Contrast-associated acute kidney injury in acute ischemic stroke patients following multi-dose iodinated contrast
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.
References (14)
- et al.
Use of intravenous iodinated contrast media in patients with kidney disease: consensus statements from the American College of Radiology and the National Kidney Foundation
Kidney Med.
(2020) - et al.
Impact of creatinine screening on contrast-induced nephropathy following computerized tomography for stroke
Am. J. Emerg. Med.
(2021) - et al.
Renal safety of intra-arterial treatment after acute ischemic stroke with multimodal CT imaging selection
J. Stroke Cerebrovasc. Dis.
(2019) - et al.
Heart disease and stroke statistics—2021 update: a report from the American Heart Association
Circulation
(2021) - Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999–2019....
- et al.
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association
Stroke
(2019) - et al.
Renal safety of multimodal brain imaging followed by endovascular therapy
Stroke
(2021)