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      Effectiveness of contrast-associated acute kidney injury prevention methods; a systematic review and network meta-analysis

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          Abstract

          Background

          Different methods to prevent contrast-associated acute kidney injury (CA-AKI) have been proposed in recent years. We performed a mixed treatment comparison to evaluate and rank suggested interventions.

          Methods

          A comprehensive Systematic review and a Bayesian network meta-analysis of randomised controlled trials was completed. Results were tabulated and graphically represented using a network diagram; forest plots and league tables were shown to rank treatments by the surface under the cumulative ranking curve (SUCRA). A stacked bar chart rankogram was generated. We performed main analysis with 200 RCTs and three analyses according to contrast media and high or normal baseline renal profile that includes 173, 112 & 60 RCTs respectively.

          Results

          We have included 200 trials with 42,273 patients and 44 interventions. The primary outcome was CI-AKI, defined as ≥25% relative increase or ≥ 0.5 mg/dl increase from baseline creatinine one to 5 days post contrast exposure. The top ranked interventions through different analyses were Allopurinol, Prostaglandin E1 (PGE1) & Oxygen (0.9647, 0.7809 & 0.7527 in the main analysis). Comparatively, reference treatment intravenous hydration was ranked lower but better than Placebo (0.3124 VS 0.2694 in the main analysis).

          Conclusion

          Multiple CA-AKI preventive interventions have been tested in RCTs. This network evaluates data for all the explored options. The results suggest that some options (particularly allopurinol, PGE1 & Oxygen) deserve further evaluation in a larger well-designed RCTs.

          Electronic supplementary material

          The online version of this article (10.1186/s12882-018-1113-0) contains supplementary material, which is available to authorized users.

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          Most cited references285

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          Evidence Synthesis for Decision Making 4

          Inconsistency can be thought of as a conflict between “direct” evidence on a comparison between treatments B and C and “indirect” evidence gained from AC and AB trials. Like heterogeneity, inconsistency is caused by effect modifiers and specifically by an imbalance in the distribution of effect modifiers in the direct and indirect evidence. Defining inconsistency as a property of loops of evidence, the relation between inconsistency and heterogeneity and the difficulties created by multiarm trials are described. We set out an approach to assessing consistency in 3-treatment triangular networks and in larger circuit structures, its extension to certain special structures in which independent tests for inconsistencies can be created, and describe methods suitable for more complex networks. Sample WinBUGS code is given in an appendix. Steps that can be taken to minimize the risk of drawing incorrect conclusions from indirect comparisons and network meta-analysis are the same steps that will minimize heterogeneity in pairwise meta-analysis. Empirical indicators that can provide reassurance and the question of how to respond to inconsistency are also discussed.
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            Contrast-induced nephropathy: definition, epidemiology, and patients at risk.

            Radiological procedures utilizing intravascular iodinated contrast media injections are being widely applied for both diagnostic and therapeutic purposes. This has resulted in an increasing incidence of procedure-related contrast-induced nephropathy (CIN). The definition of CIN includes absolute (> or = 0.5 mg/dl) or relative increase (> or = 25%) in serum creatinine at 48-72 h after exposure to a contrast agent compared to baseline serum creatinine values, when alternative explanations for renal impairment have been excluded. Although the risk of renal function impairment associated with radiological procedures is low (0.6-2.3%) in the general population, it may be very high in selected patient subsets (up to 20%), especially in patients with underlying cardiovascular disease. This review provides information on the known risk factors for the development of CIN, and completes with describing user-friendly CIN risk score based on the readily available information.
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              Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial.

              Intravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. However, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. This was the aim of the AMACING trial.
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                Author and article information

                Contributors
                Khalidmd20@gmail.com
                terri.mcveigh@gmail.com
                cerneviciute.raminta@gmail.com
                sara.mohamed@nuigalway.ie
                muhammad.tubassam@hse.ie
                ekarim@cheos.ubc.ca
                stewartredmond.walsh@nuigalway.ie
                Journal
                BMC Nephrol
                BMC Nephrol
                BMC Nephrology
                BioMed Central (London )
                1471-2369
                13 November 2018
                13 November 2018
                2018
                : 19
                : 323
                Affiliations
                [1 ]ISNI 0000 0004 0488 0789, GRID grid.6142.1, Lambe Institute for Translational Research, , Discipline of Surgery National University of Ireland, ; Galway, Republic of Ireland
                [2 ]ISNI 0000 0004 0617 9371, GRID grid.412440.7, Department of Vascular surgery, , Galway University Hospital, ; Galway, Republic of Ireland
                [3 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, School of Population and Public Health, , University of British Columbia, Scientist / Biostatistician, Centre for Health Evaluation and Outcome Sciences (CHEOS), St. Paul’s Hospital, ; Vancouver, Canada
                [4 ]ISNI 0000 0004 0488 0789, GRID grid.6142.1, HRB Clinical Research Facility Galway, ; Galway, Republic of Ireland
                Author information
                http://orcid.org/0000-0001-5243-6234
                Article
                1113
                10.1186/s12882-018-1113-0
                6234687
                30424723
                baec9540-8388-418c-863c-03fee76adf78
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 13 November 2017
                : 22 October 2018
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Nephrology
                contrast induced acute kidney injury,contrast nephropathy,prevention methods,contrast associated acute kidney injury

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