Review Article
Hydration Strategies for Preventing Contrast-Induced Acute
Kidney Injury: A Systematic Review and Bayesia
n
Network Meta-Analysi
s
Qiuping Cai, Ran Jing, Wanfen Zhang, Yushang Tang, Xiaoping Li, and Tongqiang Liu
Division of Nephrology, �e Affiliated Changzhou NO.2 People’s Hospital of Nanjing Medical University, Changzhou 213003,
Jiangsu, China
Correspondence should be addressed to Tongqiang Liu; liuyf1106@126.com
Received 25 May 2019; Accepted 31 December 2019; Published 11 February 202
0
Academic Editor: Paul M. Grossman
Copyright © 2020 Qiuping Cai et al. -is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Aims. Many previous studies have examined the effect of different hydration strategies on prevention of contrast-induced acute
kidney injury (CI-AKI), but the optimal strategy is unknown. We performed a network meta-analysis (NWM) of these previous
studies to identify the optimal strategy. Methods and Results. Web of Science, PubMed, OVID Medline, and Cochrane Librar
y
were searched from their inception dates to September 30, 2018. Randomized controlled trials (RCTs) were selected based on strict
inclusion criteria, and a Bayesian NWM was performed using WinBUGS V.1.4.3. We finally analyzed 60 eligible RCTs, which
examined 21,293 patients and 2232 CI-AKI events. Compared to intravenous 0.9% sodium chloride (reference), intravenous
sodium bicarbonate (OR [95% CI]: 0.74 [0.57, 0.93]), hemodynamic guided hydration (0.41 [0.18, 0.93]), and RenalGuard guided
hydration (0.32 [0.14, 0.70]) significantly reduced the occurrence of CI-AKI. Oral hydration and intravenous 0.9% sodium
chloride were each noninferior to no hydration in preventing CI-AKI. Intravenous 0.9% sodium chloride, sodium bicarbonate,
and hemodynamic guided hydration were each noninferior to oral hydration in preventing CI-AKI. Based on surface under the
cumulative ranking curve values, the RenalGuard system was best (0.974) and hemodynamic guided hydration was second best
(0.849). Conclusion. -ere was substantial evidence to support the use of RenalGuard or hemodynamic guided hydration for
preventing CI-AKI in high-risk patients, especially those with chronic kidney disease or cardiac dysfunction.
1. Introduction
Contrast-induced acute kidney injury (CI-AKI), also re-
ferred to as contrast-induced nephropathy (CIN), is an
iatrogenic complication that can occur following intravas-
cular administration of iodinated contrast medium (CM
)
prior to radiography. CI-AKI is the third leading cause of
hospital-acquired acute renal injury (AKI) [1]. CI-AKI has a
low incidence in the general population, but it has a sig-
nificant incidence in patients with certain risk factors.
Moreover, the occurrence of CI-AKI following cardiac
catheterization procedures is associated with an in-hospital
mortality of 20%, a 1-year mortality of up to 66%, and an
even higher mortality in patients who require dialysis [2, 3].
However, even if patients with high risk of CI-AKI can be
identified a priori, no known pharmaceutical treatment can
effectively prevent or treat CI-AKI.
Guidelines recommend intravascular hydration to pre-
vent CI-AKI [4, 5], and there are several specific hydration
strategies, but researchers have not yet established an op-
timal strategy [6–9]. Notably, recent randomized controlled
trials (RCTs) have led to doubts about the effectiveness of
various hydration strategies in prevention of CI-AKI. For
example, Nijssen et al. [10] conducted an RCTwith 660 high-
risk patients and found that no prophylaxis was noninferior
or cost-saving relative to intravenous hydration. Weisbord
et al. [11] enrolled 5177 high-risk patients and reported no
benefit of intravenous sodium bicarbonate relative to normal
saline. Another RCT [12] concluded that the benefit of
sodium bicarbonate was marginal relative to isotonic
Hindawi
Journal of Interventional Cardiology
Volume 2020, Article ID 7292675, 16 pages
https://doi.org/10.1155/2020/7292675
mailto:liuyf1106@126.com
https://orcid.org/0000-0002-5990-725
1
https://creativecommons.org/licenses/by/4.0/
https://creativecommons.org/licenses/by/4.0/
https://doi.org/10.1155/2020/729267
5
sodium chloride for preventing CI-AKI among critically ill
patients. However, other studies indicated that the Renal-
Guard System [13–16] and hemodynamic guided hydration
[17–19] were safe and effective in preventing CI-AKI. Be-
cause of these apparently discrepant results, we conducted a
network meta-analysis (NMA) to assess the effects of various
hydration strategies on the occurrence of CI-AKI in an effort
to identify the optimal strategy for prevention of CI-AKI.
2. Methods
2.1. Data Search. -is systematic review and meta-analysis
were performed according to Cochrane Handbook guide-
lines [20].-eWeb of Science, PubMed, OVIDMedline, and
Cochrane Library databases were searched using medical
subject headings or keywords. Relevant published original
studies that were published up to September 30, 2018, were
examined. -e search syntax was as follows: “contrast-in-
duced acute kidney injury OR contrast-induced nephrop-
athy OR CIN OR CI-AKI OR contrast acute renal failure OR
contrast nephropathy” AND “hydration OR fluid admin-
istration OR volume expansion OR intravenous sodium
bicarbonate OR saline infusion.”
2.2. Study Selection. An initial eligibility screen of all cita-
tions was conducted, and only studies that examined CI-AKI
and hydration were selected for further full-text review. All
included studies were RCTs; experimental studies were
excluded. In addition, all included studies reported the
prevention of CI-AKI after intravascular administration of
CM; used clinical protocols that were hydration strategies,
not pharmaceutical prevention strategies; had clear defini-
tions of CI-AKI; and provided data on the outcome of in-
terest (occurrence of CI-AKI within 2 days to 1 week after
procedures).
2.3. Data Extraction and Quality Assessment. Two authors
(C. Q. P. and J. R.) independently reviewed each article for
eligibility. Any disagreement was resolved by discussion
among the authors or involvement of a third author. Data
extraction included the year of publication, sample size, pa-
tient characteristics, risk factors associated with CI-AKI (old
age, diabetes mellitus, renal impairment, heart failure), and
type and dosage of contrast medium. -e primary endpoint
was the occurrence of CI-AKI within 2 days to 1 week after
intravascular administration of CM. Two investigators inde-
pendently evaluated the quality of each study using the Jadad
scale, which ranges from 0 (worst) to 5 (best) [21].
2.4. Statistical Analyses. -e advantages of Bayesian NM
A
over traditional meta-analysis are its greater flexibility, its
provision of more naturally interpretable results, and its
ability to rank treatments by comparative effectiveness [22].
-e occurrence of CI-AKI as a dichotomous outcome
variable was expressed as an odds ratio (OR) and 95%
confidence interval (CI). All P values were 2-sided, and a P
value below 0.05 was considered significant. All analyses
were conducted using the Bayesian Markov chain Monte
Carlo method inWinBUGS V.1.4.3 (MRC Biostatistics Unit,
Cambridge, United Kingdom) using the Microsoft Excel-
based macro NetMetaXL V.1.6.1 (Canadian Agency for
Drugs and Technologies in Health, Ottawa, Canada) [23]. A
convergence test for each analysis was conducted by
checking whether the Monte Carlo error was less than 5% of
the SD of the effect estimates or the variance between the
studies. Convergence was achieved for all analyses using
1000 “burn in” runs and 1000 model runs. NetMetaXL was
also used to generate a forest plot, league table, and “ran-
kogram” with surface under the cumulative ranking curve
(SUCRA), which ranges from 0 (worst) to 100% (best).
Inconsistency was assessed by comparing the residual de-
viance and deviance information criterion statistics in fitted
consistency and inconsistency models.
3. Results
3.1. Literature Search. We initially identified 3620 publica-
tions, assessed 703 RCTs for eligibility by review of the full
texts, and ultimately included 60 RCTs which met the eli-
gibility criteria (Figure 1). -ese studies examined 21,29
3
patients (median: 222, interquartile range [IQR]: 120, 350)
and 2232 CI-AKI events. All included RCTs were full-length
journal articles. Agreement between the two reviewers at the
full-text review stage was excellent (Cohen’s κ� 0.85).
3.2.Characteristics of Studies andParticipants. Table 1 shows
the characteristics of the included studies. -e publication
date ranged from 2002 to 2018, and about 50% of the studies
were published after 2013. -e proportion of male patients
ranged from 25.0% to 98.1% (median [IQR]: 65.7 [56.9,
74.8]), and the mean age ranged from 56.2 to 82.9 years (67.8
[63.1, 72.5]).-irty-one studies enrolled 12,519 patients who
had high risk of CI-AKI.-e baseline serum creatinine (SCr)
level ranged from 61.4 to 236.4 μmol/L (117.1 [89.5, 136.9]),
and the baseline estimated glomerular filtration rate (eGFR)
ranged from 32 to 93.1mL/min/1.73m2 (49.2 [44.1, 74.2]).
