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Contrast-induced Nephropathy
Approaches to Contrast-induced Nephropathy
Mohammad Khaled Shamseddin, MD, ABIM, FRCPC
1
and Brendan J Barrett, MB, MSc, FRCPI, FACP, FRCPC
2
1. Nephrology Fellow; 2. Professor of Medicine (Nephrology and Clinical Epidemiology), Division of Nephrology, Memorial University of Newfoundland
Abstract
Contrast-induced nephropathy is a form of acute kidney injury seen after intravascular injection of iodinated contrast agents. This condition is
mainly a concern in patients with pre-existing kidney disease. While most cases are mild and transient, the clinical relevance of the condition
is partly due to the association with other major cardiovascular events and early death. Risk for contrast-induced nephropathy can be predicted
from the clinical circumstances. A number of interventions including fluid and N-acetylcysteine are commonly used to reduce this risk, but their
effectiveness remains uncertain. The optimal approach to prevention and whether prevention of contrast-induced nephropathy would also
reduce the associated clinical adverse events is currently unclear.
Keywords
Contrast, nephrotoxicity, epidemiology, prevention
Disclosure: Mohammad Khaled Shamseddin, MD, has no conflicts of interest to declare.Brendan J Barrett, MB, MSc, has received speaker fees and holds a grant for investigator-
initiated research from Bracco Diagnostics.
Received: April 14, 2009 Accepted: May 18, 2009
Correspondence: Mohammad Khaled Shamseddin, MD, ABIM, FRCPC, Patient Research Centre, Health Science Centre, 300 Prince Phillip Drive, St John’s, NL, A1B 3V6, Canada.
E:
k.shamseddin@mun.ca
Over recent years, continued growth in the use of interventional having coronary angiography, sCr increased by more than 25% in 14.5%
radiological procedures requiring injection of intravascular iodinated of cases (95% confidence interval [CI] 12.9–16.1%).
7
Only 0.77% of those
contrast media has been observed. After exposure to parenteral iodinated cases required dialysis, all of whom had a baseline estimated creatinine
contrast media, mild, transient kidney function changes are commonly clearance below 47ml/minute (0.78ml/second).
7
Registry data from a
detected by sensitive tests.
1–3
Clinically important kidney injury, known as large study showed a 0.44% incidence rate of CIN requiring dialysis after
contrast-induced nephropathy (CIN), is less common, especially in patients percutaneous coronary intervention.
9
The frequency of mild kidney
with normal pre-existing kidney function. CIN is usually defined as an impairment after intravenous contrast injection reflected by minor
acute decline in kidney function within three days of an intravascular changes in sCr appears to be many times less common than after intra-
injection of iodinated contrast media in the absence of other arterial cardiac angiography.
10,11
Harris et al.,
12
Tepel et al.,
13
and Garcia et
etiologies.
4
Although there is no single satisfactory operational al.
14
showed that intravenous injection of non-ionic low-osmolality
definition, CIN is commonly defined as a 25% increase in serum contrast media (LOCM) in patients with chronic kidney disease (CKD)
creatinine (sCr) or an absolute increase in sCr of 0.5mg/dl (44µmol/l) carries a low risk for CIN. The background variability in sCr due to other
relative to pre-contrast values.
5,6
Alternate markers of acute kidney causes makes control groups not receiving contrast necessary to
injury such as urinary interleukin-18 (uIL-18), NGAL, or serum cystatin C accurately judge the risk to the kidney from intravenous contrast. The
will likely be used in future studies of CIN and may predict later CIN- incidence of CIN varies by type of contrast media. An early meta-analysis
associated morbidity and mortality.
2,3
Indeed, given the mild and found a lower incidence of CIN with LOCM than with high-osmolar
transient nature of the acute kidney injury in most cases of CIN, it is the contrast media, although this difference was significant only in those
association with later more significant clinical adverse events that patients with pre-existing kidney disease receiving intra-arterial injection
underpins the current interest in prevention of CIN. (odds ratio [OR] 0.61, 95% CI 0.48–0.77).
15
More recent analyses suggest
that the incidence of CIN may be higher with iohexol than with other
Incidence LOCM, but the comparisons were across rather than within studies.
16
The incidence of CIN is reported as ranging from 1 to 30%. There has been debate as to whether iso-osmolar contrast media (IOCM)
This variability is due in part to a lack of consensus in CIN definitions and are less nephrotoxic than LOCM. A meta-analysis of pooled data from 16
variation in patient populations, hydration, contrast doses, and the route randomized controlled trials (RCTs) comprising 2,727 patients suggested
of injection (intra-arterial versus intravenous).
5–8
In one study of patients that intra-arterial injection of the IOCM iodixanol is associated with
36 © TOUCH BRIEFINGS 2009
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