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Review Article Hydration Strategies for Preventing Contrast-Induced Acute Kidney Injury: A Systematic Review and Bayesian Network Meta-Analysis

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; [email protected]

Received 25 May 2019; Accepted 31 December 2019; Published 11 February 2020

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 Library 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

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 NMA 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 21,293 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

Ta bl

e 1:

C ha ra ct er ist ic s of

th e in cl ud

ed st ud

ie s.

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(n )

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et al .[ 11 ]

49 93

H ig h ri sk

fo r

re na l

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an d sc he du

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fo ra

ng io gr ap hy

69 .8

93 .6

13 2. 6

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7. 4

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lo r lo w -

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85 5

49 93

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93 .6

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80 .9

7. 4

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lo rl ow

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85 5

va n M ou

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74

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44 .6

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31 .1

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74

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89 .3

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[2 6]

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3

4 Journal of Interventional Cardiology

Ta bl

e 1:

C on

tin ue d.

St ud

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Pa tie nt s

(n )

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26 4

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5 26 4

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et al .

[3 0]

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16 9. 3

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59 .1

35 .5

SC vs .S

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m en tio

ne d

10 7

4 39 1

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an gi og ra ph

y w ith

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<4 5 m l/m

in /

1. 73

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72 57 .5

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59 .1

35 .5

SC vs

SB N ot

m en tio

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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

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m en tio

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12 0

3 13 0

Re ce iv in g C M

fo r C T sc an

57 .5

64 .3

79 .6

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vs SB

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12 0

3

Ju ra do

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et al .

[3 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 .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

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vs SC

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ic 17 4

2

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al .

[1 3]

11 2

TA V R

81 40 .2

87 .1

51 .5

54 .6

25 SC

vs .

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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

or 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

TA :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

us 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 es is:

in tr av en ou

s 0. 9%

so di um

ch lo ri de

+ di ur es is;

0. 45

SC :0

.4 5%

so di um

ch lo ri de .

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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