Twenty-three studies provided the values of left ventricular
ejection fraction (LVEF); the mean LVEF ranged from 25%
to 57.8% (49.0 [42.8, 54.5]). -e percentage of diabetes
mellitus (DM) patients ranged from 8% to 100%, and the
percentage with heart failure (HF) ranged from 0.6% to
45.8%. A total of 8176 patients from 32 studies received
intravenous low-osmolar nonionic CM, 9993 patients from
17 studies received iso-osmolar nonionic CM, and 317
patients from 2 studies received low-osmolar ionic CM. -e
mean Jadad score of the 60 RCTs was 3.2 (3 [2, 4]), indicating
the overall study quality was good.
3.3. Network Meta-Analysis. Figure 2 shows all the com-
parisons in the NMA. -irty-seven studies (13,365 partici-
pants) compared the efficacy of intravenous sodium
bicarbonate and 0.9% sodium chloride. -e other hydration
strategies were nonhydration (8 studies, 1396 patients), oral
hydration (6 studies, 355 patients), intravenous half iso-
osmolar saline (3 studies, 968 patients), intravenous
2 Journal of Interventional Cardiology
hydration, mainly normal saline + diuresis (
2 studies
[26, 31], 501 patients), hemodynamic guided hydration (3
studies, 458 patients), and RenalGuard system guided hy-
dration (4 studies, 348 patients).
We compared the ORs of the different hydration
strategies using a forest plot (Figure 3) and analyzed the
results of the random effects consistency NMA using a
league table, which shows all pairwise comparisons (Figure 4).
Taken together, these results indicate that, relative to typical
intravenous 0.9% sodium chloride hydration (reference), the
occurrence of CI-AKI was significantly reduced by intra-
venous sodium bicarbonate (OR [95% CI]: 0.74 [0.57, 0.93]),
hemodynamic guided hydration (0.41 [0.18, 0.93]), and
RenalGuard system guided hydration (0.32 [0.14, 0.70]).
Oral hydration (0.72 [0.28, 1.82]) and intravenous 0.9%
sodium chloride (0.64 [0.39, 1.08]) were each noninferior to
no hydration for prevention of CI-AKI. Relative to oral
hydration (reference), intravenous 0.9% sodium chloride or
sodium bicarbonate and hemodynamic guided hydration
were each noninferior in prevention of CI-AKI, but
RenalGuard guided hydration was superior (0.21 [0.07,
0.63]). Intravenous hydration plus diuresis also did not
decrease the risk of CI-AKI relative to oral hydration and no
hydration.
A rankogram and SUCRA values indicated the Renal-
Guard system was best (SUCRA� 0.974) followed by he-
modynamic guided hydration (SUCRAs� 0.849; Figure 5).
Intravenous sodium bicarbonate had a SUCRA of 0.667.-e
SUCRAs for intravenous 0.9% sodium chloride, intravenous
hydration plus diuresis, oral and no hydration, and the other
treatments ranged from 0.197 to 0.441, and their rankings
were similar. Hydration using half iso-osmolar saline alone
was the least effective treatment.
3.4. Inconsistency Analysis. We performed network incon-
sistency assessment for the fixed effect model for the 60
studies (Figure 6). -e resulting plot demonstrated that
nearly all the studies were near the line of equality and that
the results were therefore consistent. However, there was
some evidence of inconsistency in 3 noninferiority studies
[10, 31]. In particular, Martin-Moreno et al. [31] and Nijssen
et al. [10] found that intravenous sodium bicarbonate and
0.9% sodium chloride were noninferior to oral hydration.
4. Discussion
To our knowledge, this is the first NMA to compare different
hydration strategies for prevention of CI-AKI. We included
60 RCTs which examined 21,293 participants and 2232 CI-
AKI events. Our comparison of 8 hydration strategies for
preventing CI-AKI confirmed that, relative to intravenous
0.9% sodium chloride hydration, three treatments during
CM administration significantly reduced the risk for CI-
AKI: the RenalGuard system, hemodynamic guided hy-
dration, and intravenous sodium bicarbonate. Relative to no
hydration, oral hydration and intravenous 0.9% sodium
chloride were each noninferior in prevention of CI-AKI.
Relative to oral hydration, intravenous 0.9% sodium chlo-
ride and sodium bicarbonate were each noninferior
in
prevention of CI-AKI. -us, we ranked the
RenalGuard
system as the best strategy and hemodynamic guided hy-
dration as the second best.
Guidelines for the prevention of CI-AKI in high-risk
patients routinely recommend hydration protocols before
contrast exposure as an established preventive measure
[77, 78]. A recent large RCT [10] led us to reanalyze the
efficacy of hydration for prevention of CI-AKI. In particular,
the AMAstricht Contrast-Induced Nephropathy Guideline
(AMACING) study [10] enrolled 660 patients with high risk
of CI-AKI and concluded that, relative to intravenous hy-
dration, no prophylaxis was less expensive and noninferior
in prevention of CI-AKI. In our meta-analysis, five studies
compared the effectiveness of intravenous 0.9% sodium
chloride and three studies compared bicarbonate with
nonhydration, leading to our conclusion that, relative to no
hydration (reference), oral hydration or hydration with
intravenous 0.9% sodium chloride was noninferior in pre-
vention of CI-AKI. -ese results were unsurprising, because
simple oral or intravenous hydration can lead to compli-
cations, such as heart failure, pulmonary edema, and elec-
trolyte disorders. -us, the safety window of hydration is
relatively narrow for patients undergoing percutaneous
coronary intervention (PCI), and other more effective or
precise hydration strategies may be needed to decrease the
incidence of CI-AKI.
Most meta-analyses before 2016 [79–83] confirmed that
intravenous sodium bicarbonate was more effective than
sodium chloride in preventing CI-AKI. However, two recent
3620 citations identified
2348 identified through Web of Science search
411 identified through PubMed search
431 identified through Cochrane Library search
430 identified through OVID search
847 excluded
748 were not RCTs
99 were reviews or comments
643 excluded
339 were not about hydration
220 had no outcomes of interest
84 were protocols
2070 excluded during initial screen for not
meeting inclusion criteria
1534 were duplicates
536 had unrelated population or outcome
1550 studies screened in full-text review
703 RCTs assessed for eligibility
60 RCTs included in final analysis
Figure 1: Identification and selection of studies for Bayesian
network meta-analysis.
Journal of Interventional Cardiology 3
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gi
og
ra
ph
y/
PC
I
w
ith
eG
FR
of
le
ss
th
an
6
0
m
l/m
in
/
1.
73
m
2
75
74
13
0.
8
44
25
84
SC
vs
.
Re
na
lG
ua
rd
Io
di
xa
no
l
15
6
3
12
4
C
or
on
ar
y
an
gi
og
ra
ph
y/
PC
I
w
ith
eG
FR
of
le
ss
th
an
60
m
l/m
in
/
1.
73
m
2
75
74
13
0.
8
44
25
84
SC
vs
Re
na
lG
ua
rd
Io
di
xa
no
l
15
6
3
Tu
re
di
et
al
.
[2
9]
17
2
C
on
tr
as
t-
en
ha
nc
ed
C
TP
A
on
su
sp
ic
io
n
of
P
E
w
ith
at
le
as
to
ne
ri
sk
fa
ct
or
fo
r
C
IN
75
.5
51
.7
85
.4
SC
vs
.S
B
W
at
er
-s
ol
ub
le
,
no
ni
on
ic
,l
ow
–
os
m
ol
ar
<1 00
3
17
2
C
on
tr
as
t-
en
ha
nc
ed
C
TP
A
on
su
sp
ic
io
n
of
PE
w
ith
at
le
as
t
on
e
ri
sk
fa
ct
or
fo
r
C
IN
75
.5
51
.7
85
.4
SC
vs
SB
W
at
er
-s
ol
ub
le
,
no
ni
on
ic
,l
ow
–
os
m
ol
ar
<1 00 3
4 Journal of Interventional Cardiology
Ta
bl
e
1:
C
on
tin
ue
d.
St
ud
ie
s
Pa
tie
nt
s
(n
)
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
(y
ea
rs
)
M
al
es
(%
)
Ba
se
lin
e
SC
r
(m
g/
dL
)
Ba
se
lin
e
eG
FR
(m
L/
m
in
/
1.
73
m
2 )
M
ea
n
LV
EF
(%
)
D
M
(%
)
H
F
(%
)
Tr
ea
tm
en
t
gr
ou
ps
Ty
pe
s
of
C
M
C
M
do
sa
ge
(m
L)
Ja
da
d
sc
or
e
N
o.
of
pa
tie
nt
s
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
M
al
e
(%
)
Ba
se
lin
e
SC
r
Ba
se
lin
e
eG
FR
M
ea
n
LV
EF
D
M
(%
)
H
F
(%
)
G
ro
up
s
Ty
pe
s
of
C
M
D
os
ag
e
of
C
M
Ja
da
d
sc
or
e
Q
ia
n
et
al
.[
19
]
26
4
C
K
D
an
d
C
H
F
un
de
rg
oi
ng
co
ro
na
ry
pr
oc
ed
ur
es
63
.5
74
.6
15
1
37
.5
39
.5
47
.3
SC
vs
.H
D
y
Io
di
xa
no
l
16
6
5
26
4
C
K
D
an
d
C
H
F
un
de
rg
oi
ng
co
ro
na
ry
pr
oc
ed
ur
es
63
.5
74
.6
15
1
37
.5
39
.5
47
.3
SC
vs
H
D
y
Io
di
xa
no
l
16
6
5
So
lo
m
on
et
al
.
