Acute Kidney Injury
Culprits, Cures, and Consequences
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Contrast-induced acute kidney injury (CI-AKI) occurs in ≈7% of all patients and in >25% of high risk patients undergoing coronary angiography.1 The definition of CI-AKI by relative or absolute changes in serum creatinine has evolved over the past decade, and there is increasing recognition that CI-AKI is associated with increased mortality, readmission to the hospital, and progression of existing chronic kidney disease. No evidence-based treatment for established CI-AKI has been developed, but prevention of CI-AKI has been the subject of many studies.2 In this issue of Circulation: Cardiovascular Interventions, Diab et al3 present an invasive approach to curing at-risk patients of CI-AKI: coronary sinus aspiration of contrast. The role of this highly invasive method of preventing CI-AKI should be seen in the broader context of our limited understanding of the potential causes, preventive strategies, and consequences of CI-AKI.
See Article by Diab et al
Pathogenesis of CI-AKI
Patient and procedural characteristics that increase the likelihood of developing CI-AKI include the following: chronic kidney disease, congestive heart failure, advanced age, female sex, hemodynamic instability, diabetes mellitus, anemia, and the urgency of the procedure. Procedural characteristics include the need for vasopressor support and the amount and type of contrast used for imaging the coronary vessels.4 The mechanism of injury in CI-AKI involves ischemic and nephrotoxic injury.5 The pathophysiologic evidence for injury may obscure the fact that the definition of CI-AKI requires the exclusion of other causes of AKI, unrelated to contrast administration. For example, noncontrast computed tomography scans performed 24 hours after coronary angiography reveal frequent persistent global nephrograms (that could be consistent with CI-AKI), as well as segmental lesions, suggesting localized areas of decreased perfusion (that might be consistent with embolic disease).6,7 Such lesions can be seen in the absence of a change in …