JACC in a Flash | Contrast-induced acute kidney injury (CIAKI), a common complication of contrast media injection during coronary angiography or PCI, often leads to a prolonged hospitalization and an increased risk of mortality. Recently, statins have gained attention for their possible nephroprotective effects. Two studies published in JACC evaluated the safety and efficacy of rosuvastatin in preventing CIAKI in patients who are particularly vulnerable to kidney injury—one in patients with diabetes and chronic kidney disease (CKD), and the other in patients with acute coronary syndrome (ACS).

In the first, Leoncini et al. reported results from the Protective Effect of Rosuvastatin and Antiplatelet Therapy on Contrast-Induced Acute Kidney Injury and Myocardial Damage in Patients with Acute Coronary Syndromes (PRATO-ACS) study—a prospective, randomized trial designed to evaluate the impact of early high-dose statin administration in preventing CIAKI in ACS patients selected for an early invasive strategy.

The primary endpoint of CIAKI (defined as an increase in serum creatinine of ≥0.5 mg/dL or ≥25% over the baseline value within 72 hours after contrast agent administration) occurred in 55 of the 504 patients: 17 (6.7%) in the statin group and 38 (15.1%) in the control group. The absolute CIAKI reduction in the statin group was 8.3%, meaning that the number needed to treat is 12 patients to prevent one case of CIAKI. This reduction remained significant and consistent throughout the study population, even in the pre-specified risk categories of patients (such as those with reduced renal function and other high-risk clinical features for CIAKI development), supporting the recommendation for routine on-admission use of high-dose statin therapy in statin-naïve patients with non-ST-elevation ACS scheduled for early invasive strategy.

In their study, Han et al. looked specifically at the preventive effects of short-term statin use in patients with diabetes or CKD, whose risk for CIAKI is dramatically higher than that of patients with normal renal function. Nearly 3,000 patients were included in their study: 1,498 received rosuvastatin 10 mg daily for a short duration (5 days) and 1,500 were allocated to the control group. The incidence of CIAKI was lower in the rosuvastatin-treated group; there was, however, no significant difference in occurrence of all-cause deaths or dialysis/hemofiltration between control and statin-treated groups.

Dr. Han and colleagues also described several easily-identifiable independent risk factors for CIAKI (ACS, New York Heart Association functional classification, anemia, and decreased estimated glomerular filtration rate) that should be addressed when treating to prevent CIAKI in these patients.

As Martin A. Alpert, MD, pointed out in an accompanying editorial, the recent interest in the nephroprotective role of statins in patients undergoing coronary angiography or percutaneous PCI is due primarily to their anti-inflammatory properties, their ability to improve endothelial function, and their anti-apoptotic effects. “All of these properties counteract specific pathophysiologic mechanisms that promote the development of CIAKI,” he wrote, but noted that further exploration into the mechanisms of this nephroprotective effect is needed. “Moreover, there are no large head-to-head studies involving rosuvastatin to determine whether it is superior to other statins in reducing the risk of CIAKI and its intermediate and long-term sequelae.”

In the future, prospective randomized trials should be conducted to determine the optimal timing and duration of statin therapy for mitigates the risk of CIAKI in at-risk patients, Dr. Alpert added.

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Alpert MA. J Am Coll Cardiol. 2014;63:80-2.
Han Y, Zhu G, Han L, et al. J Am Coll Cardiol. 2014;63:62-70.
Leoncini M, Toso A, Maioli M. J Am Coll Cardiol. 2014;63:71-9.

Keywords: Contrast Media, Fluorobenzenes, Acute Coronary Syndrome, Coronary Angiography, Acute Kidney Injury, Pyrimidines, Risk Factors, Glomerular Filtration Rate, Sulfonamides, ACC Publications, CardioSource WorldNews

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