[3
0]
39
1
El
ec
tiv
e
co
ro
na
ry
or
pe
ri
ph
er
al
an
gi
og
ra
ph
y
w
ith
eG
FR
<4 5 m l/m
in
/
1.
73
m
2
72
57
.5
16
9.
3
32
.8
59
.1
35
.5
SC
vs
.S
B
N
ot
m
en
tio
ne
d
10
7
4
39
1
El
ec
tiv
e
co
ro
na
ry
or
pe
ri
ph
er
al
an
gi
og
ra
ph
y
w
ith
eG
FR
<4 5 m l/m in / 1. 73 m 2 72 57 .5 16 9. 3 32 .8 59 .1 35 .5 SC vs
SB
N
ot
m
en
tio
ne
d
10
7
4
M
ar
tin
–
M
or
en
o
et
al
.
[3
1]
13
0
Re
ce
iv
in
g
C
M
fo
r
C
T
sc
an
57
.5
64
.3
79
.6
N
on
vs
SB
N
ot
m
en
tio
ne
d
12
0
3
13
0
Re
ce
iv
in
g
C
M
fo
r
C
T
sc
an
57
.5
64
.3
79
.6
N
on
vs
SB
N
ot
m
en
tio
ne
d
12
0
3
Ju
ra
do
–
Ro
m
án
et
al
.
[3
2]
40
8
ST
EM
I
un
de
rg
oi
ng
p
r
im
ar
y
PC
I
63
.1
73
.4
89
22
.5
14
.7
N
on
vs
.S
C
Is
o-
os
m
ol
ar
no
ni
on
ic
17
4
2
40
8
ST
EM
I
un
de
rg
oi
ng
pr
im
ar
y
PC
I
63
.1
73
.4
89
22
.5
14
.7
N
on
vs
SC
Is
o-
os
m
ol
ar
no
ni
on
ic
17
4
2
Ba
rb
an
ti
et
al
.
[1
3]
11
2
TA
V
R
81
40
.2
87
.1
51
.5
54
.6
25
SC
vs
.
Re
na
lG
ua
rd
Bu
ck
in
gh
am
sh
ir
e
17
5
3
11
2
TA
V
R
81
40
.2
87
.1
51
.5
54
.6
25
SC
vs
Re
na
lG
ua
rd
Bu
ck
in
gh
am
sh
ir
e
17
5
3
Ye
ga
ne
hk
ha
h
et
al
.[
33
]
10
0
C
A
G
59
.7
53
99
.5
43
.8
39
SC
vs
.S
B
Io
he
xo
l
45
.4
3
10
0
C
A
G
59
.7
53
99
.5
43
.8
39
SC
vs
SB
Io
he
xo
l
45
.4
3
Ya
ng
et
al
.
[3
4]
32
0
El
ec
tiv
e
ca
rd
io
va
sc
ul
ar
pr
oc
ed
ur
es
in
cl
ud
in
g
C
A
G
or
in
te
rv
en
tio
na
l
tr
ea
tm
en
t
59
.2
53
.1
70
.2
93
.1
55
.1
20
SC
+
N
A
C
vs
.
SB
+
N
A
C
Io
pr
om
id
e
12
5
3
32
0
El
ec
tiv
e
ca
rd
io
va
sc
ul
ar
pr
oc
ed
ur
es
in
cl
ud
in
g
C
A
G
or
in
te
rv
en
tio
na
l
tr
ea
tm
en
t
59
.2
53
.1
70
.2
93
.1
55
.1
20
SC
+
N
A
C
vs
SB
+
N
A
C
Io
pr
om
id
e
12
5
3
Ya
ng
et
al
.
[3
4]
32
0
El
ec
tiv
e
ca
rd
io
va
sc
ul
ar
pr
oc
ed
ur
es
in
cl
ud
in
g
C
A
G
or
in
te
rv
en
tio
na
l
tr
ea
tm
en
t
59
.2
53
.1
70
.2
93
.1
55
.1
20
SC
vs
.S
B
Io
pr
om
id
e
12
5
3
32
0
El
ec
tiv
e
ca
rd
io
va
sc
ul
ar
pr
oc
ed
ur
es
in
cl
ud
in
g
C
A
G
or
in
te
rv
en
tio
na
l
tr
ea
tm
en
t
59
.2
53
.1
70
.2
93
.1
55
.1
20
SC
vs
SB
Io
pr
om
id
e
12
5
3
–
ay
ss
en
et
al
.
[3
5]
36
2
ST
EM
I
un
de
rg
oi
ng
pr
im
ar
y
PC
I
w
ith
in
12
ho
ur
s
fr
om
th
e
on
se
t
of
ch
es
tp
ai
n
62
.5
78
.5
77
90
.5
50
9.
7
SC
vs
.S
B
Io
di
xa
no
l
14
0
5
36
2
ST
EM
I
un
de
rg
oi
ng
pr
im
ar
y
PC
I
w
ith
in
12
ho
ur
s
fr
om
th
e
on
se
t
of
ch
es
tp
ai
n
62
.5
78
.5
77
90
.5
50
9.
7
SC
vs
SB
Io
di
xa
no
l
14
0
5
N
ie
to
-R
io
s
et
al
.[
36
]
22
0
To
m
og
ra
ph
y
sc
an
us
in
g
C
M
or
an
gi
og
ra
ph
y
60
57
.7
11
5.
8
37
.3
SC
vs
.S
B
Io
he
xo
l
10
0
3
22
0
To
m
og
ra
ph
y
sc
an
us
in
g
C
M
or
an
gi
og
ra
ph
y
60
57
.7
11
5.
8
37
.3
SC
vs
SB
Io
he
xo
l
10
0
3
M
an
ar
ie
ta
l.
[3
7]
59
2
ST
EM
I
w
ith
in
12
h
fr
om
sy
m
pt
om
on
se
t
re
fe
rr
ed
fo
r
pr
im
ar
y
an
gi
op
la
st
y
65
74
.8
88
.5
81
48
16
.6
11
.8
SC
vs
.S
B
Io
di
xa
no
l
19
8
3
59
2
ST
EM
I
w
ith
in
12
h
fr
om
sy
m
pt
om
on
se
t
re
fe
rr
ed
fo
r
pr
im
ar
y
an
gi
op
la
st
y
65
74
.8
88
.5
81
48
16
.6
11
.8
SC
vs
SB
Io
di
xa
no
l
19
8
3
M
ah
m
oo
di
et
al
.[
38
]
35
0
C
or
on
ar
y
in
te
rv
en
tio
ns
64
.4
8
51
.4
10
3
64
.8
SC
vs
.S
B
Io
he
xo
l
2
35
0
C
or
on
ar
y
in
te
rv
en
tio
ns
64
.4
8
51
.4
10
3
64
.8
SC
vs
SB
Io
he
xo
l
2
Lu
o
et
al
.[
39
]
21
6
ST
EM
I
67
65
.7
77
77
.6
25
N
on
vs
.S
C
Io
pa
m
ir
on
23
4.
9
3
21
6
ST
EM
I
67
65
.7
77
77
.6
25
N
on
vs
SC
Io
pa
m
ir
on
23
4.
9
3
K
oo
im
an
et
al
.
[4
0]
54
8
C
K
D
pa
tie
nt
s
re
ce
iv
in
g
C
E-
C
T
72
.1
60
.4
50
.4
26
.8
16
.4
SC
vs
.S
B
Io
m
ep
ro
l
10
5
5
54
8
C
K
D
pa
tie
nt
s
re
ce
iv
in
g
C
E-
C
T
72
.1
60
.4
50
.4
26
.8
16
.4
SC
vs
SB
Io
m
ep
ro
l
10
5
5
K
oo
im
an
et
al
.
[4
1]
13
8
C
K
D
pa
tie
nt
s
re
ce
iv
in
g
C
TP
A
70
.5
50
49
.2
16
.7
8
N
on
vs
.S
B
Io
pr
om
id
e
or
io
bi
tr
id
ol
o
r
io
di
xa
no
l
74
5
13
8
C
K
D
pa
tie
nt
s
re
ce
iv
in
g
C
TP
A
70
.5
50
49
.2
16
.7
8
N
on
vs
SB
Io
pr
om
id
e,
or
io
bi
tr
id
ol
,o
r
io
di
xa
no
l
74
5
Journal of Interventional Cardiology 5
Ta
bl
e
1:
C
on
tin
ue
d.
St
ud
ie
s
Pa
tie
nt
s
(n
)
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
(y
ea
rs
)
M
al
es
(%
)
Ba
se
lin
e
SC
r
(m
g/
dL
)
Ba
se
lin
e
eG
FR
(m
L/
m
in
/
1.
73
m
2 )
M
ea
n
LV
EF
(%
)
D
M
(%
)
H
F
(%
)
Tr
ea
tm
en
t
gr
ou
ps
Ty
pe
s
of
C
M
C
M
do
sa
ge
(m
L)
Ja
da
d
sc
or
e
N
o.
of
pa
tie
nt
s
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
M
al
e
(%
)
Ba
se
lin
e
SC
r
Ba
se
lin
e
eG
FR
M
ea
n
LV
EF
D
M
(%
)
H
F
(%
)
G
ro
up
s
Ty
pe
s
of
C
M
D
os
ag
e
of
C
M
Ja
da
d
sc
or
e
Br
ar
et
al
.[
17
]
39
6
Re
fe
rr
ed
to
th
e
ca
rd
ia
c
ca
th
et
er
iz
at
io
n
la
bo
ra
to
ry
w
ith
eG
FR
≤
60
m
L/
m
in
/1
.7
3
m
2 ,
an
d
at
le
as
to
ne
of
th
ef
ol
lo
w
in
g:
D
M
,C
H
F,
hy
pe
rt
en
sio
n,
or
ag
e
ol
de
r
th
an
75
ye
ar
s
72
61
.9
12
3.
