Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic radiographic contrast agent

Clinical feasibility of deep learning based synthetic contrast enhanced abdominal CT in patients undergoing non enhanced CT scans

Our objective was to develop and evaluate the clinical feasibility of deep-learning-based synthetic contrast-enhanced computed tomography (DL-SynCCT) in patients designated for nonenhanced CT (NECT). We proposed a weakly supervised learning with the utilization of virtual non-contrast CT (VNC) for the development of DL-SynCCT. Training and internal validations were performed with 2202 pairs of retrospectively collected contrast-enhanced CT (CECT) images with the corresponding VNC images acquired from dual-energy CT. Clinical validation was performed using an external validation set including 398 patients designated for true nonenhanced CT (NECT), from multiple vendors at three institutes. Detection of lesions was performed by three radiologists with only NECT in the first session and an additionally provided DL-SynCCT in the second session. The mean peak signal-to-noise ratio (PSNR) and structural similarity index map (SSIM) of the DL-SynCCT compared to CECT were 43.25 ± 0.41 and 0.92 ± 0.01, respectively. With DL-SynCCT, the pooled sensitivity for lesion detection (72.0% to 76.4%, P < 0.001) and level of diagnostic confidence (3.0 to 3.6, P < 0.001) significantly increased. In conclusion, DL-SynCCT generated by weakly supervised learning showed significant benefit in terms of sensitivity in detecting abnormal findings when added to NECT in patients designated for nonenhanced CT scans.

A case report of acute renal failure caused by anti-brucellosis treatment

RATIONALE

Rifampicin, as a main chemotherapy drug treating brucellosis, is widely used in clinical practice. Rifampicin-associated ARF is not rare, especially in those rifampicin re-exposure patients. However, this was rare complication of severe renal involvement due to multiple factors including rifampicin, nephrotoxic gentamicin, and contrast medium, and few studies have reported it.

PATIENT CONCERNS

A 59-year-old male presented to our hospital with acute renal failure (ARF) caused by anti-brucellosis treatment with rifampicin (675 mg/day), gentamicin (320 mg/day), and doxycycline (200 mg/day). He had a contrast-enhanced CT of the upper abdomen before the onset of. After stopping rifampicin and undergoing integrated therapy, the patient's renal function gradually recovered.

DIAGNOSES

Considering that the patient had a history of using rifampicin for pulmonary tuberculosis in the past, based on the examination results, the patient was diagnosed with rifampicin-associated ARF.

INTERVENTIONS

Symptomatic treatment such as hemodialysis, and anti-brucella treatment with doxycycline and moxifloxacin were given.

OUTCOMES

The patient had significant anuric and polyuric periods and acute tubular necrosis is considered. After treatment, his renal function and urine volume returned to normal, and Brucella melitensis was not isolated from blood cultures.

LESSONS

The case reveals that severe renal involvement due to multiple factors including rifampicin, nephrotoxic gentamicin, and contrast medium. Misdiagnosis and mistreatment can deteriorate the patient's condition. Renal function should be closely monitored in the susceptible patients. Early recognition can provide appropriate therapy to patients. If unexplained renal failure during the use of rifampicin, especially in those rifampicin re-exposure patients, rifampicin-associated ARF should be considered.

Prevention of contrast-associated acute kidney injury in an era of increasingly complex interventional procedures

Radiological and interventional cardiology procedures are in continuous expansion, leading to an important increase in the incidence of contrast-associated acute kidney injury (CA-AKI). Although numerous methods of CA-AKI prevention have been studied, at present, there is no consensus on the definition of this entity or on its prevention. In this paper, we aim to provide a critical analysis of the existing data on the epidemiology, pathophysiology, and clinical significance of CA-AKI. Existing and emergent approaches for CA-AKI prevention are also discussed, with a focus on parenteral fluid administration and on the most recent clinical and experimental data. We also emphasize a number of questions that remain to be answered, and we identify hotspots for future research.

Contrast removal from coronary sinus for prevention of contrast-induced nephropathy: a review

The occurrence of contrast-induced-nephropathy (CIN) is related to the amount of contrast administration. Any removal of contrast from systemic circulation before reaching the kidneys might be beneficial using a device that removes contrast from a coronary sinus (CS). This manuscript aims to review the available literature regarding contrast removal from CS during coronary angiography or intervention for the prevention of CIN.

