Remote ischemic preconditioning for prevention of contrast-induced acute kidney injury in chronic kidney disease patients undergoing percutaneous vascular interventions: a systematic review and meta-analysis of randomized trials.

BACKGROUND

Remote ischemic preconditioning (rIPC) has been demonstrated to be protective against contrast-induced acute kidney injury (CI-AKI). However, it remains controversial whether rIPC reduces the risk of CI-AKI and other adverse outcomes in chronic kidney disease (CKD) patients receiving percutaneous vascular interventions.

METHODS

A systematic search was conducted in the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases from their inception until February 2025. Risk ratios were pooled using a random effects model. Meta-regression, subgroup analysis, sensitivity analysis, and Begg’s and Egger’s tests were subsequently conducted.

RESULTS

Fourteen randomized controlled trials (1,556 participants) were included. Two studies were rated as having a high risk of bias due to lack of blinding of participants and personnel, while the risk of bias was unclear in another 2 studies, with other domains of bias assessed as low risk. Compared with the control group, rIPC significantly decreased the risk of CI-AKI (RR, 0.52; 95% CI, 0.36–0.75; p < 0.001) in patients with CKD. The renoprotective effect of rIPC seemed more prominent in CKD stage-3 (p < 0.001) rather than CKD stage-2 patients (p = 0.38), and in those who received low-osmolar (p < 0.001) rather than iso-osmolar contrast media (p = 0.35). For rIPC protocol, both 50 mmHg (p = 0.005) and 200 mmHg cuff pressure (p = 0.006) were effective. Based on the intervals reported in the included studies, early-phase rIPC (time interval between rIPC and contrast injection ≤ 1 h, p < 0.001) with 4-cycle ischemia/reperfusion (p < 0.001) might be preferable than late-phase rIPC (time interval ≥ 2 h, p = 0.344) or 3-cycle (p = 0.42). Moreover, rIPC was associated with a smaller increase in serum creatinine within 48 h (p = 0.02) and fewer major adverse kidney events (MAKEs, the composite endpoint comprising death and the need for RRT during hospitalization/follow-up, p = 0.002), while no significant differences in length of hospital stay, in-hospital mortality, or the need for RRT were observed.

CONCLUSIONS

rIPC is an effective nonpharmacological intervention in reducing the incidence of CI-AKI and MAKEs in CKD patients receiving angiography. Future studies are required to optimize the timing and protocol implementation of rIPC, and to unveil its underlying mechanism. CLINICAL TRIAL NUMBER: Not applicable.