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; Tongqiang Liu

doi:10.1155/2020/7292675

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

Cai, Qiuping;Jing, Ran;Zhang, Wanfen;Tang, Yushang;Li, Xiaoping;Liu, Tongqiang 2020-02-11 00:00:00 Hindawi Journal of Interventional Cardiology Volume 2020, Article ID 7292675, 16 pages https://doi.org/10.1155/2020/7292675 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; liuyf1106@126.com 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. identiﬁed a priori, no known pharmaceutical treatment can 1.Introduction eﬀectively prevent or treat CI-AKI. Contrast-induced acute kidney injury (CI-AKI), also re- Guidelines recommend intravascular hydration to pre- ferred to as contrast-induced nephropathy (CIN), is an vent CI-AKI [4, 5], and there are several speciﬁc hydration iatrogenic complication that can occur following intravas- strategies, but researchers have not yet established an op- cular administration of iodinated contrast medium (CM) timal strategy [6–9]. Notably, recent randomized controlled prior to radiography. CI-AKI is the third leading cause of trials (RCTs) have led to doubts about the eﬀectiveness of hospital-acquired acute renal injury (AKI) [1]. CI-AKI has a various hydration strategies in prevention of CI-AKI. For low incidence in the general population, but it has a sig- example, Nijssen et al. [10] conducted an RCT with 660 high- niﬁcant incidence in patients with certain risk factors. risk patients and found that no prophylaxis was noninferior Moreover, the occurrence of CI-AKI following cardiac or cost-saving relative to intravenous hydration. Weisbord catheterization procedures is associated with an in-hospital et al. [11] enrolled 5177 high-risk patients and reported no mortality of 20%, a 1-year mortality of up to 66%, and an beneﬁt of intravenous sodium bicarbonate relative to normal even higher mortality in patients who require dialysis [2, 3]. saline. Another RCT [12] concluded that the beneﬁt of However, even if patients with high risk of CI-AKI can be sodium bicarbonate was marginal relative to isotonic 2 Journal of Interventional Cardiology were conducted using the Bayesian Markov chain Monte sodium chloride for preventing CI-AKI among critically ill patients. However, other studies indicated that the Renal- Carlo method in WinBUGS V.1.4.3 (MRC Biostatistics Unit, Cambridge, United Kingdom) using the Microsoft Excel- Guard System [13–16] and hemodynamic guided hydration [17–19] were safe and eﬀective in preventing CI-AKI. Be- based macro NetMetaXL V.1.6.1 (Canadian Agency for cause of these apparently discrepant results, we conducted a Drugs and Technologies in Health, Ottawa, Canada) [23]. A network meta-analysis (NMA) to assess the eﬀects of various convergence test for each analysis was conducted by hydration strategies on the occurrence of CI-AKI in an eﬀort checking whether the Monte Carlo error was less than 5% of to identify the optimal strategy for prevention of CI-AKI. 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 2.Methods also used to generate a forest plot, league table, and “ran- 2.1. Data Search. -is systematic review and meta-analysis kogram” with surface under the cumulative ranking curve were performed according to Cochrane Handbook guide- (SUCRA), which ranges from 0 (worst) to 100% (best). lines [20]. -e Web of Science, PubMed, OVID Medline, and Inconsistency was assessed by comparing the residual de- Cochrane Library databases were searched using medical viance and deviance information criterion statistics in ﬁtted subject headings or keywords. Relevant published original consistency and inconsistency models. studies that were published up to September 30, 2018, were examined. -e search syntax was as follows: “contrast-in- 3. Results duced acute kidney injury OR contrast-induced nephrop- 3.1. Literature Search. We initially identiﬁed 3620 publica- athy OR CIN OR CI-AKI OR contrast acute renal failure OR tions, assessed 703 RCTs for eligibility by review of the full contrast nephropathy” AND “hydration OR ﬂuid admin- texts, and ultimately included 60 RCTs which met the eli- istration OR volume expansion OR intravenous sodium gibility criteria (Figure 1). -ese studies examined 21,293 bicarbonate OR saline infusion.” patients (median: 222, interquartile range [IQR]: 120, 350) and 2232 CI-AKI events. All included RCTs were full-length 2.2. Study Selection. An initial eligibility screen of all cita- journal articles. Agreement between the two reviewers at the tions was conducted, and only studies that examined CI-AKI full-text review stage was excellent (Cohen’s κ � 0.85). and hydration were selected for further full-text review. All included studies were RCTs; experimental studies were 3.2. Characteristics ofStudies and Participants. Table 1 shows excluded. In addition, all included studies reported the the characteristics of the included studies. -e publication prevention of CI-AKI after intravascular administration of date ranged from 2002 to 2018, and about 50% of the studies CM; used clinical protocols that were hydration strategies, were published after 2013. -e proportion of male patients not pharmaceutical prevention strategies; had clear deﬁni- ranged from 25.0% to 98.1% (median [IQR]: 65.7 [56.9, tions of CI-AKI; and provided data on the outcome of in- 74.8]), and the mean age ranged from 56.2 to 82.9 years (67.8 terest (occurrence of CI-AKI within 2 days to 1 week after [63.1, 72.5]). -irty-one studies enrolled 12,519 patients who procedures). 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]), 2.3. Data Extraction and Quality Assessment. Two authors and the baseline estimated glomerular ﬁltration rate (eGFR) (C. Q. P. and J. R.) independently reviewed each article for ranged from 32 to 93.1 mL/min/1.73 m (49.2 [44.1, 74.2]). eligibility. Any disagreement was resolved by discussion Twenty-three studies provided the values of left ventricular among the authors or involvement of a third author. Data ejection fraction (LVEF); the mean LVEF ranged from 25% extraction included the year of publication, sample size, pa- to 57.8% (49.0 [42.8, 54.5]). -e percentage of diabetes tient characteristics, risk factors associated with CI-AKI (old mellitus (DM) patients ranged from 8% to 100%, and the age, diabetes mellitus, renal impairment, heart failure), and percentage with heart failure (HF) ranged from 0.6% to type and dosage of contrast medium. -e primary endpoint 45.8%. A total of 8176 patients from 32 studies received was the occurrence of CI-AKI within 2 days to 1 week after intravenous low-osmolar nonionic CM, 9993 patients from intravascular administration of CM. Two investigators inde- 17 studies received iso-osmolar nonionic CM, and 317 pendently evaluated the quality of each study using the Jadad patients from 2 studies received low-osmolar ionic CM. -e scale, which ranges from 0 (worst) to 5 (best) [21]. mean Jadad score of the 60 RCTs was 3.2 (3 [2, 4]), indicating the overall study quality was good. 2.4. Statistical Analyses. -e advantages of Bayesian NMA over traditional meta-analysis are its greater ﬂexibility, its 3.3. Network Meta-Analysis. Figure 2 shows all the com- provision of more naturally interpretable results, and its parisons in the NMA. -irty-seven studies (13,365 partici- ability to rank treatments by comparative eﬀectiveness [22]. pants) compared the eﬃcacy of intravenous sodium -e occurrence of CI-AKI as a dichotomous outcome bicarbonate and 0.9% sodium chloride. -e other hydration variable was expressed as an odds ratio (OR) and 95% strategies were nonhydration (8 studies, 1396 patients), oral conﬁdence interval (CI). All P values were 2-sided, and a P hydration (6 studies, 355 patients), intravenous half iso- value below 0.05 was considered signiﬁcant. All analyses osmolar saline (3 studies, 968 patients), intravenous Journal of Interventional Cardiology 3 treatments ranged from 0.197 to 0.441, and their rankings 3620 citations identified were similar. Hydration using half iso-osmolar saline alone 2348 identified through Web of Science search 411 identified through PubMed search was the least eﬀective treatment. 431 identified through Cochrane Library search 430 identified through OVID search 3.4. Inconsistency Analysis. We performed network incon- 2070 excluded during initial screen for not sistency assessment for the ﬁxed eﬀect model for the 60 meeting inclusion criteria studies (Figure 6). -e resulting plot demonstrated that 1534 were duplicates nearly all the studies were near the line of equality and that 536 had unrelated population or outcome the results were therefore consistent. However, there was 1550 studies screened in full-text review some evidence of inconsistency in 3 noninferiority studies [10, 31]. In particular, Martin-Moreno et al. [31] and Nijssen 847 excluded et al. [10] found that intravenous sodium bicarbonate and 748 were not RCTs 99 were reviews or comments 0.9% sodium chloride were noninferior to oral hydration. 