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Risk of Acute Kidney Injury with Consecutive, Multidose Use of Iodinated Contrast in Patients with Acute Ischemic Stroke
Abstract
SUMMARY:
Currently, CTA is the imaging technique most frequently used to
evaluate acute ischemic stroke, and patients with intracranial
large-vessel occlusion usually undergo endovascular treatment. This
single-center, prospective, cohort study showed that consecutive,
multidose use of contrast during CTA and DSA does not increase the
incidence of acute kidney injury in patients with acute ischemic stroke,
though acute kidney injury tended to have a higher incidence in the
contrast multiexposure group (P = .172).
CTA and CTP are the most frequently used noninvasive vascular imaging techniques to evaluate acute ischemic stroke (AIS).1,2
Analyses from a number of observational studies suggest that the risk
of contrast-induced acute kidney injury (AKI) secondary to CTA/CTP
imaging is relatively low in patients with AIS, particularly those with
no history of renal impairment.1⇓–3
Apart
from CTA/CTP, most patients with AIS, within the time window of
recanalization, undergo intra-arterial thrombectomy, which is associated
with exposure to additional iodinated contrast medium during DSA.4⇓⇓⇓–8
Because the potential risk from iodinated contrast exposure is
proportional to the dose of contrast medium administered, multiple,
consecutive doses of contrast medium could imply a greater risk for AKI.9,10
Although several studies have cited data regarding the safety of the
consecutive use of contrast medium in patients with AIS for CTA/CTP and
DSA, the sample sizes have been small, most of the studies were
retrospective, and the definition of AKI differed among the studies.11⇓⇓–14
Hence, AKI induced by consecutive multidosing of contrast medium is
still a perceived risk. We therefore performed this prospective study to
determine whether consecutive, multidose use of contrast increases the
incidence of AKI compared with its single use in patients with AIS.
Materials and Methods
Study Design and Patient Enrollment
This
study is a prospective, registered, cohort study performed from
September 2016 to September 2017 at a single medical center with the
approval of the institutional review board of the center. Informed
consent was obtained from all patients or their legal representatives.
Patient
inclusion criteria were the following: 1) 18 years of age or older; 2)
suspicion of AIS; 3) seen within 6 hours of developing anterior
circulation symptoms or within 24 hours of posterior circulation
symptoms; 4) no intracranial hemorrhage; and 5) underwent CTA. Exclusion
criteria were lack of a baseline creatinine level or lack of a
follow-up creatinine level 48 hours after CTA.
Imaging
All
imaging was performed on a 64-section CT scanner (Optima CT660, GE
Healthcare, Milwaukee, Wisconsin). For CTA, isotonic contrast material
(1.5 mL/kg) (iodixanol, 320 mg I/mL, Visipaque 320; GE Healthcare,
Piscataway, New Jersey) was injected at a rate of 4 mL/s, followed by a
20-mL saline bolus chaser using a dual-head injector. The upper limit
volume of the contrast material was 100 mL.
Endovascular Treatment
Intra-arterial
treatment consisted of thrombolysis, mechanical thrombectomy with a
stent retriever or aspiration catheter, balloon angioplasty and stent
insertion, or carotid artery stent placement. The volume of the contrast
(iodixanol, 320 mg I/mL, Visipaque 320) used during the procedure was
recorded.
Definition of AKI
AKI
was defined as a >25% increase in the serum creatinine value over
the baseline value 48 hours after CTA. The incidence of AKI was compared
between patients given iodinated contrast medium for CTA (single
exposure, CTA group) versus those given contrast medium for CTA and DSA
(consecutive multiexposure, DSA group).
Statistical Analysis
The Student t test or the Mann-Whitney U
test (for unevenly distributed categoric variables) was used to
identify the difference in continuous variables. The difference in each
of the categoric variables between the 2 groups was tested using a χ2 or Fisher exact test. Two-tailed P < .05 was considered statistically significant.
Results
Altogether, 181 patients with AIS were included in this study (Figure and Table 1),
of whom 87 underwent CTA examinations and 94 underwent both CTA and DSA
examinations. All patients were given intravenous normal saline for
hydration.
FIGURE.
Flow chart of the study.
Table 1:
Baseline demographics and characteristicsa
The mean serum creatinine levels are shown in Table 2. Nine patients (5.0%) met the diagnostic criteria for AKI: 2 in the CTA group (2.3%) and 7 in the DSA group (7.4%) (P
= .172). On average, patients with AKI had creatinine level increases:
0.24 ± 0.06 mg/dL (31.0% ± 6.9%) in the CTA group and 1.71 ± 2.42 mg/dL
(131.6% ± 160.2%) in the DSA group.
Table 2:
Incidence of acute kidney injury in 2 study cohorts
Discussion
This
prospective study showed that the additional use of contrast for
endovascular treatment after CTA did not increase the incidence of AKI,
consistent with the results of previous studies.10⇓⇓⇓⇓–15
Although
the study was designed prospectively, we did not expect that the
postimaging laboratory studies would be unavailable for patients with
mild symptoms who left the hospital early. Loss of patients presents a
potential risk of biasing the results. In addition, the prevalence of
underlying medical comorbidities, such as atrial fibrillation and heart
failure, was higher in the DSA group, which may predispose the patients
to develop AKI.
There was no statistically significant
difference in AKI incidence between the CTA and DSA groups, though a
trend toward a higher incidence of AKI was observed with consecutive,
multidose use of contrast (7.4% versus 2.3%). We agree that the benefits
of the endovascular treatment most likely outweigh the potential risks
of AKI because these benefits were confirmed in 5 prior trials.4⇓⇓⇓–8 We do think that controlling the total volume of contrast medium during the endovascular treatment is still necessary.
The
definition of AKI varied in previous studies, ranging from an increase
in the serum creatinine level of 25%–50% from the baseline level to an
absolute increase of 0.3 or 0.5 mg/dL.10⇓⇓⇓⇓–15
In the current study, we chose a >25% increase in the serum
creatinine level as the threshold for an AKI diagnosis, which was more
sensitive than the criterion of a >50% increase or a >0.5-mg/dL
increase, and it may have led to a higher incidence of AKI (7.4% in the
DSA group) compared with the rate of AKI reported in previous studies
(0%–9%) with varying standards.10⇓⇓⇓⇓–15
Conclusions
This
prospective study showed that consecutive, multidose use of contrast
for CTA and DSA did not significantly increase the rate of AKI in
patients with AIS compared with the 1-time use of contrast for CTA. The
trend toward an increased AKI incidence after using more contrast should
be further investigated.
Footnotes
- Zhen Yu Jia and Shao Xian Wang contributed equally to this work.
- This work was supported by the Construction Program of Jiangsu Provincial Clinical Research Center Support System (BL 2014084). Clinical Trial Registration: http://www.clinicaltrials.gov; NCT03132558.
Indicates open access to non-subscribers at www.ajnr.org
REFERENCES
- Received September 17, 2018.
- Accepted after revision November 18, 2018.
- © 2019 by American Journal of Neuroradiology
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