Refining the assessment of contrast-induced acute kidney injury: the load-to-damage relationship

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Abstract

Aims

Comparing the nephrotoxicity of individual contrast agents is challenging, as contrast-induced acute kidney injury (CI-AKI), a widely used trial endpoint, is unable to discriminate between contrast-related and contrast-unrelated causes of renal damage. We established a quantitative method to selectively evaluate the dose-dependent nephrotoxic effect of different contrast agents.

Methods

We randomized 113 patients undergoing coronary procedures to either iodixanol 320 mg/ml or iobitridol 350 mg/ml. We calculated baseline creatinine clearance (CrCl) and postprocedural change in serum creatinine. We then calculated the regression of the individual iodine load against the creatinine maximum change [load-to-damage relationship (LDR)]. We assumed that its R2 estimates the predictive accuracy of contrast dose-dependent effects on renal function changes, and that the slope of the LDR characterizes the intrinsic nephrotoxicity of the contrast. We also performed a semi-quantitative evaluation of procedural complexity to assess its complementary role in postprocedural AKI.

Results

We found significant correlations between contrast load and creatinine changes for both iobitridol (R2: 0.29; P <0.0001) and iodixanol (R2: 0.15; P = 0.00028). The LDR slope was, however, significantly steeper for iobitridol compared with iodixanol (19.03 ± 4.02 vs. 14.50 ± 4.63 Cr*CrCl/I; P <0.001) and in diabetic compared with nondiabetic patients (24.35 ± 4.96 vs. 4.59 ± 3.25 Cr*CrCl/I; P <0.001). Adding the procedural complexity score to the contrast load significantly increased the predictive ability of the regression model for postprocedural renal function changes (P < 0.02 for the R2 increase in overall population), suggesting a role for procedural complexity in postprocedural renal function damage.

Conclusion

The LDR slope is a promising method to evaluate the specific contrast-related fraction of postprocedural AKI.

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