703 RCTs assessed for eligibility 4. Discussion To our knowledge, this is the ﬁrst NMA to compare diﬀerent 643 excluded hydration strategies for prevention of CI-AKI. We included 339 were not about hydration 60 RCTs which examined 21,293 participants and 2232 CI- 220 had no outcomes of interest 84 were protocols 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- 60 RCTs included in final analysis AKI: the RenalGuard system, hemodynamic guided hy- dration, and intravenous sodium bicarbonate. Relative to no Figure 1: Identiﬁcation and selection of studies for Bayesian hydration, oral hydration and intravenous 0.9% sodium network meta-analysis. chloride were each noninferior in prevention of CI-AKI. Relative to oral hydration, intravenous 0.9% sodium chlo- hydration, mainly normal saline + diuresis (2 studies ride and sodium bicarbonate were each noninferior in [26, 31], 501 patients), hemodynamic guided hydration (3 prevention of CI-AKI. -us, we ranked the RenalGuard studies, 458 patients), and RenalGuard system guided hy- system as the best strategy and hemodynamic guided hy- dration (4 studies, 348 patients). dration as the second best. We compared the ORs of the diﬀerent hydration Guidelines for the prevention of CI-AKI in high-risk strategies using a forest plot (Figure 3) and analyzed the patients routinely recommend hydration protocols before results of the random eﬀects consistency NMA using a contrast exposure as an established preventive measure league table, which shows all pairwise comparisons (Figure 4). [77, 78]. A recent large RCT [10] led us to reanalyze the eﬃcacy of hydration for prevention of CI-AKI. In particular, Taken together, these results indicate that, relative to typical intravenous 0.9% sodium chloride hydration (reference), the the AMAstricht Contrast-Induced Nephropathy Guideline occurrence of CI-AKI was signiﬁcantly reduced by intra- (AMACING) study [10] enrolled 660 patients with high risk venous sodium bicarbonate (OR [95% CI]: 0.74 [0.57, 0.93]), of CI-AKI and concluded that, relative to intravenous hy- hemodynamic guided hydration (0.41 [0.18, 0.93]), and dration, no prophylaxis was less expensive and noninferior RenalGuard system guided hydration (0.32 [0.14, 0.70]). in prevention of CI-AKI. In our meta-analysis, ﬁve studies Oral hydration (0.72 [0.28, 1.82]) and intravenous 0.9% compared the eﬀectiveness of intravenous 0.9% sodium sodium chloride (0.64 [0.39, 1.08]) were each noninferior to chloride and three studies compared bicarbonate with no hydration for prevention of CI-AKI. Relative to oral nonhydration, leading to our conclusion that, relative to no hydration (reference), intravenous 0.9% sodium chloride or hydration (reference), oral hydration or hydration with sodium bicarbonate and hemodynamic guided hydration intravenous 0.9% sodium chloride was noninferior in pre- vention of CI-AKI. -ese results were unsurprising, because were each noninferior in prevention of CI-AKI, but RenalGuard guided hydration was superior (0.21 [0.07, simple oral or intravenous hydration can lead to compli- 0.63]). Intravenous hydration plus diuresis also did not cations, such as heart failure, pulmonary edema, and elec- decrease the risk of CI-AKI relative to oral hydration and no trolyte disorders. -us, the safety window of hydration is hydration. relatively narrow for patients undergoing percutaneous A rankogram and SUCRA values indicated the Renal- coronary intervention (PCI), and other more eﬀective or Guard system was best (SUCRA � 0.974) followed by he- precise hydration strategies may be needed to decrease the modynamic guided hydration (SUCRAs � 0.849; Figure 5). incidence of CI-AKI. Intravenous sodium bicarbonate had a SUCRA of 0.667. -e Most meta-analyses before 2016 [79–83] conﬁrmed that SUCRAs for intravenous 0.9% sodium chloride, intravenous intravenous sodium bicarbonate was more eﬀective than hydration plus diuresis, oral and no hydration, and the other sodium chloride in preventing CI-AKI. However, two recent 4 Journal of Interventional Cardiology Table 1: Characteristics of the included studies. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) High risk for High risk for renal renal Weisbord Iodixanol or low- complications Iodixanol or low- 4993 complications 69.8 93.6 132.6 50.2 80.9 7.4 SC vs. SB 85 5 4993 69.8 93.6 132.6 50.2 80.9 7.4 SC vs. SB 85 5 et al. [11] osmolar and scheduled osmolar and scheduled for for angiography angiography Symptomatic Symptomatic aortic valve aortic valve stenosis and stenosis and van Mourik 74 impaired renal 82.9 44.6 104.3 47.4 31.1 SC vs. SB Iopromide 90 3 74 impaired renal 82.9 44.6 104.3 47.4 31.1 SC vs SB Iopromide 90 3 et al. [24] function who function who underwent pre- underwent pre- TAVI CTA TAVI CTA Elective EVAR Elective EVAR Saratzis et al. 58 for infrarenal 75 89.7 65.5 13.8 SC vs. SB Iomeprol 126 3 58 for infrarenal 75 89.7 65.5 13.8 SC vs SB Iomeprol 126 3 [25] AAA AAA Elective Elective Maioli et al. coronary coronary 296 71 68.2 89.3 48 24.7 SC vs. HDy Iodixanol 131 3 296 71 68.2 89.3 48 24.7 SC vs HDy Iodixanol 131 3 [18] angiographic angiographic procedures procedures CKD patients CKD patients undergoing undergoing elective elective Kooiman et al. cardiovascular cardiovascular 333 73 64.6 50.5 38.7 16.5 SC vs. SB Not mentioned 113 3 333 73 64.6 50.5 38.7 16.5 SC vs SB Not mentioned 113 3 [26] diagnostic or diagnostic or interventional interventional contrast contrast procedures procedures Critically ill Critically ill patients with patients with stable renal stable renal Valette et al. 307 function who 56.2 67.8 61.4 13.4 6.5 SC vs. SB Low-osmolar 90 4 307 function who 56.2 67.8 61.4 13.4 6.5 SC vs SB Low-osmolar 90 4 [12] received received intravascular intravascular CM CM High-risk High-risk patients with patients with eGFR of eGFR of 30–59 ml/min/ 30–59 ml/min/ 2 2 Nijssen et al. 1.73 m , 1.73 m , 660 72 61.7 118 47.4 32.6 Non vs. SC Iopromide 90.5 3 660 72 61.7 118 47.4 32.6 Non vs SC Iopromide 90.5 3 [10] undergoing an undergoing an elective elective procedure procedure requiring CM requiring CM administration administration Patients Patients receiving CM receiving CM Alonso et al. 93 during CRT 66.5 65.3 110.5 28.5 37 SC vs. SB Iodixanol 102 2 93 during CRT 66.5 65.3 110.5 28.5 37 SC vs SB Iodixanol 102 2 [27] devices devices implantation implantation Coronary Coronary angiography/ angiography/ Usmiani et al. PCI with eGFR SC vs. PCI with eGFR SC vs 124 75 74 130.8 44 25 84 Iodixanol 156 3 124 75 74 130.8 44 25 84 Iodixanol 156 3 [28] of less than RenalGuard of less than RenalGuard 60 ml/min/ 60 ml/min/ 2 2 1.73 m 1.73 m Contrast- Contrast- enhanced enhanced CTPA on Water-soluble, CTPA on Water-soluble, Turedi et al. 172 suspicion of PE 75.5 51.7 85.4 SC vs. SB nonionic, low- <100 3 172 suspicion of PE 75.5 51.7 85.4 SC vs SB nonionic, low- <100 3 [29] with at least one osmolar with at least osmolar risk factor for one risk factor CIN for CIN Journal of Interventional Cardiology 5 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) CKD and CHF CKD and CHF undergoing undergoing Qian et al. [19] 264 63.5 74.6 151 37.5 39.5 47.3 SC vs. HDy Iodixanol 166 5 264 63.5 74.6 151 37.5 39.5 47.3 SC vs HDy Iodixanol 166 5 coronary coronary procedures procedures Elective Elective coronary or coronary or peripheral peripheral Solomon et al. 391 angiography 72 57.5 169.3 32.8 59.1 35.5 SC vs. SB Not mentioned 107 4 391 angiography 72 57.5 169.3 32.8 59.1 35.5 SC vs SB Not mentioned 107 4 [30] with eGFR with eGFR <45 ml/min/ <45 ml/min/ 2 2 1.73 m 1.73 m Martin- Receiving CM Receiving CM Moreno et al. 130 57.5 64.3 79.6 Non vs SB Not mentioned 120 3 130 57.5 64.3 79.6 Non vs SB Not mentioned 120 3 for CT scan for CT scan [31] Jurado- STEMI STEMI Iso-osmolar Iso-osmolar Roman ´ et al. 408 undergoing 63.1 73.4 89 22.5 14.7 Non vs. SC 174 2 408 undergoing 63.1 73.4 89 22.5 14.7 Non vs SC 174 2 nonionic nonionic [32] primary PCI primary PCI Barbanti et al. SC vs. SC vs 112 TAVR 81 40.2 87.1 51.5 54.6 25 Buckinghamshire 175 3 112 TAVR 81 40.2 87.1 51.5 54.6 25 Buckinghamshire 175 3 [13] RenalGuard RenalGuard Yeganehkhah 100 CAG 59.7 53 99.5 43.8 39 SC vs. SB Iohexol 45.4 3 100 CAG 59.7 53 99.5 43.8 39 SC vs SB Iohexol 45.4 3 et al. [33] Elective Elective cardiovascular cardiovascular procedures SC + NAC procedures Yang et al. SC + NAC vs 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 vs. Iopromide 125 3 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 Iopromide 125 3 [34] SB + NAC or SB + NAC or interventional interventional treatment treatment Elective Elective cardiovascular cardiovascular procedures procedures Yang et al. 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 SC vs. SB Iopromide 125 3 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 SC vs SB Iopromide 125 3 [34] or or interventional interventional treatment treatment STEMI STEMI undergoing undergoing -ayssen et al. primary PCI primary PCI 362 62.5 78.5 77 90.5 50 9.7 SC vs. SB Iodixanol 140 5 362 62.5 78.5 77 90.5 50 9.7 SC vs SB Iodixanol 140 5 [35] within 12 hours within 12 hours from the onset from the onset of chest pain of chest pain Tomography Tomography Nieto-Rios 220 scan using CM 60 57.7 115.8 37.3 SC vs. SB Iohexol 100 3 220 scan using CM 60 57.7 115.8 37.3 SC vs SB Iohexol 100 3 et al. [36] or angiography or angiography STEMI within STEMI within 12 h from 12 h from Manari et al. symptom onset symptom onset 592 65 74.8 88.5 81 48 16.6 11.8 SC vs. SB Iodixanol 198 3 592 65 74.8 88.5 81 48 16.6 11.8 SC vs SB Iodixanol 198 3 [37] referred for referred for primary primary angioplasty angioplasty Mahmoodi Coronary Coronary 350 64.48 51.4 103 64.8 SC vs. SB Iohexol 2 350 64.48 51.4 103 64.8 SC vs SB Iohexol 2 et al. [38] interventions interventions Luo et al. [39] 216 STEMI 67 65.7 77 77.6 25 Non vs. SC Iopamiron 234.9 3 216 STEMI 67 65.7 77 77.6 25 Non vs SC Iopamiron 234.9 3 CKD patients CKD patients Kooiman et al. 548 receiving CE- 72.1 60.4 50.4 26.8 16.4 SC vs. SB Iomeprol 105 5 548 receiving CE- 72.1 60.4 50.4 26.8 16.4 SC vs SB Iomeprol 105 5 [40] CT CT Iopromide or CKD patients Iopromide, or Kooiman et al. CKD patients 138 70.5 50 49.2 