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.
1 - The clinical and renal consequences of contrast-induced nephropathy. Finn WF. Nephrol Dial Transplant (2006) 21 [Suppl 1]: i2–i10 doi:10.1093/ndt/gfl213. 2 - Contrast-Induced Acute Kidney Injury. McCullough P.A. JACC Vol. 51, No. 15, 2008. ISSN 0735-1097/08/doi:10.1016/j.jacc.2007.12.035.3 - Preventing contrast-induced nephropathy: problems, challenges and future directions. Solomon R. BMC Medicine 2009, 7:24 doi: 10.1186/1741-7015-7-24.4 - Nephrotoxic Effects in High-Risk Patients Undergoing Angiography. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. for the NEPHRIC Study Investigators. N Engl J Med 2003; 348:491-499February 6, 2003DOI: 10.1056/NEJMoa021833.5 - Renal toxicity evaluation and comparison between visipaque (iodixanol) and hexabrix (ioxaglate) in patients with renal insufficiency undergoing coronary angiography: the RECOVERstudy:a randomized controlled trial. Jo SH, Youn TJ, Koo BK, Park JS, Kang HJ, Cho YS, Chung WY, Joo GW, Chae IH, Choi DJ, Oh BH, Lee MM, Park YB, Kim HS. J Am Coll Cardiol. 2006 Sep 5;48(5):924-30. Epub 2006 Aug 17.6 - Dosing of contrast material to prevent contrast nephropathy in patients with renal disease. Cigarroa RG, Lange RA, Williams RH, Hillis LD. Am J Med.1989;86:649–652.7 - Contrast-induced nephropathy in interventional cardiology. Sudarsky D, Nikolsky E. Int J Nephrol Renovasc Dis. 2011; 4:85–99.8 - Risk scoring system to predict contrast induced nephropathy following percutaneous coronary intervention. Victor S.M, Gnanaraj A, S vijayakumar, Deshmukh R, Kandasamy M, Janakiraman E, Pandurangi U.M, Latchumanadhas K, Abraham G, Mullasari A.S. Ind Heart J (in press)DOI: 10.1016/j.ihj.2014.05.025.9 - A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention. Mehran R, Aymong E.D, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G. J Am Coll Cardiol. 2004;44(7):13931399. doi:10.1016/j.jacc.2004.06.068.10 - Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Bartholomew BA1, Harjai KJ, Dukkipati S, Boura JA, Yerkey MW, Glazier S, Grines CL, O'Neill WW. Am J Cardiol. 2004 Jun 15;93(12):1515-9.11 - Sodium bicarbonate versus saline for the prevention of contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. Maioli MToso ALeoncini M. J Am Coll Cardiol. 2008 Aug 19;52(8):599-604. doi: 10.1016/j.jacc.2008.05.026.12 - Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial. Brar SS, Shen AY, Jorgensen MB, Kotlewski A, Aharonian VJ, Desai N, Ree M, Shah AI, Burchette RJ. JAMA. 2008 Sep 3;300(9):1038-46. doi: 10.1001/jama.300.9.1038.13 - Sodium bicarbonate for the prevention of contrast-induced nephropathy: the efficacy of high concentrationsolution. Tamai N, Ito S, Nakasuka K, Morimoto K, Miyata K, Inomata M, Yoshida T, Suzuki S, Murakami Y, Sato K. J Invasive Cardiol. 2012 Sep;24(9):439-42.14 - Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. Tepel M, van Der GM, Schwarzfeld C, Laufer U, Liermann D, Zidek W. N Engl J Med. 2000; 343(3):180–184.15 - Safety and performance of targeted renal therapy: the Be-RITe! Registry. Weisz G, Filby SJ, Cohen MG, Allie DE, Weinstock BS, Kyriazis D, Walker CM, Moses JW, Danna P, Fearon WF, Sachdev N, Wiechmann BN, Vora K, Findeiss L, Price MJ, Mehran R, Leon MB, Teirstein PS. J Endovasc Ther. 2009; 16(1):1–12.16 - Renalguard system in high-risk patients for contrast-induced acute kidney injury. Briguori C. Minerva Cardioangiol. 2012 Jun;60(3):291-7.17 - Radiocontrast media associated nephrotoxicity. Berns J, Rudnick M. Kidney 1992;24:1-518 - Acute renal failure. Brady RB, Singer GG. Lancet 1995;346:1533-1540
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:
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