OBJECTIVE: To evaluate the efficacy of aggressive hydration compared with general hydration for contrast-induced acute kidney injury (CI-AKI) prevention among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).
METHODS: The Aggressive hydraTion in patients with STEMI undergoing pPCI to prevenT Contrast-Induced Acute Kidney Injury study is an open-label, randomised controlled study at 15 teaching hospitals in China. A total of 560 adult patients were randomly assigned (1:1) to receive aggressive hydration or general hydration treatment. Aggressive hydration group received preprocedural loading dose of 125/250 mL normal saline within 30 min, followed by postprocedural hydration performed for 4 hours under left ventricular end-diastolic pressure guidance and additional hydration until 24 hours after pPCI. General hydration group received =500 mL 0.9% saline at 1 mL/kg/hour for 6 hours after randomisation. The primary end point is CI-AKI, defined as a >25% or 0.5 mg/dL increased in serum creatinine from baseline during the first 48-72 hours after primary angioplasty. The safety end point is acute heart failure.
RESULTS: From July 2014 to May 2018, 469 patients were enrolled in the final analysis. CI-AKI occurred less frequently in aggressive hydration group than in general hydration group (21.8% vs 31.1%; risk ratio (RR) 0.70, 95% CI 0.52 to 0.96). Acute heart failure did not significantly differ between the aggressive hydration group and the general hydration group (8.1% vs 6.4%, RR 1.13, 95% CI 0.66 to 2.44). Several subgroup analysis showed the better effect of aggressive hydration in CI-AKI prevention in male, renal insufficient and non-anterior myocardial infarction participants.
CONCLUSIONS: Comparing with general hydration, the peri-operative aggressive hydration seems to be safe and effective in preventing CI-AKI among patients with STEMI undergoing pPCI.
Bad idea. Like beta blockers, acute treatment makes sense until there is a complication and then there is an iatrogenic error. Better to measure the left ventricular filling pressure before overloading the patient with fluid.
This is very relevant to my current practice. The findings of this pragmatic study are interesting but quite surprising to what I would have expected. In my practice, most STEMI presentations are late and tend to have some degree of acute heart failure at presentation. The standard thinking has always been that aggressive hydration of these patients might result in poor outcomes.
I do not think the main outcome is relevant. Such small change in creatinine levels may not be consistent with important prevention. The cystatine C outcome illustrates that. The incidence of acute heart failure, albeit statistically similar between both groups, does not display sufficient power to make one feel comfortable. I think the good news is the subgroup of CRF patients who had better results with the "aggressive" hydration (which is not that aggressive). These data warrant other trials with chronic renal failure patients.
Similar design and similar findings to Poseidon.