16.7 8 Non vs. SB iobitridol or 74 5 138 receiving 70.5 50 49.2 16.7 8 Non vs SB iobitridol, or 74 5 [41] receiving CTPA iodixanol CTPA iodixanol 6 Journal of Interventional Cardiology Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Referred to the Referred to the cardiac cardiac catheterization catheterization laboratory with laboratory with eGFR≤ 60 mL/ eGFR≤ 60 mL/ min/1.73 m , min/1.73 m , Brar et al. [17] 396 72 61.9 123.8 48 51.3 20.5 SC vs. HDy Ioxilan 108 3 396 and at least one 72 61.9 123.8 48 51.3 20.5 SC vs HDy Ioxilan 108 3 and at least one of the of the following: following: DM, DM, CHF, CHF, hypertension, hypertension, or age older or age older than 75 years than 75 years At least one of At least one of the high-risk the high-risk factors for factors for Akyuz et al. developing CI- developing CI- 225 63.4 68.9 79.6 84.5 47.5 60.9 7.6 Oral vs. SC Not mentioned 108 2 225 63.4 68.9 79.6 84.5 47.5 60.9 7.6 Oral vs SC Not mentioned 108 2 [42] AKI and AKI and undergoing undergoing CAG and/or CAG and/or PCI PCI Stage 3 or Stage 3 or higher CKD higher CKD Kristeller et al. 92 who underwent 72.5 57.6 119.1 44.6 34.8 SC vs SB Not mentioned 79 5 92 who underwent 72.5 57.6 119.1 44.6 34.8 SC vs SB Not mentioned 79 5 [43] cardiac surgery cardiac surgery using CPB using CPB Koc et al. [44] 195 DM patients 62 52.3 88.4 100 SC vs. SB Not mentioned 90 4 195 DM patients 62 52.3 88.4 100 SC vs SB Not mentioned 90 4 Coronary Coronary SC vs. SC vs Gu et al. [45] 859 angiography or 59 72.2 90.1 74.2 20.6 0.6 Not mentioned 100 2 859 angiography or 59 72.2 90.1 74.2 20.6 0.6 Not mentioned 100 2 SC + diuresis SC + diuresis angioplasty angioplasty Diabetic Diabetic patients with patients with impaired renal impaired renal Low-osmolar Low-osmolar Boucek et al. function, function, 120 65 75 165 44.1 100 SC vs. SB nonionic 110 5 120 65 75 165 44.1 100 SC vs SB nonionic 110 5 [46] undergoing undergoing iodinated iodinated intra-arterial or intra-arterial or intravenous use intravenous use of CM of CM CKD CKD Marenzi et al. undergoing SC vs. undergoing SC vs 170 73 78.2 154.7 39 51.5 36.4 Iomeprol 170 3 170 73 78.2 154.7 39 51.5 36.4 Iomeprol 170 3 [47] coronary RenalGuard coronary RenalGuard procedures procedures Deﬁnitive or Deﬁnitive or Kong et al. suspected suspected 80 56.5 53.8 105 23.8 Oral vs. SC Iopromide 152 3 80 56.5 53.8 105 23.8 Oral vs SC Iopromide 152 3 [48] coronary artery coronary artery disease disease Renal Renal insuﬃciency insuﬃciency Klima et al. undergoing undergoing 258 77 64 137 43.6 37 44 SC vs. SB Not mentioned 100 5 258 77 64 137 43.6 37 44 SC vs SB Not mentioned 100 5 [49] intravascular intravascular contrast contrast procedures procedures Patients at Patients at moderate to moderate to high risk for high risk for Gomes et al. developing CIN developing 301 64 47.5 132.6 18.9 SC vs. SB Not mentioned 125 2 301 64 47.5 132.6 18.9 SC vs SB Not mentioned 125 2 [50] who were CIN who were referred for referred for elective CAG or elective CAG or PCI PCI eGFR <60 ml/ eGFR <60 ml/ 2 2 min/1.73 m min/1.73 m Motohiro who were who were 155 72.5 69.7 136.6 44.3 55 60 SC vs. SB Iopamidol 135 3 155 72.5 69.7 136.6 44.3 55 60 SC vs SB Iopamidol 135 3 et al. [51] undergoing undergoing coronary coronary angiography angiography Journal of Interventional Cardiology 7 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) STEMI STEMI Maioli et al. 300 undergoing 65 25 95.9 42.5 21.7 24 Non vs. SB Iodixanol 216 3 300 undergoing 65 25 95.9 42.5 21.7 24 Non vs SB Iodixanol 216 3 [52] primary PCI primary PCI Diabetic Diabetic patients with patients with renal disease renal disease (serum (serum Lee et al. [53] 382 68 70.9 132.6 46 100 SC vs. SB Iodixanol 116.5 3 382 68 70.9 132.6 46 100 SC vs SB Iodixanol 116.5 3 creatinine creatinine >1.1 mg/dl and >1.1 mg/dl and eGFR <60 ml/ eGFR <60 ml/ 2 2 min/1.73 m ) min/1.73 m ) Patients with Patients with baseline renal baseline renal Haﬁz et al. insuﬃciency Nonionic, low- insuﬃciency Nonionic, low- 320 73 56.9 141.4 47.2 SC vs. SB 115 3 320 73 56.9 141.4 47.2 SC vs SB 115 3 [54] scheduled to osmolar scheduled to osmolar undergo undergo catheterization catheterization High-risk High-risk patients with an patients with Briguori et al. eGFR ≤30 ml/ SB vs. an eGFR SB vs 292 76 65.4 158.7 32 47 70.2 28.4 Iodixanol 140 3 292 76 65.4 158.7 32 47 70.2 28.4 Iodixanol 140 3 [55] min/1.73 m RenalGuard ≤30 ml/min/ RenalGuard and/or a risk 1.73 m and/or score ≥11 a risk score ≥11 Coronary Coronary angiography angiography and/or and/or Wrobel ´ et al. angioplasty, angioplasty, 102 65.5 56.9 236.4 Oral vs. SC Loversol 69.5 2 102 65.5 56.9 236.4 Oral vs SC Loversol 69.5 2 [56] and had and had comorbidities comorbidities that increase that increase the risk of CIN the risk of CIN CAG, with SCr CAG, with SCr 1.5 mg/dL 1.5 mg/dL Vasheghani- within 2 weeks, 0.45 SC vs. within 2 weeks, 0.45 SC vs Farahani et al. 72 62 79.2 151.2 44.2 36.1 34.7 45.8 Iohexol 117.5 3 72 62 79.2 151.2 44.2 36.1 34.7 45.8 Iohexol 117.5 3 having at least 1 SB having at least 1 SB [57] of the risk of the risk factors factors Undergoing an Undergoing an Cho et al. [58] 91 78 50.5 123 38.5 17.6 SC vs. SB Isoversol 128 2 91 78 50.5 123 38.5 17.6 SC vs SB Isoversol 128 2 elective CAG elective CAG Serum Serum creatinine level creatinine level Vasheghani- of 1.5 mg/dL or of 1.5 mg/dL or Farahani et al. 265 63.3 83 145.4 45.9 51.7 21.5 SC vs. SB Iohexol 114 5 265 63.3 83 145.4 45.9 51.7 21.5 SC vs SB Iohexol 114 5 greater greater [59] undergoing undergoing elective CAG elective CAG Scheduled for Scheduled for Tamura et al. 144 elective CAG or 72.8 87.5 121.1 39.1 57.8 58.3 SC vs. SB Iohexol 85 3 144 elective CAG or 72.8 87.5 121.1 39.1 57.8 58.3 SC vs SB Iohexol 85 3 [60] PCI PCI Undergoing Undergoing Pakfetrat et al. 192 elective CAG or 57.9 61.5 97.2 72.2 50.5 29.7 5.2 SC vs. SB Iodixanol 65 4 192 elective CAG or 57.9 61.5 97.2 72.2 50.5 29.7 5.2 SC vs SB Iodixanol 65 4 [61] PCI PCI At increased At increased risk of risk of postoperative postoperative acute renal acute renal dysfunction dysfunction Haase et al. who were who were 100 71 66 90.7 SC vs. SB Not mentioned 5 100 71 66 90.7 SC vs SB Not mentioned 5 [62] scheduled for scheduled for elective or elective or urgent cardiac urgent cardiac surgery surgery necessitating necessitating the use of CPB the use of CPB 8 Journal of Interventional Cardiology Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Nonemergent Nonemergent CAG, baseline CAG, baseline serum serum creatinine creatinine Budhiraja >1.0 mg/dL, >1.0 mg/dL, 187 68 125.8 57.2 30.5 SC vs. SB Iopromide 199 2 187 68 125.8 57.2 30.5 SC vs SB Iopromide 199 2 et al. [63] and availability and availability of serum of serum creatinine creatinine values at days values at days 1–3 1–3 Scheduled for Scheduled for elective CAG, elective CAG, with or without Angoulvant with or without 201 PTCA with a 62 80.6 86.2 Oral vs. SC Not mentioned 290 3 201 62 80.6 86.2 Oral vs SC Not mentioned 290 3 et al. [64] PTCA with a baseline baseline SCr< SCr< 140 μmol/ 140 μmol/L Undergoing Undergoing coronary coronary angiographic angiographic Maioli et al. procedures with procedures 502 74 59 107 46.5 59.1 SC vs. SB Iodixanol 165 3 502 74 59 107 46.5 59.1 SC vs SB Iodixanol 165 3 [65] estimated with estimated creatinine creatinine clearance clearance <60 ml/min <60 ml/min Myocardial Myocardial ischemia ischemia (angina or (angina or positive positive Chen et al. Iso-osmolar Iso-osmolar 660 exercise 60 85 114.9 54 8 Non vs. SC 285 2 660 exercise 60 85 114.9 54 8 Non vs SC 285 2 [66] nonionic nonionic treadmill) treadmill) scheduled for scheduled for PCI, with PCI, with SCr<1.5 mg/dl SCr< 1.5 mg/dl Myocardial Myocardial ischemia ischemia (angina or (angina or positive positive Chen et al. Iso-osmolar Iso-osmolar 276 exercise 63 82 221 41 22 Non vs. SC 298 2 276 exercise 63 82 221 41 22 Non vs SC 298 2 [66] nonionic nonionic treadmill) treadmill) scheduled for scheduled for PCI, with PCI, with SCr≥ 1.5 mg/dl SCr≥ 1.5 mg/dl Patients with Patients with stable renal stable renal Brar et al. [67] 353 disease and 71 63.9 131.7 48 57 44.5 27.2 SC vs. SB Ioxilan 132 5 353 disease and 71 63.9 131.7 48 57 44.5 27.2 SC vs SB Ioxilan 132 5 undergoing undergoing CAG CAG Stable renal Stable renal insuﬃciency insuﬃciency and and undergoing undergoing Adolph et al. elective 145 72.6 77.9 132.6 33.8 SC vs. SB Iodixanol 140 5 145 elective 72.6 77.9 132.6 33.8 SC vs SB Iodixanol 140 5 [68] diagnostic or diagnostic or interventional interventional coronary coronary angiography angiography Schmidt et al. 96 CAG 67.6 74 146.7 64.6 SC vs. SB Optiray 186 2 96 CAG 67.6 74 146.7 64.6 SC vs SB Optiray 186 2 [69] Scheduled for Scheduled for CAG or PCI CAG or PCI Ozcan et al. and had a and had a 264 69 74.6 122.9 45.1 26.5 SC vs. SB Ioxaglate 110 2 264 69 74.6 122.9 45.1 26.5 SC vs SB Ioxaglate 110 2 [70] baseline baseline creatinine level creatinine level >1.2 mg/dL >1.2 mg/dL Journal of Interventional Cardiology 9 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Scheduled to Scheduled to undergo an undergo an Masuda et al. emergency emergency 59 75 44.1 116.2 30.5 SC vs. SB Iopamidol 116 3 59 75 44.1 116.2 30.5 SC vs SB Iopamidol 116 3 [71] coronary coronary angiography or angiography or intervention intervention CKD, who were CKD, who were undergoing undergoing Dussol et al. SC vs. Nonionic, low SC vs Nonionic, low 156 radiological 65 67.9 204.5 33.1 28.8 16 117 5 156 radiological 65 67.9 204.5 33.1 28.8 16 117 5 [72] SC + diuresis osmolar SC + diuresis osmolar procedures with procedures CM with CM Scheduled for Scheduled for Mueller et al. 0.45 SC vs. 0.45 SC vs 425 elective or 64 75 89 16 Iopromide 226 2 425 elective or 64 75 89 16 Iopromide 226 2 [73] SC SC emergency PCI emergency PCI Stable renal Stable renal insuﬃciency insuﬃciency undergoing undergoing diagnostic or diagnostic or Merten et al. interventional interventional 119 68 74.8 159.1 47.9 SC vs. SB Iopamidol 132 3 119 68 74.8 159.1 47.9 SC vs SB Iopamidol 132 3 [74] procedures procedures requiring requiring radiographic radiographic contrast, SCr> contrast, SCr> 1.1 mg/dL 1.1 mg/dL Scheduled to Scheduled to Trivedi et al. undergo Ionic, low- undergo Ionic, low- 53 67.9 98.1 106.4 52.1 18.9 Oral vs. SC 148 2 53 67.9 98.1 106.4 52.1 18.9 Oral vs SC 148 2 [75] nonemergency osmolar nonemergency osmolar CAG CAG Scheduled for Scheduled for elective or 0.45 SC vs Ultravist, or Mueller et al. elective or 0.45 SC vs. Ultravist or 1383 64 74.4 81.77 15.7 234 2 1383 64 74.4 81.77 15.7 234 2 [76] emergency SC imeron emergency SC imeron CAG CAG 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 media; 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; NAC: N-acetylcysteine. Treatment groups: SC: intravenous 0.9% sodium chloride; SB: intravenous sodium bicarbonate; Non: nonhydration; Oral: oral hydration; RenalGuard: RenalGuard system; HDy: hemodynamic guided hydration; SC + diuresis: intravenous 0.9% sodium chloride + diuresis; 0.45 SC: 0.45% sodium chloride. 