8
48
51
.3
20
.5
SC
vs
.H
D
y
Io
xi
la
n
10
8
3
39
6
Re
fe
rr
ed
to
th
e
ca
rd
ia
c
ca
th
et
er
iz
at
io
n
la
bo
ra
to
ry
w
ith
eG
FR
≤
60
m
L/
m
in
/1
.7
3
m
2 ,
an
d
at
le
as
to
ne
of
th
e
fo
llo
w
in
g:
D
M
,
C
H
F,
hy
pe
rt
en
sio
n,
or
ag
e
ol
de
r
th
an
75
ye
ar
s
72
61
.9
12
3.
8
48
51
.3
20
.5
SC
vs
H
D
y
Io
xi
la
n
10
8
3
A
ky
uz
et
al
.
[4
2]
22
5
A
tl
ea
st
on
e
of
th
e
hi
gh
-r
isk
fa
ct
or
s
fo
r
de
ve
lo
pi
ng
C
I-
A
K
I
an
d
un
de
rg
oi
ng
C
A
G
an
d/
or
PC
I
63
.4
68
.9
79
.6
84
.5
47
.5
60
.9
7.
6
O
ra
lv
s.
SC
N
ot
m
en
tio
ne
d
10
8
2
22
5
A
tl
ea
st
on
e
of
th
e
hi
gh
-r
isk
fa
ct
or
s
fo
r
de
ve
lo
pi
ng
C
I-
A
K
I
an
d
un
de
rg
oi
ng
C
A
G
an
d/
or
PC
I
63
.4
68
.9
79
.6
84
.5
47
.5
60
.9
7.
6
O
ra
lv
s
SC
N
ot
m
en
tio
ne
d
10
8
2
K
ri
st
el
le
re
ta
l.
[4
3]
92
St
ag
e
3
or
hi
gh
er
C
K
D
w
ho
un
de
rw
en
t
ca
rd
ia
c
su
rg
er
y
us
in
g
C
PB
72
.5
57
.6
11
9.
1
44
.6
34
.8
SC
vs
SB
N
ot
m
en
tio
ne
d
79
5
92
St
ag
e
3
or
hi
gh
er
C
K
D
w
ho
un
de
rw
en
t
ca
rd
ia
c
su
rg
er
y
us
in
g
C
PB
72
.5
57
.6
11
9.
1
44
.6
34
.8
SC
vs
SB
N
ot
m
en
tio
ne
d
79
5
K
oc
et
al
.[
44
]
19
5
D
M
pa
tie
nt
s
62
52
.3
88
.4
10
0
SC
vs
.S
B
N
ot
m
en
tio
ne
d
90
4
19
5
D
M
pa
tie
nt
s
62
52
.3
88
.4
10
0
SC
vs
SB
N
ot
m
en
tio
ne
d
90
4
G
u
et
al
.[
45
]
85
9
C
or
on
ar
y
an
gi
og
ra
ph
y
or
an
gi
op
la
st
y
59
72
.2
90
.1
74
.2
20
.6
0.
6
SC
vs
.
SC
+
di
ur
es
is
N
ot
m
en
tio
ne
d
10
0
2
85
9
C
or
on
ar
y
an
gi
og
ra
ph
y
or
an
gi
op
la
st
y
59
72
.2
90
.1
74
.2
20
.6
0.
6
SC
vs
SC
+
di
ur
es
is
N
ot
m
en
tio
ne
d
10
0
2
Bo
uc
ek
et
al
.
[4
6]
12
0
D
ia
be
tic
pa
tie
nt
s
w
ith
im
pa
ir
ed
re
na
l
fu
nc
tio
n,
un
de
rg
oi
ng
in
tr
a-
ar
te
ri
al
or
in
tr
av
en
ou
s
us
e
of
C
M
65
75
16
5
44
.1
10
0
SC
vs
.S
B
Lo
w
-o
sm
ol
ar
no
ni
on
ic
io
di
na
te
d
11
0
5
12
0
D
ia
be
tic
pa
tie
nt
s
w
ith
im
pa
ir
ed
re
na
l
fu
nc
tio
n,
un
de
rg
oi
ng
in
tr
a-
ar
te
ri
al
or
in
tr
av
en
ou
su
se
of
C
M
65
75
16
5
44
.1
10
0
SC
vs
SB
Lo
w
-o
sm
ol
ar
no
ni
on
ic
io
di
na
te
d
11
0
5
M
ar
en
zi
et
al
.
[4
7]
17
0
C
K
D
un
de
rg
oi
ng
co
ro
na
ry
pr
oc
ed
ur
es
73
78
.2
15
4.
7
39
51
.5
36
.4
SC
vs
.
Re
na
lG
ua
rd
Io
m
ep
ro
l
17
0
3
17
0
C
K
D
un
de
rg
oi
ng
co
ro
na
ry
pr
oc
ed
ur
es
73
78
.2
15
4.
7
39
51
.5
36
.4
SC
vs
Re
na
lG
ua
rd
Io
m
ep
ro
l
17
0
3
K
on
g
et
al
.
[4
8]
80
D
efi
ni
tiv
e
or
su
sp
ec
te
d
co
ro
na
ry
ar
te
ry
di
se
as
e
56
.5
53
.8
10
5
23
.8
O
ra
lv
s.
SC
Io
pr
om
id
e
15
2
3
80
D
efi
ni
tiv
e
or
su
sp
ec
te
d
co
ro
na
ry
ar
te
ry
di
se
as
e
56
.5
53
.8
10
5
23
.8
O
ra
lv
s
SC
Io
pr
om
id
e
15
2
3
K
lim
a
et
al
.
[4
9]
25
8
Re
na
l
in
su
ffi
ci
en
cy
un
de
rg
oi
ng
in
tr
av
as
cu
la
r
co
nt
ra
st
pr
oc
ed
ur
es
77
64
13
7
43
.6
37
44
SC
vs
.S
B
N
ot
m
en
tio
ne
d
10
0
5
25
8
Re
na
l
in
su
ffi
ci
en
cy
un
de
rg
oi
ng
in
tr
av
as
cu
la
r
co
nt
ra
st
pr
oc
ed
ur
es
77
64
13
7
43
.6
37
44
SC
vs
SB
N
ot
m
en
tio
ne
d
10
0
5
G
om
es
et
al
.
[5
0]
30
1
Pa
tie
nt
s
at
m
od
er
at
e
to
hi
gh
ri
sk
fo
r
de
ve
lo
pi
ng
C
IN
w
ho
w
er
e
re
fe
rr
ed
fo
r
el
ec
tiv
e
C
A
G
or
PC
I
64
47
.5
13
2.
6
18
.9
SC
vs
.S
B
N
ot
m
en
tio
ne
d
12
5
2
30
1
Pa
tie
nt
s
at
m
od
er
at
e
to
hi
gh
ri
sk
fo
r
de
ve
lo
pi
ng
C
IN
w
ho
w
er
e
re
fe
rr
ed
fo
r
el
ec
tiv
eC
A
G
or
PC
I
64
47
.5
13
2.
6
18
.9
SC
vs
SB
N
ot
m
en
tio
ne
d
12
5
2
M
ot
oh
ir
o
et
al
.[
51
]
15
5
eG
FR
<6
0
m
l/
m
in
/1
.7
3
m
2
w
ho
w
er
e
un
de
rg
oi
ng
co
ro
na
ry
an
gi
og
ra
ph
y
72
.5
69
.7
13
6.
6
44
.3
55
60
SC
vs
.S
B
Io
pa
m
id
ol
13
5
3
15
5
eG
FR
<6
0
m
l/
m
in
/1
.7
3
m
2
w
ho
w
er
e
un
de
rg
oi
ng
co
ro
na
ry
an
gi
og
ra
ph
y
72
.5
69
.7
13
6.
6
44
.3
55
60
SC
vs
SB
Io
pa
m
id
ol
13
5
3
6 Journal of Interventional Cardiology
Ta
bl
e
1:
C
on
tin
ue
d.
St
ud
ie
s
Pa
tie
nt
s
(n
)
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
(y
ea
rs
)
M
al
es
(%
)
Ba
se
lin
e
SC
r
(m
g/
dL
)
Ba
se
lin
e
eG
FR
(m
L/
m
in
/
1.
73
m
2 )
M
ea
n
LV
EF
(%
)
D
M
(%
)
H
F
(%
)
Tr
ea
tm
en
t
gr
ou
ps
Ty
pe
s
of
C
M
C
M
do
sa
ge
(m
L)
Ja
da
d
sc
or
e
N
o.
of
pa
tie
nt
s
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
M
al
e
(%
)
Ba
se
lin
e
SC
r
Ba
se
lin
e
eG
FR
M
ea
n
LV
EF
D
M
(%
)
H
F
(%
)
G
ro
up
s
Ty
pe
s
of
C
M
D
os
ag
e
of
C
M
Ja
da
d
sc
or
e
M
ai
ol
ie
ta
l.
