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Contrast-induced Nephropathy
Prevention of Contrast-induced Nephropathy
Sam W Wu, MD,
1
Siddharth Shah, MD,
1
Kevin A Sterling, MD
1
and Michael R Rudnick, MD
2
1. Nephrology Fellow; 2. Associate Professor of Medicine, and Chief, Renal Electrolyte and Hypertension Division,
Presbyterian Medical Center, University of Pennsylvania School of Medicine
Abstract
Contrast-induced nephropathy is an increasing cause of acute kidney injury and is associated with significant morbidity and mortality. The
number of published studies on pathogenesis, clinical significance, diagnosis, and preventive measures has increased in recent years. In
this article, major studies on the clinical significance of contrast-induced nephropathy are reviewed, along with the evidence basis of
various preventive strategies. Future developments in this field will focus on refining the prevalence and clinical significance of this
complication, especially in the outpatient setting, as well as clarifying the role for bicarbonate and iso-osmolal contrast agents as
preventive strategies.
Keywords
Contrast-induced nephropathy, renal failure, contrast media, hydration, saline, acetylcysteine, bicarbonate, osmolal
Disclosure: The authors have no conflicts of interest to declare.
Received: April 29, 2009 Accepted: June 1, 2009
Correspondence: Michael R Rudnick, MD, 240 Medical Office Building, Penn Presbyterian Medical Center, Philadelphia, PA 19104. E:
Rudnickm@uphs.upenn.edu
Acute kidney injury (AKI) associated with administration of iodinated developed for CIN, such as that developed by Mehran et al. for patients
contrast media (CM) is the third most common cause of renal failure in undergoing coronary angiography.
9
There is no threshold volume of CM
hospitalized patients.
1
The number of patients at risk for contrast-induced below which CIN will not occur, but the volume of CM administered
nephropathy (CIN) has been increasing, due largely to the increasing correlates with the risk of CIN, as well as the mortality rate. Laskey et
incidence of chronic kidney disease (CKD), as well as the increased al. reported that a contrast volume to creatinine ratio greater than 3.7
burden of diabetes and other factors with predisposition for kidney was associated with an increased risk for CIN.
10
Similarly, Marenzi et al.
disease in an expanding elderly population.
2,3
In addition, advances in reported that administration of a higher volume of CM is associated
medical technology, coupled with the increased number of procedures with more prolonged and complicated hospital stays, as well as an
being carried out that utilize CM for both diagnostic and therapeutic almost five-fold increase in mortality rate (13 versus 2.8%).
10
purposes, place an increasing number of patients at risk for CIN. This
combination leads to an increasing incidence of CIN worldwide.
4
The There have been studies that have examined long-term outcomes for
incidence, pathophysiology, and clinical features of CIN have been patients with CIN. Retrospective studies examining patients with CIN
reviewed elsewhere.
5–7
This article will focus on the new developments after coronary angiography have reported mortality rates as high as
and data regarding outcomes and preventive strategies for CIN. 34%.
1,12
The main limitation of these retrospective studies is that they are
unable to definitively determine whether the cause of the increased
CIN has no cure once it occurs, and treatments for the condition mortality is related to CIN itself or to the fact that CIN patients are sicker
involve mainly supportive care. Fortunately, the timing of CM with a greater number of comorbidities. In addition, the data from these
administration is often planned, which allows for the identification of studies are based on creatinine measurements obtained pre- and post-
patients at high risk for CIN so that preventive measures can be procedure, which results in ascertainment bias because such
undertaken. Most of the risk factors for CIN can be obtained by pre- measurements are more likely to be seen in patients at higher risk for
procedural history and physical and laboratory examination. It is known developing CIN. In contrast to retrospective studies, a recently published
that pre-existing CKD is the most important risk factor for CIN, whereas small prospective study by Weisbord et al. reported a mortality rate of
pre-existing diabetes further heightens the risk, although only when 0.55% at 30 days in patients undergoing outpatient coronary
coupled with CKD.
8
Other important risk factors include advanced age, angiography.
13
It is unclear whether the data from coronary angiography
volume depletion, heart failure, hypertension, proteinuria, and can be extrapolated to patients undergoing computed tomography (CT)
concomitant use of nephrotoxic agents such as non-steroidal anti- imaging with contrast, because the volume of CM administered, the
inflammatory drugs (NSAIDs). Risk prediction models have been route of administration, and the baseline patient characteristics are
© TOUCH BRIEFINGS 2009 41
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