Contrast Induce Nephropathy

Collage Of Medicine – Al-Qadisiya University Iraq

Done By :- Ziyad Salih

Index :

• Introduction

• Definition

• Epidemiology

• Pathophysiology

• Risk markers

• Risk score

• Contrast agents

• Management

INTRODUCTION

• CIN (CI -AKI ) it’s a leading cause of acute

kidney injury in hospitalized patients.

• Most frequent renal complication of

endovascular interventional procedures.

• Increases short and long term morbidity and

mortality.

• Treatment is limited to supportive measures

while awaiting the resolution of renal

impairement

QUESTIONS IN MIND

• How CIN occurs ?

• What is the definition of CIN ?

• Are contrast agents directly nephrotoxic ?

• How can it be prevented ?

• Will CIN be never having an effective

treatment ?

Historical view about contrast

• In 1906,Von Lichtenberg and Voelcker used

2% colloidal silver solution,for retrograde

pyelography studies.(toxic to kidneys,death).

• In 1920, Osborne and colleagues ,10% “NaI”

for Rx of syphilis, fortuiously found it to be

radiopaque ,excreted by kidneys.--first

pyelogram.

• 1924,Brooks – first angiogram (under GA).

Definition

• CI-AKI is defined by the Kidney Disease

Global Outcomes (KDIGO) guidelines as an :-

“…increase in serum creatinine of 0.5 mg/dL or

greater within 48 hours of contrast use or a

25% or greater increase from baseline serum

creatinine within 7 days”.

The serum creatinine usually increases within 24 -48hrs after contrast administration, peaks at 3 to 5 days,and returns to baseline in 1 -3 weeks.

Epidemiology

• According to the US FDA, the incidence of renal failure after contrast administration ,ranged from 0.6%to2.3%.

• However, rates of CIN maybe as high as 50%, depending on the presence of well characterized risk factors, the most important of which are baseline chronic renal insufficiency and DM.

Risk Factors

•Systolic blood pressure <80 mm Hg - 5 points•Intraarterial balloon pump– 5 points•Congestive heart failure (history of pulmonary edema .– 5 points

•Age >75 y - 4 points •Hematocrit level <39% for men and <35% for women -3 points•Diabetes - 3 points•Contrast media volume - 1 point for each 100 mL•Renal insufficiency - 4 points

Risk Factors • Scoring:

5 or less points

• Risk of CIN - 7.5

• Risk of Dialysis - 0.04%

6–10 points

• Risk of CIN - 14.0

• Risk of Dialysis - 0.12%

11–16 points

• Risk of CIN - 26.1*

• Risk of Dialysis - 1.09%

>16 points

• Risk of CIN - 57.3

• Risk of Dialysis - 12.8%

Risk Factors

Or the CIN can be classified on the basis of GFR

• Low Risk: GFR> 60 ml/min

• Moderate Risk: GFR 30-59 ml/min

• High Risk: GFR < 30ml/min

Pathophysiology

• Not well understood until now , but there's theoretical explanation :-

1- tubular toxicity

2- microvascular alteration

3- oxidative stress

4- inflammation

5- protein precipitation

6- Regional Hypoxia

Pathophysiology

Important considerations in choosing a

contrast agent

• Its an important factor is to choose the appropriate contrast media depending on its harmful or beneficial effect

Types Of Contrast Media

A decreased incidence of contrast nephropathy appears to be associated with nonionic agents ,which, are either low osmolal or iso-osmolal

• SOLUBILITY Classified into ionic and nonionicgroups based on water solubility.

• OSMOLALITY ( High – Iso – Low )

• VISCOSITY ( High – Low )

How could hyperosmolality

cause nephropathy ?

How could hyperosmolality

cause nephropathy ?

Types Of Contrast Media

• So, recommended to use of either Isosmolaror Low Osmolar iodinated contrast media, rather than High Osmolar iodinated contrast media in patients at increased risk of CI-AKI.

Why we use Iso-Osmolar ?

• ISOSMOLAR Iodinated contrast media is recommended for the following groups of patients:

• –All high risk patients (eGFR<30 mL/min)

• –Dialysis patients

• –Moderate Risk (eGFR<60 mL/min) patients for intra-arterial procedures

Is there any role for drugs in CIN ?

• The use of some drugs that had been found to increase the posibility of Contrast induced nephropthy , through , their mechanism of action ..

The following drugs should be discontinued 24 hours before until 48 hours after contrast media administration

–NSAIDs

–Aminoglycosides

–Metformin

–Anti-virals(Acyclovir and Foscarnet)

–Amphotericin B

–High dose diuretics

–ACE-inhibitors

–ARBs

Clinical Manifestaion

• Contrast-induced nephropathy most commonly manifests as a nonoliguric and asymptomatic transient decline in renal function.

