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1. Contrast Volume During Primary Percutaneous Coronary Intervention...

   • Anonymous Anonymous

   I read with interest the article by Marenzi et al, Ann Intern Med. 2009;150:170-177, "Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality".

   I am puzzled by the conclusion that there is a volume limit for safe use of contrast during STEMI PCI. As best I can determine from the article, the risk of contrast volume is continuous and nearly linear.

   The "limit" suggested by the authors (=(Wt in Kg x 5)/creatinine in mg/dl) seems specious (1). There was no demonstration of a clean break-point in risk. The apparent break point shown in Figure 4 is illusory, reflecting a non-proportional scaling of the X axis. Less contrast is safer, and this is true at every level of dye exposure. More contrast is more dangerous, and this is true at level of dye exposure.

   I grant that in the penultimate paragraph the authors did write, "Further investigation is needed to determine whether limiting contrast volume to less than the MCD during primary PCI improves patient outcomes. Future studies are also needed to evaluate the relative usefulness of contrast volume and renal function indices and contrast ratio for predicting CIN." The case remains open, as it should.

   In many institutions, the cardiac catheterization laboratory has become a gold rush town, with about the same level of decorum. I have recently seen a colleague battered because he exceeded the "limit" of contrast proposed in the Marenzi article. If you could possibly keep this potential for carnage in mind as you vet these articles, I would be grateful.

   Here is a Web-based calculator that I have created, based on the article: http://www.zunis.org/Risk_Calculators/Proposed% 20Contrast Limit in STEMI PCI.htm

   References

   1. Giancarlo Marenzi, Emilio Assanelli, Jeness Campodonico, Gianfranco Lauri, Ivana Marana, Monica De Metrio, Marco Moltrasio, Marco Grazi, Mara Rubino, Fabrizio Veglia, Franco Fabbiocchi, and Antonio L. Bartorelli Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality Ann Intern Med 2009; 150: 170-177

   Conflict of Interest:

   None declared

   Submit response
   Published June 23, 2009
2. Contrast-Induced Nephropathy is a Misleading Expression for Renal Impairment after PCI

   • Hitinder S. Gurm, MD
   • Pascal Meier, MD

   University of Michigan Medical Center and Veterans Affair Ann Arbor Healthcare System, Ann Arbor, MI

   We would like to commend Marenzi et al.(1) on their excellent study demonstrating an association between contrast volume and renal failure in patients undergoing STEMI. As the authors have astutely pointed out, it is not clear if the association is causal or is simply related to confounding. In general, patients who are the sickest or have a suboptimal result after PCI are more likely to receive a greater contrast volume.

   While studies of bicarbonate, acetylcysteine, or different contrast agents have shown a dramatic reduction in contrast-induced nephropathy (CIN), a corresponding reduction in mortality has not been demonstrated (2,3). While one cannot disagree with the need to avoid excess contrast volume in any patient undergoing PCI, it is unlikely that contrast media is the sole factor responsible for renal dysfunction in the patient population undergoing primary PCI.

   We believe the term CIN to describe this syndrome is misleading and prematurely ascribes a causal relationship. It would be preferable to use a more neutral expression such as Nephropathy Associated with Primary PCI (NAPP) to describe this entity until the etiopathogenesis of this syndrome is better delineated.

   References

   1. Marenzi G, Assanelli E, Campodonico J, et al. Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality. Ann Intern Med. Feb 3 2009;150(3):170- 177.

   2. Nallamothu B, Shojania K, Saint S, et al. Is Acetylcysteine Effective in Preventing Contrast-Related Nephropathy? A Meta-analysis. Am J Med. 2004;117:938-947.

   3. Hogan SE, L'Allier P, Chetcuti S, et al. Current role of sodium bicarbonate-based preprocedural hydration for the prevention of contrast-induced acute kidney injury: a meta-analysis. Am Heart J. Sep 2008;156(3):414-421.

   Conflict of Interest:

   None declared

   Submit response
   Published February 16, 2009