels, presence of diabetes, as well as administration of angiotensin-converting enzyme inhibitors and loop diuretics (see Table 5). Thus, there were no differences in survival, depending on the occurrence of CIN within 72 h (dotted line in A; P=0.8). In contrast, patients who suffered at 30 days from elevated creatinine levels showed markedly and significantly reduced survival (dotted line in B; P=0.03)