CORRESPONDENCE: LETTER TO THE EDITOR
Visipaque (Iodixanol) and Hexabrix (Ioxaglate) in Renal Insufficiency
Gilbert Deray, MD*
* Pitie-Salpetriere Hospital, Nephrology, 47-83 Boulevard de l’Hopital, Paris, 75013, France (Email: gilbert.deray{at}psl.ap-hop-paris.fr).
I read with great interest the RECOVER (Renal Toxicity Evaluation and Comparison Between Visipaque and Hexabrix in Patients With Renal Insufficiency Undergoing Coronary Angiography) study by Jo et al. (1). They compared the renal tolerance of iodixanol and ioxaglate in patients with renal insufficiency after coronary angiography. They found that the incidence of contrast-induced nephropathy (CIN) was lower in the iodixanol group (7.9%) as compared with the ioxaglate group (17%) (p  0.021).
I would be interested in obtaining some details as to why substantial differences exist in the number of patients presented in different meetings (n = 281) (2,3) and in the final publication (n = 275). In this regard, I also do not understand how 164 and 117 patients for the iodixanol and the ioxaglate groups, respectively, may have been presented in previous meetings while the plan’s sample size was 150 patients in each group with a permuted block-randomization method.
Also, an intention-to-treat analysis would seem more appropriate than a per-protocol analysis. Furthermore, among risk factors that might have influenced the results, age (4) and hydration status (5,6) are crucial. Patients were older in the ioxaglate group (68.7 ± 7.5 years vs. 66.1 ± 8.6 years; p < 0.01). Although the investigators indicate that the difference is likely to be too small to be relevant it may still represent a bias that may explain at least partially their results. Volume supplementation remains the cornerstone for the prevention of CIN. Hydration status was not assessed and/or not presented. Body weight, diuresis, and volume given to the patients should be indicated to ensure comparability between groups.
Finally, CIN remains a major health issue. Only one study (7) has shown in diabetic patients with renal insufficiency that iodixanol is less nephrotoxic than iohexol. Further trials should be conducted to assess the comparative renal tolerance of low osmolar contrast media (both ionic and nonionic) and nonionic dimers.
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1. Jo SH, Youn TJ, Koo BK, et al. Renal toxicity evaluation and comparison between Visipaque (iodixanol) and Hexabrix (ioxaglate) in patients with renal insufficiency undergoing coronary angiography: the RECOVER study: a randomized controlled trial J Am Coll Cardiol 2006;48:924-930.[Abstract/Free Full Text]2. Jo SH, Youn TJ, Koo BK, et al. Renal toxicity evaluation and comparison between Visipaque (iodixanol) and Hexabrix (ioxaglate) in coronary angiography in renal insufficiency—RECOVER trial. 2005Paper presented at: European Society of Cardiology Annual Congress; September 3–7; Stockholm, Sweden.[Abstract/Free Full Text] 3. Jo SH, Youn TJ, Park JS, et al. Iodixanol is less nephrotoxic than ioxaglate in patients with renal insufficiency after coronary angiography J Am Coll Cardiol 2005;45(Suppl A):32A. 4. Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation J Am Coll Cardiol 2004;44:1393-1399.[Abstract/Free Full Text] 5. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial JAMA 2004;291:2328-2334.[Abstract/Free Full Text] 6. Mueller C, Buerkle G, Buettner HJ, et al. Prevention of contrast media-associate nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty Arch Intern Med 2002;162:329-336.[Abstract/Free Full Text] 7. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effects in high-risk patients undergoing angiography N Engl J Med 2003;348:491-499.[Abstract/Free Full Text]
Related Article
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Reply
- Sang-Ho Jo, Bon-Kwon Koo, Tae-Jin Youn, and Hyo-Soo Kim
J. Am. Coll. Cardiol. 2007 49: 1669-1670.
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