Haemodynamic-Guided Fluid Administration for the Prevention of Contrast-Induced Acute Kidney Injury: The POSEIDON Randomised Controlled Trial
What is the efficacy of a left ventricular end-diastolic pressure (LVEDP)–based hydration strategy for prevention of contrast-induced nephropathy?
The POSEIDON (Prevention of Contrast Renal Injury With Different Hydration Strategies) trial authors performed a randomized, parallel-group, comparator-controlled, single-blind trial to assess the efficacy of a new fluid protocol based on LVEDP for the prevention of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. CI-AKI was defined as a >25% or >0.5 mg/dl increase in serum creatinine concentration. A total of 396 patients undergoing cardiac catheterization with an estimated glomerular filtration rate of ≥60 ml/min/1.73 m2 and one or more of several risk factors (diabetes mellitus, history of congestive heart failure, hypertension, or age >75 years) were randomized to LVEDP–guided volume expansion (n = 196) or the control group (n = 200), who received a standard fluid administration protocol. Patients and laboratory personnel were masked to treatment assignment, but the physicians who did the procedures were not masked. Both groups received intravenous 0.9% sodium chloride at 3 ml/kg for 1 hour before cardiac catheterization.
Patients in the LVEDP–guided group were less likely to develop CI-AKI (6.7% vs. 16.3%; relative risk, 0.41; 95% confidence interval, 0.22-0.79; p = 0.005) compared with control patients. Hydration treatment was terminated prematurely because of shortness of breath in three patients in each group.
The authors concluded that LVEDP–guided fluid administration is safe and effective in preventing CI-AKI in patients undergoing cardiac catheterization.
CI-AKI is a common complication of invasive cardiac procedures, and is associated with an increased morbidity and mortality. The two most effective strategies at preventing CI-AKI are adequate hydration and minimizing the volume of contrast media administered. The study strategy of using LVEDP–guided hydration is based on solid physiological principles, and its demonstrated efficacy and simplicity make it a logical hydration strategy for patients undergoing an invasive cardiac procedure. Confirmation of this benefit versus risk in a confirmatory randomized trial would solidify the generalizability of this strategy even further.
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