Mehran.qxp 10/10/08 9:12 am Page 12
Diagnostics and Imaging
30.1% of control patients (p=0.54). Thus, fenoldopam cannot be beneficial renal effects of the drugs while minimising systemic side effects.
66
recommended for prophylactic use in patients at high risk of CIN. Ongoing trials are addressing the issue of whether local drug delivery may
Theophylline, an adenosine A1-receptor antagonist, may attenuate the reduce CIN rates in patients undergoing contrast media exposure.
decrease in renal blood flow and GFR induced by exposure to contrast
media. Some randomised studies have shown that the prophylactic Contrast Medium Use
intravenous administration of theophylline reduces the incidence of CIN in Contrast media are categorised according to their ionicity (ionic or non-
patients with chronic kidney disease,
53,54
while other studies failed to ionic), their chemical structure (monomeric or dimeric molecules) and their
demonstrate any benefit in favour of theophylline compared with osmolality (high osmolal [HOCM] ~2,000mOsm/kg, low-osmolal [LOCM]
placebo.
50,55,56
Still, in two meta-analyses of published studies, the 600–800mOsm/kg and isosmolal [IOCM] 290mOsm/kg). Numerous
prophylactic administration of theophylline was protective in preventing a studies comparing different contrast agents have been conducted. In a
radiocontrast-induced decline in kidney function.
57,58
meta-analysis by Barrett et al.
67
of 31 randomised trials comparing LOCM
and HOCM, LOCM were shown to significantly reduce the risk of a rise in
Some retrospective series analysed the efficacy of pre-treatment with serum creatinine of >0.5mg/dl in comparison with HOCM in patients with
statins on the development of CIN in patients undergoing cardiac renal impairment (OR 0.5; confidence interval [CI] 0.36–0.68), but not in
catheterisation.
59,60
In a large series of 29,409 patients exposed to patients with normal renal function (OR 0.75; CI 0.52–1.1).
67
In a
contrast media during diagnostic and therapeutic procedures, studied prospective, randomised, double-blind, multicentrer trial by Rudnick et al.
by Khanal et al., pre-treatment with statins was associated with a lower comparing the LOCM iohexol with the HOCM diatrizoate in 1,196
incidence of CIN (4.4 versus 5.9%; p<0.0001) and requirement for patients undergoing cardiac angiography, renal function deterioration
dialysis (0.32 versus 0.49%; p=0.03).
60
However, in the double-blind, (increase in serum creatinine of >1mg/dl at 48–72 hours post-procedure)
placebo-controlled, randomised Simvastatin Prevents the Contrast was observed in 7% of patients receiving diatrizoate compared with 3%
Induced Acute Renal Failure in Patients Undergoing Coronary of patients receiving iohexol (p<0.002).
68
Differences in nephrotoxicity
Angiography (PROMISS)
61
trial of 247 patients with chronic renal between the two contrast groups were again confined to patients with
insufficiency undergoing coronary angiography pre-treatment with previous renal insufficiency or renal insufficiency and diabetes.
simvastatin 40mg orally every 12 hours starting the evening before and
ending the morning after the procedure, the incidence of CIN was A number of studies have evaluated whether an IOCM might provide a
similar in the treatment and placebo arms (2.5 versus 3.4%, similar benefit over the LOCM agents, but no consensus has emerged on
respectively; p=1.00). this point. In a pooled analysis of 16 double-blind, randomised, controlled
trials (2,727 patients) comparing the IOCM iodixanol with LOCM,
69
CIN
Dialysis and Haemofiltration occurred less frequently in the iodixanol group than in the LOCM
Several studies have assessed the effect of haemodialysis immediately comparator group in all analysed patients (1.4 versus 3.5%; p<0.001).
after exposure to contrast media in preventing renal function deterioration However, the majority of patients in these trials did not have chronic
in patients with pre-existing chronic kidney disease. In two of these kidney disease (CKD), and most subjects received one of only two LOCM:
studies, prophylactic haemodialysis failed to diminish the rates of CIN
62,63
iohexol or ioxaglate.
and even had negative effects in another study.
48
However, in a recent
randomised study conducted by Lee et al.,
64
prophylactic haemodialysis In the Renal Toxicity Evaluation and Comparison Between Visipaque
improved renal outcomes in 82 patients with chronic kidney disease (iodixanol) and Hexabrix (ioxaglate) in Coronary Angiography in Renal
undergoing coronary angiography. In this study, patients were Insufficiency (RECOVER) and A Prospective, Randomized, Placebo-
randomised to receive either hydration with normal saline intravenously controlled Trial of Ioxaglate versus Iodixanol in Patients at Increased Risk
and prophylactic haemodialysis post-procedure or hydration alone. for Contrast Nephropathy (ICON) trials, high-risk patients with renal
Prophylactic haemodialysis was associated with a smaller decrease in impairment were randomly assigned to either the IOCM iodixanol or the
creatinine clearance within 72 hours of contrast exposure (0.4 versus ionic LOCM ioxaglate. In the RECOVER trial, using a composite end-point
2.2ml/minute/1.73m
2
; p<0.001), a lower level of serum creatinine at day the incidence of CIN was significantly lower with iodixanol than with
4 (5.1 versus 6.3mg/dl; p=0.01) and lower rates of temporary renal ioxaglate (7.9 versus 17.0%; p=0.021),
70
while in the ICON trial in-hospital
replacement therapy (2 versus 35%; p<0.001). One randomised study acute renal failure occurred with similar incidences in the iodixanol and
investigated the role of haemofiltration performed for six hours before the ioxaglate groups (18.4 versus 22.2%; p=0.80).
71
There was no
and for 18–24 hours after contrast exposure in preventing CIN in patients difference in mean increase in serum creatinine (0.20mg/dl in the
with chronic kidney disease (creatinine clearance ≤30ml/minute) iodixanol group versus 0.35mg/dl in the ioxaglate group; p=0.140).
undergoing coronary interventions.
65
Among 92 patients, CIN developed
significantly less frequently in patients treated with haemofiltration More recent trials comparing the IOCM with other LOCM agents
compared with routine hydration (3 versus 40%; p<0.0013). (iopamidol, iomeprol and ioversol) in patients with pre-existing renal
Haemodialysis requirements were also lower in the hemofiltration group dysfunction have failed to show a benefit to the use of the iso-osmolar
(0 versus 30%, respectively; p=0.002). agent. In the randomised Cardiac Angiography in Renally Impaired
Patients (CARE) study, rates of CIN (defined by multiple end-points) were
Other Treatment Modalities similar in 414 angiography patients randomised to iodixanol or iopamidol
Targeted renal therapy is a novel catheter-based approach aimed at (p=0.44), although mean changes in serum creatinine were higher in
delivering renal vasodilator agents such as fenoldopam and nesiritide patients receiving the iso-osmolar agent (0.12 versus 0.07mg/dl;
(a B-type natriuretic peptide) directly to the kidneys via the renal arteries p=0.03).
72
In the COntrast media and NephroToxicity following coronary
using the Benephit™ Infusion System (FlowMedica, Inc.) to maximise the Revascularization by AngioplaSTy (CONTRAST) study, CIN was seen in
12 INTERVENTIONAL CARDIOLOGY
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