What is the role of periprocedural extracorporeal blood purification (ECBP) in the prevention of contrast-induced nephropathy (CIN)?

Updated: Dec 18, 2018
  • Author: Anita Basu, MD, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

A meta-analysis by Cruz et al—8 trials (6 randomized and 2 nonrandomized, controlled studies) were included in the analysis, with a pooled sample size of 412 patients—indicated that periprocedural extracorporeal blood purification (ECBP) does not significantly reduce the incidence of CIN in comparison with standard medical therapy. ECBP in the study consisted of HD (6 trials), continuous venovenous hemofiltration (1 trial), and continuous venovenous hemodiafiltration (1 trial). [53] Cruz et al found that the incidence of CIN in the standard medical therapy group was 35.2%, compared with 27.8% in the ECBP group. Renal death (combined endpoint of death or dialysis dependence) was 12.5% in the standard medical therapy group, compared with 7.9% in the ECBP group.

An important consideration is the role of ECBP therapy in patients with severe renal impairment (ie, stage 5 CKD) not yet on maintenance dialysis. A study by Lee et al indicated that in patients with chronic renal failure who are undergoing coronary angiography, prophylactic HD can improve renal outcome. The study included 82 patients with stage 5 CKD who were not on dialysis and who were referred for coronary angiography. [54] The patients were randomly assigned to either undergo prophylactic HD (initiated within 81 ± 32 min) or to receive intravenous normal saline (control group).

Of patients in the control group, 35% required temporary renal replacement therapy, compared with 2% of the dialysis group. In addition, long-term, postdischarge dialysis was required in 13% of the control patients but in none of the dialysis patients. Among those patients who did not require chronic dialysis, an increase in SCr at discharge of over 1 mg/dL from baseline was found in 13 patients in the control group and in 2 patients in the dialysis group. [54]

The study, though hopeful, does raise some concerns. While the change in creatinine clearance on day 4 from baseline was statistically significant, the day 4 creatinine clearance itself was not significantly different between the 2 groups. Also, the results were not expressed as CIN incidence.  How much time off dialysis a single HD session was able to buy these patients was not discussed. The duration of follow-up was also not clear.

Marenzi et al found better outcomes in patients who received venovenous hemofiltration both pre- and post-CM administration than in patients who received post-CM hemofiltration or no hemofiltration at all. These outcomes included a lower likelihood of CIN, no need for HD, and no 1-year mortality, in the pre-/post-CM group. [55]


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