[5
2]
30
0
ST
EM
I
un
de
rg
oi
ng
pr
im
ar
y
PC
I
65
25
95
.9
42
.5
21
.7
24
N
on
vs
.S
B
Io
di
xa
no
l
21
6
3
30
0
ST
EM
I
un
de
rg
oi
ng
pr
im
ar
y
PC
I
65
25
95
.9
42
.5
21
.7
24
N
on
vs
SB
Io
di
xa
no
l
21
6
3
Le
e
et
al
.[
53
]
38
2
D
ia
be
tic
pa
tie
nt
s
w
ith
re
na
ld
ise
as
e
(s
er
um
cr
ea
tin
in
e
>1
.1
m
g/
dl
an
d
eG
FR
<6
0
m
l/
m
in
/1
.7
3
m
2 )
68
70
.9
13
2.
6
46
10
0
SC
vs
.S
B
Io
di
xa
no
l
11
6.
5
3
38
2
D
ia
be
tic
pa
tie
nt
s
w
ith
re
na
ld
ise
as
e
(s
er
um
cr
ea
tin
in
e
>1
.1
m
g/
dl
an
d
eG
FR
<6
0
m
l/
m
in
/1
.7
3
m
2 )
68
70
.9
13
2.
6
46
10
0
SC
vs
SB
Io
di
xa
no
l
11
6.
5
3
H
afi
z
et
al
.
[5
4]
32
0
Pa
tie
nt
s
w
ith
ba
se
lin
e
re
na
l
in
su
ffi
ci
en
cy
sc
he
du
le
d
to
un
de
rg
o
ca
th
et
er
iz
at
io
n
73
56
.9
14
1.
4
47
.2
SC
vs
.S
B
N
on
io
ni
c,
lo
w
–
os
m
ol
ar
11
5
3
32
0
Pa
tie
nt
s
w
ith
ba
se
lin
e
re
na
l
in
su
ffi
ci
en
cy
sc
he
du
le
d
to
un
de
rg
o
ca
th
et
er
iz
at
io
n
73
56
.9
14
1.
4
47
.2
SC
vs
SB
N
on
io
ni
c,
lo
w
–
os
m
ol
ar
11
5
3
Br
ig
uo
ri
et
al
.
[5
5]
29
2
H
ig
h-
ri
sk
pa
tie
nt
sw
ith
an
eG
FR
≤3
0
m
l/
m
in
/1
.7
3
m
2
an
d/
or
a
ri
sk
sc
or
e
≥1
1
76
65
.4
15
8.
7
32
47
70
.2
28
.4
SB
vs
.
Re
na
lG
ua
rd
Io
di
xa
no
l
14
0
3
29
2
H
ig
h-
ri
sk
pa
tie
nt
s
w
ith
an
eG
FR
≤3
0
m
l/m
in
/
1.
73
m
2
an
d/
or
a
ri
sk
sc
or
e
≥1
1
76
65
.4
15
8.
7
32
47
70
.2
28
.4
SB
vs
Re
na
lG
ua
rd
Io
di
xa
no
l
14
0
3
W
ró
be
le
ta
l.
[5
6]
10
2
C
or
on
ar
y
an
gi
og
ra
ph
y
an
d/
or
an
gi
op
la
st
y,
an
d
ha
d
co
m
or
bi
di
tie
s
th
at
in
cr
ea
se
th
e
ri
sk
of
C
IN
65
.5
56
.9
23
6.
4
O
ra
lv
s.
SC
Lo
ve
rs
ol
69
.5
2
10
2
C
or
on
ar
y
an
gi
og
ra
ph
y
an
d/
or
an
gi
op
la
st
y,
an
d
ha
d
co
m
or
bi
di
tie
s
th
at
in
cr
ea
se
th
e
ri
sk
of
C
IN
65
.5
56
.9
23
6.
4
O
ra
lv
s
SC
Lo
ve
rs
ol
69
.5
2
V
as
he
gh
an
i-
Fa
ra
ha
ni
et
al
.
[5
7]
72
C
A
G
,w
ith
SC
r
1.
5
m
g/
dL
w
ith
in
2
w
ee
ks
,
ha
vi
ng
at
le
as
t1
of
th
e
ri
sk
fa
ct
or
s
62
79
.2
15
1.
2
44
.2
36
.1
34
.7
45
.8
0.
45
SC
vs
.
SB
Io
he
xo
l
11
7.
5
3
72
C
A
G
,w
ith
SC
r
1.
5
m
g/
dL
w
ith
in
2
w
ee
ks
,
ha
vi
ng
at
le
as
t1
of
th
e
ri
sk
fa
ct
or
s
62
79
.2
15
1.
2
44
.2
36
.1
34
.7
45
.8
0.
45
SC
vs
SB
Io
he
xo
l
11
7.
5
3
C
ho
et
al
.[
58
]
91
U
nd
er
go
in
g
an
el
ec
tiv
e
C
A
G
78
50
.5
12
3
38
.5
17
.6
SC
vs
.S
B
Is
ov
er
so
l
12
8
2
91
U
nd
er
go
in
g
an
el
ec
tiv
e
C
A
G
78
50
.5
12
3
38
.5
17
.6
SC
vs
SB
Is
ov
er
so
l
12
8
2
V
as
he
gh
an
i-
Fa
ra
ha
ni
et
al
.
[5
9]
26
5
Se
ru
m
cr
ea
tin
in
e
le
ve
l
of
1.
5
m
g/
dL
or
gr
ea
te
r
un
de
rg
oi
ng
el
ec
tiv
e
C
A
G
63
.3
83
14
5.
4
45
.9
51
.7
21
.5
SC
vs
.S
B
Io
he
xo
l
11
4
5
26
5
Se
ru
m
cr
ea
tin
in
e
le
ve
l
of
1.
5
m
g/
dL
or
gr
ea
te
r
un
de
rg
oi
ng
el
ec
tiv
e
C
A
G
63
.3
83
14
5.
4
45
.9
51
.7
21
.5
SC
vs
SB
Io
he
xo
l
11
4
5
Ta
m
ur
a
et
al
.
[6
0]
14
4
Sc
he
du
le
d
fo
r
el
ec
tiv
e
C
A
G
or
PC
I
72
.8
87
.5
12
1.
1
39
.1
57
.8
58
.3
SC
vs
.S
B
Io
he
xo
l
85
3
14
4
Sc
he
du
le
d
fo
r
el
ec
tiv
eC
A
G
or
PC
I
72
.8
87
.5
12
1.
1
39
.1
57
.8
58
.3
SC
vs
SB
Io
he
xo
l
85
3
Pa
kf
et
ra
te
ta
l.
[6
1]
19
2
U
nd
er
go
in
g
el
ec
tiv
e
C
A
G
or
PC
I
57
.9
61
.5
97
.2
72
.2
50
.5
29
.7
5.
2
SC
vs
.S
B
Io
di
xa
no
l
65
4
19
2
U
nd
er
go
in
g
el
ec
tiv
eC
A
G
or
PC
I
57
.9
61
.5
97
.2
72
.2
50
.5
29
.7
5.
2
SC
vs
SB
Io
di
xa
no
l
65
4
H
aa
se
et
al
.
[6
2]
10
0
A
t
in
cr
ea
se
d
ri
sk
of
po
st
op
er
at
iv
e
ac
ut
e
re
na
l
dy
sf
un
ct
io
n
w
ho
w
er
e
sc
he
du
le
d
fo
r
el
ec
tiv
e
or
ur
ge
nt
ca
rd
ia
c
su
rg
er
y
ne
ce
ss
ita
tin
g
th
e
us
e
of
C
PB
71
66
90
.7
SC
vs
.S
B
N
ot
m
en
tio
ne
d
5
10
0
A
t
in
cr
ea
se
d
ri
sk
of
po
st
op
er
at
iv
e
ac
ut
e
re
na
l
dy
sf
un
ct
io
n
w
ho
w
er
e
sc
he
du
le
d
fo
r
el
ec
tiv
e
or
ur
ge
nt
ca
rd
ia
c
su
rg
er
y
ne
ce
ss
ita
tin
g
th
e
us
e
of
C
PB
71
66
90
.7
SC
vs
SB
N
ot
m
en
tio
ne
d
5
Journal of Interventional Cardiology 7
Ta
bl
e
1:
C
on
tin
ue
d.
St
ud
ie
s
Pa
tie
nt
s
(n
)
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
(y
ea
rs
)
M
al
es
(%
)
Ba
se
lin
e
SC
r
(m
g/
dL
)
Ba
se
lin
e
eG
FR
(m
L/
m
in
/
1.
73
m
2 )
M
ea
n
LV
EF
(%
)
D
M
(%
)
H
F
(%
)
Tr
ea
tm
en
t
gr
ou
ps
Ty
pe
s
of
C
M
C
M
do
sa
ge
(m
L)
Ja
da
d
sc
or
e
N
o.
of
pa
tie
nt
s
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
M
al
e
(%
)
Ba
se
lin
e
SC
r
Ba
se
lin
e
eG
FR
M
ea
n
LV
EF
D
M
(%
)
H
F
(%
)
G
ro
up
s
Ty
pe
s
of
C
M
D
os
ag
e
of
C
M
Ja
da
d
sc
or
e
Bu
dh
ir
aj
a
et
al
.[
63
]
18
7
N
on
em
er
ge
nt
C
A
G
,b
as
el
in
e
se
ru
m
cr
ea
tin
in
e
>1
.0
m
g/
dL
,
an
d
av
ai
la
bi
lit
y
of
se
ru
m
cr
ea
tin
in
e
va
lu
es
at
da
ys
1–
3
68
12
5.
