Association of Intravenous Radiocontrast With Kidney Function A Regression Discontinuity Analysis
Association of Intravenous Radiocontrast With Kidney Function A Regression Discontinuity Analysis
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DOI：
10.1001/jamainternmed.2021.0916
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发表时间：
2021-04-05
影响因子：
39
通讯作者：
Tamblyn, Robyn
中科院分区：
文献类型：
--
作者：
Goulden, Robert;Rowe, Brian H.;Tamblyn, Robyn
重要的放射造影剂长期以来一直被认为是肾毒性的；然而，最近的一些观察性研究发现，没有证据表明静脉造影剂与肾脏损伤之间存在联系。由于这些研究存在混淆和选择偏差的高风险，因此需要替代的研究设计来实现对这种关联的更强有力的评估。目的使用一项允许比现有观察性研究更强的因果解释的研究设计来确定静脉注射造影剂暴露是否与临床上显著的长期肾脏损害相关。设计、设置和参与者该队列研究包括2013至2018年间在加拿大阿尔伯塔省接受D-二聚体检测的所有18岁或18岁以上的急诊科患者。采用模糊回归不连续设计，利用CT肺血管造影术(CTPA)合格截止点两侧的个体--通常为500 ng/mL--有明显不同的对比剂暴露概率，但在其他方面与潜在混杂因素相似。实验采用CTPA形式的静脉造影剂。在急诊科就诊后6个月内，主要结果和测量估计的肾小球滤过率(EGFR)。平均年龄53岁，男性68206人(44%)，女性87822人(56%)，平均基线EGFR水平为86mL/min/1.73m(2)。仅高于CTPA资格界限和低于CTPA资格界限的患者在测量的混杂因素方面相似。直到6个月后，没有证据表明造影剂与EGFR之间存在关联，与CTPA暴露相关的EGFR的平均变化为-0.4mL/min/1.73m(2)(95%CI，-4.9至4.0)。同样没有证据表明需要肾脏替代治疗(风险差异[RD]，0.07%；95%CI，-0.47%至0.61%)、死亡率(RD，0.3%；95%CI，-2.9%至3.2%)和急性肾损伤(RD，4.3%；95%CI，-2.7%至12.9%)，尽管后一项分析因缺少数据而受到限制。亚组分析可能与糖尿病患者的危害一致(平均EGFR变化-6.4毫升/分钟/1.73米(2)；95%可信区间，-15.4至0.2)，但不在其他报告的造影剂肾病危险因素中；然而，这些分析相对不足。结论和相关性采用队列研究设计和分析，允许比现有观察性研究更强的因果解释，我们没有发现在紧急情况下静脉注射CTPA造影剂对肾功能有害影响的证据。(C)2021年美国医学会。版权所有。
IMPORTANCE Radiocontrast has long been thought of as nephrotoxic; however, a number of recent observational studies found no evidence of an association between intravenous contrast and kidney injury. Because these studies are at high risk of confounding and selection bias, alternative study designs are required to enable more robust evaluation of this association.OBJECTIVE To determine whether intravenous radiocontrast exposure is associated with clinically significant long-term kidney impairment, using a study design that permits stronger causal interpretation than existing observational research.DESIGN, SETTING, AND PARTICIPANTS This cohort study included all emergency department patients aged 18 years or older undergoing D-dimer testing between 2013 and 2018 in the Canadian province of Alberta. A fuzzy regression discontinuity design was used, exploiting the fact that individuals just either side of the eligibility cutoff for computed tomographic pulmonary angiogram (CTPA)-typically 500 ng/mL-have markedly different probabilities of contrast exposure, but should otherwise be similar with respect to potential confounders.EXPOSURES Intravenous contrast in the form of a CTPA.MAIN OUTCOMES AND MEASURES Estimated glomerular filtration rate (eGFR) up to 6 months following the index emergency department visit.RESULTS During the study period 156 028 individuals received a D-dimer test. The mean age was 53 years, 68 206 (44%) were men and 87 822 (56%) were women, and the mean baseline eGFR level was 86 mL/min/1.73 m(2). Patients just above and below the CTPA eligibility cutoff were similar in terms of measured confounders. There was no evidence for an association of contrast with eGFR up to 6 months later, with a mean change in eGFR of -0.4 mL/min/1.73 m(2) (95% CI, -4.9 to 4.0) associated with CTPA exposure. There was similarly no evidence for an association with need for kidney replacement therapy (risk difference [RD], 0.07%; 95% CI, -0.47% to 0.61%), mortality (RD, 0.3%; 95% CI, -2.9% to 3.2%), and acute kidney injury (RD, 4.3%; 95% CI, -2.7% to 12.9%), though the latter analysis was limited by missing data. Subgroup analyses were potentially consistent with harm among patients with diabetes (mean eGFR change -6.4 mL/min/1.73 m(2); 95% CI, -15.4 to 0.2), but not among those with other reported risk factors for contrast-induced nephropathy; these analyses, however, were relatively underpowered.CONCLUSIONS AND RELEVANCE Using a cohort study design and analysis that permits stronger causal interpretation than existing observational research, we found no evidence for a harmful effect on kidney function of intravenous contrast administered for CTPA in an emergency setting. (c) 2021 American Medical Association. All rights reserved.