1 study 3 studies 2 studies 1 study 1 study 10 Journal of Interventional Cardiology Nonhydration RenalGuard guided hydration Oral hydration Hemodynamic-guided hydration Half isotonic sodium chloride Intravenous hyration + diuresis 37 studies D E Intravenous Intravenous sodium chloride sodium bicarbonate 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. inﬂuential studies concluded that intravenous sodium bi- do not recommend alkalization with intravenous sodium carbonate provided no beneﬁt over intravenous sodium bicarbonate as a single strategy, and a more eﬀective chloride in high-risk patients [11] and critically ill patients hydration strategy is needed to prevent CI-AKI. [12]. Our NMA included 37 studies that compared intra- Several recent RCTs of high risk patients [13, 28, 47, 55] venous sodium chloride with sodium bicarbonate, and our showed that furosemide-induced high-volume forced di- results also indicated that intravenous sodium bicarbonate uresis with matched hydration using the RenalGuard system led to a reduced risk for CI-AKI, although the eﬀect size was eﬀectively prevented CI-AKI. RenalGuard is a closed-loop ﬂuid-management system, in which each volume of urine small (OR [95% CI]: 0.74 [0.57, 0.93]). Alkalization with bicarbonate perfusion could theoretically reduce the for- that enters the collection bag leads to the infusion of an equal mation of reactive oxygen species by decreasing the volume of saline into the patient. Two meta-analyses [14, 16] production of hydroxyl radicals due to inhibition of the of RCTs concluded that the RenalGuard system signiﬁ- Haber-Weiss and Fenton reactions [84]. However, the cantly reduced the risk of CI-AKI and the need for renal HYDRAREA study [12] assessed 307 critically ill patients replacement therapy in high-risk patients undergoing with stable renal function and found that hydration with coronary angiography. Our rankogram analysis indicated bicarbonate provided no beneﬁt relative to hydration with that the RenalGuard system of guided hydration had the isotonic sodium chloride. -ese researchers also noted highest rank, with a SUCRA of 0.974. However, we did not assess the eﬀectiveness of intravenous hydration plus di- that bicarbonate provided a greater beneﬁt in the smaller studies, suggesting publication bias. Recently, Weisbord uresis without a guided system, and the rankogram indi- cated that hemodynamic guided hydration was the second et al. [11] enrolled 5177 patients with high risk for renal complications and found that administration of sodium best method, with a SUCRA of 0.849. Brar et al. [17] used bicarbonate did not reduce the occurrence of CI-AKI. -is left ventricular end-diastolic pressure to guide ﬂuid ad- result supports the interpretation that sodium bicarbonate ministration and demonstrated that this method was safe is not more eﬀective than sodium chloride in preventing and eﬀective in prevention of CI-AKI among patients CI-AKI or longer-term adverse outcomes after angiog- undergoing cardiac catheterization. Another study [19] raphy. However, there was high heterogeneity among our demonstrated that central venous pressure-guided ﬂuid 60 studies regarding concurrent medications, comor- administration safely and eﬀectively reduced the risk of CI- bidities (CHF, DM), types of CM, periprocedural hy- AKI in patients with CKD and CHF. Maioli et al. [18] assessed body ﬂuid level using bioimpedance vector dration protocols, concentrations and dosages of sodium bicarbonate, and radiographic procedures [12]. -us, we analysis (BIVA), which allows adjustment of intravascular 2 studies 3 studies 3 studies 5 studies 6 studies Journal of Interventional Cardiology 11 Treatment 1 vs. treatment 2 O.R. (95% Cr.I.) RenalGuard versus half SC 0.09 (0.03–0.24) 0.07 (0.02–0.30) Hemodynamic guided versus 0.13 (0.05–0.34) half SC 0.13 (0.03–0.54) RenalGuard versus no hydration 0.16 (0.09–0.27) 0.15 (0.06–0.38) IV + diuresis versus half SC 0.22 (0.08–0.55) 0.21 (0.07–0.63) Hemodynamic guided versus no 0.23 (0.14–0.38) hydration 0.23 (0.06–0.80) RenalGuard versus oral 0.24 (0.12–0.50) hydration 0.23 (0.07–0.75) IV SB versus half SC 0.28 (0.11–0.63) 0.24 (0.10–0.51) RenalGuard versus IV SC 0.28 (0.17–0.45) 0.26 (0.10–0.70) IV SC versus half SC 0.32 (0.13–0.73) 0.32 (0.09–1.02) RenalGuard versus IV SB 0.33 (0.20–0.53) 0.32 (0.14–0.70) Hemodynamic guided versus 0.36 (0.18–0.71) 0.33 (0.07–1.57) oral hydration Oral hydration versus half SC 0.38 (0.13–1.03) 0.36 (0.08–1.42) IV + diuresis versus no hydration 0.39 (0.24–0.61) 0.36 (0.12–1.13) RenalGuard versus IV + diuresis 0.41 (0.22–0.77) 0.40 (0.11–1.43) Hemodynamic guided versus IV 0.42 (0.27–0.63) 0.41 (0.18–0.93) SC Hemodynamic guided versus IV 0.48 (0.31–0.74) 0.47 (0.28–0.81) SB IV SB versus no hydration 0.48 (0.38–0.62) 0.50 (0.13–1.76) IV SC versus no hydration 0.56 (0.45–0.72) 0.56 (0.24–1.33) No hydration versus half SC 0.57 (0.22–1.34) 0.58 (0.18–1.79) IV + diuresis versus oral 0.59 (0.29–1.16) 0.64 (0.39–1.08) hydration Hemodynamic guided versus 0.61 (0.34–1.09) 0.65 (0.29–1.46) IV + diuresis Oral hydration versus no 0.66 (0.36–1.22) 0.66 (0.22–2.15) hydration RenalGuard versus 0.68 (0.36–1.28) 0.72 (0.24–1.94) hemodynamic guided IV + diuresis versus IV SC 0.68 (0.46–1.02) 0.72 (0.28–1.82) IV SB versus oral hydration 0.74 (0.42–1.31) 0.74 (0.57–0.93) IV + diuresis versus IV SB 0.80 (0.52–1.20) 0.89 (0.42–1.93) IV SC versus oral hydration 0.86 (0.49–1.50) 0.91 (0.27–3.32) IV SB versus IV SC 0.86 (0.77–0.96) 0.98 (0.34–2.57) 0.01 0.1 1 10 Heterogeneity (vague) = 0.5817 Favours treatment 1 Favours treatment 2 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. 12 Journal of Interventional Cardiology OR <1 means the treatment in top le is better RenalGuard 0.58 Hemodynamic (0.18–1.79) guided 0.32 0.56 IV SB (0.14–0.70) (0.24–1.33) 0.24 0.41 0.74 IV SC (0.10–0.51) (0.18–0.93) (0.57–0.93) 0.23 0.40 0.72 0.98 IV + diuresis (0.06–0.80) (0.11–1.43) (0.24–1.94) (0.34–2.57) 0.21 0.36 0.65 0.89 0.91 Oral hydration (0.07–0.63) (0.12–1.13) (0.29–1.46) (0.42–1.93) (0.27–3.32) 0.15 0.26 0.47 0.64 0.66 0.72 No hydration (0.06–0.38) (0.10–0.70) (0.28–0.81) (0.39–1.08) (0.22–2.15) (0.28–1.82) 0.07 0.13 0.23 0.32 0.33 0.36 0.50 Half SC (0.02–0.30) (0.03–0.54) (0.07–0.75) (0.09–1.02) (0.07–1.57) (0.08–1.42) (0.13–1.76) Figure 4: League table, showing all pairwise comparisons of studies. Random effects (vague) rankogram Fixed effects 0.9 1.5 Nijssen EC 2017 0.8 Martin-Moreno PL 2015 0.7 0.6 0.5 0.5 0.4 0 0.5 1 1.5 2 Consistency model 0.3 Figure 6: Inconsistency plot of enrolled studies, showing the 0.2 posterior mean deviance of each study from the consistency model (horizontal axis) and the inconsistency model (vertical 0.1 axis). Rank Best Worst inﬂuence on CI-AKI, but because of the high heteroge- neity of speciﬁc protocols used in the included studies, we RenalGuard IV SC could not analyze distinct protocols, such as the eﬀect of Hemodynamic-guided Half SC diﬀerent concentrations of sodium bicarbonate, and the IV + diuresis Oral hydration eﬀect of hydration duration. Secondly, several con- IV SB No hydration founding factors that we did consider may have impacted Figure 5: Rankogram of the eﬀect of diﬀerent hydration strategies the eﬀects of hydration, including dosage and types of in reducing the risk of contrast-induced acute kidney injury. 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, volume expansion, and this led to a lower incidence of CI- such as left ventricular end-diastolic pressure, central AKI after angiographic procedures. -erefore, our results venous pressure, and bioimpedance. 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. 6. Conclusion -is Bayesian NMA provided substantial evidence to sup- 5.Limitations port the use of RenalGuard or hemodynamic guided hy- dration to prevent CI-AKI in high-risk patients, especially It is essential to note several limitations of our study. those with CKD or cardiac dysfunction. 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Publisher: Hindawi Publishing Corporation
Copyright: Copyright © 2020 Qiuping Cai et al. This 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.
