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Dr. Ajit Mullasari
Dr. Suma. M Victor
Patients at high risk for developing contrast-induced nephropathy should be identified early and low or iso-osmolar, non-ionic contrast media at minimum possible volume should be used. Periprocedural hydration is imperative. Here the authors provide an update on the optimal contrast media and administration, risk markers and biomarkers, risk estimation, prevention, as well as on the latest guidelines and management of this iatrogenic renal dysfunction.
For the lack of alternatives, despite its renal toxicity, iodinated contrast media remain the agent of choice in cardiac interventional procedures. Patients at high risk for developing CIN should be identified early and low or iso-osmolar, non-ionic contrast media at minimum possible volume should be used. Periprocedural hydration is imperative. A growing number of patients receive cardiac interventions and therefore, contrast induced media. Here are some basic facts regarding contrast induced nephropathy (CIN):
The ability of contrast media (CM) to cause renal toxicity is influenced by its ionic content, osmolality and viscosity. While ionic CM are currently seldom used, non-ionic, low osmolar or iso-osmolar CM have emerged as the alternatives to choose from for cardiovascular imaging. Here is what has been determined so far:
Gadolinium based CM have shown no benefit over iodine based CM in patients with moderate renal impairment and their use in this subset of patients is associated with nephrogenic systemic fibrosis, a chronic debilitating condition with no known cure.
Several risk markers have been implicated in the pathogenesis of CIN:
Two novel biomarkers have been proposed to identify early subclinical acute kidney injury (AKI) following contrast admission:
However, it is still unclear whether these markers can be used to define and risk stratify patients for CIN.Table 1. Risk markers for development of CIN.
eGFR: eGFR should be calculated for all the patients meant to undergo procedures involving contrast media, and patients with chronic kidney disease (eGFR< 60 ml/min/1,73 m2) are especially at high risk for developing CIN. But since CIN is a result of complex interplay of several risk markers, e GFR alone may not accurately predict the risk, hence, various risk scoring systems have been developed to predict the cumulative effect of these factors on the outcome of CIN (8,9,10).
Prevention of CIN should start with identifying the patients at high risk - figure 1 depicts an integrated algorithm for employing evidence based strategies.
However, the role of sodium bicarbonate for intravenous hydration, which was advocated earlier, is now questionable, after recent randomised trials have shown no benefit of sodium bicarbonate over isotonic saline in reducing the incidence of CIN (11, 12). Although a single study showed benefit of administration of higher concentration (833 mEq/L) of sodium bicarbonate to prevent CIN in patients with renal dysfunction (13), currently there are no recommendations yet.
The 2014 ESC guidelines, based on the currently available evidence, recommend:
Figure 1. An integrated algorithm for employing evidence based strategies in identifying patients at high risk for CIN.
In summary, contrast-induced nephropathy (CIN) is a frequent complication following cardiac catheterisation, and is associated with significant morbidity and mortality. Patients at high risk of developing CIN should be identified early and prophylactic measures are to be implemented before the procedure. Low or iso-osmolar, non-ionic contrast media at minimum possible volume should be used in all at high risk for CIN. Periprocedural hydration is imperative in prevention of CIN and current evidence for employing pharmaceutical intervention is inconsistent and warrants further prospective studies.
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Dr. Suma M. Victor, DNBConsultant Cardiologist, Madras Medical Mission, ChennaiDr. Ajit Mullasari, DM, FRCPDirector of cardiology,Madras Medical Mission, Chennai
Authors's disclosures: None declared.
The e-journal had published an article in 2009 How to prevent contrast-induced nephropathy in patients undergoing contrast procedures by Alegría Barrero E., Moreno Arribas J.
The authors list the items that have been updated in the present article: