LAUSR

Angiography is dependent on administration of contrast medium (CM), a “necessary evil” indispensable to procedural performance, but which incurs the “price” of contrast-induced acute kidney injury (CI-AKI), a complication associated with increased peri-procedural morbidity and mortality. The key to successful avoidance of this complication is preprocedural “anticipation”. Patient-related “Risk Scores” should be calculated: Factors include diabetes mellitus, congestive heart failure and age >75; not surprisingly, the most potent risk predictor is chronic kidney disease (CKD). Procedure-related contributors include high contrast volume and repeated exposures to CM within 72 hr; accordingly, procedural planning is essential. Over the past 25 years, great attention has been focused on ameliorating the adverse renal impact of CM. The advent of low osmolarity CM has been beneficial. Various renal protective strategies have been designed, but only two have been proven effective to curtail CI-AKI: Minimization of contrast volume administered; and Pre-procedural volume expansion. Unfortunately CIAKI remains an unsolved threat, particularly to those with CKD. In the present paper, Oyamada et al report striking benefits achieved by a novel renal protective strategy in patients with CKD: High flow-volume intermittent hemodiafiltration (HF-IHDF) which attempts to remove contrast from the blood pool as it circulates in the body. This technique differs from standard continuous hemodiafiltration (CHDF) by achieving 5X greater filtration flow rates. Administered by their protocol implemented before, during and for 2.5 hr after the angiographic procedure, HF-IDF is thought to remove >90% of contrast, and in 1/sixth of the time required for CHDF. The present study retrospectively compared the post-angiographic incidence of CI-AKI in 130 consecutive patients with advanced CKD (stage G3b or G4) undergoing interventions managed by HF-IHDF plus saline (N = 76 patients) versus saline alone (N = 54). Lowosmolarity contrast medium was used in all cases. Important results showed significantly lower incidence of CI-AKI in those managed by HF-IHDF versus saline alone (at 2–3 days, 0 vs. 9.3%, p < .05; and at 1 month 3.9 vs. 14.8%, p < .05). The authors should be congratulated for this novel approach to minimizing CI-AKI, demonstrating that the HF-IHDF strategy employed may prevent CI-AKI in patients with advanced CKD.