Michael J. Connor, Jr., MD
Critical Care Medicine & Nephrology
Emory University School of Medicine
Dr. Connor’s full presentation is available for download on his Twitter feed: @criticalbeansmd
Timal RJ, et al Effect of No Prehydration vs Sodium Bicarbonate Prehydration Prior to Contrast-Enhanced Computed Tomography in the Prevention of Postcontrast Acute Kidney Injury in Adults With Chronic Kidney Disease: The Kompas Randomized Clinical Trial. JAMA Intern Med. 2020 Feb 17. [Epub ahead of print]
Full-text for Emory users.
RESULTS: Of 554 patients randomized, 523 were included in the intention-to-treat analysis. The median (interquartile range) age was 74 (67-79) years; 336 (64.2%) were men and 187 (35.8%) were women. The mean (SD) relative increase in creatinine level 2 to 5 days after contrast administration compared with baseline was 3.0% (10.5) in the no prehydration group vs 3.5% (10.3) in the prehydration group (mean difference, 0.5; 95% CI, -1.3 to 2.3; P < .001 for noninferiority). Postcontrast acute kidney injury occurred in 11 patients (2.1%), including 7 of 262 (2.7%) in the no prehydration group and 4 of 261 (1.5%) in the prehydration group, which resulted in a relative risk of 1.7 (95% CI, 0.5-5.9; P = .36). None of the patients required dialysis or developed acute heart failure. Subgroup analyses showed no evidence of statistical interactions between treatment arms and predefined subgroups. Mean hydration costs were €119 (US $143.94) per patient in the prehydration group compared with €0 (US $0) in the no prehydration group (P < .001). Other health care costs were similar.
Hinson JS, Ehmann MR, Fine DM, et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017 May;69(5):577-586.e4.
Full-text for Emory users.
Results: “Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months. Clinicians were less likely to prescribe contrast to patients with decreased renal function and more likely to prescribe intravenous fluids if contrast was administered.”
One discussion this week included readmission rates following parathyroidectomy.
References: Ferrandino R, et al. Unplanned 30-day readmissions after parathyroidectomy in patients with chronic kidney disease: a nationwide analysis. Otolaryngology – Head and Neck Surgery. 2017 Dec;157(6):955-965. doi:10.1177/0194599817721154.
Summary: A retrospective cohort study was performed using the 2013 Nationwide Readmissions Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). In a total of 2756 parathyroidectomies performed in patients with chronic kidney disease, 17.2% had at least one unplanned readmission rate within the first 30-days, and 2.4% had more than one readmission. Overall, readmission rates for chronic kidney disease patients are nearly 5-times that of the general population (Ferrandino et al, 2017).
Hypocalcemia/hungry bone syndrome accounted for 40% of readmissions. While readmissions occurred uniformly throughout the 30 days after discharge, those for hypocalcemia/hungry bone syndrome peaked in the first 10 days and decreased over time.
Weight loss/malnutrition at time of parathyroidectomy and length of stay of 5-6 days conferred increased risk of readmission with adjusted odds ratios of 3.31 and 1.87, respectively. Relative to primary hyperparathyroidism, parathyroidectomies performed for secondary hyperparathyroidism were associated with higher risk of readmission.
The authors conclude: “While there are few patient-specific predictors of readmission, we note that the bulk of these readmissions can be attributed to hypocalcemia. To improve readmission rates after parathyroidectomy in CKD patients, we propose focusing on accurate, appropriate medication reconciliation, and optimizing communication and transitions of care to outside facilities (skilled nursing, dialysis, etc.) to facilitate the comprehensive care of this high-risk patient population” (Ferrandino et al, p.964).
Additional Reading: Sharma J, et al. Improved long-term survival of dialysis patients after near-total parathyroidectomy. Journal of the American College of Surgeons. 2012 Apr;214(4):400-407. doi:10.1016/j.jamcollsurg.2011.12.046.
Westerdahl J, et al. Risk factors for postoperative hypocalcemia after surgery for primary hyperparathyroidism. Archives of Surgery. 2000 Feb;135(2):142-147.