ISSN: 1540-8183
eISSN: 0896-4327
DOI: 10.1155/2020/7292675
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Abstract

Hindawi Journal of Interventional Cardiology Volume 2020, Article ID 7292675, 16 pages https://doi.org/10.1155/2020/7292675 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; liuyf1106@126.com 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. identiﬁed a priori, no known pharmaceutical treatment can 1.Introduction eﬀectively prevent or treat CI-AKI. Contrast-induced acute kidney injury (CI-AKI), also re- Guidelines recommend intravascular hydration to pre- ferred to as contrast-induced nephropathy (CIN), is an vent CI-AKI [4, 5], and there are several speciﬁc hydration iatrogenic complication that can occur following intravas- strategies, but researchers have not yet established an op- cular administration of iodinated contrast medium (CM) timal strategy [6–9]. Notably, recent randomized controlled prior to radiography. CI-AKI is the third leading cause of trials (RCTs) have led to doubts about the eﬀectiveness of hospital-acquired acute renal injury (AKI) [1]. CI-AKI has a various hydration strategies in prevention of CI-AKI. For low incidence in the general population, but it has a sig- example, Nijssen et al. [10] conducted an RCT with 660 high- niﬁcant incidence in patients with certain risk factors. risk patients and found that no prophylaxis was noninferior Moreover, the occurrence of CI-AKI following cardiac or cost-saving relative to intravenous hydration. Weisbord catheterization procedures is associated with an in-hospital et al. [11] enrolled 5177 high-risk patients and reported no mortality of 20%, a 1-year mortality of up to 66%, and an beneﬁt of intravenous sodium bicarbonate relative to normal even higher mortality in patients who require dialysis [2, 3]. saline. Another RCT [12] concluded that the beneﬁt of However, even if patients with high risk of CI-AKI can be sodium bicarbonate was marginal relative to isotonic 2 Journal of Interventional Cardiology were conducted using the Bayesian Markov chain Monte sodium chloride for preventing CI-AKI among critically ill patients. However, other studies indicated that the Renal- Carlo method in WinBUGS V.1.4.3 (MRC Biostatistics Unit, Cambridge, United Kingdom) using the Microsoft Excel- Guard System [13–16] and hemodynamic guided hydration [17–19] were safe and eﬀective in preventing CI-AKI. Be- based macro NetMetaXL V.1.6.1 (Canadian Agency for cause of these apparently discrepant results, we conducted a Drugs and Technologies in Health, Ottawa, Canada) [23]. A network meta-analysis (NMA) to assess the eﬀects of various convergence test for each analysis was conducted by hydration strategies on the occurrence of CI-AKI in an eﬀort checking whether the Monte Carlo error was less than 5% of to identify the optimal strategy for prevention of CI-AKI. 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 2.Methods also used to generate a forest plot, league table, and “ran- 2.1. Data Search. -is systematic review and meta-analysis kogram” with surface under the cumulative ranking curve were performed according to Cochrane Handbook guide- (SUCRA), which ranges from 0 (worst) to 100% (best). lines [20]. -e Web of Science, PubMed, OVID Medline, and Inconsistency was assessed by comparing the residual de- Cochrane Library databases were searched using medical viance and deviance information criterion statistics in ﬁtted subject headings or keywords. Relevant published original consistency and inconsistency models. studies that were published up to September 30, 2018, were examined. -e search syntax was as follows: “contrast-in- 3. Results duced acute kidney injury OR contrast-induced nephrop- 3.1. Literature Search. We initially identiﬁed 3620 publica- athy OR CIN OR CI-AKI OR contrast acute renal failure OR tions, assessed 703 RCTs for eligibility by review of the full contrast nephropathy” AND “hydration OR ﬂuid admin- texts, and ultimately included 60 RCTs which met the eli- istration OR volume expansion OR intravenous sodium gibility criteria (Figure 1). -ese studies examined 21,293 bicarbonate OR saline infusion.” patients (median: 222, interquartile range [IQR]: 120, 350) and 2232 CI-AKI events. All included RCTs were full-length 2.2. Study Selection. An initial eligibility screen of all cita- journal articles. Agreement between the two reviewers at the tions was conducted, and only studies that examined CI-AKI full-text review stage was excellent (Cohen’s κ � 0.85). and hydration were selected for further full-text review. All included studies were RCTs; experimental studies were 3.2. Characteristics ofStudies and Participants. Table 1 shows excluded. In addition, all included studies reported the the characteristics of the included studies. -e publication prevention of CI-AKI after intravascular administration of date ranged from 2002 to 2018, and about 50% of the studies CM; used clinical protocols that were hydration strategies, were published after 2013. -e proportion of male patients not pharmaceutical prevention strategies; had clear deﬁni- ranged from 25.0% to 98.1% (median [IQR]: 65.7 [56.9, tions of CI-AKI; and provided data on the outcome of in- 74.8]), and the mean age ranged from 56.2 to 82.9 years (67.8 terest (occurrence of CI-AKI within 2 days to 1 week after [63.1, 72.5]). -irty-one studies enrolled 12,519 patients who procedures). 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]), 2.3. Data Extraction and Quality Assessment. Two authors and the baseline estimated glomerular ﬁltration rate (eGFR) (C. Q. P. and J. R.) independently reviewed each article for ranged from 32 to 93.1 mL/min/1.73 m (49.2 [44.1, 74.2]). eligibility. Any disagreement was resolved by discussion Twenty-three studies provided the values of left ventricular among the authors or involvement of a third author. Data ejection fraction (LVEF); the mean LVEF ranged from 25% extraction included the year of publication, sample size, pa- to 57.8% (49.0 [42.8, 54.5]). -e percentage of diabetes tient characteristics, risk factors associated with CI-AKI (old mellitus (DM) patients ranged from 8% to 100%, and the age, diabetes mellitus, renal impairment, heart failure), and percentage with heart failure (HF) ranged from 0.6% to type and dosage of contrast medium. -e primary endpoint 45.8%. A total of 8176 patients from 32 studies received was the occurrence of CI-AKI within 2 days to 1 week after intravenous low-osmolar nonionic CM, 9993 patients from intravascular administration of CM. Two investigators inde- 17 studies received iso-osmolar nonionic CM, and 317 pendently evaluated the quality of each study using the Jadad patients from 2 studies received low-osmolar ionic CM. -e scale, which ranges from 0 (worst) to 5 (best) [21]. mean Jadad score of the 60 RCTs was 3.2 (3 [2, 4]), indicating the overall study quality was good. 2.4. Statistical Analyses. -e advantages of Bayesian NMA over traditional meta-analysis are its greater ﬂexibility, its 3.3. Network Meta-Analysis. Figure 2 shows all the com- provision of more naturally interpretable results, and its parisons in the NMA. -irty-seven studies (13,365 partici- ability to rank treatments by comparative eﬀectiveness [22]. pants) compared the eﬃcacy of intravenous sodium -e occurrence of CI-AKI as a dichotomous outcome bicarbonate and 0.9% sodium chloride. -e other hydration variable was expressed as an odds ratio (OR) and 95% strategies were nonhydration (8 studies, 1396 patients), oral conﬁdence interval (CI). All P values were 2-sided, and a P hydration (6 studies, 355 patients), intravenous half iso- value below 0.05 was considered signiﬁcant. All analyses osmolar saline (3 studies, 968 patients), intravenous Journal of Interventional Cardiology 3 treatments ranged from 0.197 to 0.441, and their rankings 3620 citations identified were similar. Hydration using half iso-osmolar saline alone 2348 identified through Web of Science search 411 identified through PubMed search was the least eﬀective treatment. 431 identified through Cochrane Library search 430 identified through OVID search 3.4. Inconsistency Analysis. We performed network incon- 2070 excluded during initial screen for not sistency assessment for the ﬁxed eﬀect model for the 60 meeting inclusion criteria studies (Figure 6). -e resulting plot demonstrated that 1534 were duplicates nearly all the studies were near the line of equality and that 536 had unrelated population or outcome the results were therefore consistent. However, there was 1550 studies screened in full-text review some evidence of inconsistency in 3 noninferiority studies [10, 31]. In particular, Martin-Moreno et al. [31] and Nijssen 847 excluded et al. [10] found that intravenous sodium bicarbonate and 748 were not RCTs 99 were reviews or comments 0.9% sodium chloride were noninferior to oral hydration. 