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contrast nephropathy (contrast-induced nephropathy, CIN)

Etiology: 1) contrast agents - intravenous contrast material is not responsible for most of the serum creatinine elevations after contrast-enhanced computed tomography [16] - no evidence of contrast nephropathy from contrast agents used in computed tomography [30,32] - no evidence for a harmful effect on kidney function of intravenous contrast administered for CT pulmonary angiography in an emergency setting [39] - intravenous contrast not associated with increased risk of hemodialysis or death [22] - low-osmolarity IV contrast not associated with acute kidney injury in critically ill patients [38] 2) patients at risk: (up to 27%) [4,10] a) patients with severe renal insufficiency - risk negligible if eGRR > 30 mL/min/1.73 m2 - risk 0-17% for G4 & G5 renal failure b) diabetic patients with mild renal insufficiency c) hypotension d) heart failure e) intra-aortic balloon pump f) age > 75-80 [4] g) anemia h) urgent or emergency procedure Epidemiology: - up to 33% with angioplasty [11] Pathology: 1) vasoconstriction, obstruction & direct tubular toxicity 2) acute tubular necrosis (ATN) [17] 3) hyperosmolarity of contrast agent may play role [5] Clinical manifestasions - generally nonoliguric - only a few patients develop oliguric acute renal failure Laboratory: 1) increase in serum creatinine - 24-48 hours after administration of contrast agent - increase in serum creatinine of 25% from baseline at 48 hours after contrast administration [2] 2) serum creatinine peaks in 3-5 days 3) defined as 25% increase in serum creatinine 4) return of serum creatinine to baseline within 1-2 weeks [2] 5) fractional excretion of Na+ (FENA) is < 1% 6) urine osmolality is generally high 7) urinalysis - muddy brown casts due to acute tubular necrosis (ATN) Management: 1) prevention a) prophylaxis not indicated if stable eGFR > 30-45 mL/min/1.73 m2 [2] b) hydration: - 1 mL/kg/hr normal saline for 3-8 hours prior to contrast & 6-8 hours after contrast exposure for patients with G4 & G5 renal failure [35,37] - isotonic sodium bicarbonate is alternative to normal saline [2] - no benefit of sodium bicarbonate over normal saline [40] - use normal saline (NEJM) [40] - bioimpedance vector analysis promising non-invasive method to assess clinical hydration status [33] c) manage pharmacotherapy - not necessary to hold metformin [40] - hold NSAIDS, diuretics unless volume overload - statins may reduce risk of contrast nephropathy in patients undergoing coronary angiography (relative risk = 0.58) [29] - potassium nitrate (capsules) 1415 mg/day for 5 days starting the day prior to angiography [41] - two beetroot shots/day (OTC) contains equivalent potassium nitrate [41] - green leafy vegetables such as spinach also contain potassium nitrate but no specific dosage given d) forced diuresis - high dose loop diuretics may aggravate contrast nephropathy - use of mannitol may increase risk e) use of low or iso-osmolar iodinated contrast [35] - use case with chronic renal failure G3b, eGFR= 32 mL/min/1.73 m2 f) N-acetylcysteine is effective [13]; do not use (MKSAP) [2] (NEJM) [40] a) neither bicarbonate nor N-acetylcysteine reduces contrast nephropathy relative to saline in patients undergoing coronary angiography [32] b) benefit uncertain, may benefit patients with serum creatinine > 1.2 mg/dL [15] c 600 mg BID one day before & on the day of the procedure (4 doses) - of benefit [3,4,6] - of marginal or no benefit [7] {2 doses only; 1 hour prior to & 3 hours after} d) 1200 mg IV prior to angioplasty, then 1200 mg PO BID for 2 days [11] reduced contrast nephropathy 8% vs 33% 7) efficacy of calcium channel blockers not established 8) continuous venovenous hemofiltration of benefit in patients with chronic renal failure undergoing coronary angiography [8] 9) NaHCO3 154 mEq/L @ 3 mL/kg/hour for hour prior to contrast administration & @ 1 mL/kg/hour during & for 6 hours after procedure reduces contrast nephropathy (14% vs 2% vs normal saline) [9] - further studies have failed to replicate this finding [35,37] - not beneficial before computed tomography [36] - use normal saline (NEJM) [40] 10) use of alternative imaging modality a) non-contrast CT or MRI b) ultrasonography 2) generally low morbidity & mortality 3) iodinated contrast is safe in patients on hemodialysis [1]

Related

contrast agent

Specific

nephrogenic systemic fibrosis; nephrogenic fibrosing dermopathy (NSF/NFD)

General

nephropathy iatrogenic disease

References

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