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Research Article | DOI: https://doi.org/10.31579/2692-9759/035
1 Dept. of Cardiology, Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad, India.
2 Additional Professor of Cardiology, Dept. of Cardiology, Nizam’s Institute of Medical Sciences, Panjagutta Hyderabad, India.
3 Dept. of Cardiology, Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad, India.
*Corresponding Author: N. Rama Kumari, Additional Professor, Dept. of Cardiology, Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad – 500082, Telangana, India.
Citation: Shahood Ajaz Kakroo, Rama Kumari N, Archana Remala (2022) Study of Risk Factors and Applicability of Mehran Risk Score in Predicting Contrast Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention Patients – A Prospective Observational Cohort Study. J. Cardiology Research and Reports 4(3); DOI: 10.31579/2692-9759/035
Copyright: © 2022, N. Rama Kumari, 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.
Received: 09 December 2021 | Accepted: 20 January 2022 | Published: 12 March 2022
Keywords: contrast induced nephropathy; mehran risk score; acute coronary syndrome; percutaneous coronary intervention
Background: Contrast induced nephropathy (CIN) is a grave but underdiagnosed complication of percutaneous coronary intervention that is associated with increased in-hospital morbidity and mortality. Our aim was to study the incidence, risk factors of CIN and applicability of Mehran risk score (MRS) in Indian population.
Methods: A total number of 432 patients were enrolled in the study. Patients of age ≥ 18 years with known CAD, ACS who underwent PCI were included. Patients were followed for development of CIN.
Results: Mean eGFR of 88.4 + 30.65 ml/min/1.73 m2 and mean contrast volume usage of 122.8 + 41.9 ml. 64 patients (14.8%) developed CIN. On univariate analysis, age (p 0.435), gender (0.125), hypertension (0.679), diabetes (0.177), contrast volume (0.155) were not associated with development of CIN whereas, smoking (0.021), hypotension (<0.001), heart failure (<0.001), anemia (0.001) and median eGFR (p < 0.001) were significantly associated with development of CIN. The incidence of CIN was 2.7 fold higher (OR : 2.68, 95% CI : 1.299-5.540, p = 0.008) in the intermediate group (MRS 6-10), 5.4 fold higher (OR : 5.403, 95% CI : 2.249-12.978, p <0.001) in the high risk group (MRS 11-15) and 51 fold higher (OR : 51.059, 95% CI : 18.195-143.278, p <0.001) in the very high risk groups (MRS > 16) when compared to the low risk group (MRS < 5) respectively.
Conclusions: The incidence of CIN in the very high risk group (MRS > 16) was substantially higher in our study (77.8 %) as compared to same group in Mehran study (57.3 %).
ACE Angiotensin converting enzyme
ACS Acute coronary syndrome
AKI Acute kidney injury
AKI-D Acute kidney injury requiring dialysis AMI Acute myocardial infarction
ARF Acute renal failure
BUN Blood urea nitrogen
CAG Coronary angiography
CHF Congestive heart failure
CIN Contrast induced nephropathy
CKD Chronic kidney disease
CM Contrast media
CS- CIN Clinically significant contrast induced nephropathy
e- GFR Estimated glomerular filtration rate
LVEF Left ventricular ejection fraction
MRS Mehran risk score
NSTEMI Non ST segment elevation myocardial infarction
PCI Percutaneous coronary intervention
STEMI ST segment elevation myocardial infarction
Coronary heart disease is one of the leading causes of death worldwide and remains a substantial contributor to morbidity, mortality and healthcare expenditure. One of the modalities of treatment is revascularization using percutaneous coronary intervention (PCI). Advances in PCI technology have resulted in increasing numbers of patients undergoing coronary revascularization via this approach [1]. However, the use of such contrast media might result in acute events and injuries after the procedure. Contrast-induced acute kidney injury (CI-AKI) is a prevalent but underdiagnosed complication of PCI that is associated with increased in-hospital morbidity and mortality [2-5].
Acute kidney injury (AKI) in the setting after contrast media (CM) administration derives from many causes including ischemia, atheroembolism, or nephrotoxicity of the contrast media itself. The latter is referred to as contrast induced nephropathy (CIN) [6]. Contrast induced nephropathy is generally defined as an increase in serum creatinine concentration of > 0.5 mg/dl (>44 μmol/ L) or 25
Study Design: Prospective Observational Cohort Study
Study Period: March 2019 to March 2020.
Recruitment and method: This study was done after explaining the study details in a language understandable to the patient. The patient was provided with information sheet and consent form. Informed consent was taken from the patients who were willing to get enrolled in the study.
A total number of 432 patients were enrolled in the study.
Inclusion Criteria
Acute coronary syndrome (ACS) diagnosis was based on fourth universal definition of myocardial infarction defined by standard criteria of elevation of cardiac troponin levels with presence of atleast one of the following - chest pain, ischemic changes in ECG, imaging evidence of new regional wall motion abnormality or identification of coronary thrombus by angiography.
Exclusion criteria
Baseline characteristics Demographic data (age, sex), risk factors and indication for intervention was collected. Cardiac catheterization and PCI was performed in accordance with established clinical practice using standard diagnostic and guide catheters, wires, balloon catheters, and stents via the femoral/radial approach. The amount of contrast media administered was decided by the interventional cardiologist.
All patients were admitted to the hospital one day before cardiac catheterization. Risk stratification for development of CIN was calculated for all patients using the Mehran risk score. The risk score included hypotension (5 points, if systolic blood pressure <80>75 years), anemia (3 points, if hematocrit <39>16 indicates a risk for CIN of 7.5%, 14%, 26%, and 57%, respectively.
Serum creatinine concentrations and GFR was determined at hospital admission (prior to the procedure), and at 24 hours and 48 hours after the procedure. The changes of serum creatinine level was analyzed. The eGFR was calculated according to the Modification of Diet in Renal Disease (MDRD) formula. CIN was defined as an increase in the serum creatinine level of more than 0.5 mg/dl or more than 25% from baseline within 48 hours after procedure without any other identifiable cause of acute kidney injury.
Outcomes
Number of patients who developed CIN post percutaneous coronary intervention (incidence of CIN) was measured by change in serum creatinine concentration.
Statistical Analysis
Data was entered in a Microsoft Excel spreadsheet and analysed using STATA 15. Continuous variables were summarized as mean and standard deviation. Categorical variables were summarized as percentage. Incidence of CIN was reported in percentage along with its 95% confidence interval. Unadjusted Odds Ratio was reported for each individual risk factor. Chi-square test for independence was used to test the relationship between two categorical variables. A multivariate binary logistic regression model was used to assess the independent effect of potential risk factors on CIN. Adjusted odds ratio was reported along with their 95% confidence intervals. Two sided p values were reported and a p value <0>
In our study, 432 patients who were enrolled for the study underwent percutaneous coronary intervention and were followed for the development of CIN. 132 patients who underwent optical coherence tomography (OCT) guided percutaneous coronary intervention were also included in the study. (Table 1)
Values are given n (%), mean± Standard deviation
Patients were categorized into four groups based on Mehran risk score (MRS) into low risk (MRS < 5> 16). (Table 2).
The patients were followed for the development of CIN. Majority of the patients (61.3 %) belonged to the low risk category (MRS < 5> 16). Among the 432 patients who were followed for development of CIN, only 64 patients (14.8%) developed CIN. (Figure 1)
CIN contrast induced nephropathy, OR Odds ratio, CI Confidence interval, IABP Intra aortic balloon counterpulsation, CHF Congestive heart failure
When the categorical variables were adjusted for other covariables, it was found out that hypotension, congestive heart failure and anemia were significantly associated with development of CIN, and however, smoking was not significantly associated with development of CIN (p 0.104).
Estimated glomerular filtration rate (eGFR) with development of CIN
Among our study population of 432 patients, median eGFR was 96 ml/min/1.73 m2 (Table 10). Out of these, 64 patients who developed CIN, median eGFR was 58 ml/min/1.73 m2 and among the 368 patients who didn’t develop CIN had a median eGFR of 98 ml/min/1.73 m2and the difference between two groups was found to be statistically significant. (p < 0>
Among the 432 patients, who were enrolled in the study, the median use of contrast volume was 100 ml. Out of these who developed CIN, median use of contrast volume was 120 ml, whereas those who didn’t develop CIN, median use of contrast volume was 100 ml, however, the difference was not statistically significant (p 0.155).
Patients were categorized into four MRS subgroups based on Mehran Risk Score (MRS) as low (< 5> 16) and the incidence of CIN in each subgroup was 6.4%, 15.5%, 27 % and 77.8 % respectively. Higher Mehran risk score was associated with increased incidence of CIN, and the observation was statistically significant. (p <0>
The incidence of CIN was 2.7 fold higher (OR : 2.68, 95% CI : 1.299-5.540, p = 0.008), 5.4 fold higher (OR : 5.403, 95% CI : 2.249-12.978, p <0> 16) when compared to the low risk group (MRS < 5>
In our study of 432 patients, who were followed for development of contrast induced nephropathy (CIN), 64(14.8%) patients developed CIN whereas 368 (85.2 %) patients didn’t develop CIN. Mehran et al (2004)9 in their study found an incidence of 13.1 % of contrast induced nephropathy in post percutaneous intervention patients.
In our study, it was seen that with increasing MRS the observed risk of CIN was exponentially higher. Our study and Mehran study were compared for the incidence of CIN across various MRS subgroups, and it was found that the incidence of CIN across low, intermediate and high risk groups were comparable between our study and Mehran study, however, the incidence of CIN among very high risk group patients was substantially higher than the Mehran study. (Table 6)
Mehran risk score was formulated and validated in the western population, but its applicability in the Indian population holds true as well. The incidence of CIN in the very high risk group (MRS > 16) was substantially higher in our study (77.8 %) as compared to same group in Mehran study (57.3 %). Our observation was further validated by Sanjai Pattu Valappil et al10who conducted a study on the predictors of contrast induced nephropathy and the applicability of the Mehran risk score in high risk patients undergoing coronary angioplasty—A study from a tertiary care center in South India and found that the Mehran risk score prediction for CIN is pertinent even in Indian population, however, the risk of CIN in high risk Mehran groups is substantially higher in the Indian population than in the western population. The incidence of CIN in the very high risk group (MRS > 16) was 83.3 % in their study which was comparable to our study (77.8 %) but significantly higher than the Mehran study (57.3%).
In our study of 432 patients,
None declared.
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