8
57
.2
30
.5
SC
vs
.S
B
Io
pr
om
id
e
19
9
2
18
7
N
on
em
er
ge
nt
C
A
G
,b
as
el
in
e
se
ru
m
cr
ea
tin
in
e
>1
.0
m
g/
dL
,
an
d
av
ai
la
bi
lit
y
of
se
ru
m
cr
ea
tin
in
e
va
lu
es
at
da
ys
1–
3
68
12
5.
8
57
.2
30
.5
SC
vs
SB
Io
pr
om
id
e
19
9
2
A
ng
ou
lv
an
t
et
al
.[
64
]
20
1
Sc
he
du
le
d
fo
r
el
ec
tiv
e
C
A
G
,
w
ith
or
w
ith
ou
t
PT
C
A
w
ith
a
ba
se
lin
e
SC
r< 14 0 μm
ol
/
L
62
80
.6
86
.2
O
ra
lv
s.
SC
N
ot
m
en
tio
ne
d
29
0
3
20
1
Sc
he
du
le
d
fo
r
el
ec
tiv
e
C
A
G
,
w
ith
or
w
ith
ou
t
PT
C
A
w
ith
a
ba
se
lin
e
SC
r< 14 0μ
m
ol
/L
62
80
.6
86
.2
O
ra
lv
s
SC
N
ot
m
en
tio
ne
d
29
0
3
M
ai
ol
ie
ta
l.
[6
5]
50
2
U
nd
er
go
in
g
co
ro
na
ry
an
gi
og
ra
ph
ic
pr
oc
ed
ur
es
w
ith
es
tim
at
ed
cr
ea
tin
in
e
cl
ea
ra
nc
e
<6 0 m l/m
in
74
59
10
7
46
.5
59
.1
SC
vs
.S
B
Io
di
xa
no
l
16
5
3
50
2
U
nd
er
go
in
g
co
ro
na
ry
an
gi
og
ra
ph
ic
pr
oc
ed
ur
es
w
ith
es
tim
at
ed
cr
ea
tin
in
e
cl
ea
ra
nc
e
<6 0 m l/m in 74 59 10 7 46 .5 59 .1 SC vs SB Io di xa no l 16 5 3
C
he
n
et
al
.
[6
6]
66
0
M
yo
ca
rd
ia
l
isc
he
m
ia
(a
ng
in
a
or
po
sit
iv
e
ex
er
ci
se
tr
ea
dm
ill
)
sc
he
du
le
d
fo
r
PC
I,
w
ith
SC
r<
1.
5
m
g/
dl
60
85
11
4.
9
54
8
N
on
vs
.S
C
Is
o-
os
m
ol
ar
no
ni
on
ic
28
5
2
66
0
M
yo
ca
rd
ia
l
isc
he
m
ia
(a
ng
in
a
or
po
sit
iv
e
ex
er
ci
se
tr
ea
dm
ill
)
sc
he
du
le
d
fo
r
PC
I,
w
ith
SC
r<
1.
5
m
g/
dl
60
85
11
4.
9
54
8
N
on
vs
SC
Is
o-
os
m
ol
ar
no
ni
on
ic
28
5
2
C
he
n
et
al
.
[6
6]
27
6
M
yo
ca
rd
ia
l
isc
he
m
ia
(a
ng
in
a
or
po
sit
iv
e
ex
er
ci
se
tr
ea
dm
ill
)
sc
he
du
le
d
fo
r
PC
I,
w
ith
SC
r≥
1.
5
m
g/
dl
63
82
22
1
41
22
N
on
vs
.S
C
Is
o-
os
m
ol
ar
no
ni
on
ic
29
8
2
27
6
M
yo
ca
rd
ia
l
isc
he
m
ia
(a
ng
in
a
or
po
sit
iv
e
ex
er
ci
se
tr
ea
dm
ill
)
sc
he
du
le
d
fo
r
PC
I,
w
ith
SC
r≥
1.
5
m
g/
dl
63
82
22
1
41
22
N
on
vs
SC
Is
o-
os
m
ol
ar
no
ni
on
ic
29
8
2
Br
ar
et
al
.[
67
]
35
3
Pa
tie
nt
s
w
ith
st
ab
le
re
na
l
di
se
as
e
an
d
un
de
rg
oi
ng
C
A
G
71
63
.9
13
1.
7
48
57
44
.5
27
.2
SC
vs
.S
B
Io
xi
la
n
13
2
5
35
3
Pa
tie
nt
s
w
ith
st
ab
le
re
na
l
di
se
as
e
an
d
un
de
rg
oi
ng
C
A
G
71
63
.9
13
1.
7
48
57
44
.5
27
.2
SC
vs
SB
Io
xi
la
n
13
2
5
A
do
lp
h
et
al
.
[6
8]
14
5
St
ab
le
re
na
l
in
su
ffi
ci
en
cy
an
d
un
de
rg
oi
ng
el
ec
tiv
e
di
ag
no
st
ic
or
in
te
rv
en
tio
na
l
co
ro
na
ry
an
gi
og
ra
ph
y
72
.6
77
.9
13
2.
6
33
.8
SC
vs
.S
B
Io
di
xa
no
l
14
0
5
14
5
St
ab
le
re
na
l
in
su
ffi
ci
en
cy
an
d
un
de
rg
oi
ng
el
ec
tiv
e
di
ag
no
st
ic
or
in
te
rv
en
tio
na
l
co
ro
na
ry
an
gi
og
ra
ph
y
72
.6
77
.9
13
2.
6
33
.8
SC
vs
SB
Io
di
xa
no
l
14
0
5
Sc
hm
id
te
t
al
.
[6
9]
96
C
A
G
67
.6
74
14
6.
7
64
.6
SC
vs
.S
B
O
pt
ir
ay
18
6
2
96
C
A
G
67
.6
74
14
6.
7
64
.6
SC
vs
SB
O
pt
ir
ay
18
6
2
O
zc
an
et
al
.
[7
0]
26
4
Sc
he
du
le
d
fo
r
C
A
G
or
PC
I
an
d
ha
d
a
ba
se
lin
e
cr
ea
tin
in
e
le
ve
l
>1
.2
m
g/
dL
69
74
.6
12
2.
9
45
.1
26
.5
SC
vs
.S
B
Io
xa
gl
at
e
11
0
2
26
4
Sc
he
du
le
d
fo
r
C
A
G
or
PC
I
an
d
ha
d
a
ba
se
lin
e
cr
ea
tin
in
e
le
ve
l
>1
.2
m
g/
dL
69
74
.6
12
2.
9
45
.1
26
.5
SC
vs
SB
Io
xa
gl
at
e
11
0
2
8 Journal of Interventional Cardiology
Ta
bl
e
1:
C
on
tin
ue
d.
St
ud
ie
s
Pa
tie
nt
s
(n
)
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
(y
ea
rs
)
M
al
es
(%
)
Ba
se
lin
e
SC
r
(m
g/
dL
)
Ba
se
lin
e
eG
FR
(m
L/
m
in
/
1.
73
m
2 )
M
ea
n
LV
EF
(%
)
D
M
(%
)
H
F
(%
)
Tr
ea
tm
en
t
gr
ou
ps
Ty
pe
s
of
C
M
C
M
do
sa
ge
(m
L)
Ja
da
d
sc
or
e
N
o.
of
pa
tie
nt
s
In
cl
us
io
n
cr
ite
ri
a/
ri
sk
of
C
I-
A
K
I
M
ea
n
ag
e
M
al
e
(%
)
Ba
se
lin
e
SC
r
Ba
se
lin
e
eG
FR
M
ea
n
LV
EF
D
M
(%
)
H
F
(%
)
G
ro
up
s
Ty
pe
s
of
C
M
D
os
ag
e
of
C
M
Ja
da
d
sc
or
e
M
as
ud
a
et
al
.
[7
1]
59
Sc
he
du
le
d
to
un
de
rg
o
an
em
er
ge
nc
y
co
ro
na
ry
an
gi
og
ra
ph
y
or
in
te
rv
en
tio
n
75
44
.1
11
6.
2
30
.5
SC
vs
.S
B
Io
pa
m
id
ol
11
6
3
59
Sc
he
du
le
d
to
un
de
rg
o
an
em
er
ge
nc
y
co
ro
na
ry
an
gi
og
ra
ph
y
or
in
te
rv
en
tio
n
75
44
.1
11
6.
2
30
.5
SC
vs
SB
Io
pa
m
id
ol
11
6
3
D
us
so
le
t
al
.
[7
2]
15
6
C
K
D
,w
ho
w
er
e
un
de
rg
oi
ng
ra
di
ol
og
ic
al
pr
oc
ed
ur
es
w
ith
C
M
65
67
.9
20
4.
5
33
.1
28
.8
16
SC
vs
.
