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How do centres begin the process to prevent contrast-induced acute kidney injury: a report from a new regional collaborative
  1. Jeremiah R Brown1,2,
  2. Peter A McCullough3,
  3. Mark E Splaine1,4,
  4. Louise Davies5,
  5. Cathy S Ross1,
  6. Harold L Dauerman6,
  7. John F Robb2,
  8. Richard Boss7,
  9. David J Goldberg8,
  10. Frank A Fedele9,
  11. Mirle A Kellett10,
  12. William J Phillips11,
  13. Peter N Ver Lee12,
  14. Eugene C Nelson1,
  15. Todd A MacKenzie4,
  16. Gerald T O'Connor1,
  17. Mark J Sarnak13,
  18. David J Malenka2,
  19. for the Northern New England Cardiovascular Disease Study Group
  1. 1The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire, USA
  2. 2Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  3. 3St. John Providence Health System, Providence Park Heart Institute, 47601 Grand River Avenue; Suite B-125 Novi, MI 48374, USA
  4. 4Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  5. 5VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont, USA
  6. 6Fletcher Allen Cardiology, Cardiovascular Catheterization Laboratories, Fletcher Allen Health Care and University of Vermont College of Medicine, Burlington, Vermont, USA
  7. 7Concord Hospital Cardiac Associates, Concord, New Hampshire, USA
  8. 8New England Heart Institute, Catholic Medical Center, Manchester, New Hampshire, USA
  9. 9Cardiovascular Medicine, Atlantic Cardiology Associates, Portsmouth Regional Hospital, Portsmouth, New Hampshire, USA
  10. 10Cardiac Services, Maine Medical Center, Portland, Maine, USA
  11. 11Central Maine Heart and Vascular Institute, Central Maine Medical Center, Lewiston, Maine, USA
  12. 12Northeast Cardiology Associates, Eastern Maine Medical Center, Bangor, Maine, USA
  13. 13Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Jeremiah R Brown, Dartmouth-Hitchcock Medical Center, HB 7505, One Medical Center Drive, Lebanon, NH 03756, USA; jbrown{at}


Objectives This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI.

Background CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged hospitalisation, end-stage renal disease, and all-cause mortality. Reducing the risk of CI-AKI is a patient safety objective set by the National Quality Forum.

Methods This study prospectively collected quantitative and qualitative data from 10 centres, which participate in the Northern New England Cardiovascular Disease Study Group PCI Registry. Quantitative data were collected from the PCI Registry. Qualitative data were obtained through clinical team meetings to map care processes related to CI-AKI and focus groups to understand attitudes towards CI-AKI prophylaxis. Fixed and random effects modelling were conducted to test the differences across centres.

Results Significant variation in rates of CI-AKI were found across 10 medical centres. Both fixed effects and mixed effects logistic regression demonstrated significant variability across centres, even after adjustment for baseline covariates (p<0.001 for both modelling approaches). Patterns were found in reported processes and clinical leadership that were attributable to centres with lower rates of CI-AKI. These included reducing nil by mouth (NPO) time to 4 h prior to case, and standardising volume administration protocols in combination with administering three to four high doses of N-acetylcysteine (1200 mg) for each patient.

Conclusions These data suggest that clinical leadership and institution-focused efforts to standardise preventive practices can help reduce the incidence of CI-AKI.

  • Contrast media
  • acute kidney injury
  • patient safety
  • quality improvement
  • healthcare quality improvement
  • comparative effectiveness research
  • randomised controlled trial
  • laboratory medicine
  • hospital medicine
  • quality measurement

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  • Funding This project was supported by grant number K01 HS018443 (Dr Brown) from the Agency for Healthcare Research and Quality and K24 DK078204 (Dr Sarnak) from the National Institute of Diabetes and Digestive and Kidney Diseases. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the National Institute of Health.

  • Competing interests None.

  • Ethics approval Center for the protection of human subjects at Dartmouth, others.

  • Provenance and peer review Not commissioned; externally peer reviewed.