Original Titlte: Prevention of Contrast-Induced Nephropathy by Central Venous Pressure–Guided Fluid Administration in Chronic Kidney Disease and Congestive Heart Failure Patients. Reference: GengQian et al. JACC: Cardiovascular interventions 2015
Courtesy of Dr. Agustín Vecchia.
Hospital Alemán, Buenos Aires, Argentina.
The aim of this study was to assess a venous pressure guided hydration technique in patients with cardiac failure and chronic kidney failure, to reduce contrast induced nephropathy rates and, at the same time, prevent acute heart failure.
This prospective randomized double blind study included 264 patients with cardiac failure (ejection fraction <50% and one hospitalization for cardiac failure the previous year) and chronic kidney failure (MDRD: 15-60 ml/min/1.73 m2) to be assessed by angiography and PCI.
Patients were randomized to venous pressure guided hydration (CPV guided group) vs. standard hydration (1 ml/kg/h from 6 hrs.before to 12 hrs.after procedure). In the CPV group, the infusion was adjusted according to CVP level entry hour: group 1 (PVC < 6 cmH2O), group 2 (PVC 6 to 12 cm H2O) and group 3 (PVC > 12 cm H2O). The infusion rate was adjusted as follows: 3 ml/kg/h for group 1, 1.5 ml/kg/h for group 2 and 1 ml/kg/h for group 3. CIN was defined as an absolute increase in serum creatinine (SCr) >0.5 mg/dl (44.2 μmol/l) or a relative increase >25% compared with baseline SCr.
Baseline characteristics were well balanced in both groups. The average volume of administered fluid was significantly higher in the CPV group: (1,827 ± 497 ml vs. 1,202 ± 247 ml; p<0.001) and the CIN rate was significantly reduced in the CPV group(15.9% vs. 29.5%; p=0.006). The incidence of heart failure was no different in both groups (3.8% vs. 3.0%; p=0.500).
Conclusion
The authors concluded that the CPV guided fluid administration is safe and effective to reduce contrast induced nephropathy in patients with cardiac failure and chronic kidney failure.
Editorial Comment
CIN incidence in chronic kidney failure patients is about 20% in registries, and is associated to a significant increase in mortality. At present, guidelines recommend hydration as essential to prevent CIN, but there are no specific objectives in high risk patients such as the ones analyzed in this study.The use of drugs such as n-acetylcysteine has been widely challenged and is weakly recommended.Hemodynamic guided fluid administration is not new and has been shown effective by the Poseidon trial (Lancet 2014; 383: 1814–23),where hemodynamic monitoring was based on left ventricular end-diastolic pressure-guided volume expansion, with similar outcomes.
Among the limitations to this study, we should note the invasive procedure undergone by CPV patients and the mono centric character of the study.