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Contrast-induced nephropathy
From WikEM
Contents
Background
- Often defined as creatinine rise of more than 0.5mg/dL or ≥25% above baseline[1]
- Vasoconstriction leading to ischemia in the deeper portion of the outer medulla
- Toxic to kidney tubular cells, inducing vacuolization, change in mitochondrial function, and apoptosis
- Less likely to occur with low and iso-osmolar contrast agents
Healthy Patients
Impaired Renal Function
- Administration should follow your local hospital protocols
- Less likely to occur in iso-osmolar contrast agents (iodixanol/Visipaque) and contrary to traditional teaching, maybe not even an occurrence in patients with creatinine greater than 2.0mg/dL. [4]
Risk Factors
- Renal disease
- Recent contrast study within 72 hrs
- Hypotension
- Dehydration
- DM
- Multiple myeloma
- Age > 70
- hypertension
- Hyperuricemia
- Diuretics
Clinical Features
- Decreased urine output
- 0.5mg/dl absolute or >25% relative increase in serum creatinine 48-72hrs after contrast exposure
Differential Diagnosis
- Poor renal perfusion
- Nephrotoxic medications
Contrast induced complications
- Contrast induced allergic reaction
- Contrast-induced nephropathy
- CT contrast media extravasation
- Nephrogenic Systemic Fibrosis - gadolinium in GFRs < 60
Evaluation
- Same as for AKI
Management
Hallmark of management is prevention in at-risk patients.
Hydration
- Isotonic hydration with Normal Saline 1-1.5L (15ml/kg) prior to the contrast load in patients with impaired renal function may lessen the chances of developing CIN [5][6][7]
- If suspect the development or confirm the diagnosis continue adequate hydration to maintain urine output of 0.7cc-1cc/kg
- Early research suggests a potential benefit for forced furosemide diuresis (300ml/h) while continuing intravenous hydration fluids (0.5mg/kg) but should be performed in consult with radiologist and nephrologist[8]
N-acetylcysteine
Other Measures
- Low osmolar contrast agents
- Bicarbonate infusion
- Hypertonic saline
See Also
- Creatinine screening prior to IV contrast
- MRI contraindications
- CT contrast media extravasation
- Contrast induced allergic reaction
References
- ↑ Goldfarb, S. et al. Contrast-Induced Acute Kidney Injury: Specialty-Specific Protocols for Interventional Radiology, Diagnostic Computed Tomography Radiology, and Interventional Cardiology. Mayo Clin Proc. Feb 2009; 84(2): 170–179 Text
- ↑ Davenport MS. et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013 Apr;267(1):94-105
- ↑ Sinert R, Brandler E, et al. Acad Emerg Med2012;19(11):1261
- ↑ McDonald RJ, McDonald JS, et al. Radiology. 2013;267(1):106
- ↑ Mueller C. et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162(3):329
- ↑ Bertrand Dussol. et al. A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients. Nephrol. Dial. Transplant. 2006. 21 (8): 2120-2126
- ↑ 7.0 7.1 Traub SJ, et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med 2013;62(5):511-20 PDF
- ↑ Marenzi G. et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial. JACC Cardiovasc Interv. 2012 Jan;5(1):90-7
- ↑ ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011 Sep 13;124(11):1250-9 PDF
Authors
Daniel Ostermayer, Ross Donaldson, Silas Chiu, Kevin Lu, Michael Holtz, Neil Young
