Mehran.qxp 10/10/08 9:13 am Page 15
Contrast-induced Nephropathy in a High-risk Patient Population
22.7% of the 162 patients randomised to iodixanol and in 27.7% of the Conclusion
162 patients randomised to the low osmolar agent iomeprol (p=0.25).
73
Although rare in the general population, CIN is highly prevalent in
Most recently, in the Visipaque Angiography/interventions with Laboratory patients with well-known risk factors, including older age, chronic
Outcomes in Renal insufficiency (VALOR) study, the incidence of CIN in renal insufficiency and diabetes. The best approach to prevent CIN is
299 patients with angiography with CKD was 21.8% after iodixanol and to identify the patients at risk, provide adequate peri-procedural
23.8% after the low osmolar agent ioversol (p=0.78).
74
These results hydration and minimise the amount of contrast administered. The role
suggest that the LOCM agents cannot be thought of as a class when it of various drugs in the prevention of CIN is still controversial and
comes to renal tolerability and that the potential benefit ascribed to the warrants future studies. So far, no single agent has shown a consistent
iso-osmolar agent has been overestimated based on earlier trials. benefit above and beyond hydration in preventing CIN. Study results
are mixed as to whether prophylactic oral NAC reduces the incidence
Volume of Contrast Media of CIN, although its use is generally recommended given its low cost
The correlation between the amount of contrast and the risk of CIN has and favourable side effect profile. Prophylactic haemodialysis and
been documented in several studies. According to McCullough et al., haemofiltration may represent an important option to prevent CIN in
the risk of CIN is minimal in patients receiving less than 100ml of the highest-risk cohort, although further studies of these invasive
contrast.
4
However, in patients with chronic kidney disease, even modalities are needed. Several novel pharmacological agents and
relatively low doses of contrast (<100ml) can induce permanent renal devices offer promise in preventing CIN and are currently undergoing
failure and the need for haemodialysis.
75,76
In a study on a diabetic investigation. Despite the remaining uncertainty regarding the degree
population, CIN developed in approximately every fifth, fourth and of nephrotoxicity produced by various contrast agents, in current
second patient who received 200–400ml, 400–600ml or >600ml of practice non-ionic low-osmolar contrast media may be preferred in
contrast, respectively.
77
high-risk patients for CIN. ■
1. Parfrey PS, Griffiths SM, Barrett BJ, et al., N Engl J Med, Cardiol, 2003;15(12):699–702. nephropathy, Nephrol Dial Transplant, 1999;(Suppl. 4):13–15.
1989;320(3):143–9. 31. Merten GJ, Burgess WP, Gray LV, et al., JAMA, 56. Shammas NW, Kapalis MJ, Harris M, et al., J Invasive Cardiol,
2. Hou SH, Bushinsky DA, Wish JB, et al., Am J Med, 2004;291(19):2328–34. 2001;13(11):738–40.
1983;74(2):243–8. 32. Briguori C, Airoldi F, D’Andrea D, et al., Circulation, 57. Ix JH, McCulloch CE, Chertow GM, Nephrol Dial Transplant,
3. Gruberg L, Mintz GS, Mehran R, et al., J Am Coll Cardiol, 2007;115(10):1211–17. 2004;19(11):2747–53.
2000;36(5):1542–8. 33. Ozcan EE, Guneri S, Akdeniz B, et al., Am Heart J, 2007;154(3): 58. Bagshaw SM, Ghali WA, Arch Intern Med, 2005;165(10):
4. McCullough PA, Wolyn R, Rocher LL, et al., Am J Med, 539–44. 1087–93.
1997;103(5):368–75. 34. Brar S, et al., A Randomized Controlled Trial for the Prevention 59. Attallah N, Yassine L, Musial J, et al., Clin Nephrol, 2004;62(4):
5. Levy EM, Viscoli CM, Horwitz RI, JAMA, 1996;275(19)1489–94. of Contrast Induced Nephropathy with Sodium Bicarbonate 273–8.
