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.

backgroundRemote 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.

methodsA 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.

resultsFourteen 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.

conclusionsrIPC 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.