• The serum creatinine level begins to rise within 24 hr of contrast administration, usually peaks within 3–5 days, and returns to baseline within 10–14 day

Clinical Manifestaion

• Oliguric acute renal failure requiring hemodialysis can also occur. This condition presents with oliguria (24-hr urine volume < 400 mL) within 24 hr of contrast administration and typically persists for 2–5 days.

• Morbidity and mortality rates are significantly higher in this group of patients when compared with those who have nonoliguric renal failure

Investigations

o Urinary epithelial cell casts,

o debris,

o urate and calcium oxalate crystals

are nonspecific findings in contrast-induced nephropathy.

o Low urinary sodium and fractional excretion of sodium (< 1%) have been reported as being distinctive characteristics of this condition.

Diagnostic criteria for CIN

Diagnostic criteria for CIN

Exposure to contrast

Increase Sr.Creatinin

Prevention ….

o Hydration ... Hydraion ... And Hyrdraion

Hydration

o correct any decreases in renal blood flow by ensuring that intravascular volume is replete.

Hydration

• Simplest and most effective way of protecting

renal function.(decreases by 50% chance of

CI-AKI)

• Effect of contrast agents on kidney is

prolonged in dehydration.(RBF,GFR) … so

the hydration is very important .

Hydration

• How can I do a good hydration ?

• In which mean ?

• By any type of fluid ?

Hydration

ORAL: Low risk patients should be instructed to take 1-2 liters of water 12 hours before the procedure. Patients should be placed on NPO 4 hours before the procedure and IV fluids may be started if additional hydration is needed

Hydration

• While in High Risk patients …

IV Hydration : ≥ 1.0–1.5 ml/kg/h of NSS has to be administered for 3–12 hours before, and up to 6–12 hours after contrast media exposure.

• –Example: For a 60 kg patient, 60 –90 cc/hour for 3-12 hours prior to the procedure and up to 6-12 hours after the procedure.

Hydration

• In patients with poor systolic function OrChronic Renal failure use lower dose ( 0.5 ml/kg/hr )

Hydration

• Which type of I.V Fluids ?

Hydration

• Isotonic saline is superior to other types of fluids , since isotonic saline is a more effective volume expander.

NaHCo3

• Since alkalinization may protect against free radical injury, the possibility that sodium bicarbonate may be so important

• 3 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.

• Prepare = 150 meq of sodium bicarbonate in 850 ml of Dextrose

N-acetylcysteine

• There are great heterogeneity and conflicting results in the available clinical trials and study-analyses examining the effectiveness of acetylcysteine in the prevention of contrast nephropathy

• Being a precursor for glutathione synthesis, NAC has the potential to diminish oxidative stress by directly scavenging superoxide radicals and increasing intracellular glutathione.

N-acetylcysteine

Acetylcysteine Dosing :-

• Tolerating PO intake?

600-1200 mg capsules PO Q12h.

4 doses :-

2 doses pre-contrast and

2 doses post-contrast is optimal

• Emergent Procedure?

1 dose before and 3 doses post procedure is acceptable (Q12h x 4 doses total)

N-acetylcysteine

Acetylcysteine Dosing :-

For a high risk patient undergoing cardiac catheterization or PE protocol CT scan with no PO access

• IV Acetylcysteine?

600-1200 mg IV x 1 over 15 minutes, then 600-1200 mg PO q12h x 4 doses post-procedure .

Statins

• Statins may improve endothelial function,

• Reduce arterial stiffness, and reduce inflammation and oxidative stress.

• There are no sufficient data to support the use of statins for the prevention of contrast nephropathy.

Statins

Statins

• 2998 patients with type2 diabetes and CKD were assigned to receive rosuvastatin or to a control group prior to adiagnosticangiogram with or without percutaneous intervention.

• Patients assigned to rosuvastatin received 10 mg daily two days prior and three days after the scheduled procedure.

Contrast-induced was less common among patients assigned to rosuvastat incomparedwith control.

theophylline

• In a randomized study, prophylactic intravenous administration of theophylline 200mg reduced the incidence of CIN in 100 patients at risk ,as compared with placebo .

Calcium Channel Blocker

• In a small, randomized, placebo controlled study of 35 patients, eGFR was preserved in patients treated with nitrendipine but decreased in patients that received placebo.

Hemodialysis

• Iodinated contrast agents

are readily dialyzable.

• The plasma clearance of most modern contrast media is 50–70mL/min ,with more than 80% removed from the plasma within 4–5 hours of hemodialysis.

• Subsequent removal of CM is unlikely to stop the cascade of renal injury ,which would have already begun.