6. Rihal CS, Textor SC, Grill DE, et al., Circulation, 2002;105(19): versus Sodium Chloride in Persons Undergoing Coronary 60. Khanal S, Attallah N, Smith DE, et al., Am J Med,
2259–64. Angiography, ACC meeting, 2007; abstract 209. 2005;118(8):843–9.
7. Solomon R, Deray G, Kidney Int Suppl, 2006;100:S51–3. 35. From AM, Bartholmai BJ, Williams AW, et al., Clin J Am Soc 61. Jo SH, Koo BK, Park JS, et al., Am Heart J, 2008;155(3):499
8. Murphy SW, Barrett BJ, Parfrey PS, J Am Soc Nephrol, Nephrol, 2008;3(1):10–18. e491–8.
2000;11(1):177–82. 36. Tepel M, van der Giet M, Schwarzfeld C, et al., N Engl J Med, 62. Vogt B, Ferrari P, Schonholzer C, et al., Am J Med,
9. Maeder M, Klein M, Fehr T, Rickli H, J Am Coll Cardiol, 2000;343(3):180–84. 2001;111(9):692–8.
2004;44(9)1763–71. 37. Diaz-Sandoval LJ, Kosowsky BD, The APART trial, A J Cardiol, 63. Lehnert T, Keller E, Gondolf K, et al., Nephrol Dial Transplant,
10. Goldenberg I, Matetzky S, CMAJ, 2005;172(11):1461–71. 2002:356–8. 1998;13(2):358–62.
11. Rich MW, Crecelius CA, Arch Intern Med, 1990;150(6): 38. Briguori C, Manganelli F, Scarpato P, et al., J Am Coll Cardiol, 64. Lee PT, Chou KJ, Liu CP, et al., J Am Coll Cardiol,
1237–42. 2002;40(2):298–303. 2007;50(11):1015–20.
12. Gleeson TG, Bulugahapitiya S, AJR Am J Roentgenol, 39. Webb JG, Pate GE, Humphries KH, et al., Am Heart J, 65. Marenzi G, Lauri G, Campodonico J, et al., Am J Med,
2004;183(6):1673–89. 2004;148(3):422–9. 2006;119(2):155–62.
13. Mehran R, Nikolsky E, Kidney Int Suppl, 2006(100):S11–15. 40. Misra D, Leibowitz K, Gowda RM, et al., Clin Cardiol, 66. Ng MK, Tremmel J, Fitzgerald PJ, Fearon WF, J Interv Cardiol,
14. Cochran ST, Wong WS, Roe DJ, AJR Am J Roentgenol, 2004;27:607–10. 2006;19(1):75–9.
1983;141(5):1027–33. 41. Alonso A, Lau J, Jaber BL, et al., Am J Kidney Dis, 67. Barrett BJ, Carlisle EJ, Radiology, 1993;188(1):171–8.
15. Mehran R, Aymong ED, Nikolsky E, et al., J Am Coll Cardiol, 2004;43(1):1–9. 68. Rudnick MR, Goldfarb S, Wexler L, et al., Kidney Int,
2004;44(7):1393–9. 42. Bagshaw SM, Ghali WA, BMC Med, 2004;2:38. 1995;47(1):254–61.
16. Messana JM, Cieslinski DA, Humes HD, Ren Fail, 43. Kshirsagar AV, Poole C, Mottl A, et al., J Am Soc Nephrol, 69. McCullough PA, Bertrand ME, Brinker JA, Stacul F, J Am Coll
1990;12(2):75–82. 2004;15(3):761–9. Cardiol, 2006;48(4):692–9.
17. Katholi RE, Woods WT Jr, Taylor GJ, et al., Am J Kidney Dis, 44. Birck R, Krzossok S, Markowetz F, et al., Lancet, 70. Jo SH, Youn TJ, Koo BK, et al., J Am Coll Cardiol,
1998;32(1):64–71. 2003;362(9384):598–603. 2006;48(5):924–30.