703 RCTs assessed for eligibility 4. Discussion To our knowledge, this is the ﬁrst NMA to compare diﬀerent 643 excluded hydration strategies for prevention of CI-AKI. We included 339 were not about hydration 60 RCTs which examined 21,293 participants and 2232 CI- 220 had no outcomes of interest 84 were protocols 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- 60 RCTs included in final analysis AKI: the RenalGuard system, hemodynamic guided hy- dration, and intravenous sodium bicarbonate. Relative to no Figure 1: Identiﬁcation and selection of studies for Bayesian hydration, oral hydration and intravenous 0.9% sodium network meta-analysis. chloride were each noninferior in prevention of CI-AKI. Relative to oral hydration, intravenous 0.9% sodium chlo- hydration, mainly normal saline + diuresis (2 studies ride and sodium bicarbonate were each noninferior in [26, 31], 501 patients), hemodynamic guided hydration (3 prevention of CI-AKI. -us, we ranked the RenalGuard studies, 458 patients), and RenalGuard system guided hy- system as the best strategy and hemodynamic guided hy- dration (4 studies, 348 patients). dration as the second best. We compared the ORs of the diﬀerent hydration Guidelines for the prevention of CI-AKI in high-risk strategies using a forest plot (Figure 3) and analyzed the patients routinely recommend hydration protocols before results of the random eﬀects consistency NMA using a contrast exposure as an established preventive measure league table, which shows all pairwise comparisons (Figure 4). [77, 78]. A recent large RCT [10] led us to reanalyze the eﬃcacy of hydration for prevention of CI-AKI. In particular, Taken together, these results indicate that, relative to typical intravenous 0.9% sodium chloride hydration (reference), the the AMAstricht Contrast-Induced Nephropathy Guideline occurrence of CI-AKI was signiﬁcantly reduced by intra- (AMACING) study [10] enrolled 660 patients with high risk venous sodium bicarbonate (OR [95% CI]: 0.74 [0.57, 0.93]), of CI-AKI and concluded that, relative to intravenous hy- hemodynamic guided hydration (0.41 [0.18, 0.93]), and dration, no prophylaxis was less expensive and noninferior RenalGuard system guided hydration (0.32 [0.14, 0.70]). in prevention of CI-AKI. In our meta-analysis, ﬁve studies Oral hydration (0.72 [0.28, 1.82]) and intravenous 0.9% compared the eﬀectiveness of intravenous 0.9% sodium sodium chloride (0.64 [0.39, 1.08]) were each noninferior to chloride and three studies compared bicarbonate with no hydration for prevention of CI-AKI. Relative to oral nonhydration, leading to our conclusion that, relative to no hydration (reference), intravenous 0.9% sodium chloride or hydration (reference), oral hydration or hydration with sodium bicarbonate and hemodynamic guided hydration intravenous 0.9% sodium chloride was noninferior in pre- vention of CI-AKI. -ese results were unsurprising, because were each noninferior in prevention of CI-AKI, but RenalGuard guided hydration was superior (0.21 [0.07, simple oral or intravenous hydration can lead to compli- 0.63]). Intravenous hydration plus diuresis also did not cations, such as heart failure, pulmonary edema, and elec- decrease the risk of CI-AKI relative to oral hydration and no trolyte disorders. -us, the safety window of hydration is hydration. relatively narrow for patients undergoing percutaneous A rankogram and SUCRA values indicated the Renal- coronary intervention (PCI), and other more eﬀective or Guard system was best (SUCRA � 0.974) followed by he- precise hydration strategies may be needed to decrease the modynamic guided hydration (SUCRAs � 0.849; Figure 5). incidence of CI-AKI. Intravenous sodium bicarbonate had a SUCRA of 0.667. -e Most meta-analyses before 2016 [79–83] conﬁrmed that SUCRAs for intravenous 0.9% sodium chloride, intravenous intravenous sodium bicarbonate was more eﬀective than hydration plus diuresis, oral and no hydration, and the other sodium chloride in preventing CI-AKI. However, two recent 4 Journal of Interventional Cardiology Table 1: Characteristics of the included studies. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) High risk for High risk for renal renal Weisbord Iodixanol or low- complications Iodixanol or low- 4993 complications 69.8 93.6 132.6 50.2 80.9 7.4 SC vs. SB 85 5 4993 69.8 93.6 132.6 50.2 80.9 7.4 SC vs. SB 85 5 et al. [11] osmolar and scheduled osmolar and scheduled for for angiography angiography Symptomatic Symptomatic aortic valve aortic valve stenosis and stenosis and van Mourik 74 impaired renal 82.9 44.6 104.3 47.4 31.1 SC vs. SB Iopromide 90 3 74 impaired renal 82.9 44.6 104.3 47.4 31.1 SC vs SB Iopromide 90 3 et al. [24] function who function who underwent pre- underwent pre- TAVI CTA TAVI CTA Elective EVAR Elective EVAR Saratzis et al. 58 for infrarenal 75 89.7 65.5 13.8 SC vs. SB Iomeprol 126 3 58 for infrarenal 75 89.7 65.5 13.8 SC vs SB Iomeprol 126 3 [25] AAA AAA Elective Elective Maioli et al. coronary coronary 296 71 68.2 89.3 48 24.7 SC vs. HDy Iodixanol 131 3 296 71 68.2 89.3 48 24.7 SC vs HDy Iodixanol 131 3 [18] angiographic angiographic procedures procedures CKD patients CKD patients undergoing undergoing elective elective Kooiman et al. cardiovascular cardiovascular 333 73 64.6 50.5 38.7 16.5 SC vs. SB Not mentioned 113 3 333 73 64.6 50.5 38.7 16.5 SC vs SB Not mentioned 113 3 [26] diagnostic or diagnostic or interventional interventional contrast contrast procedures procedures Critically ill Critically ill patients with patients with stable renal stable renal Valette et al. 307 function who 56.2 67.8 61.4 13.4 6.5 SC vs. SB Low-osmolar 90 4 307 function who 56.2 67.8 61.4 13.4 6.5 SC vs SB Low-osmolar 90 4 [12] received received intravascular intravascular CM CM High-risk High-risk patients with patients with eGFR of eGFR of 30–59 ml/min/ 30–59 ml/min/ 2 2 Nijssen et al. 1.73 m , 1.73 m , 660 72 61.7 118 47.4 32.6 Non vs. SC Iopromide 90.5 3 660 72 61.7 118 47.4 32.6 Non vs SC Iopromide 90.5 3 [10] undergoing an undergoing an elective elective procedure procedure requiring CM requiring CM administration administration Patients Patients receiving CM receiving CM Alonso et al. 93 during CRT 66.5 65.3 110.5 28.5 37 SC vs. SB Iodixanol 102 2 93 during CRT 66.5 65.3 110.5 28.5 37 SC vs SB Iodixanol 102 2 [27] devices devices implantation implantation Coronary Coronary angiography/ angiography/ Usmiani et al. PCI with eGFR SC vs. PCI with eGFR SC vs 124 75 74 130.8 44 25 84 Iodixanol 156 3 124 75 74 130.8 44 25 84 Iodixanol 156 3 [28] of less than RenalGuard of less than RenalGuard 60 ml/min/ 60 ml/min/ 2 2 1.73 m 1.73 m Contrast- Contrast- enhanced enhanced CTPA on Water-soluble, CTPA on Water-soluble, Turedi et al. 172 suspicion of PE 75.5 51.7 85.4 SC vs. SB nonionic, low- <100 3 172 suspicion of PE 75.5 51.7 85.4 SC vs SB nonionic, low- <100 3 [29] with at least one osmolar with at least osmolar risk factor for one risk factor CIN for CIN Journal of Interventional Cardiology 5 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) CKD and CHF CKD and CHF undergoing undergoing Qian et al. [19] 264 63.5 74.6 151 37.5 39.5 47.3 SC vs. HDy Iodixanol 166 5 264 63.5 74.6 151 37.5 39.5 47.3 SC vs HDy Iodixanol 166 5 coronary coronary procedures procedures Elective Elective coronary or coronary or peripheral peripheral Solomon et al. 391 angiography 72 57.5 169.3 32.8 59.1 35.5 SC vs. SB Not mentioned 107 4 391 angiography 72 57.5 169.3 32.8 59.1 35.5 SC vs SB Not mentioned 107 4 [30] with eGFR with eGFR <45 ml/min/ <45 ml/min/ 2 2 1.73 m 1.73 m Martin- Receiving CM Receiving CM Moreno et al. 130 57.5 64.3 79.6 Non vs SB Not mentioned 120 3 130 57.5 64.3 79.6 Non vs SB Not mentioned 120 3 for CT scan for CT scan [31] Jurado- STEMI STEMI Iso-osmolar Iso-osmolar Roman ´ et al. 408 undergoing 63.1 73.4 89 22.5 14.7 Non vs. SC 174 2 408 undergoing 63.1 73.4 89 22.5 14.7 Non vs SC 174 2 nonionic nonionic [32] primary PCI primary PCI Barbanti et al. SC vs. SC vs 112 TAVR 81 40.2 87.1 51.5 54.6 25 Buckinghamshire 175 3 112 TAVR 81 40.2 87.1 51.5 54.6 25 Buckinghamshire 175 3 [13] RenalGuard RenalGuard Yeganehkhah 100 CAG 59.7 53 99.5 43.8 39 SC vs. SB Iohexol 45.4 3 100 CAG 59.7 53 99.5 43.8 39 SC vs SB Iohexol 45.4 3 et al. [33] Elective Elective cardiovascular cardiovascular procedures SC + NAC procedures Yang et al. SC + NAC vs 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 vs. Iopromide 125 3 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 Iopromide 125 3 [34] SB + NAC or SB + NAC or interventional interventional treatment treatment Elective Elective cardiovascular cardiovascular procedures procedures Yang et al. 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 SC vs. SB Iopromide 125 3 320 including CAG 59.2 53.1 70.2 93.1 55.1 20 SC vs SB Iopromide 125 3 [34] or or interventional interventional treatment treatment STEMI STEMI undergoing undergoing -ayssen et al. primary PCI primary PCI 362 62.5 78.5 77 90.5 50 9.7 SC vs. SB Iodixanol 140 5 362 62.5 78.5 77 90.5 50 9.7 SC vs SB Iodixanol 140 5 [35] within 12 hours within 12 hours from the onset from the onset of chest pain of chest pain Tomography Tomography Nieto-Rios 220 scan using CM 60 57.7 115.8 37.3 SC vs. SB Iohexol 100 3 220 scan using CM 60 57.7 115.8 37.3 SC vs SB Iohexol 100 3 et al. [36] or angiography or angiography STEMI within STEMI within 12 h from 12 h from Manari et al. symptom onset symptom onset 592 65 74.8 88.5 81 48 16.6 11.8 SC vs. SB Iodixanol 198 3 592 65 74.8 88.5 81 48 16.6 11.8 SC vs SB Iodixanol 198 3 [37] referred for referred for primary primary angioplasty angioplasty Mahmoodi Coronary Coronary 350 64.48 51.4 103 64.8 SC vs. SB Iohexol 2 350 64.48 51.4 103 64.8 SC vs SB Iohexol 2 et al. [38] interventions interventions Luo et al. [39] 216 STEMI 67 65.7 77 77.6 25 Non vs. SC Iopamiron 234.9 3 216 STEMI 67 65.7 77 77.6 25 Non vs SC Iopamiron 234.9 3 CKD patients CKD patients Kooiman et al. 548 receiving CE- 72.1 60.4 50.4 26.8 16.4 SC vs. SB Iomeprol 105 5 548 receiving CE- 72.1 60.4 50.4 26.8 16.4 SC vs SB Iomeprol 105 5 [40] CT CT Iopromide or CKD patients Iopromide, or Kooiman et al. CKD patients 138 70.5 50 49.2 16.7 8 Non vs. SB iobitridol or 74 5 138 receiving 70.5 50 49.2 16.7 8 Non vs SB iobitridol, or 74 5 [41] receiving CTPA iodixanol CTPA iodixanol 6 Journal of Interventional Cardiology Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Referred to the Referred to the cardiac