Contrast-associated acute kidney injury in acute ischemic stroke patients following multi-dose iodinated contrast

https://doi.org/10.1016/j.clineuro.2022.107351Get rights and content

Highlights

  • No significant association between multi-dose iodinated contrast and CA-AKI was found in AIS patients.

  • Exposure to multiple doses of iodinated contrast in AIS patients does not increase the rate of AKI.

  • Concern for CA-AKI should not deter physicians from pursuing timely and appropriate advanced neuroimaging of AIS patients.

Abstract

Background and objective

lthough intravenous contrast in neuroimaging has become increasingly important in selecting patients for stroke treatment, clinical concerns remain regarding contrast-associated acute kidney injury (CA-AKI). Given the increasing utilization of CT angiography and/or perfusion coupled with cerebral angiography, the purpose of this study was to assess the association of CA-AKI and multi-dose iodinated contrast in acute ischemic stroke (AIS) patients.

Materials and methods

etrospective review of AIS patients at a comprehensive stroke center was performed from January 2018 to December 2019. Data collection included patient demographics, stroke risk factors, stroke severity, discharge disposition, modified Rankin Scale, contrast type/volume, and creatinine levels (baseline, 48–72 h). CA-AKI was defined as creatinine increase ≥ 25 % from baseline. Bivariate analyses and multivariable logistic regression models were implemented to compare AIS patients with multi-dose and single-dose contrast.

Results

Of 440 AIS patients, 215 (48.9 %) were exposed to a single-dose contrast, and 225 (51.1 %) received multi-dose. In single-dose patients, CA-AKI at 48/72 h was 9.7 %/10.2 % compared to 8.0 %/8.9 % in multi-dose patients. Multi-dose patients were significantly more likely to receive a higher volume of contrast (mean 142.1 mL versus 80.8 mL; p < 0.001), but there was no significant difference in their creatinine levels or CA-AKI. NIHSS score (OR=1.08, 95 % CI=[1.04,1.13]), and patient transfer from another hospital (OR=3.84, 95 % CI=[1.94,7.62]) were significantly associated with multi-dose contrast.

Conclusions

No significant association between multi-dose iodinated contrast and CA-AKI was seen in AIS patients. Concerns of CA-AKI should not deter physicians from pursuing timely and appropriate contrast-enhanced neuroimaging that may optimize treatment outcomes in AIS patients.

Introduction

Acute ischemic stroke (AIS) is a leading cause of disability and mortality in the United States [1], [2]. Early detection of stroke features, such as large vessel occlusion and/or perfusion deficits, are of crucial importance in reducing long-term disability and death. Multi-modal neuroimaging requiring multiple doses of intravenous iodinated contrast, from CT angiography and/or perfusion and cerebral angiography, has become an essential tool for establishing a prompt and accurate assessment of AIS patient eligibility for endovacular thrombectomy [3]. However, there are lingering clinical concerns regarding development of contrast-associated acute kidney injury (CA-AKI), representing a key trigger of kidney failure [4].

Despite the potential risks, the most recent American Heart Association guidelines for the early management of AIS patients state that it is reasonable to perform CT angiography (CTA) prior to obtaining serum creatinine levels in patients who have no history of renal impairement [3]. While there remains some debate regarding the risk of CA-AKI after contrast administration, empirical evidence on the effects of multi-dose use of iodinated contrast is scarce. To our knowledge, no recent randomized controlled trials confirm the causal nephrotoxic potential of multiple doses of iodinated contrast. Using the randomized DEFUSE-3 trial population, one study found that CTA and CT perfusion (CTP) before endovascular therapy was not associated with a decline in renal function in AIS patients [5]. Related literature using a natural experiment to simulate a randomized event suggested that elimination of creatinine screening upon hospital arrival did not increase the incidence of CA-AKI among AIS patients [6].

Several prior nonrandomized studies have found no evidence of an association between multiple doses of contrast for CTA or CTA+CTP with a higher incidence of acute kidney injury (AKI) in patients with AIS [7], [8], [9], [10]. Only a few studies have documented no association of CA-AKI following CTA+CTP and subsequent digital subtraction angiography (DSA) in AIS patients with possible large vessel occlusion [11], [12].

Given the increasing utilization of CT angiography and/or perfusion coupled with cerebral angiography, patients with suspected AIS are more likely to undergo multi-modal neuroimaging using larger total volume of iodinated contrast. However, clinical concerns regarding CA-AKI may result in delay or omission of contrast-based neuroimaging, with a potential impact on acute stroke treatment and outcomes. Therefore, this study aims to assess the association between multiple doses of iodinated contrast and the rate of CA-AKI in AIS patients, compared to single-dose patients.

Section snippets

Study Cohort

A retrospective review of consecutive patients in the Get With The Guidelines (GWTG) stroke database from a comprehensive stroke center in the New York metropolitan area was conducted from January 1, 2018 to December 31, 2019. Institutional review board approval was obtained with waiver of consent based on the retrospective study design.

Inclusion criteria were (1) adult patients 18 years or older, (2) with a clinical diagnosis of AIS (3) and serum creatinine measurement at admission and 48–72 h

Results

A total of 1787 ischemic stroke patients were evaluated at the comprehensive stroke center from January 1, 2018 to December 31, 2019. Of these, 1156 were missing a follow-up creatinine measurement within 48 or 72 h after exposure to iodinated contrast, and 211 did not have contrast volume recorded in the electronic medical record (Fig. 1). The remaining 440 (24.6 %) AIS patients were included in this study. Patients were divided into two groups: 48.9 % (215/440) received a single dose and

Discussion

This study examined whether multiple doses of intravenous iodinated contrast were associated with a higher rate of CA-AKI among AIS patients. We found no significant association between the rate of CA-AKI and multi-dose versus single-dose contrast in a sample of patients undergoing early CT-based neuroimaging for AIS. During the study period, our facility did not wait for serum creatinine levels prior to intravenous contrast administration to AIS patients, unless there was a history of chronic

Sources of funding

This research did not receive any external support or grant from a funding agency.

Disclosures

The authors declare that they had full access to all of the data in this study. The authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. All authors have read and approved the submitted manuscript. The manuscript has not been submitted elsewhere nor published elsewhere in whole or in part.

Conflict of interest information

Maria X. Sanmartin and Artem Boltyenkov hold Visiting Scholar appointments at the Feinstein Institutes for Medical Research in the Center for Health Innovations and Outcomes Research and are employees of Siemens Medical Solutions USA Inc. Maria X. Sanmartin and Artem Boltyenkov are shareholders of Siemens Healthineers. Jeffrey M. Katz, Jason J. Wang, and Pina C. Sanelli receive research support from Siemens Healthineers.

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