Therapeutics
Review: Periprocedural high-dose statins reduce contrast-induced acute kidney injury after coronary angiography Clinical impact ratings:
多多多多多夞夞
Ukaigwe A, Karmacharya P, Mahmood M, et al. Meta-analysis on efficacy of statins for prevention of contrast-induced acute kidney injury in patients undergoing coronary angiography. Am J Cardiol. 2014;114:1295-302.
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Question In patients having coronary angiography, do periprocedural statins reduce contrast-induced acute kidney injury (CI-AKI)?
For correspondence: Dr. A. Ukaigwe, Reading Health System, West Reading, Pennsylvania, USA. E-mail [email protected].
Review scope
Commentary CI-AKI is a serious and potentially preventable complication of coronary angiography. Risk for CI-AKI varies, based partly on patient-related risk factors, including CKD and diabetes (1). There is no treatment for CI-AKI, so efforts have focused on prevention. Early studies and meta-analyses showed that renalprotective interventions, such as NAC and sodium bicarbonate, reduce CI-AKI. These treatments were incorporated into practice, but subsequent large RCTs found them to be ineffective (2-4). To date, hydration and minimizing the amount of contrast are the only strategies that reduce CI-AKI (5), but they have limited effectiveness, especially in higher-risk patients and emergency situations.
Included studies compared high-dose statins (atorvastatin, 40 or 80 mg; simvastatin, 40 or 80 mg; rosuvastatin, 10 or 40 mg; or an increase in statin dose from a baseline) with placebo or a lower-dose statin in patients who were having coronary angiography, regardless of renal function or other comorbid conditions, all of whom received the same adjunctive treatment (saline solution, bicarbonate, or N-acetyl cysteine [NAC]). The outcome was CI-AKI (≥ 25% or ≥ 0.5-mg/dL [44.2-μmol/L] increase in creatinine from baseline, or > 10% increase in cystatin C within 48 to 120 h of the procedure).
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, Cochrane Central Register of Controlled Trials, Web of Knowledge (all to Jan 2014), and reference lists were searched for randomized controlled trials (RCTs). 12 RCTs (n = 5564, mean age range 54 to 76 y) met selection criteria. 6 placebo-controlled trials assessed high-dose atorvastatin (80 or 40 mg), 1 high-dose simvastatin (40 mg), and 2 rosuvastatin (10 or 40 mg); 2 RCTs compared high-dose (80 or 40 mg) with low-dose atorvastatin (10 mg); and 1 compared high-dose (80 mg) with low-dose simvastatin (20 mg). All patients were statin-naı¨ve. 10 RCTs used periprocedural hydration, and 4 included NAC. 9 RCTs had low risk for bias for randomization, 4 for allocation concealment, 3 for blinding of patients and personnel, and 1 for blinded outcome assessment. Subgroup analysis was done by statin, lipophilicity, and for patients with diabetes mellitus and chronic kidney disease (CKD) at baseline.
The meta-analysis by Ukaigwe and colleagues found that, in patients having coronary angiography, pretreatment with a highdose statin reduced the incidence of CI-AKI compared with placebo or lower-dose statin, irrespective of type. Significant benefit was seen among all subgroups, including patients with diabetes or CKD. Although the results are promising, important limitations remain. The analyses lacked patient-level data, and studies were heterogeneous in endpoint definitions, treatment protocols, and study populations. Although caution is warranted, given the excellent safety record of statins, the data support risk assessment for CI-AKI in patients scheduled for coronary angiography (1) and consideration of high-dose statin pretreatment for those with increased risk. Additional well-designed, adequately powered RCTs are needed to confirm these conclusions. Richard G. Bach, MD Washington University School of Medicine St. Louis, Missouri, USA
Main results The main results are in the Table.
Conclusion References
In patients having coronary angiography, periprocedural highdose statins reduce contrast-induced acute kidney injury compared with placebo or lower-dose statins.
1. Mehran R, Aymong ED, Nikolsky E et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44:1393-9.
Source of funding: No external funding.
2. ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial Effect of periprocedural high-dose statin vs placebo or lower-dose statin (ACT). Circulation. 2011;124:1250-9.
(control) on contrast-induced acute kidney injury in patients having coronary angiography* Subgroups
Number of trials (n)
Weighted event rates
At 48 h to 5 d
High-dose statin
Control
RRR (95% CI)
NNT (CI)
12 (5564)
3.4%
7.6%
55% (43 to 65)
24 (21 to 31)
Atorvastatin
8 (1598)
2.2%
81% (70 to 88)
11 (10 to 13)
Simvastatin
2 (467)
3.9%
9.3%
59% (11 to 81)
19 (14 to 98)
Rosuvastatin†
2 (3502)
2.5%
4.5%
45% (20 to 62)
51 (37 to 111)
10 (2062)
4.2%
62% (46 to 73)
15 (13 to 20)
All
Lipophilic‡
12%
11%
Diabetes mellitus
4 (3228)
3.0%
5.0%
41% (15 to 59)
49 (34 to 131)
Chronic kidney disease
5 (1274)
6.3%
9.7%
35% (5 to 57)
30 (19 to 229)
3. Maioli M, Toso A, Leoncini M, et al. Sodium bicarbonate versus saline for the prevention of contrastinduced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. J Am Coll Cardiol. 2008;52:599-604. 4. Thayssen P, Lassen JF, Jensen SE, et al. Prevention of contrast-induced nephropathy with N-acetylcysteine or sodium bicarbonate in patients with STsegment-myocardial infarction: a prospective, randomized, open-labeled trial. Circ Cardiovasc Interv. 2014;7:216-24. 5. McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008;51:1419-28.
*Abbreviations defined in Glossary. Weighted event rates, RRR, NNT, and CI calculated from control event rates and odds ratios in article using a fixed-effect model. †Hydrophilic statin. ‡Atorvastatin or simvastatin.
姝 2015 American College of Physicians JC4 ACP Journal Club Downloaded From: http://annals.org/ by a Penn State University Hershey User on 05/27/2015
Annals of Internal Medicine
17 February 2015
Review: Periprocedural high-dose statins reduce contrast-induced acute kidney injury after coronary angiography Clinical impact ratings:
多多多多多夞夞
Ukaigwe A, Karmacharya P, Mahmood M, et al. Meta-analysis on efficacy of statins for prevention of contrast-induced acute kidney injury in patients undergoing coronary angiography. Am J Cardiol. 2014;114:1295-302.
多多多多多多夞
Question In patients having coronary angiography, do periprocedural statins reduce contrast-induced acute kidney injury (CI-AKI)?
For correspondence: Dr. A. Ukaigwe, Reading Health System, West Reading, Pennsylvania, USA. E-mail [email protected].
Review scope
Commentary CI-AKI is a serious and potentially preventable complication of coronary angiography. Risk for CI-AKI varies, based partly on patient-related risk factors, including CKD and diabetes (1). There is no treatment for CI-AKI, so efforts have focused on prevention. Early studies and meta-analyses showed that renalprotective interventions, such as NAC and sodium bicarbonate, reduce CI-AKI. These treatments were incorporated into practice, but subsequent large RCTs found them to be ineffective (2-4). To date, hydration and minimizing the amount of contrast are the only strategies that reduce CI-AKI (5), but they have limited effectiveness, especially in higher-risk patients and emergency situations.
Included studies compared high-dose statins (atorvastatin, 40 or 80 mg; simvastatin, 40 or 80 mg; rosuvastatin, 10 or 40 mg; or an increase in statin dose from a baseline) with placebo or a lower-dose statin in patients who were having coronary angiography, regardless of renal function or other comorbid conditions, all of whom received the same adjunctive treatment (saline solution, bicarbonate, or N-acetyl cysteine [NAC]). The outcome was CI-AKI (≥ 25% or ≥ 0.5-mg/dL [44.2-μmol/L] increase in creatinine from baseline, or > 10% increase in cystatin C within 48 to 120 h of the procedure).