cardiac catheterization catheterization laboratory with laboratory with eGFR≤ 60 mL/ eGFR≤ 60 mL/ min/1.73 m , min/1.73 m , Brar et al. [17] 396 72 61.9 123.8 48 51.3 20.5 SC vs. HDy Ioxilan 108 3 396 and at least one 72 61.9 123.8 48 51.3 20.5 SC vs HDy Ioxilan 108 3 and at least one of the of the following: following: DM, DM, CHF, CHF, hypertension, hypertension, or age older or age older than 75 years than 75 years At least one of At least one of the high-risk the high-risk factors for factors for Akyuz et al. developing CI- developing CI- 225 63.4 68.9 79.6 84.5 47.5 60.9 7.6 Oral vs. SC Not mentioned 108 2 225 63.4 68.9 79.6 84.5 47.5 60.9 7.6 Oral vs SC Not mentioned 108 2 [42] AKI and AKI and undergoing undergoing CAG and/or CAG and/or PCI PCI Stage 3 or Stage 3 or higher CKD higher CKD Kristeller et al. 92 who underwent 72.5 57.6 119.1 44.6 34.8 SC vs SB Not mentioned 79 5 92 who underwent 72.5 57.6 119.1 44.6 34.8 SC vs SB Not mentioned 79 5 [43] cardiac surgery cardiac surgery using CPB using CPB Koc et al. [44] 195 DM patients 62 52.3 88.4 100 SC vs. SB Not mentioned 90 4 195 DM patients 62 52.3 88.4 100 SC vs SB Not mentioned 90 4 Coronary Coronary SC vs. SC vs Gu et al. [45] 859 angiography or 59 72.2 90.1 74.2 20.6 0.6 Not mentioned 100 2 859 angiography or 59 72.2 90.1 74.2 20.6 0.6 Not mentioned 100 2 SC + diuresis SC + diuresis angioplasty angioplasty Diabetic Diabetic patients with patients with impaired renal impaired renal Low-osmolar Low-osmolar Boucek et al. function, function, 120 65 75 165 44.1 100 SC vs. SB nonionic 110 5 120 65 75 165 44.1 100 SC vs SB nonionic 110 5 [46] undergoing undergoing iodinated iodinated intra-arterial or intra-arterial or intravenous use intravenous use of CM of CM CKD CKD Marenzi et al. undergoing SC vs. undergoing SC vs 170 73 78.2 154.7 39 51.5 36.4 Iomeprol 170 3 170 73 78.2 154.7 39 51.5 36.4 Iomeprol 170 3 [47] coronary RenalGuard coronary RenalGuard procedures procedures Deﬁnitive or Deﬁnitive or Kong et al. suspected suspected 80 56.5 53.8 105 23.8 Oral vs. SC Iopromide 152 3 80 56.5 53.8 105 23.8 Oral vs SC Iopromide 152 3 [48] coronary artery coronary artery disease disease Renal Renal insuﬃciency insuﬃciency Klima et al. undergoing undergoing 258 77 64 137 43.6 37 44 SC vs. SB Not mentioned 100 5 258 77 64 137 43.6 37 44 SC vs SB Not mentioned 100 5 [49] intravascular intravascular contrast contrast procedures procedures Patients at Patients at moderate to moderate to high risk for high risk for Gomes et al. developing CIN developing 301 64 47.5 132.6 18.9 SC vs. SB Not mentioned 125 2 301 64 47.5 132.6 18.9 SC vs SB Not mentioned 125 2 [50] who were CIN who were referred for referred for elective CAG or elective CAG or PCI PCI eGFR <60 ml/ eGFR <60 ml/ 2 2 min/1.73 m min/1.73 m Motohiro who were who were 155 72.5 69.7 136.6 44.3 55 60 SC vs. SB Iopamidol 135 3 155 72.5 69.7 136.6 44.3 55 60 SC vs SB Iopamidol 135 3 et al. [51] undergoing undergoing coronary coronary angiography angiography Journal of Interventional Cardiology 7 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) STEMI STEMI Maioli et al. 300 undergoing 65 25 95.9 42.5 21.7 24 Non vs. SB Iodixanol 216 3 300 undergoing 65 25 95.9 42.5 21.7 24 Non vs SB Iodixanol 216 3 [52] primary PCI primary PCI Diabetic Diabetic patients with patients with renal disease renal disease (serum (serum Lee et al. [53] 382 68 70.9 132.6 46 100 SC vs. SB Iodixanol 116.5 3 382 68 70.9 132.6 46 100 SC vs SB Iodixanol 116.5 3 creatinine creatinine >1.1 mg/dl and >1.1 mg/dl and eGFR <60 ml/ eGFR <60 ml/ 2 2 min/1.73 m ) min/1.73 m ) Patients with Patients with baseline renal baseline renal Haﬁz et al. insuﬃciency Nonionic, low- insuﬃciency Nonionic, low- 320 73 56.9 141.4 47.2 SC vs. SB 115 3 320 73 56.9 141.4 47.2 SC vs SB 115 3 [54] scheduled to osmolar scheduled to osmolar undergo undergo catheterization catheterization High-risk High-risk patients with an patients with Briguori et al. eGFR ≤30 ml/ SB vs. an eGFR SB vs 292 76 65.4 158.7 32 47 70.2 28.4 Iodixanol 140 3 292 76 65.4 158.7 32 47 70.2 28.4 Iodixanol 140 3 [55] min/1.73 m RenalGuard ≤30 ml/min/ RenalGuard and/or a risk 1.73 m and/or score ≥11 a risk score ≥11 Coronary Coronary angiography angiography and/or and/or Wrobel ´ et al. angioplasty, angioplasty, 102 65.5 56.9 236.4 Oral vs. SC Loversol 69.5 2 102 65.5 56.9 236.4 Oral vs SC Loversol 69.5 2 [56] and had and had comorbidities comorbidities that increase that increase the risk of CIN the risk of CIN CAG, with SCr CAG, with SCr 1.5 mg/dL 1.5 mg/dL Vasheghani- within 2 weeks, 0.45 SC vs. within 2 weeks, 0.45 SC vs Farahani et al. 72 62 79.2 151.2 44.2 36.1 34.7 45.8 Iohexol 117.5 3 72 62 79.2 151.2 44.2 36.1 34.7 45.8 Iohexol 117.5 3 having at least 1 SB having at least 1 SB [57] of the risk of the risk factors factors Undergoing an Undergoing an Cho et al. [58] 91 78 50.5 123 38.5 17.6 SC vs. SB Isoversol 128 2 91 78 50.5 123 38.5 17.6 SC vs SB Isoversol 128 2 elective CAG elective CAG Serum Serum creatinine level creatinine level Vasheghani- of 1.5 mg/dL or of 1.5 mg/dL or Farahani et al. 265 63.3 83 145.4 45.9 51.7 21.5 SC vs. SB Iohexol 114 5 265 63.3 83 145.4 45.9 51.7 21.5 SC vs SB Iohexol 114 5 greater greater [59] undergoing undergoing elective CAG elective CAG Scheduled for Scheduled for Tamura et al. 144 elective CAG or 72.8 87.5 121.1 39.1 57.8 58.3 SC vs. SB Iohexol 85 3 144 elective CAG or 72.8 87.5 121.1 39.1 57.8 58.3 SC vs SB Iohexol 85 3 [60] PCI PCI Undergoing Undergoing Pakfetrat et al. 192 elective CAG or 57.9 61.5 97.2 72.2 50.5 29.7 5.2 SC vs. SB Iodixanol 65 4 192 elective CAG or 57.9 61.5 97.2 72.2 50.5 29.7 5.2 SC vs SB Iodixanol 65 4 [61] PCI PCI At increased At increased risk of risk of postoperative postoperative acute renal acute renal dysfunction dysfunction Haase et al. who were who were 100 71 66 90.7 SC vs. SB Not mentioned 5 100 71 66 90.7 SC vs SB Not mentioned 5 [62] scheduled for scheduled for elective or elective or urgent cardiac urgent cardiac surgery surgery necessitating necessitating the use of CPB the use of CPB 8 Journal of Interventional Cardiology Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Nonemergent Nonemergent CAG, baseline CAG, baseline serum serum creatinine creatinine Budhiraja >1.0 mg/dL, >1.0 mg/dL, 187 68 125.8 57.2 30.5 SC vs. SB Iopromide 199 2 187 68 125.8 57.2 30.5 SC vs SB Iopromide 199 2 et al. [63] and availability and availability of serum of serum creatinine creatinine values at days values at days 1–3 1–3 Scheduled for Scheduled for elective CAG, elective CAG, with or without Angoulvant with or without 201 PTCA with a 62 80.6 86.2 Oral vs. SC Not mentioned 290 3 201 62 80.6 86.2 Oral vs SC Not mentioned 290 3 et al. [64] PTCA with a baseline baseline SCr< SCr< 140 μmol/ 140 μmol/L Undergoing Undergoing coronary coronary angiographic angiographic Maioli et al. procedures with procedures 502 74 59 107 46.5 59.1 SC vs. SB Iodixanol 165 3 502 74 59 107 46.5 59.1 SC vs SB Iodixanol 165 3 [65] estimated with estimated creatinine creatinine clearance clearance <60 ml/min <60 ml/min Myocardial Myocardial ischemia ischemia (angina or (angina or positive positive Chen et al. Iso-osmolar Iso-osmolar 660 exercise 60 85 114.9 54 8 Non vs. SC 285 2 660 exercise 60 85 114.9 54 8 Non vs SC 285 2 [66] nonionic nonionic treadmill) treadmill) scheduled for scheduled for PCI, with PCI, with SCr<1.5 mg/dl SCr< 1.5 mg/dl Myocardial Myocardial ischemia ischemia (angina or (angina or positive positive Chen et al. Iso-osmolar Iso-osmolar 276 exercise 63 82 221 41 22 Non vs. SC 298 2 276 exercise 63 82 221 41 22 Non vs SC 298 2 [66] nonionic nonionic treadmill) treadmill) scheduled for scheduled for PCI, with PCI, with SCr≥ 1.5 mg/dl SCr≥ 1.5 mg/dl Patients with Patients with stable renal stable renal Brar et al. [67] 353 disease and 71 63.9 131.7 48 57 44.5 27.2 SC vs. SB Ioxilan 132 5 353 disease and 71 63.9 131.7 48 57 44.5 27.2 SC vs SB Ioxilan 132 5 undergoing undergoing CAG CAG Stable renal Stable renal insuﬃciency insuﬃciency and and undergoing undergoing Adolph et al. elective 145 72.6 77.9 132.6 33.8 SC vs. SB Iodixanol 140 5 145 elective 72.6 77.9 132.6 33.8 SC vs SB Iodixanol 140 5 [68] diagnostic or diagnostic or interventional interventional coronary coronary angiography angiography Schmidt et al. 96 CAG 67.6 74 146.7 64.6 SC vs. SB Optiray 186 2 96 CAG 67.6 74 146.7 64.6 SC vs SB Optiray 186 2 [69] Scheduled for Scheduled for CAG or PCI CAG or PCI Ozcan et al. and had a and had a 264 69 74.6 122.9 45.1 26.5 SC vs. SB Ioxaglate 110 2 264 69 74.6 122.9 45.1 26.5 SC vs SB Ioxaglate 110 2 [70] baseline baseline creatinine level creatinine level >1.2 mg/dL >1.2 mg/dL Journal of Interventional Cardiology 9 Table 1: Continued. Baseline Inclusion Mean Baseline Mean CM Inclusion Patients Males eGFR DM HF Treatment Jadad No. of Mean Male Baseline Baseline Mean DM HF Dosage Jadad Studies criteria/risk of age SCr LVEF Types of CM dosage criteria/risk of Groups Types of CM (n) (%) (mL/min/ (%) (%) groups score patients age (%) SCr eGFR LVEF (%) (%) of CM score CI-AKI (years) (mg/dL) (%) (mL) CI-AKI 1.73 m ) Scheduled to Scheduled to undergo an undergo an Masuda et al. emergency emergency 59 75 44.1 116.2 30.5 SC vs. SB Iopamidol 116 3 59 75 44.1 116.2 30.5 SC vs SB Iopamidol 116 3 [71] coronary coronary angiography or angiography or intervention intervention CKD, who were CKD, who were undergoing undergoing Dussol et al. SC vs. Nonionic, low SC vs Nonionic, low 156 radiological 65 67.9 204.5 33.1 28.8 16 117 5 156 radiological 65 67.9 204.5 33.1 28.8 16 117 5 [72] SC + diuresis osmolar SC + diuresis osmolar procedures with procedures CM with CM Scheduled for Scheduled for Mueller et al. 0.45 SC vs. 0.45 SC vs 425 elective or 64 75 89 16 Iopromide 226 2 425 elective or 64 75 89 16 Iopromide 226 2 [73] SC SC emergency PCI emergency PCI Stable renal Stable renal insuﬃciency insuﬃciency undergoing undergoing diagnostic or diagnostic or Merten et al. interventional interventional 119 68 74.8 159.1 47.9 SC vs. SB Iopamidol 132 3 119 68 74.8 159.1 47.9 SC vs SB Iopamidol 132 3 [74] procedures procedures requiring requiring radiographic radiographic contrast, SCr> contrast, SCr> 1.1 mg/dL 1.1 mg/dL Scheduled to Scheduled to Trivedi et al. undergo Ionic, low- undergo Ionic, low- 53 67.9 98.1 106.4 52.1 18.9 Oral vs. SC 148 2 53 67.9 98.1 106.4 52.1 18.9 Oral vs SC 148 2 [75] nonemergency osmolar nonemergency osmolar CAG CAG Scheduled for Scheduled for elective or 0.45 SC vs Ultravist, or Mueller et al. elective or 0.45 SC vs. Ultravist or 1383 64 74.4 81.77 15.7 234 2 1383 64 74.4 81.77 15.7 234 2 [76] emergency SC imeron emergency SC imeron CAG CAG 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 media; 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; NAC: N-acetylcysteine. Treatment groups: SC: intravenous 0.9% sodium chloride; SB: intravenous sodium bicarbonate; Non: nonhydration; Oral: oral hydration; RenalGuard: RenalGuard system; HDy: hemodynamic guided hydration; SC + diuresis: intravenous 0.9% sodium chloride + diuresis; 0.45 SC: 0.45% sodium chloride. 