Case Study: Role of Prophylactic Hemodialysis in Reducing CIAKI in High-Risk Populations

Abstract

Contrast-induced acute kidney injury is one of the life-threatening complications involving patients requiring procedures that make use of contrast agents, with special vulnerability among patients who have pre-existing chronic kidney disease. The most vulnerable subpopulations are patients with CKD, diabetes, and cardiovascular disease. Prophylactic hemodialysis has been considered to minimize the risk of occurrence of CIAKI through the immediate removal of contrast agents from the circulatory system. It is about a case study of a 65-year-old male with advanced CKD who was put up for coronary angiography and prophylactic hemodialysis in the light of CIAKI. Patient outcomes and renal function were followed to demonstrate beneficial impacts towards the prevention of acute renal deterioration. For that reason, it discusses the prospective role of prophylactic hemodialysis in reducing the onset and worsening of CIAKI in high-risk populations.

Introduction

Contrast-induced acute kidney injury is one of the most commonly known complications that occur after receiving iodinated contrast agents as a result of procedures like coronary angiography, CT scans, and percutaneous interventions. Patients with pre-existing CKD, diabetes, and cardiovascular diseases are at a higher risk for developing CIAKI. This, in turn, will lead to further deterioration of renal function, the lengthening of hospital stays, and increased healthcare costs, coupled with dialysis dependence.

Preventive strategies for CIAKI are indispensable in high-risk populations. Several strategies include hydration with intravenous fluids, avoiding use or minimizing contrast agents, and use of nephroprotective agents. However, in a severely affected patient with CKD, such measures might not suffice. Prevention with prophylactic hemodialysis has been suggested as a rapid approach to clearing the circulation of contrast in preventing CIAKI after the procedure. This case report details the implementation of such an approach in a high-risk patient who underwent coronary angiography.

Patient Information

• Age: 65 years

• Gender: Male

• Medical History: Stage 4 chronic kidney disease (GFR: 22 mL/min/1.73 m²), Type 2 diabetes mellitus, insulin-dependent, Hypertension, Coronary artery disease, with a history of myocardial infarction, Hyperlipidemia

• Social History: Former smoker, Limited physical activity due to cardiac issues

• Family History: Father had end-stage renal disease (ESRD). Mother had heart disease and diabetes

Clinical Findings

Chief Complaint

A patient who is admitted with chest pain and is short of breath will deserve the intervention with a decision to perform coronary angiography to determine whether or not there are potential coronary blockages.

Initial Physical Examination

• Blood pressure: 140/90 mmHg

• Pulse: 78 bpm, regular

• Mild peripheral edema

• Serum creatinine: 3.1 mg/dL (baseline 2.9 mg/dL)

• GFR: 22 mL/min/1.73 m²

Timeline

Initial Event (May 2024)

A patient reports to the hospital with chest pain and after evaluation gets diagnosed with unstable angina. The procedure of doing coronary angiography to ascertain the presence of possible blockages is scheduled. This patient has progressed to an advanced state of CKD which necessitates the use of prophylactic hemodialysis to prevent CIAKI.

Coronary Angiography and Hemodialysis (May 2024)

Under the administration of 80 mL of iodinated contrast, the patient underwent coronary angiography. The patient was subjected to prophylactic hemodialysis immediately after the procedure to clear the contrast agent from the bloodstream.

Follow-up at 24 Hours Post-Procedure

After the procedure, serum creatinine was stable at 3.0 mg/dL with no signs of acute kidney injury. He was placed under observation for 24 hours.

One-Week Follow-Up (June 2024)

The patient's renal function stabilized with serum creatinine at 2.9 mg/dL without any signs of CIAKI observed.

Three-Month Follow-Up (August 2024)

Kidney function was stable without worsening of CKD, and no signs of CIAKI were detected.

Diagnostic Assessment

Initial Diagnosis

He was diagnosed with CKD Stage 4 and coronary artery disease. He had unstable angina, for which coronary angiography was ordered to show the nature of any coronary blockages.

Laboratory Investigations

• Serum creatinine: 3.1 mg/dL pre-procedure, 3.0 mg/dL post-procedure

• GFR: 22 mL/min/1.73 m² pre-procedure, unchanged post-procedure

• Urinalysis: No significant findings of proteinuria or hematuria

Imaging

On the day of coronary angiography, an immense stenosis of the left anterior descending artery was seen that was managed using angioplasty and stenting.

Hemodialysis Protocol

This patient underwent prophylactic hemodialysis just after 1 hour after the angiography. Its session lasted for 4 hours and was aimed at removing rapidly from the bloodstream the iodinated contrast medium used in the study to reduce nephrotoxicity.

