“A relief for patients, appointment coordinators and doctors”

Estelle Nijssen and Joachim Wildberger

“A relief for patients, appointment coordinators and doctors”

The societal impact of UM research

22-11-2023 · Interview

In today’s world, the societal impact of research findings seems more important than getting published in an academic journal like Nature or The Lancet. What impact has research conducted at UM had in recent years? This week: how the AMACING trial changed the international standard of care for patients with poor kidney function undergoing contrast procedures.

The AMACING trial has made it into Observant before; Estelle Nijssen from the Radiology Department of the Maastricht University Medical Centre+ (MUMC+) was interviewed after winning the UM Dissertation Prize for her PhD, completed before the pandemic hit the Netherlands. She and her team studied whether it is beneficial to give intravenous (IV) fluids to patients with poor kidney function before a procedure with iodinated contrast material. This preventive measure had become standard practice worldwide in this century, as recommended in guidelines that were strictly followed in the Netherlands. It was intended to prevent kidney damage, “based on the idea that your kidneys are tasked with filtering the large contrast molecules from your blood”, explains Nijssen. “Diseased kidneys may struggle with this, so doctors administered extra fluids to support them. The rationale makes sense.”

Drawbacks

However, IV hydration is not without its drawbacks. It’s a financial and logistic burden on the hospital (requiring patients to be admitted for a day) and can be a medical burden on the patient, notes Professor of Radiology Joachim Wildberger, Nijssen’s PhD supervisor. “It’s a preventive measure that can have serious side effects in a certain group of patients.”

“And ironically, it was precisely this group of patients that often received IV hydration”, adds Nijssen. “Heart failure patients regularly undergo procedures involving contrast administration. But poor heart function and poor kidney function often go hand in hand. These patients were given extra fluids even though it may put added strain on the heart.”

The question was whether the benefits of the practice outweighed its potential risks. Nijssen was surprised to find that there was no hard evidence supporting the existing guidelines. The AMACING trial was the first randomised controlled trial assessing the effectiveness of IV hydration. The answer was a resounding “no”: the researchers found no difference between the group that received IV hydration and the group that didn’t. After publication in The Lancet, guidelines worldwide were updated to reflect the AMACING results. “They were easy to implement in practice”, says Nijssen. “You didn’t have to do anything new; you just had to stop doing something. The new approach has brought relief for patients, appointment coordinators, doctors, budgets… It has been an improvement for everyone.”

Careful monitoring

Is this reflected in the statistics? Hundreds of millions of contrast procedures are performed worldwide each year. “We’ve published a calculation method in European Radiology that lets hospitals calculate their cost savings”, says Wildberger cautiously. “In that context, based on our data, we’ve shown that the new approach saves MUMC+ just over a million euros per year.” “And that’s a conservative estimate”, adds Nijssen. “I’m proud to say that in this hospital, 99 patients per year no longer face the complications of IV hydration – and we’ve freed up more than 1500 bed days per year.”

Nijssen and Wildberger would like to stress that it’s not their intention to eliminate IV hydration for this group of patients altogether. “All we’re saying is that doctors must take the patient’s situation into account”, explains Nijssen. “Doctors can depart from the guidelines if it’s in the patient’s best interest. What we’re seeing now is that some are going too far the other way – they’re ready to do away with IV hydration even for patients with very poor kidney function. This is a small group, less than 1.5 per cent of all MUMC+ patients undergoing contrast procedures. For safety reasons, we and the Medical Ethics Review Committee decided not to include them in our randomised trial. Based on observational data from recent years, we believe that IV hydration is beneficial in these patients. There is a risk of side effects, but it can be mitigated with careful monitoring.”

Visibly proud

For this purpose, MUMC+ established the Contrast Preparation Outpatient Clinic. Nijssen and Wildberger are visibly proud of this outcome of their research; their faces light up when they talk about it. “Each patient is screened again by a clinic team member”, explains Nijssen. “They also support the patient during their appointment, monitor fluid administration and often consult with the cardiologist as well. It’s truly unique.” “It’s great to be able to do something for this very vulnerable group of patients”, adds Wildberger.

Both researchers are strong advocates of repetition in science. It’s ironic, then, that AMACING has not yet been repeated – and perhaps it never will be. Nijssen explains why: “The results of the AMACING trial were so clear that it is no longer ethically justifiable to randomly administer IV hydration to patients.” Wildberger adds, “Initially, the question was whether our research was ethical; now, you can no longer just give extra fluids to patients undergoing contrast procedures. The approach has almost been turned on its head.”

Photo: Ellen Oosterhof

Categories: Science
Tags: Societal impact,Radiology,Estelle Nijssen,Joachim Wildberger

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