The DVD Trial

Source Reinecke H, Fobker M, Wellmann J, et al. A randomized controlled trial comparing hydration therapy to additional hemodialysis or N-acetylcysteine for prevention of contrast medium-induced nephropathy: the Dialysis- versus-Diuresis (DVD) trial. Clin Res Cardiol. 2007;96(3):130–139.

Background There has been an increase in the frequency of contrast-medium-induced nephropathy (CIN) as the number of patients with pre-existing chronic kidney disease (CKD) who are exposed to contrast medium has rapidly increased. CIN has profound consequences on prognosis as it increases the modality by up to a 20-fold during in-hospital stay. Various modalities have been used including hemodialysis to address CIN. Previous analyses of surrogate parameters have suggested beneficial effects of hemodialysis.

Aim To test the hypothesis that a combined treatment of hydration plus hemodialysis, or hydration plus N-acetylcysteine (N-ACC) would be superior to hydration only in preventing CIN.

Methods

Key results There were no significant differences in CIN within 24 h between the three treatment groups. But within 72 h, CIN occurred markedly more often in patients of the hemodialysis group (p=0.008). The frequency of CIN from 48 to 72 h after catheterization was 6.1% in the hydration-only group, 15.9% with hemodialysis treatment, and 5.3% in the N-ACC group. There were no differences between the treatment groups with regard to increased serum creatinine concentrations after 30–60 days (4.8%, 5.1%, and 3.1%, respectively for hydration-only group, hydration plus hemodialysis group, and hydration plus N-ACC group; p=0.700). Analyses of long-term follow-up (range 63–1316 days) by Cox regressions models of the study groups found quite similar survival rates (p=0.500). Patients who still had elevated creatinine concentrations at 30–60 days suffered from a markedly higher 2-year mortality (46% vs 17%, p=0.002).

Conclusion Hemodialysis in addition to hydration therapy does not provide any outcome benefit in prevention of CIN; on the contrary this study provides evidence that this combination would harm the patient. Also, as observed, increased creatinine concentrations at 30–60 days, but not within 72 h, were associated with markedly reduced long-term survival. Hemodialysis when coupled with hydration therapy is associated with significant decrements in long-term survival.