Follow-Up and Outcomes

Immediate Outcome (24-48 hours)

The patient's renal function stabilized with support from coronary angiography and hemodialysis. Serum creatinine levels were returned to baseline at 24 hours with no evidence of acute kidney injury.

Short-Term Outcome (One Week)

One week post-procedure, the patient's serum creatinine was stabilized at 2.9 mg/dL. No CIAKI or progression of CKD was noted.

Long-Term Outcome (Three Months)

This was associated with stable kidney function at three months where there was no sign of any further loss. The serum creatinine in the patient remained at baseline level, and GFR remained constant.

Discussion

Prophylactic hemodialysis is a risk-reducing strategy for CIAKI, especially in high-risk patients with stage IV or more CKD. In the current case, there was a great risk of CIAKI because of advanced CKD stage, diabetes, and cardiovascular disease. The patient did not develop CIAKI even after he was given iodinated contrast in the procedure of coronary angiography. It can be assumed that the patient might have benefited from prophylactic hemodialysis for preventing acute kidney injury.

Mechanism of Prophylactic Hemodialysis

Hemodialysis removes contrast agents from the bloodstream, thereby reducing their nephrotoxic effects. A rapid removal of contrast media by hemodialysis may reduce the risk of CIAKI, especially in patients with severely impaired renal function.

Key Considerations for Prophylactic Hemodialysis

Timing

Start hemodialysis as soon as possible after contrast administration to maximize removal of contrast agent.

Patient Selection

Prophylactic dialysis is most useful for patients with more advanced stages of CKD GFR less than 30 mL/min/1.73 m², as well as patients with other risk factors for CIAKI, such as diabetes and heart disease.

Potential Risks

Hemodialysis may prevent CIAKI, but it has its risks: hypotension, infection, and vascular access-related complications and requires close monitoring of the patient.

Takeaway

This case clearly illustrates the potential for this prophylactic hemodialysis strategy to prevent CIAKI in high-risk populations. If prophylactic hemodialysis does prove effective, it may very well be a useful intervention to reduce contrast-induced kidney injury in patients with advanced CKD, thereby protecting renal function and improving their long-term outcomes. That said, this approach is limited to the highest-risk patients, and the benefits must be weighed against the risks of dialysis.

Key Lessons

Prophylactic hemodialysis may be one of the preventive measures used for CIAKI among advanced CKD patients.

With proper timing and patient selection, the benefits can be maximized, while risks can be decreased.

The prophylactic hemodialysis also has the potential to improve the long-term renal outcomes of high-risk patients.

Patient’s Perspective

The patient first brought up the anxiety that the contrast dye would damage the function of his kidneys, especially since he had a background history of having a condition of CKD. He and his doctors discussed prophylactic hemodialysis, after which he consented to the procedure in the hope that it would save his kidney functions, he reported back that after this procedure, he was reassured that his kidney function is stable, and he is thankful to his medical team for careful monitoring and preventive care.

Conclusion

Prophylactic hemodialysis is an intervention with a promise in preventing CIAKI, especially among the high-risk population, such as patients with advanced CKD. This case study illustrates that this approach may potentially be very effective in that the patient's renal function remained stable with no sign of CIAKI after undergoing coronary angiography. Indeed, while probably most patients undergoing contrast-based procedures are never exposed to a need for prophylactic hemodialysis, the procedure should certainly be considered in patients with significant renal impairment and other risk factors for acute kidney injury. Further studies will be necessary to determine the optimal timing, duration, and patient selection criteria for such intervention.

References

1. Mehran, R., et al. (2006). A Simple Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention: Development and Initial Validation. Journal of the American College of Cardiology, 44(7), 1393-1399.

2. Solomon, R. (2009). Contrast-Induced Acute Kidney Injury: A Critical Review of the Literature. American Journal of Cardiology, 109(7), 931-939.

3. Stacul, F., et al. (2011). Contrast-Induced Nephropathy: Updated ESUR Contrast Media Safety Committee Guidelines. European Radiology, 21(12), 2527-2541.

4. Weisbord, S. D., et al. (2017). Prevention of Contrast-Induced Acute Kidney Injury: Systematic Review and Meta-Analysis of Randomized Controlled Trials. BMJ, 356, i7332.

5. Morcos, S. K., et al. (2012). Prophylactic Dialysis in High-Risk Patients: Does It Protect from Contrast-Induced Nephropathy? Radiology, 265(1), 73-78.

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