Effect of Remote Ischemic Preconditioning to Prevent Acute Kidney Injury in Chronic Kidney Disease Patient Undergoing Contrast-enhanced Computed Tomography: A Randomized Controlled Trial
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Abstract
Background: Chronic kidney disease (CKD) is an important risk factor of contrast-induced acute kidney injury (CI-AKI). Remote ischemic preconditioning (RIPC); transient ischemia followed by reperfusion of the extremity may subsequently protect against ischemia-induced injury in other organs. A case where RIPC can prevent CI-AKI after contrast-enhanced computed tomography (CT) has not been reported. Method: We conducted a randomized controlled trial in CKD patients, with glomerular infiltration rate (GFR) less than 60 mL/min/1.73m2, whom underwent contrast-enhanced CT during July 2018 to January 2019 at Phramongkutklao Hospital. All patients received standard protocolS to prevent CI-AKI. Patients were allocated in 1:1 ratio to receive RIPC or not (control) by using block of 4 randomization. RIPC consists of 4 cycles of 5 minutes of cuff to induce arm ischemia with 5 minutes of reperfusion before undergoing contrast-enhanced CT. All patients were closely monitored for possible complications. Results: A total of 70 CKD patients (35 in the RIPC group, 35 in the control group) were enrolled. The mean age was 73.6±9.9 years and the baseline GFR was 45.3±12.2 mL/min/1.73m2. Forty-two (60%) patients were male. The incidence of CI-AKI is lower in the RIPC group than the control group (8.57% vs 0%), p-value=0.07. Changes of serum creatinine from the baseline to 48-hour and from 24-hour to 48-hour were better in the RIPC group than those in the control group: -0.09 ±0.16 vs -0.02±0.20 mg/dL, p-value=0.13, and 0.00±0.12 vs 0.08±0.17 mg/dL, p-value = 0.03, respectively. Changes of GFR from 24-hour to 48-hour was also better in the RIPC group than those in the control group; -0.0±5.4 vs -2.4±6.3 mL/min/1.73m2. In the RIPC group, 25 (71.4%) patients had local numbness. Eighteen (51.4%) patients experienced arm pain, with mean pain score 3.1±1.2 of 10, which immediately resolved after the procedure. No serious complication was observed.
Conclusion: RIPC may decrease the risk of CI-AKI in CKD patient undergoing contrast-enhanced CT, without any serious side effect.
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References
importance of acute renal failure after percutaneous coronary intervention. Circulation. 2002 ;105(19):2259-64.
2: Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, et al. The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol. 2000;36(5):1542-8.
3: James MT, Samuel SM, Manning MA, Tonelli M, Ghali WA, Faris P, et al. Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2013;6(1):37-43.
4. Aubry P, Brillet G, Catella L, Schmidt A, Benard S. Outcomes, risk factors and health burden of contrast-induced acute kidney injury: an observational study of one million hospitalizations with image-guided cardiovascular procedures. BMC Nephrol. 2016; 17(1): 167.
5. Atanda AC, Olafiranye O. Contrast-induced acute kidney injury in interventional cardiology: Emerging evidence and unifying mechanisms of protection by remote ischemic conditioning. Cardiovasc Revasc Med. 2017; 18(7): 549-53.
6. Machado MN, Nakazone MA, Maia LN. Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery. Rev Bras Cir Cardiovasc. 2014; 29(3): 299-307.
7: Hoole SP, Heck PM, Sharples L, Khan SN, Duehmke R, Densem CG, et al. Cardiac Remote Ischemic Preconditioning in Coronary Stenting (CRISP Stent) Study: a prospective, randomized control trial. Circulation. 2009;119(6):820-7.
8: Er F, Nia AM, Dopp H, Hellmich M, Dahlem KM, Caglayan E, et al. Ischemic preconditioning for prevention of contrast medium-induced nephropathy: randomized pilot RenPro Trial (Renal
Protection Trial). Circulation. 2012;126(3):296-303.
9. Luo SJ, Zhou YJ, Shi DM, Ge HL, Wang JL, Liu RF. Remote ischemic preconditioning reduces myocardial injury in patients undergoing coronary stent implantation. Can J Cardiol. 2013; 29(9): 1084-9.
