Experts Consider Role of Statins in Prevention of Contrast-Induced Nephropathy

Patients with ACS are at high-risk for acute kidney injury (AKI) during PCI, but the role of statins in the prevention of renal damage currently remains uncertain. In a debate held at TCT 2014, two experts offered opposing views on whether statins should be used to protect against contrast-induced nephropathy.  

Multifactorial benefit 

Richard Solomon, MD, of the University of Vermont, Burlington, Vt., drew attention to the fact that statins have many other purposes besides lowering cholesterol. A robust number of observational and randomized trials have evaluated statins to prevent AKI, he noted.

“The whole issue over whether or not statins have an effect on contrast-induced nephropathy is related to their ability to interfere with pathways that are primarily involved in inflammation and tissue remodeling,” Solomon said. “There are a number of reasons why statins may be valuable in patients who are undergoing coronary angiography.”

Results of the PRATO-ACS trial showed lower risk of contrast-induced AKI in patients assigned rosuvastatin (Crestor, AstraZeneca) vs. placebo (6.7% vs. 15.1%; adjusted OR 0.38; 95% CI 0.20-0.71; P=.003).

Solomon also cited a study published in 2014 in the Journal of the American College of Cardiology. The largest trial to date on the topic, enrolling nearly 3,000 patients with diabetes and chronic kidney disease (most statin-naive), observed a reduction in AKI incidence with rosuvastatin (2.3%) compared with control (3.9%; P=.01).

“These are the two largest and most recent trials and are the only trials that show a statistically significant benefit of statins on contrast-induced nephropathy,” he said. “The benefit of high-dose vs. low-dose statins suggest that even in patients previously on statin therapy, escalation of dose may offer additional protection and reductions in the incidence of acute kidney injury.”

While Solomon conceded that meta-analyses are only as good as the studies that are in them, he asserted, “that’s all the data that we have, and there is no real harm. Patients are going to be on statins anyway, so I don’t see why we shouldn’t give [them] to statin-naive patients.” 

Not ready for primetime 

Somjot S. Brar, MD, MPH, of Kaiser Permanente, Los Angeles, Calif., said meta-analyses offer little clarity on whether statins prevent kidney damage and argued that more trials are needed on patients at high risk.

Brar conducted his own meta-analysis of 18 clinical trials and calculated a relative risk of 0.52 (95% CI 0.40 -0.67) favoring statin use in prevention of contrast-induced nephropathy. However, intermediate or higher doses were needed to achieve an effect, and most trials had high levels of unexpected event rates among low-risk patients, he reported.

“Statin-use for this indication isn’t ready for primetime,” Brar emphasized. “Many positive trials were performed in patients with eGFR of 80 or more — the event rates between 10% and 20% are expected, and the efficacy of therapy in these studies with eGFR less than 60 are questionable.”

Looking over the broad scope of data, Brar described it as inconclusive regarding which patient population should receive statin therapy. According to Brar, “meta-analyses have misleading results. Confusing studies [going in] lead to confusing results out. We need more trials that include the right patients (eGFR <60), we need volume expansion per protocol in all patients and studies should be appropriately powered.”

Disclosures: 

• Brar reports no relevant conflict of interest.

• Solomon reports serving on the scientific advisory committees for Bracco Diagnostics, Ischemix, MD Sci, MediBeacon and PLC Med.