Continued Controversy Between Contrast and Kidneys

April 26, 2024

Written by Caitlin Nicholson

Spoon Feed
In patients with ACS and concern for STEMI/NSTEMI requiring urgent intervention, randomization to the contrast volume reduction (CVR) group reduced the rate of acute kidney injury (AKI) and sustained kidney damage.

Continued controversy between contrast and kidneys…
The REMEDIAL IV trial (REnal Insufficiency Following Contrast MEDIA Administration Trial IV) was a well designed, randomized, single-blind trial aiming to identify whether a reduction in contrast media (CM) volume reduced AKI rate. The trial randomized 550 patients with STEMI or high-risk NSTEMI undergoing urgent invasive therapy to either a CM reduction group (276) or a control group (274). Patients in the CM reduction group were administered a significantly lower volume of CM via the DyeVert CM diversion system (95 +/- 30mL vs 160 +/- 23mL; p<0.001).  Patients randomized to the CVR group were shown to have a significant reduction in AKI (16% vs 24.3%; RR: 0.66; p = 0.018) as well as sustained kidney damage (6.1% vs 13.8%; p = 0.003).

There are a few important things to note about this trial. First, the use of the DyeVert CM diversion system did not result in any prolongation of time to revascularization. Also, the reduction in AKI did not correlate with a reduction in mortality.

How will this change my practice?
Contrast-associated AKI continues to be a controversial topic, with quite a few studies previously covered here on Journal Feed. While this interesting trial does support CM minimization in patients undergoing emergency invasive procedures, it will not be changing my practice at this time. In the emergency department setting, the use of contrast in critically ill patients is a matter of risk vs benefit on a case by case basis. In most patients, I think it is reasonable to continue to follow the guidelines outlined by the American College of Radiology and the National Kidney Foundation in the 2020 Consensus Statement.

Editor’s note: I covered this study, not because I care about this device, but because there is precious little RCT data related to contrast-associated nephropathy. This adds some and supports ACR recommendations to use the lowest amount possible in high risk patients. ~Clay Smith

Source
Kidney Injury After Minimal Radiographic Contrast Administration in Patients With Acute Coronary Syndromes. J Am Coll Cardiol. 2024;83(11):1059-1069. doi:10.1016/j.jacc.2024.01.016