18. Bakris GL, Lass NA, Glock D, Kidney Int, 1999;56(1):206–10. 45. Pannu N, Manns B, Lee H, Tonelli M, Kidney Int, 71. Mehran R, ICON Study, Proc Transcatheter Cardio Ther,
19. Deray G, Baumelou B, Martinez F, et al., Clin Nephrol, 2004;65(4):1366–74. 2006;3:10.
1991;36(2):93–6. 46. Isenbarger DW, Kent SM, O’Malley PG, Am J Cardiol, 72. Solomon RJ, Natarajan MK, Doucet S, et al., Circulation,
20. Pucelikova T, Dangas G, Mehran R, Catheter Cardiovasc Interv, 2003;92(12):1454–8. 2007;115(25):3189–96.
2008;71(1):62–72. 47. Kelly AM, Dwamena B, Cronin P, et al., Ann Intern Med, 73. Wessely R, Koppara T, Kastrati A, et al., Randomized clinical
21. McCullough PA, J Am Coll Cardiol, 2008;51(15):1419–28. 2008;148(4):284–94. trial to compare the nephrotoxic effects of iso-osmolar versus
22. Hizoh I, Haller C, Invest Radiol, 2002;37(8):428–34. 48. Kapoor A, Sinha N, Sharma RK, et al., Int J Cardiol, low-osmolar contrast medium in patients with impaired renal
23. Erley CM, Nephrol Dial Transplant, 1999;14(5):1064–6. 1996;53(3):233–6. function undergoing percutaneous coronary intervention: the
24. Mueller C, Kidney Int Suppl, 2006(100):S16–19. 49. Gare M, Haviv YS, Ben-Yehuda A, et al., J Am Coll Cardiol, COntrast media and NephroToxicity following coronary
25. Solomon R, Werner C, Mann D, et al., N Engl J Med, 1999;34(6):1682–8. revascularization by angioplaSTy (CONTRAST) Study. Presented
1994;331(21):1416–20. 50. Abizaid AS, Clark CE, Mintz GS, et al., Am J Cardiol, at SCAI-ACCi2 2008, 1 April 2008, Chicago.
26. Mueller C, Buerkle G, Buettner HJ, et al., Arch Intern Med, 1999;83(2):260–63. 74. Rudnick MR, Davidson C, Laskey W, et al., Am Heart J,
2002;162(3):329–36. 51. Allaqaband S, Tumuluri R, Malik AM, et al., Catheter Cardiovasc 2008;0:1–7.
27. Taylor AJ, Hotchkiss D, Morse RW, McCabe J, Chest, Interv, 2002;57(3):279–83. 75. Manske CL, Sprafka JM, Strony JT, Wang Y, Am J Med,
1998;114(6):1570–74. 52. Stone GW, McCullough PA, Tumlin JA, et al., JAMA, 1990;89(5):615–20.
28. Trivedi HS, Moore H, Nasr S, et al., Nephron Clin Pract, 2003;290(17):2284–91. 76. Vlietstra RE, Nunn CM, Narvarte J, Browne KF, Am Heart J,
2003;93:C29–34. 53. Huber W, Ilgmann K, Page M, et al., Radiology, 1996;132(5):1049–50.
29. Bader BD, Berger ED, Heede MB, et al., Clin Nephrol, 2002;223(3):772–9. 77. Nikolsky E, Mehran R, Turcot D, et al., Am J Cardiol,
2004;62(1):1–7. 54. Kolonko A, Wiecek A, Kokot F, J Nephrol, 1998;11(3):151–6. 2004;94(3):300–305.
30. Krasuski RA, Beard BM, Geoghagan JD, et al., J Invasive 55. Erley CM, Nephrotoxicity: focusing on radiocontrast
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