SC
+
di
ur
es
is
N
on
io
ni
c,
lo
w
os
m
ol
ar
11
7
5
15
6
C
K
D
,w
ho
w
er
e
un
de
rg
oi
ng
ra
di
ol
og
ic
al
pr
oc
ed
ur
es
w
ith
C
M
65
67
.9
20
4.
5
33
.1
28
.8
16
SC
vs
SC
+
di
ur
es
is
N
on
io
ni
c,
lo
w
os
m
ol
ar
11
7
5
M
ue
lle
r
et
al
.
[7
3]
42
5
Sc
he
du
le
d
fo
r
el
ec
tiv
e
or
em
er
ge
nc
y
PC
I
64
75
89
16
0.
45
SC
vs
.
SC
Io
pr
om
id
e
22
6
2
42
5
Sc
he
du
le
d
fo
r
el
ec
tiv
e
or
em
er
ge
nc
y
PC
I
64
75
89
16
0.
45
SC
vs
SC
Io
pr
om
id
e
22
6
2
M
er
te
n
et
al
.
[7
4]
11
9
St
ab
le
re
na
l
in
su
ffi
ci
en
cy
un
de
rg
oi
ng
di
ag
no
st
ic
or
in
te
rv
en
tio
na
l
pr
oc
ed
ur
es
re
qu
ir
in
g
ra
di
og
ra
ph
ic
co
nt
ra
st
,S
C
r>
1.
1
m
g/
dL
68
74
.8
15
9.
1
47
.9
SC
vs
.S
B
Io
pa
m
id
ol
13
2
3
11
9
St
ab
le
re
na
l
in
su
ffi
ci
en
cy
un
de
rg
oi
ng
di
ag
no
st
ic
or
in
te
rv
en
tio
na
l
pr
oc
ed
ur
es
re
qu
ir
in
g
ra
di
og
ra
ph
ic
co
nt
ra
st
,S
C
r>
1.
1
m
g/
dL
68
74
.8
15
9.
1
47
.9
SC
vs
SB
Io
pa
m
id
ol
13
2
3
Tr
iv
ed
ie
ta
l.
[7
5]
53
Sc
he
du
le
d
to
un
de
rg
o
no
ne
m
er
ge
nc
y
C
A
G
67
.9
98
.1
10
6.
4
52
.1
18
.9
O
ra
lv
s.
SC
Io
ni
c,
lo
w
–
os
m
ol
ar
14
8
2
53
Sc
he
du
le
d
to
un
de
rg
o
no
ne
m
er
ge
nc
y
C
A
G
67
.9
98
.1
10
6.
4
52
.1
18
.9
O
ra
lv
s
SC
Io
ni
c,
lo
w
–
os
m
ol
ar
14
8
2
M
ue
lle
r
et
al
.
[7
6]
13
83
Sc
he
du
le
d
fo
r
el
ec
tiv
e
or
em
er
ge
nc
y
C
A
G
64
74
.4
81
.7
7
15
.7
0.
45
SC
vs
.
SC
U
ltr
av
ist
or
im
er
on
23
4
2
13
83
Sc
he
du
le
d
fo
r
el
ec
tiv
e
or
em
er
ge
nc
y
C
A
G
64
74
.4
81
.7
7
15
.7
0.
45
SC
vs
SC
U
ltr
av
ist
,o
r
im
er
on
23
4
2
C
I-
A
K
I:
co
nt
ra
st
-in
du
ce
d
ac
ut
e
ki
dn
ey
in
ju
ry
;S
C
r:
se
ru
m
cr
ea
tin
in
e;
eG
FR
:e
st
im
at
ed
gl
om
er
ul
ar
fil
tr
at
io
n
ra
te
;L
V
EF
:l
ef
tv
en
tr
ic
ul
ar
ej
ec
tio
n
fr
ac
tio
n;
D
M
:d
ia
be
te
s
m
el
lit
us
;H
F:
he
ar
tf
ai
lu
re
;C
M
:c
on
tr
as
t
m
ed
ia
;C
T
A
:c
om
pu
te
d
to
m
og
ra
ph
y
an
gi
og
ra
ph
y;
TA
V
I:
tr
an
sc
at
he
te
ra
or
tic
va
lv
e
im
pl
an
ta
tio
n;
EV
A
R:
el
ec
tiv
e
en
do
va
sc
ul
ar
an
eu
ry
sm
re
pa
ir
;A
A
A
:a
bd
om
in
al
ao
rt
ic
an
eu
ry
sm
;C
K
D
:c
hr
on
ic
ki
dn
ey
di
se
as
e;
C
RT
:c
ar
di
ac
re
sy
nc
hr
on
iz
at
io
n
th
er
ap
y;
C
TP
A
:c
om
pu
te
d
to
m
og
ra
ph
y
pu
lm
on
ar
y
an
gi
og
ra
ph
y;
PE
:p
ul
m
on
ar
y
em
bo
lis
m
;C
IN
:c
on
tr
as
t-
in
du
ce
d
ne
ph
ro
pa
th
y;
C
H
F:
ch
ro
ni
c
he
ar
t
fa
ilu
re
;C
T:
co
m
pu
te
d
to
m
og
ra
ph
y;
TA
V
R:
tr
an
sc
at
he
te
r
ao
rt
ic
va
lv
e
re
pl
ac
em
en
t;
C
A
G
:
co
ro
na
ry
an
gi
og
ra
ph
y;
C
E-
C
T:
co
nt
ra
st
m
ed
ia
-e
nh
an
ce
d
co
m
pu
te
d
to
m
og
ra
ph
y;
C
PB
:
ca
rd
io
pu
lm
on
ar
y
by
pa
ss
;
PT
C
A
:
pe
rc
ut
an
eo
us
tr
an
slu
m
in
al
co
ro
na
ry
an
gi
op
la
st
y;
N
A
C
:N
-a
ce
ty
lc
ys
te
in
e.
Tr
ea
tm
en
tg
ro
up
s:
SC
:i
nt
ra
ve
no
u
s
0.
9%
so
di
um
ch
lo
ri
de
;S
B:
in
tr
av
en
ou
ss
od
iu
m
bi
ca
rb
on
at
e;
N
on
:n
on
hy
dr
at
io
n;
O
ra
l:
or
al
hy
dr
at
io
n;
Re
na
lG
ua
rd
:
Re
na
lG
ua
rd
sy
st
em
;H
D
y:
he
m
od
yn
am
ic
gu
id
ed
hy
dr
at
io
n;
SC
+
di
ur
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Journal of Interventional Cardiology 9
influential studies concluded that intravenous sodium bi-
carbonate provided no benefit over intravenous sodium
chloride in high-risk patients [11] and critically ill patients
[12]. Our NMA included 37 studies that compared intra-
venous sodium chloride with sodium bicarbonate, and our
results also indicated that intravenous sodium bicarbonate
led to a reduced risk for CI-AKI, although the effect size was
small (OR [95% CI]: 0.74 [0.57, 0.93]). Alkalization with
bicarbonate perfusion could theoretically reduce the for-
mation of reactive oxygen species by decreasing the
production of hydroxyl radicals due to inhibition of the
Haber-Weiss and Fenton reactions [84]. However, the
HYDRAREA study [12] assessed 307 critically ill patients
with stable renal function and found that hydration with
bicarbonate provided no benefit relative to hydration with
isotonic sodium chloride. -ese researchers also noted
that bicarbonate provided a greater benefit in the smaller
studies, suggesting publication bias. Recently, Weisbord
et al. [11] enrolled 5177 patients with high risk for renal
complications and found that administration of sodium
bicarbonate did not reduce the occurrence of CI-AKI.-is
result supports the interpretation that sodium bicarbonate
is not more effective than sodium chloride in preventing
CI-AKI or longer-term adverse outcomes after angiog-
raphy. However, there was high heterogeneity among our
60 studies regarding concurrent medications, comor-
bidities (CHF, DM), types of CM, periprocedural hy-
dration protocols, concentrations and dosages of sodium
bicarbonate, and radiographic procedures [12]. -us, we
do not recommend alkalization with intravenous sodium
bicarbonate as a single strategy, and a more effective
hydration strategy is needed to prevent CI-AKI.
Several recent RCTs of high risk patients [13, 28, 47, 55]
showed that furosemide-induced high-volume forced di-
uresis with matched hydration using the RenalGuard system
effectively prevented CI-AKI. RenalGuard is a closed-loop
fluid-management system, in which each volume of urine
that enters the collection bag leads to the infusion of an equal
volume of saline into the patient. Two meta-analyses [14, 16]
of RCTs concluded that the RenalGuard system signifi-
cantly reduced the risk of CI-AKI and the need for renal
replacement therapy in high-risk patients undergoing
coronary angiography. Our rankogram analysis indicated
that the RenalGuard system of guided hydration had the
highest rank, with a SUCRA of 0.974. However, we did not
assess the effectiveness of intravenous hydration plus di-
uresis without a guided system, and the rankogram indi-
cated that hemodynamic guided hydration was the second
best method, with a SUCRA of 0.849. Brar et al. [17] used
left ventricular end-diastolic pressure to guide fluid ad-
ministration and demonstrated that this method was safe
and effective in prevention of CI-AKI among patients
undergoing cardiac catheterization. Another study [19]
demonstrated that central venous pressure-guided fluid
administration safely and effectively reduced the risk of CI-
AKI in patients with CKD and CHF. Maioli et al. [18]
assessed body fluid level using bioimpedance vector
analysis (BIVA), which allows adjustment of intravascular
E
A
B
C
D
F
G
H
Nonhydration
Oral hydration
Half isotonic
sodium chloride
Intravenous
sodium chloride
Intravenous
sodium bicarbonate
Intravenous hyration
+ diuresis
Hemodynamic-guided
hydration
RenalGuard guided
hydration
37 studies
6
stu
di
es
3 s
tudie
s
1 study
1 study 5 s
tu
di
es
3 studies
3 stu
dies
2 studies
1 study
2 studies
Figure 2: Network diagram of eight hydration strategies used to prevent contrast-induced acute kidney injury in the 60 included studies.