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, Cochrane Central Register of Controlled Trials, Web of Knowledge (all to Jan 2014), and reference lists were searched for randomized controlled trials (RCTs). 12 RCTs (n = 5564, mean age range 54 to 76 y) met selection criteria. 6 placebo-controlled trials assessed high-dose atorvastatin (80 or 40 mg), 1 high-dose simvastatin (40 mg), and 2 rosuvastatin (10 or 40 mg); 2 RCTs compared high-dose (80 or 40 mg) with low-dose atorvastatin (10 mg); and 1 compared high-dose (80 mg) with low-dose simvastatin (20 mg). All patients were statin-naı¨ve. 10 RCTs used periprocedural hydration, and 4 included NAC. 9 RCTs had low risk for bias for randomization, 4 for allocation concealment, 3 for blinding of patients and personnel, and 1 for blinded outcome assessment. Subgroup analysis was done by statin, lipophilicity, and for patients with diabetes mellitus and chronic kidney disease (CKD) at baseline.
The meta-analysis by Ukaigwe and colleagues found that, in patients having coronary angiography, pretreatment with a highdose statin reduced the incidence of CI-AKI compared with placebo or lower-dose statin, irrespective of type. Significant benefit was seen among all subgroups, including patients with diabetes or CKD. Although the results are promising, important limitations remain. The analyses lacked patient-level data, and studies were heterogeneous in endpoint definitions, treatment protocols, and study populations. Although caution is warranted, given the excellent safety record of statins, the data support risk assessment for CI-AKI in patients scheduled for coronary angiography (1) and consideration of high-dose statin pretreatment for those with increased risk. Additional well-designed, adequately powered RCTs are needed to confirm these conclusions. Richard G. Bach, MD Washington University School of Medicine St. Louis, Missouri, USA
Main results The main results are in the Table.
Conclusion References
In patients having coronary angiography, periprocedural highdose statins reduce contrast-induced acute kidney injury compared with placebo or lower-dose statins.
1. Mehran R, Aymong ED, Nikolsky E et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44:1393-9.
Source of funding: No external funding.
2. ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial Effect of periprocedural high-dose statin vs placebo or lower-dose statin (ACT). Circulation. 2011;124:1250-9.
(control) on contrast-induced acute kidney injury in patients having coronary angiography* Subgroups
Number of trials (n)
Weighted event rates
At 48 h to 5 d
High-dose statin
Control
RRR (95% CI)
NNT (CI)
12 (5564)
3.4%
7.6%
55% (43 to 65)
24 (21 to 31)
Atorvastatin
8 (1598)
2.2%
81% (70 to 88)
11 (10 to 13)
Simvastatin
2 (467)
3.9%
9.3%
59% (11 to 81)
19 (14 to 98)
Rosuvastatin†
2 (3502)
2.5%
4.5%
45% (20 to 62)
51 (37 to 111)
10 (2062)
4.2%
62% (46 to 73)
15 (13 to 20)
All
Lipophilic‡
12%
11%
Diabetes mellitus
4 (3228)
3.0%
5.0%
41% (15 to 59)
49 (34 to 131)
Chronic kidney disease
5 (1274)
6.3%
9.7%
35% (5 to 57)
30 (19 to 229)
3. Maioli M, Toso A, Leoncini M, et al. Sodium bicarbonate versus saline for the prevention of contrastinduced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. J Am Coll Cardiol. 2008;52:599-604. 4. Thayssen P, Lassen JF, Jensen SE, et al. Prevention of contrast-induced nephropathy with N-acetylcysteine or sodium bicarbonate in patients with STsegment-myocardial infarction: a prospective, randomized, open-labeled trial. Circ Cardiovasc Interv. 2014;7:216-24. 5. McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008;51:1419-28.
*Abbreviations defined in Glossary. Weighted event rates, RRR, NNT, and CI calculated from control event rates and odds ratios in article using a fixed-effect model. †Hydrophilic statin. ‡Atorvastatin or simvastatin.
姝 2015 American College of Physicians JC4 ACP Journal Club Downloaded From: http://annals.org/ by a Penn State University Hershey User on 05/27/2015
Annals of Internal Medicine
17 February 2015
