@article{1f492e81128b46aa8c150a32e597a323,
title = "Prevention and Management of AKI in ACS Patients Undergoing Invasive Treatments",
abstract = "Purpose of Review: Management of patients presenting with acute coronary syndrome (ACS) includes invasive procedures that may increase the risk of acute kidney injury (AKI). AKI adversely affects the outcomes of such procedures and complicates the management of ACS. We have summarized several strategies for the prevention and management of AKI in this critical patient group including in the pre-procedural, intraprocedural, and post-procedural settings. Recent Findings: Definitive prevention and management strategies for AKI in patients presenting with ACS requiring invasive management can be confounded by the variation in data outcomes. Summary: Pre-procedural hydration with normal saline when accounting for time to catheterization, radial artery access, contrast stewardship, and close monitoring of renal function after catheterization should be implemented.",
keywords = "Acute coronary syndrome, Acute kidney injury, Cardiac catheterization, Contrast induced nephropathy",
author = "Thakker, {Ravi A.} and Aiham Albaeni and Haider Alwash and Syed Gilani",
note = "Funding Information: Aside from pre-procedural hydration, we also advocate for intravenous hydration after PCI which is supported by guidelines as well [, ]. In an observational study of 296 patients undergoing coronary angiography, patients were assigned to receive pre and post hydration with 1.5 L of 0.9% saline or NAC and sodium bicarbonate with a primary end-point of CA-AKI appearance. Intravenous hydration with 0.9% saline in patients with moderately reduced creatinine and creatinine clearance was found to be more effective (8.6% versus 17.6%) []. In a post hoc analysis of the TRUST study of over 17,000 participants, the authors evaluated intravenous hydration trends in patients who are at high risk for CA-AKI after PCI. They found independent predictors associated with increased intravenous hydration to be patients with older-age, diabetes mellitus, renal disease, hypertension, prior myocardial infraction, STEMI, high-contrast dose, multivessel disease, and ejection fraction of < 45% []. Another area of potential post-procedural optimization in prevention of CA-AKI is evaluating angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use. In a cohort study of over 200 patients undergoing non-emergent cardiac catheterization, Cirit et al. evaluated if ACE inhibitor administration had a role in the development of CA-AKI. They found higher increase in creatinine in the ACE inhibitor group (1.34 + / − 0.20 to 1.53 + / − 0.27 mg/dL) versus control (1.33 + / − 0.18 to 1.45 + / − 0.19 mg/dL) (p < 0.001) []. Equally, Holscher et al. in a randomized controlled trial demonstrated a risk of CA-AKI within 72 h after catheterization in patients who received preprocedural ACE inhibitors []. Staged PCI defines a delay or multi-staged intervention of an ischemic coronary artery. One of the rationales among cardiologists in performing staged PCIs is concern for poor renal function in addition to contrast required []. The concept is that if PCIs are done in stages rather than at all at once, this may reduce the overall burden of developing CA-AKI due to reduced contrast exposure. This is of course a topic of ongoing debate. In a retrospective cohort study of 230 patients, Shah et al. found that staged PCIs used less contrast per procedure but interestingly, the total contrast amount was more in the staged group. They defined staged as more than one PCI within 30 days that was performed electively. Furthermore, rates of AKI were not statistically different in the staged PCI vs ad hoc PCI group. In fact, staged PCI demonstrated worse renal outcomes around 4 to 12 weeks in patients with a baseline GFR of < 60 cm/min []. On the contrary, the SHOCK trial which evaluated early revascularization in patients with cardiogenic shock found that at 6 months, mortality was lower in the group that underwent revascularization compared to medications alone (50.3% versus 63.1%, p = 0.027). This finding was despite no difference in 30 day mortality between both groups []. In the CULPRIT-SHOCK trial, investigators randomized patients with cardiogenic shock who had multivessel disease to culprit lesion only PCI with option for staging versus immediate multivessel PCI. They found that the death or need for renal replacement therapy had occurred in 45.9% of patients with culprit lesion only PCI versus 55.4% in the multivessel group (relative risk: 0.83; 95% confidence interval 0.71 to 0.96; p = 0.01). They concluded that in patients who underwent PCI of the culprit lesion only, the risk of death or requirement of renal replacement therapy was lower []. Another area of post-procedural concern for AKI is in patients receiving mechanical circulatory support. In patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO), the etiology of AKI is believed to be due to factors such as hypotension, a rise in venous pressure secondary to extra fluids, a rise in the right ventricular afterload secondary to elevated intrathoracic pressures from ventilation, overall low cardiac output, concern for poor oxygen delivery, and diversion of blood flow []. Intra-aortic balloon pump can also play a role in causing AKI; most notably, this occurs due to mispositioning and occlusion of the renal artery resulting in decrease blood flow to the kidneys []. A meta-analysis was performed of five randomized control trials and one nonrandomized study comparing IABP with percutaneous assist devices (pVAD) such as Impella (Abiomed Inc) and TandemHeart in patients undergoing high-risk PCI with multivessel disease or unprotected left main disease. The combined adverse events which included AKI aside from limb ischemia, infection, major bleeding, and vascular injury in the pLVAD group compared to IABP group were increased (relative risk 1.65; 95% confidence interval 1.14 to 2.39; p = 0.008) []. On the contrary, Flaherty et al. in the Global cVAD Renal Protection Study of patients undergoing nonemergent high-risk PCI with Impella (Abiomed Inc) evaluated a primary outcome of post-procedural AKI at 48 h versus the predicted risk of AKI when using the Mehran risk score. They found a 77.6% lower AKI rate (p < 0.0001) in the Impella (Abiomed Inc) group. The limitations are to be noted of the study, such as a small sample size and the inherent biases of an observational study with no randomization. Other notable limitations as noted by the authors include lack of blinding of operators to baseline creatinine and inability to determine the exact etiology of AKI []. Ultimately, if AKI does develop post-procedurally that is refractive to conservative therapy, then, dialysis may be indicated. This carries a high in-hospital and 1-year mortality []. 3 Publisher Copyright: {\textcopyright} 2022, The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.",
year = "2022",
month = oct,
doi = "10.1007/s11886-022-01742-0",
language = "English (US)",
volume = "24",
pages = "1299--1307",
journal = "Current Cardiology Reports",
issn = "1523-3782",
publisher = "Current Medicine Group",
number = "10",
}