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Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose

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Abstract

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml × bodyweight (kilograms)/serumcreatinine (milligramsperdeciliter) . Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.

Section snippets

Database and patients:

Data were obtained from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium, which includes 8 academic and community hospitals in the state of Michigan participating in a multicenter registry of PCIs.13, 14, 15 The registry is part of a quality assessment and quality improvement program, and was approved by the institutional review board of the University of Michigan and by local institutional review boards. Data were prospectively collected using standardized definitions. Each

Demographics and clinical outcomes:

Data from 10,729 procedures comprised the development set; 117 patients were already on dialysis before the procedure and were excluded from the analysis. Of the remaining patients, complete baseline data were available for 9,242 patients (87.1%). The most common missing parameters were preprocedural serum creatinine (n = 1,019), total contrast dose (n = 313), and patient weight, which was necessary to calculate the MRCD and creatinine clearance (n = 48). Patients with NRD (n = 41, or 0.44%)

Discussion

Severe nephropathy requiring in-hospital dialysis following PCI is a rare complication associated with high in-hospital mortality. In a recent single center analysis of renal associated outcomes after PCI, McCullough et al4 reported an incidence of NRD of 0.21% and 0.77% in 2 consecutive data sets with an in-hospital mortality rate of 35.7% in patients developing NRD. In another series of 7,741 patients referred for PCI, the incidence of NRD was 0.66%, with an in-hospital mortality rate of

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    This study was supported by a grant from the Blue Cross Blue Shield of Michigan Foundation, Detroit, Michigan.

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