Tailored Versus Standard Hydration to Prevent Acute Kidney Injury After Percutaneous Coronary Intervention: Network Meta-Analysis

Abstract

Background Contrast-induced acute kidney injury (CI-AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI-AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion-rate hydration strategies. Methods and Results A systematic review and network meta-analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI-AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate-guided, central venous pressure-guided, left ventricular end-diastolic pressure-guided, and bioimpedance vector analysis-guided hydration. Primary endpoint was CI-AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate-guided and central venous pressure-guided hydration were associated with a lower incidence of CI-AKI compared with fixed-rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19-0.54] and OR, 0.45 [95% CI, 0.21-0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate-guided hydration is advantageous in terms of both CI-AKI prevention and pulmonary edema incidence when compared with other approaches. Conclusions Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline-supported fixed-rate hydration for CI-AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate-guided hydration as the most convenient strategy in terms of effectiveness and safety.

Keywords: contrast‐induced acute kidney injury; coronary angiography; hydration; percutaneous coronary intervention.

Figure 1. Network maps of study treatments: (A) contrast‐induced acute kidney injury and (B) pulmonary edema.

Nodes represent each treatment; node size is proportional to the number receiving the corresponding treatment, which is indicated below treatment name. Solid edges represent direct comparisons available in the literature. The thickness of each edge is proportional to the number of available studies, which is indicated near the edge itself. Red‐dashed edges represent indirect comparisons. BIVA indicates bioimpedance vectorial analysis; CVP, central venous pressure; LVEDP, left ventricular end‐diastolic pressure; RCT, randomized controlled trial; and UFR, urine flow rate.

Figure 2. League of tables for CI‐AKI (A) and pulmonary edema (B).

Each cell contains the odds ratio and 95% CI for the comparison of treatment reported in the column vs treatment reported in the row. Gray cells contain treatment name (C and D), P score, and ranking analysis. BIVA indicates bioimpedance vectorial analysis; CI‐AKI, contrast‐induced acute kidney injury; CVP, central venous pressure; LVEDP, left ventricular end‐diastolic pressure; and UFR, urine flow rate.

Figure 3. Summary of findings of the network meta‐analysis: CI‐AKI (efficacy outcome).

BIVA indicates bioimpedance vector analysis; CI‐AKI, contrast‐induced acute kidney injury; CVP, central venous pressure; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; LVEDP, left ventricular end‐diastolic pressure; NNT, number needed to treat; OR, odds ratio; RCT, randomized controlled trial; and UFR, urine flow‐rate.

Figure 4. Summary of findings of the network meta‐analysis: Pulmonary Edema (safety outcome)

BIVA indicates bioimpedance vector analysis; CI‐AKI, contrast‐induced acute kidney injury; CVP, central venous pressure; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; LVEDP, left ventricular end‐diastolic pressure; NNT, number needed to treat; OR, odds ratio; RCT, randomized controlled trial; and UFR, urine flow‐rate.

Figure 5. Hydration volume meta‐analysis.

A, The bubble plot for the meta‐regression of the logit event rate for CI‐AKI over mean hydration volume for each treatment arm of the studies included (efficacy outcome). B, The bubble plot for the meta‐regression of the logit event rate of pulmonary edema (safety outcome) over mean hydration volume. Bubbles represent each treatment arm, and bubble size is proportional to relative weight in the analysis. C, The league table for hydration volume differences. Each cell contains the effect size estimate for mean difference and 95% CI in hydration volume between the treatment reported in the column vs treatment reported in the row. All values are expressed in mL. A positive value means that mean hydration provided by the treatment indicated in the column is larger than the mean hydration provided by the treatment indicated in the row. Gray cells contain treatment name. CI‐AKI indicates contrast‐induced acute kidney injury; CVP, central venous pressure; LVEDP, left ventricular end‐diastolic pressure; and UFR, urine flow rate.