1 study 3 studies 2 studies 1 study 1 study 10 Journal of Interventional Cardiology Nonhydration RenalGuard guided hydration Oral hydration Hemodynamic-guided hydration Half isotonic sodium chloride Intravenous hyration + diuresis 37 studies D E Intravenous Intravenous sodium chloride sodium bicarbonate 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. inﬂuential studies concluded that intravenous sodium bi- do not recommend alkalization with intravenous sodium carbonate provided no beneﬁt over intravenous sodium bicarbonate as a single strategy, and a more eﬀective chloride in high-risk patients [11] and critically ill patients hydration strategy is needed to prevent CI-AKI. [12]. Our NMA included 37 studies that compared intra- Several recent RCTs of high risk patients [13, 28, 47, 55] venous sodium chloride with sodium bicarbonate, and our showed that furosemide-induced high-volume forced di- results also indicated that intravenous sodium bicarbonate uresis with matched hydration using the RenalGuard system led to a reduced risk for CI-AKI, although the eﬀect size was eﬀectively prevented CI-AKI. RenalGuard is a closed-loop ﬂuid-management system, in which each volume of urine small (OR [95% CI]: 0.74 [0.57, 0.93]). Alkalization with bicarbonate perfusion could theoretically reduce the for- that enters the collection bag leads to the infusion of an equal mation of reactive oxygen species by decreasing the volume of saline into the patient. Two meta-analyses [14, 16] production of hydroxyl radicals due to inhibition of the of RCTs concluded that the RenalGuard system signiﬁ- Haber-Weiss and Fenton reactions [84]. However, the cantly reduced the risk of CI-AKI and the need for renal HYDRAREA study [12] assessed 307 critically ill patients replacement therapy in high-risk patients undergoing with stable renal function and found that hydration with coronary angiography. Our rankogram analysis indicated bicarbonate provided no beneﬁt relative to hydration with that the RenalGuard system of guided hydration had the isotonic sodium chloride. -ese researchers also noted highest rank, with a SUCRA of 0.974. However, we did not assess the eﬀectiveness of intravenous hydration plus di- that bicarbonate provided a greater beneﬁt in the smaller studies, suggesting publication bias. Recently, Weisbord uresis without a guided system, and the rankogram indi- cated that hemodynamic guided hydration was the second et al. [11] enrolled 5177 patients with high risk for renal complications and found that administration of sodium best method, with a SUCRA of 0.849. Brar et al. [17] used bicarbonate did not reduce the occurrence of CI-AKI. -is left ventricular end-diastolic pressure to guide ﬂuid ad- result supports the interpretation that sodium bicarbonate ministration and demonstrated that this method was safe is not more eﬀective than sodium chloride in preventing and eﬀective in prevention of CI-AKI among patients CI-AKI or longer-term adverse outcomes after angiog- undergoing cardiac catheterization. Another study [19] raphy. However, there was high heterogeneity among our demonstrated that central venous pressure-guided ﬂuid 60 studies regarding concurrent medications, comor- administration safely and eﬀectively reduced the risk of CI- bidities (CHF, DM), types of CM, periprocedural hy- AKI in patients with CKD and CHF. Maioli et al. [18] assessed body ﬂuid level using bioimpedance vector dration protocols, concentrations and dosages of sodium bicarbonate, and radiographic procedures [12]. -us, we analysis (BIVA), which allows adjustment of intravascular 2 studies 3 studies 3 studies 5 studies 6 studies Journal of Interventional Cardiology 11 Treatment 1 vs. treatment 2 O.R. (95% Cr.I.) RenalGuard versus half SC 0.09 (0.03–0.24) 0.07 (0.02–0.30) Hemodynamic guided versus 0.13 (0.05–0.34) half SC 0.13 (0.03–0.54) RenalGuard versus no hydration 0.16 (0.09–0.27) 0.15 (0.06–0.38) IV + diuresis versus half SC 0.22 (0.08–0.55) 0.21 (0.07–0.63) Hemodynamic guided versus no 0.23 (0.14–0.38) hydration 0.23 (0.06–0.80) RenalGuard versus oral 0.24 (0.12–0.50) hydration 0.23 (0.07–0.75) IV SB versus half SC 0.28 (0.11–0.63) 0.24 (0.10–0.51) RenalGuard versus IV SC 0.28 (0.17–0.45) 0.26 (0.10–0.70) IV SC versus half SC 0.32 (0.13–0.73) 0.32 (0.09–1.02) RenalGuard versus IV SB 0.33 (0.20–0.53) 0.32 (0.14–0.70) Hemodynamic guided versus 0.36 (0.18–0.71) 0.33 (0.07–1.57) oral hydration Oral hydration versus half SC 0.38 (0.13–1.03) 0.36 (0.08–1.42) IV + diuresis versus no hydration 0.39 (0.24–0.61) 0.36 (0.12–1.13) RenalGuard versus IV + diuresis 0.41 (0.22–0.77) 0.40 (0.11–1.43) Hemodynamic guided versus IV 0.42 (0.27–0.63) 0.41 (0.18–0.93) SC Hemodynamic guided versus IV 0.48 (0.31–0.74) 0.47 (0.28–0.81) SB IV SB versus no hydration 0.48 (0.38–0.62) 0.50 (0.13–1.76) IV SC versus no hydration 0.56 (0.45–0.72) 0.56 (0.24–1.33) No hydration versus half SC 0.57 (0.22–1.34) 0.58 (0.18–1.79) IV + diuresis versus oral 0.59 (0.29–1.16) 0.64 (0.39–1.08) hydration Hemodynamic guided versus 0.61 (0.34–1.09) 0.65 (0.29–1.46) IV + diuresis Oral hydration versus no 0.66 (0.36–1.22) 0.66 (0.22–2.15) hydration RenalGuard versus 0.68 (0.36–1.28) 0.72 (0.24–1.94) hemodynamic guided IV + diuresis versus IV SC 0.68 (0.46–1.02) 0.72 (0.28–1.82) IV SB versus oral hydration 0.74 (0.42–1.31) 0.74 (0.57–0.93) IV + diuresis versus IV SB 0.80 (0.52–1.20) 0.89 (0.42–1.93) IV SC versus oral hydration 0.86 (0.49–1.50) 0.91 (0.27–3.32) IV SB versus IV SC 0.86 (0.77–0.96) 0.98 (0.34–2.57) 0.01 0.1 1 10 Heterogeneity (vague) = 0.5817 Favours treatment 1 Favours treatment 2 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. 12 Journal of Interventional Cardiology OR <1 means the treatment in top le is better RenalGuard 0.58 Hemodynamic (0.18–1.79) guided 0.32 0.56 IV SB (0.14–0.70) (0.24–1.33) 0.24 0.41 0.74 IV SC (0.10–0.51) (0.18–0.93) (0.57–0.93) 0.23 0.40 0.72 0.98 IV + diuresis (0.06–0.80) (0.11–1.43) (0.24–1.94) (0.34–2.57) 0.21 0.36 0.65 0.89 0.91 Oral hydration (0.07–0.63) (0.12–1.13) (0.29–1.46) (0.42–1.93) (0.27–3.32) 0.15 0.26 0.47 0.64 0.66 0.72 No hydration (0.06–0.38) (0.10–0.70) (0.28–0.81) (0.39–1.08) (0.22–2.15) (0.28–1.82) 0.07 0.13 0.23 0.32 0.33 0.36 0.50 Half SC (0.02–0.30) (0.03–0.54) (0.07–0.75) (0.09–1.02) (0.07–1.57) (0.08–1.42) (0.13–1.76) Figure 4: League table, showing all pairwise comparisons of studies. Random effects (vague) rankogram Fixed effects 0.9 1.5 Nijssen EC 2017 0.8 Martin-Moreno PL 2015 0.7 0.6 0.5 0.5 0.4 0 0.5 1 1.5 2 Consistency model 0.3 Figure 6: Inconsistency plot of enrolled studies, showing the 0.2 posterior mean deviance of each study from the consistency model (horizontal axis) and the inconsistency model (vertical 0.1 axis). Rank Best Worst inﬂuence on CI-AKI, but because of the high heteroge- neity of speciﬁc protocols used in the included studies, we RenalGuard IV SC could not analyze distinct protocols, such as the eﬀect of Hemodynamic-guided Half SC diﬀerent concentrations of sodium bicarbonate, and the IV + diuresis Oral hydration eﬀect of hydration duration. Secondly, several con- IV SB No hydration founding factors that we did consider may have impacted Figure 5: Rankogram of the eﬀect of diﬀerent hydration strategies the eﬀects of hydration, including dosage and types of in reducing the risk of contrast-induced acute kidney injury. 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, volume expansion, and this led to a lower incidence of CI- such as left ventricular end-diastolic pressure, central AKI after angiographic procedures. -erefore, our results venous pressure, and bioimpedance. 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. 6. Conclusion -is Bayesian NMA provided substantial evidence to sup- 5.Limitations port the use of RenalGuard or hemodynamic guided hy- dration to prevent CI-AKI in high-risk patients, especially It is essential to note several limitations of our study. those with CKD or cardiac dysfunction. 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Journal

Journal of Interventional Cardiology – Hindawi Publishing Corporation

Published: Feb 11, 2020

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

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