10. Igarashi G, Iino K, Watanabe H, Ito H. Remote ischemic pre-conditioning alleviates contrast-induced acute kidney injury in patients with moderate chronic kidney disease. Circ J. 2013; 77(12): 3037-44.
11: Yamanaka T, Kawai Y, Miyoshi T, Mima T, Takagaki K, Tsukuda S, et al. Remote ischemic preconditioning reduces contrast-induced acute kidney injury in patients with ST-elevation myocardial infarction: a randomized controlled trial. Int J Cardiol. 2015;178:136-41.
12. Savaj S, Savoj J, Jebraili I, Sezavar SH. Remote ischemic preconditioning for prevention of contrast-induced acute kidney injury in diabetic patients. Iran J Kidney Dis. 2014; 8(6): 457-60.
13: Xu X, Zhou Y, Luo S, Zhang W, Zhao Y, Yu M, et al. Effect of remote ischemic preconditioning in the elderly patients with coronary artery disease with diabetes mellitus undergoing elective drug-eluting stent implantation. Angiology. 2014;65(8):660-6.
14. Gholoobi A, Sajjadi SM, Shabestari MM, Eshraghi A, Shamloo AS. The Impact of Remote Ischemic Pre-Conditioning on Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography and Angioplasty: A Double-Blind Randomized Clinical Trial. Electron Physician. 2015; 7(8): 1557-65.
15: Balbir Singh G, Ann SH, Park J, Chung HC, Lee JS, Kim ES, et al. Remote Ischemic Preconditioning for the Prevention of Contrast-Induced Acute Kidney Injury in Diabetics Receiving Elective Percutaneous Coronary Intervention. PLoS One. 2016;11(10):e0164256.
16: Kahlert P, Hildebrandt HA, Patsalis PC, Al-Rashid F, Jánosi RA, Nensa F, et al. No protection of heart, kidneys and brain by remote ischemic preconditioning before transfemoral transcatheter aortic valve implantation: Interim-analysis of a randomized single-blinded, placebo-controlled, single-center trial. Int J Cardiol. 2017;231:248-254.
17: Walsh SR, Boyle JR, Tang TY, Sadat U, Cooper DG, Lapsley M, et al. Remote ischemic preconditioning for renal and cardiac protection during endovascular aneurysm repair: a randomized controlled trial. J Endovasc Ther. 2009;16(6):680-9.
18: Menting TP, Sterenborg TB, de Waal Y, Donders R, Wever KE, Lemson MS, et al. Remote Ischemic Preconditioning To Reduce Contrast-Induced Nephropathy: A Randomized Controlled Trial. Eur J Vasc Endovasc Surg. 2015;50(4):527-32.
19: Healy DA, Feeley I, Keogh CJ, Scanlon TG, Hodnett PA, Stack AG, et al. Remote ischemic conditioning and renal function after contrast-enhanced CT scan: A randomized trial. Clin Invest Med. 2015;38(3):E110-8.
20. Rassaf T, Totzeck M, Hendgen-Cotta UB, Shiva S, Heusch G, Kelm M. Circulating nitrite contributes to cardioprotection by remote ischemic preconditioning. Circ Res. 2014; 114(10): 1601-10.
21. Murillo D, Kamga C, Mo L, Shiva S. Nitrite as a mediator of ischemic preconditioning and cytoprotection. Nitric Oxide. 2011; 25(2): 70-80.
22. Claytor RB, Aranson NJ, Ignotz RA, Lalikos JF, Dunn RM. Remote ischemic preconditioning modulates p38 MAP kinase in rat adipocutaneous flaps. J Reconstr Microsurg. 2007; 23(2): 93-8.
23: Zarbock A, Schmidt C, Van Aken H, Wempe C, Martens S, Zahn PK, et al; RenalRIPC Investigators. Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: a randomized clinical trial. JAMA. 2015;313(21):2133-41.
24. Zarbock A, Kellum JA. Remote Ischemic Preconditioning and Protection of the Kidney--A Novel Therapeutic Option. Crit Care Med. 2016; 44(3): 607-16.
25: Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013;17(1):R25.