Left Ventricular End-Diastolic Pressure Versus Urine Flow Rate-Guided Hydration in Preventing Contrast-Associated Acute Kidney Injury

JACC Cardiovasc Interv. 2020 Sep 14;13(17):2065-2074. doi: 10.1016/j.jcin.2020.04.051.

Abstract

Objectives: This study compared left ventricular end-diastolic pressure (LVEDP)-guided and urine flow rate (UFR)-guided hydration.

Background: Tailored hydration regimens improve the prevention of contrast-associated acute kidney injury (CA-AKI).

Methods: Between July 15, 2015, and June 6, 2019, patients at high risk for CA-AKI scheduled for coronary and peripheral procedures were randomized to 2 groups: 1) normal saline infusion rate adjusted according to the LVEDP (LVEDP-guided group); and 2) hydration controlled by the RenalGuard System in order to reach UFR ≥300 ml/h (UFR-guided group). The primary endpoint was the composite of CA-AKI (i.e., serum creatinine increase ≥25% or ≥0.5 mg/dl at 48 h) and acute pulmonary edema (PE). Major adverse events (all-cause death, renal failure requiring dialysis, PE, and sustained kidney injury) at 1 month were assessed.

Results: The primary endpoint occurred in 20 of 351 (5.7%) patients in the UFR-guided group and in 36 of 351 (10.3%) patients in the LVEDP-guided group (relative risk [RR]: 0.560; 95% confidence interval [CI]: 0.390 to 0.790; p = 0.036). CA-AKI and PE rates in the UFR-guided group and LVEDP-guided group were 5.7% and 10.0% (RR: 0.570; 95% CI: 0.300 to 0.960; p = 0.048), and, respectively, 0.3% and 2.0% (RR: 0.070; 95% CI: 0.020 to 1.160; p = 0.069). Three patients in the UFR-guided group experienced complications related to the Foley catheter. Hypokalemia rate was 6.2% in the UFR-guided group and 2.3% in the LVEDP-guided group (p = 0.013). The 1-month major adverse events rate was 7.1% in the UFR-guided group and 12.0% in the LVEDP-guided group (p = 0.030).

Conclusions: The study demonstrates that UFR-guided hydration is superior to LVEDP-guided hydration to prevent the composite of CA-AKI and PE.

Keywords: acute kidney injury; contrast media; hydration.

Publication types

  • Clinical Trial, Phase III
  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Kidney Injury / diagnosis
  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / mortality
  • Acute Kidney Injury / prevention & control*
  • Aged
  • Aged, 80 and over
  • Angiography / adverse effects
  • Angioplasty / adverse effects
  • Contrast Media / adverse effects*
  • Female
  • Fluid Therapy* / adverse effects
  • Fluid Therapy* / mortality
  • Humans
  • Italy
  • Male
  • Pulmonary Edema / diagnosis
  • Pulmonary Edema / etiology
  • Pulmonary Edema / mortality
  • Pulmonary Edema / prevention & control*
  • Radiography, Interventional / adverse effects
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Urodynamics*
  • Ventricular Function, Left*
  • Ventricular Pressure*

Substances

  • Contrast Media