Comparison of route and location of contrast delivery on contrast-induced nephropathy: A systematic review and pairwise meta-analysis.

Abstract

Background: Contrast-induced nephropathy (CIN) remains a leading cause of iatrogenic acute kidney injury. Whether the route of contrast administration (intravenous [IV] versus intra-arterial [IA]) and the anatomical level of endovascular manipulation (suprarenal versus infrarenal) independently modify CIN risk is incompletely defined. We hypothesized that direct first-pass exposure of the renal vasculature to contrast and procedure-related embolic stress drive renal injury.

Methods: We performed two pairwise random-effects meta-analyses. The first compared CIN incidence after IV versus IA contrast administration across six eligible studies (n = 2961 patients). The second compared CIN incidence after suprarenal versus infrarenal endovascular procedures across fifteen studies (n = 49,838 patients). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) and 95% prediction intervals were calculated using the DerSimonian-Laird estimator.

Results: IV contrast administration was associated with a significantly lower incidence of CIN compared with IA administration (pooled OR 0.63, 95% CI 0.40-0.97; p = 0.036; I² = 48%). Suprarenal endovascular procedures were associated with a significantly higher incidence of CIN than infrarenal procedures (pooled OR 1.27, 95% CI 1.01-1.60; p = 0.043; I² = 43%). Meta-regression showed that differences in weighted mean contrast volume and incidence of diabetes mellitus significantly explained between study heterogeneity.

Conclusions: These findings support the hypothesis that route of contrast delivery and anatomical proximity of endovascular instrumentation to the renal arteries are independent determinants of CIN, supporting the first-pass high concentration exposure and embolic stress as plausible etiologies of renal injury associated with contrast requiring procedures.