Contrast Induced Nephropathy

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Contrast induced nephropathy (CIN) is agenerally reversible form of acute kidney injury (AKI) that occurs soon after the administration of radiocontrast media.

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  • 1. ByWaleedAbdEl-MalekEl-RefaeyAss. Lecturer of Internal Medicine and NephrologyFaculty of MedicineTanta University

2. Contrast-inducednephropathy(CIN)isagenerallyreversibleformofacutekidneyinjury(AKI)thatoccurssoonaftertheadministrationofradiocontrastmedia.AfterintravascularCMinjection,immediaterenaltoxicitymayoccur,andinmostcasesitremainsfortunatelyfreeofsignificantclinicalconsequences.Sandler CM. Contrast-agent-induced acute renal dysfunction is iodixanolthe answer? N EnglJ Med. 2003;348(6):5513. 3. of CIN includes:MehranR, NikolskyE. Contrast-induced nephropathy: definition, epidemiology, and patients at risk. Kidney IntSuppl. 2006(100):S115.an absolute increase in serum creatinineof 0.5 mg/dLor a 25% relative increase in serum creatininefrom the baseline valueat 4872 hours after exposure to contrast agent, peaks at 35 daysin the absence of alternative causes for acute kidney injury 4. 1 2 3 4 WeeksSerumCreatinineIn most cases, the decline in renal function is mild and transientS. Cr. usually returnsto the baseline valueafter 13 weeksSome patients have a persistent decline in renal function and require RRT (in patients with CIN risk factors) 5. Incidence of CINRisk FactorsContrast DoseType of Radiologic procedureContrast Type 6. AccordingtotheUSFDA,theincidenceofrenalfailureaftercontrastadministration,rangedfrom0.6%to2.3%.However,ratesofCINmaybeashighas50%,dependingonthepresenceofwellcharacterizedriskfactors,themostimportantofwhicharebaselinechronicrenalinsufficiencyandDM.RihalCS, TextorSC, Grill DE, et al. Incidence and prognostic importanceof acute renal failure after percutaneouscoronary intervention.Circulation. 2002;105(19):22592264. 7. The Pathogenesis of CIN is multifactorial. 8. Risk factors for the development of CIN 9. Adecreasedincidenceofcontrastnephropathyappearstobeassociatedwithnonionicagents,which,areeitherlowosmolal(500to850mosmol/kg)oriso-osmolal(approximately290mosmol/kg).LautinEM, Freeman NJ, SchoenfeldAH, et al. Radiocontrast-associated renal dysfunction: a comparison of lower- osmolalityand conventional high-osmolalitycontrast media. AJR Am J Roentgenol1991;157:59. 10. Iodine containing agentsIodine contentOsmolarityDegree of polymerizationLevel of ionizationViscosity 11. Iodixanol,theonlycurrentlyavailableiso-osmolalnonioniccontrastagent(approximately290mosmol/kg),maybeassociatedwithalowerriskofnephropathythansomelow-osmolalagents,particularlyiohexol 12. MostofthestudiesindicatethatthehighervolumeofCMisespeciallydeleteriousinthepresenceofotherriskfactors,withlowerdosesofcontrastbeingsafer,butnotfreeofrisk.Evenrelativelylowdosesofcontrast(lessthan100ml)caninducepermanentrenalfailureandtheneedfordialysisinpatientswithchronickidneydisease.VlietstraRE, Nunn CM, NarvarteJ, Browne KF. Contrast nephropathy after coronary angioplasty in chronic renal insufficiency. Am Heart J 1996; 132: 10491050. 13. In this study, low dose was defined by a formula as:However, diabetic patients with a serum creatinineconcentration >5 mg/dL(440 micromol/L) may be at risk from as little as 20 to 30 mLof contrast. 14. Toassessthecumulativeriskofseveralvariablesonrenalfunction,asimpleCINriskscorethatcouldbereadilyappliedwasdeveloped. 15. MehranR, AymongED, NikolskyE, et al. A simple risk score for prediction of contrast-induced nephropathy afterpercutaneouscoronary intervention: development and initial validation. J Am CollCardiol2004;44:1393-9.Predicting the Risk of CIN after PCICIN 16. ThereisnospecifictreatmentonceCI-AKIdevelops,andmanagementmustbeasforanycauseofATN,withthefocusonmaintainingfluidandelectrolytebalance.Thebesttreatmentofcontrast-inducedkidneyinjuryisprevention. 17. Indication for contrast-based procedurespotentialrisk of CIN 18. ConsideralternateImagingstudiesnotrequiringiodinatedcontrastmedium.Theuseoflowerdosesoflow-oriso-osmolalnonioniccontrastagentsandavoidanceofrepetitivestudiesthatarecloselyspaced(within48to72hours).Avoidanceofvolumedepletion. 19. ConcomitantnephrotoxicdrugssuchasNSAIDandnephrotoxicantibiotics,ACEIanddiureticsshouldbediscontinued48hourspriortocontrastadministration.MetforminshouldbediscontinuedonthedayoftheproposedCMadministrationandforthesubsequent48hours. 20. Goals of HydrationMaintenance of sufficient intravascular volume to increase renal perfusionEstablishment of adequate diuresisprior to contrast mediaAvoidance of hypotension 21. Isotonicsalineissuperiortoone-halfisotonicsalinesinceisotonicsalineisamoreeffectivevolumeexpander.InastudybyMuelleretal,intravenousadministrationofisotonicsalinewasfoundtobesuperior,comparedwithhalf-isotonicsaline,inreducingtheratesofCINafterpercutaneouscoronaryintervention(0.7%versus2%,respectively).Mueller C, Buerkle G, Buettner HJ, 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):329336. 