A new hydration strategy can reduce contrast-induced acute kidney injury after PCI in patients with chronic heart failure and chronic kidney disease: a two-center randomized controlled trial

Abstract Backgrounds Adequate hydration is crucial for preventing contrast-induced acute kidney injury (CI-AKI), particularly in patients with chronic kidney disease (CKD). The current guidelines recommend half-volume hydration for patients with chronic heart failure (CHF) to prevent pulmonary edema. Thus, it is challenging to administer hydration therapy in patients with CHF and CKD. This study was aimed to compare different hydration strategies in this subset of patients. Methods This two-center, open-label, randomized clinical trial enrolled 303 CHF (patients with elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion) patients with CKD (estimated glomerular filtration rate [eGFR] of 15-60 mL/min/1.73m2) undergoing selective coronary angiography (CAG) from two tertiary hospitals from October 2020 to December 2023. Patients were randomized into three groups: half-volume hydration group (HH group, 0.5 mL/Kg/h hydration), standard hydration group (SH group, 1 mL/Kg/h hydration), and standard hydration with diuretic group (SH+D group, 1 mL/Kg/h hydration + immediate postoperative intravenous injection of furosemide 20 mg). All patients received hydration from 6 to 12 hours before to 24 hours after the procedure. The primary endpoint was CI-AKI, defined as a serum creatinine (SCr) increase of more than 0.3 mg/dL or 1.5-1.9 times greater than the baseline 48-72 hours after CAG. Safety endpoints included pulmonary edema during hydration, perioperative mortality, and the need for dialysis. Results A total of 101 patients were included in each group. Baseline characteristics (mean age, proportion of males, left ventricular ejection fraction and eGFR) were similar among groups. SCr, cystatin C levels, and SCr level changes between 48 and 72 hours after procedure did not significantly differ among groups (P > 0.05). The incidence of CI-AKI was highest in the HH group (22.8%), lowest in the SH+D group (11.9%), and intermediate in the SH group (17.8%) (P = 0.041). Regarding safety endpoints, there were 2 patients in the HH group, 3 patients in the SH group and 1 patient in the SH+D group experienced heart failure or pulmonary edema during hydration, with no statistically significant differences among the groups (P = 0.874). Perioperative mortality occurred in 1 patient in the HH group and 2 patients in the SH+D group, with no statistically significant differences (P = 0.776). No patient required renal replacement therapy. Conclusions In CHF patients with CKD, the half-volume hydration regimen recommended by guidelines was associated with a higher incidence of CI-AKI compared to standard hydration. However, standard hydration combine with diuretic fails to reduce the risk of heart failure during hydration or perioperative mortality, even if this novel strategy does not increase the risk of CI-AKI compared to standard hydration therapy.