Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA.
Eur J Radiol. 2020 Mar;124:108826. doi: 10.1016/j.ejrad.2020.108826. Epub 2020 Jan 13.
Chronic kidney disease (CKD) is prevalent in transcatheter aortic valve replacement (TAVR) candidates, leading to concerns regarding contrast medium (CM) safety. We evaluated (a) the impact of low-CM imaging on pre-TAVR measurements and (b) postcontrast acute kidney injury (PC-AKI) prevalence after dual-source computed tomography (DSCT) in TAVR candidates.
All TAVR candidates with CKD (SCr≥1.5 mg/dL) who underwent weight-based low-CM, low-pitch helical 3-generation DSCT in a one-year period were included, and matched to standard-CM, non-CKD controls (N = 50). Image quality (IQ) and pre-TAVR measurement interobserver variability were evaluated. Renal function change and PC-AKI were studied in the entire TAVR cohort, irrespective of scan mode (N = 153).
Low-CM in CKD (N = 25) was performed with median 68 mL CM [52-87], 90 kV [80-90] and SCr 1.6 mg/dL [1.5-1.9], and standard-CM without CKD with median 116 mL CM [96-134], 100 kV [90-110] and SCr 1.0 mg/dL [0.9-1.1](P < 0.00). Low-CM IQ was good, though lower compared with standard-CM (P < 0.02). Interobserver measurement reliability was excellent (ICCs>0.85). Interobserver-agreement was lower in low-CM, causing prosthesis size disagreement in 5/25 (kappa-0.73) versus 0/25 with standard-CM (kappa-1.00), and transfemoral eligibility disagreement in 4/25 (kappa-0.68) versus 2/25 (kappa-0.84), respectively. Mean 1-month SCr-change in the low-CM TAVR cohort (N = 35) was -1 % [-12 to +7 %] and in standard-CM (N = 118) 0 % [-8 to +10 %](P > 0.3). PC-AKI occurred in none.
Low-CM third-generation-DSCT achieves good IQ in TAVR candidates with CKD, and seems safe, with no apparent renal function deterioration or prevalence of PC-AKI. However, standard-CM protocols in non-CKD patients provide higher measurement reproducibility. Low-CM protocols should therefore be reserved for patients at high risk for PC-AKI.
慢性肾脏疾病（CKD）在经导管主动脉瓣置换术（TAVR）患者中很常见，这引发了人们对造影剂（CM）安全性的担忧。我们评估了（a）低 CM 成像对 TAVR 患者术前测量的影响，以及（b）双源 CT（DSCT）在 TAVR 患者中的应用后对比剂急性肾损伤（PC-AKI）的发生率。
所有在一年内接受基于体重的低 CM、低螺距第三代 DSCT 的 CKD（SCr≥1.5mg/dL）TAVR 患者均被纳入研究，并与标准 CM、非 CKD 对照组（N=50）进行匹配。评估了图像质量（IQ）和术前 TAVR 测量的观察者间变异性。无论扫描模式如何（N=153），整个 TAVR 队列均研究了肾功能变化和 PC-AKI。
25 例 CKD 患者行低 CM（中位数 68mL CM [52-87]，90kV [80-90]，SCr 1.6mg/dL [1.5-1.9]），而无 CKD 的标准 CM 组患者行 116mL CM（中位数 96-134），100kV [90-110]，SCr 1.0mg/dL [0.9-1.1]（P<0.00）。低 CM 的 IQ 良好，但与标准 CM 相比较低（P<0.02）。观察者间测量的可靠性非常好（ICC>0.85）。低 CM 观察者间的一致性较低，导致 5/25 例（kappa-0.73）与 0/25 例（kappa-1.00）的假体尺寸不一致，4/25 例（kappa-0.68）与 2/25 例（kappa-0.84）的经股动脉入路的适宜性不一致。低 CM TAVR 队列（N=35）的平均 1 个月 SCr 变化为-1%[-12 至+7%]，标准 CM 组（N=118）为 0%[-8 至+10%]（P>0.3）。两组均无 PC-AKI 发生。
低 CM 第三代 DSCT 在 CKD 的 TAVR 患者中可获得良好的 IQ，且似乎是安全的，肾功能无明显恶化，也无 PC-AKI 发生。然而，非 CKD 患者的标准 CM 方案提供了更高的测量可重复性。因此，低 CM 方案应仅用于有发生 PC-AKI 高风险的患者。