22. Since alkalinizationmay protect against free radical injury, the possibility that sodium bicarbonate may be superior to isotonic saline has been examined in a number of randomized trials and meta-analyses.The results were conflictingas some showed a significantly lower rate of contrast-induced nephropathy with sodium bicarbonate, while others found equivalentrates.BriguoriC, AiroldiF, D'AndreaD, et al. Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies. Circulation 2007; 115:1211.Vasheghani-FarahaniA, SadighG, KassaianSE, et al. Sodium bicarbonate plus isotonic saline versus saline for prevention of contrast-induced nephropathy in patients undergoing coronary angiography: a randomized controlled trial. Am J Kidney Dis2009; 54:610. 23. Hydration with SalineIVF= 1 mL/kg/hr (MAX 100 ml/hr) 12 hours pre & 12 hours post contrastCHF or left ventricular ejection fraction (LVEF) < 40%?0.5 ml/kg/hr(max 50 ml/hr) 12 hrspre& post contrastEmergent procedure? (suggested regimen):Fluid bolus of 3ml/Kg prior to procedure. Hydration during procedure and/or 12 hrs after if possible (dependent on clinical status) 24. Giventhatanincreasingnumberofindividualsreceivecontrastasoutpatients,thistrialhasevaluatedtheeffectivenessoforalhydrationinpreventingcontrastnephropathy.53patientswererandomlyassignedtoeitherunrestrictedoralfluidsortonormalsalineat1mL/kgperhourfor24hoursbeginning12hourspriortothescheduledcatheterization.AKIwassignificantlymorecommonwithoralhydration(35versus4%). 25. Bicarbonate DosingIVF= 150 meqof sodium bicarbonate in 850 ml of D5W3 ml/kg bolus (MAX 300 ml) 1 hour prior to procedure and 1 mL/kg/hour (MAX 100 ml/hr) during and for 6 hours post- procedure.Glycemiccontrol issues (including patients with diabetes)?Consider mixing sodium bicarbonate in 1 liter of sterile water instead of D5W 26. Methods to guide fluid repletionLeft ventricular end- diastolic pressureRenalGuardSystemBrarSS, AharonianV, MansukhaniP, et al. Haemodynamic-guided fluid administration for the prevention of contrast- induced acute kidney injury: the POSEIDON randomisedcontrolled trial. Lancet 2014; 383:1814.BriguoriC, Visconti G, FocaccioA, et al. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuardSystem in high-risk patients for contrast-induced acute kidney injury. Circulation 2011; 124:1260. 27. Left ventricular (LV) end-diastolic pressure 28. Leftventricular(LV)end-diastolicpressureArandomizedtrialtestedthebenefitofafluidreplacementprotocolguidedbyLVend-diastolicpressureamongpatientswithCKDandotherriskfactorsforCIN.Inthistrial,350patientswereassignedtoLVend-diastolicpressure- guidedfluidmanagementortoacontrolgroup.Allpatientsreceivedintravenousisotonicsaline3mL/kgforonehourpriortocardiaccatheterization.LVend-diastolicpressurewasdeterminedinallpatientspriortoadministrationofcontrast. 29. Left ventricular (LV) end-diastolic pressureBoth groups received intravenous fluid throughout and for four hours following the procedure.IV infusion rateLV end-diastolic pressure18 mmHg1.5 mL/Kg/hourControl1.5 mL/kg/hourContrast-induced AKI occurred less frequently in the LV end-diastolic pressure group, compared with control (6.7 versus 16.3, respectively). 30. RenalGuardsystem 31. RenalGuardsystemTheRenalGuardSystemisareal-timemeasurementandmatchedfluidreplacementdevicedesignedtoaccommodatetheRenalGuardtherapy,whichisbasedonthetheorythatcreatingandmaintainingahighurineoutputisbeneficialbyallowingaquickeliminationofcontrastmedia,and,therefore,reducingitstoxiceffects. Patients with eGFR30 mL/min or a risk score 11Control groupNaHco3 + NACRenalGuardgroupIsotonic saline + NAC + furosemide 32. RenalGuardsystemContrast-induced acute kidney injury occurred in 16 of 146 patients in the RenalGuardgroup (11%) and in 30 of 146 patients in the control group (20.5%).Conclusion:RenalGuardtherapy, including hydrationwith normal saline plus high doses of NACin combination with a limited (0.25 mg/kg) dose of furosemide, seems to be an effective renoprotectivestrategy for patients at high risk for CI-AKI. 33. NephroprotectivedrugsTherearegreatheterogeneityandconflictingresultsintheavailableclinicaltrialsandmeta-analysesexaminingtheeffectivenessofacetylcysteineinthepreventionofcontrastnephropathy.Beingaprecursorforglutathionesynthesis,NAChasthepotentialtodiminishoxidativestressbydirectlyscavengingsuperoxideradicalsandincreasingintracellularglutathione.Drager LF, Andrade L, Barros de Toledo JF, Laurindo FR, Machado Cesar LA, SeguroAC. Renal effects of N acetylcysteinein patients at risk for contrast nephropathy: decrease in oxidant stress-mediated renal tubular injury. NephrolDial Transplant. 2004;19(7):18037. 34. Nephroprotectivedrugs 35. NephroprotectivedrugsThistrialstudied83patientswithchronicrenalinsufficiencywhowereundergoingcomputedtomography.Patientswererandomlyassignedeithertoreceivetheantioxidantacetylcysteine(600mgorallytwicedaily)and0.45percentsaline