Circles represent hydration strategies and lines represent direct comparisons. Circle size indicates the number of participants who received
each treatment, and line thickness indicates the number of studies in each comparison.
10 Journal of Interventional Cardiology
0.01 0.1 1 10
IV SB versus IV SC 0.86 (0.77–0.96)
0.98 (0.34–2.57)
IV SC versus oral hydration 0.86 (0.49–1.50)
0.91 (0.27–3.32)
IV + diuresis versus IV SB 0.80 (0.52–1.20)
0.89 (0.42–1.93)
IV SB versus oral hydration 0.74 (0.42–1.31)
0.74 (0.57–0.93)
IV + diuresis versus IV SC 0.68 (0.46–1.02)
0.72 (0.28–1.82)
RenalGuard versus
hemodynamic guided
0.68 (0.36–1.28)
0.72 (0.24–1.94)
Oral hydration versus no
hydration
0.66 (0.36–1.22)
0.66 (0.22–2.15)
Hemodynamic guided versus
IV + diuresis
0.61 (0.34–1.09)
0.65 (0.29–1.46)
IV + diuresis versus oral
hydration
0.59 (0.29–1.16)
0.64 (0.39–1.08)
No hydration versus half SC 0.57 (0.22–1.34)
0.58 (0.18–1.79)
IV SC versus no hydration 0.56 (0.45–0.72)
0.56 (0.24–1.33)
IV SB versus no hydration 0.48 (0.38–0.62)
0.50 (0.13–1.76)
Hemodynamic guided versus IV
SB
0.48 (0.31–0.74)
0.47 (0.28–0.81)
Hemodynamic guided versus IV
SC
0.42 (0.27–0.63)
0.41 (0.18–0.93)
RenalGuard versus IV + diuresis 0.41 (0.22–0.77)
0.40 (0.11–1.43)
IV + diuresis versus no hydration 0.39 (0.24–0.61)
0.36 (0.12–1.13)
Oral hydration versus half SC 0.38 (0.13–1.03)
0.36 (0.08–1.42)
Hemodynamic guided versus
oral hydration
0.36 (0.18–0.71)
0.33 (0.07–1.57)
RenalGuard versus IV SB 0.33 (0.20–0.53)
0.32 (0.14–0.70)
IV SC versus half SC 0.32 (0.13–0.73)
0.32 (0.09–1.02)
RenalGuard versus IV SC 0.28 (0.17–0.45)
0.26 (0.10–0.70)
IV SB versus half SC 0.28 (0.11–0.63)
0.24 (0.10–0.51)
RenalGuard versus oral
hydration
0.24 (0.12–0.50)
0.23 (0.07–0.75)
Hemodynamic guided versus no
hydration
0.23 (0.14–0.38)
0.23 (0.06–0.80)
IV + diuresis versus half SC 0.22 (0.08–0.55)
0.21 (0.07–0.63)
RenalGuard versus no hydration 0.16 (0.09–0.27)
0.15 (0.06–0.38)
Hemodynamic guided versus
half SC
0.13 (0.05–0.34)
0.13 (0.03–0.54)
RenalGuard versus half SC 0.09 (0.03–0.24)
0.07 (0.02–0.30)
Treatment 1 vs. treatment 2 O.R. (95% Cr.I.)
Favours treatment 1 Favours treatment 2Heterogeneity (vague) = 0.5817
95% CrI (0.3711–0.8451)
Fixed effects
Random effects (vague prior)
Figure 3: Forest plot showing the effect of different hydration strategies. Summary estimates from the pooled studies with 95% confidence
intervals are indicated for fixed effects (open diamonds) and random effects (filled diamonds) models.
Journal of Interventional Cardiology 11
volume expansion, and this led to a lower incidence of CI-
AKI after angiographic procedures. -erefore, our results
indicate that the RenalGuard system and hemodynamic
guided hydration are best for patients with high-risk for CI-
AKI, especially those with CKD and cardiac dysfunction.
5. Limitations
It is essential to note several limitations of our study.
Firstly, the hydration protocol should have a substantial
influence on CI-AKI, but because of the high heteroge-
neity of specific protocols used in the included studies, we
could not analyze distinct protocols, such as the effect of
different concentrations of sodium bicarbonate, and the
effect of hydration duration. Secondly, several con-
founding factors that we did consider may have impacted
the effects of hydration, including dosage and types of
CM, risk status of patients for CI-AKI, and other factors.
Finally, it may be inappropriate to define hemodynamic
guided hydration based on the use of different indexes,
such as left ventricular end-diastolic pressure, central
venous pressure, and bioimpedance.
6. Conclusion
-is Bayesian NMA provided substantial evidence to sup-
port the use of RenalGuard or hemodynamic guided hy-
dration to prevent CI-AKI in high-risk patients, especially
those with CKD or cardiac dysfunction.
OR <1 means the treatment in top le� is better
RenalGuard
0.58
(0.18–1.79)
Hemodynamic
guided
0.32
(0.14–0.70)
0.56
(0.24–1.33) IV SB
0.24
(0.10–0.51)
0.41
(0.18–0.93)
0.74
(0.57–0.93) IV SC
0.23
(0.06–0.80)
0.40
(0.11–1.43)
0.72
(0.24–1.94)
0.98
(0.34–2.57) IV + diuresis
0.21
(0.07–0.63)
0.36
(0.12–1.13)
0.65
(0.29–1.46)
0.89
(0.42–1.93)
0.91
(0.27–3.32) Oral hydration
0.15
(0.06–0.38)
0.26
(0.10–0.70)
0.47
(0.28–0.81)
0.64
(0.39–1.08)
0.66
(0.22–2.15)
0.72
(0.28–1.82) No hydration
0.07
(0.02–0.30)
0.13
(0.03–0.54)
0.23
(0.07–0.75)
0.32
(0.09–1.02)
0.33
(0.07–1.57)
0.36
(0.08–1.42)
0.50
(0.13–1.76) Half SC
Figure 4: League table, showing all pairwise comparisons of studies.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1 2 3 4 5 6 7 8
Pr
ob
ab
ili
ty
o
f b
ei
ng
ra
nk
ed
Rank
Random effects (vague) rankogram
RenalGuard
Hemodynamic-guided
IV + diuresis
IV SB
IV SC
Half SC
Oral hydration
No hydration
Best Worst
Figure 5: Rankogram of the effect of different hydration strategies
in reducing the risk of contrast-induced acute kidney injury.
0
0.5
1
1.5
2
0 0.5 1 1.5 2
In
co
ns
ist
en
cy
m
od
el
Consistency model
Fixed effects
Martin-Moreno PL 2015
Nijssen EC 2017
Figure 6: Inconsistency plot of enrolled studies, showing the
posterior mean deviance of each study from the consistency
model (horizontal axis) and the inconsistency model (vertical
axis).
12 Journal of Interventional Cardiology
Abbreviations
CI-
AKI:
Contrast-induced acute kidney injury
SCr: Serum creatinine
eGFR: Estimated glomerular filtration rate
LVEF: Left ventricular ejection fraction
DM: Diabetes mellitus
HF: Heart failure
CM: Contrast medium
CTA: Computed tomography angiography
TAVI: Transcatheter aortic valve implantation
EVAR: Elective endovascular aneurysm repair
AAA: Abdominal aortic aneurysm
CKD: Chronic kidney disease
CRT: Cardiac resynchronization therapy
CTPA: Computed tomography pulmonary angiography
PE: Pulmonary embolism
CIN: Contrast-induced nephropathy
CHF: Chronic heart failure
CT: Computed tomography
TAVR: Transcatheter aortic valve replacement
CAG: Coronary angiography
CE-CT: Contrast media-enhanced computed tomography
CPB: Cardiopulmonary bypass
PTCA: Percutaneous transluminal coronary angioplasty.
Conflicts of Interest
All authors have no conflicts of interest and no relationships
with industry.
Authors’ Contributions
Qiuping Cai and Ran Jing contributed equally to this paper.
C. Q. P. and J. R. carried out meta-analysis, participated in
data extraction, and drafted manuscript. Z.W. F. and T. Y. S.
carried out quality assessment. L. X. P. participated in study
design and performed statistical analysis. L. T. Q. conceived
the study and participated in its design and coordination and
helped to draft the manuscript. All authors read and ap-
proved the final manuscript.
Acknowledgments
-is work was supported by grants from the National
Natural Science Foundation of China (81670627),
Changzhou Health and Family Planning CommissionMajor
Sci and Tech Projects of China (ZD201501), Changzhou
Health and Family Planning Commission Youth Founda-
tion of China (QN201814), and Changzhou Sci and Tech
Program of China (CJ20159042).
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NURS 4420 Care of Adults with Multiple Compromised Health States
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