Angiotensin-Converting Enzyme Inhibitors and Contrast-Associated Acute Kidney Injury After Coronary Angiography and Intervention

Contrast-associated acute kidney injury has multiple definitions, but is generally described as worsening renal function after administration of iodinated contrast media. It is associated with high in-hospital mortality and poor long-term survival. Furthermore, patients undergoing coronary angiography commonly have comorbidities such as hypertension or congestive heart failure, which are often treated with renin-angiotensin-aldosterone system-blocking agents such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Trials assessing the effects of these renin-angiotensin-aldosterone system-blocking agents on the subsequent development of contrast-associated acute kidney injury have shown conflicting data, suggesting both beneficial and harmful effects. Therefore, there are no clear guidelines on whether clinicians should discontinue renin-angiotensin-aldosterone system-blocking agents peri-procedurally. In this article, we review the data from trials assessing the effects of peri-procedural renin-angiotensin system-blocking agent use in patients undergoing coronary and peripheral angiography and intervention. Future studies will likely focus on the extent of damage or potential benefit of these agents on renal function, cardiac function, as well as morbidity and mortality. Currently, there is insufficient evidence to recommend discontinuation of angiotensin-converting enzyme inhibitors prior to coronary angiography.

INTRAVENOUS IOPAMIDOL PHARMACOKINETICS IN COMMON CARP (CYPRINUS CARPIO)

Koi carp (Cyprinus carpio), a variety of common carp, has gained popularity as an ornamental fish worldwide. Their high monetary and sentimental value has necessitated the development of antemortem diagnostic options. Contrast-enhanced computed tomography (CT) scanning with intravenous iopamidol has been shown to be safe and diagnostically effective at a minimum dose of 480 mg iodine (I)/kg in koi. The purpose of this study was to evaluate the pharmacokinetic parameters of this dose of iopamidol, as well as excretory mechanisms specific to fish, using common carp as a model. Blood, posterior kidney, gill, and bile were collected, necessitating sacrificial sampling. Thirty-five adult fish were randomly divided into six sampling groups. Five sampling groups (n = 6/group) received 480 mg I/kg; the control group (n = 5) received an equivalent volume of saline. The iopamidol groups were sampled at the following time points postinjection: 5 min, 1 hr, 6 hr, 24 hr, and 48 hr. The control group was sampled at 48 hr. Concentrations of iopamidol were determined using liquid chromatography tandem mass spectrometry; noncompartmental analysis was used to calculate pharmacokinetic parameters. Total clearance (3.04 ml/hr per kilogram) was slower, the volume of distribution smaller (79.92 ml/ kg), and the elimination half-life (20.39 hr) prolonged compared to similar studies in mammals. The time-concentration profiles of kidney and gill were similar; these organs appear to be responsible for the majority of iopamidol excretion. However, that of bile was much different, showing slower, low-level accumulation with time, suggesting that in fish, multiple organ systems play a role in elimination beyond just the kidney. In particular, they may rely more heavily upon biliary excretion, which thus far has been noted only in mammals with renal impairment. Further research is warranted to investigate if the slower elimination allows diagnostic CT images to be acquired at different time points postinjection.

A Simple Technique to Perform Endovascular Repair of Abdominal Aortic Aneurysms with a Very Low Dose of Iodine Contrast Media

Iodinated contrast media (ICM) dose is a major factor for postoperative acute kidney injury (AKI) in patients with severe chronic kidney disease (glomerular function rate [GFR] <30 mL/min) during endovascular aortic repair (EVAR). Fusion imaging in hybrid rooms and carbon dioxide angiography represent alternatives but are limited by significant cost and availability. We here describe a simple technique allowing EVAR with a limited ICM dose (<5 mL). Using a standard C-arm, the lowest renal artery and the hypogastric arteries are blindly catheterized based on noncontrast pre-operative imaging (duplex-scan associated with noncontrast computed tomography scan and/or magnetic resonance angiography). An injection of diluted ICM (1 mL ICM + 4 mL saline) can be performed to confirm the correct catheterisation and angiography catheters are let in place as landmarks. Ten patients with GFRs between 17 and 29 ml/min were successfully treated using these tips (median ICM = 3 mL) without postoperative AKI and satisfactory mid-term results.

Contrast Media-Different Types of Contrast Media, Their History, Chemical Properties, and Relative Nephrotoxicity

History of contrast dates back to the 1890s, with the invention of the radiograph. Nephrotoxicity has been a main limitation in ideal contrast media (CM). High-osmolar contrast media no longer are in clinical use due to overwhelming evidence supporting greater nephrotoxicity with these CM compared with current CM. Contrast-induced nephropathy (CIN) remains a common cause of in-hospital acute kidney injury. The choice contrast agent is determined mainly by cost and institution practice. This review focuses on the history, chemical properties, and experimental and clinical studies on the various groups of CM and their role in CIN.

Pathophysiology of Contrast-Induced Acute Kidney Injury (CIAKI)

Contrast-induced acute kidney injury (CIAKI) is a severe complication associated with the use of iodinated contrast media (CM); a sudden but potentially reversible fall in glomerular filtration rate (GFR) typically occurring 48-72 hours after CM administration. Principal risk factors related with the presentation of CIAKI are preexisting chronic kidney disease and diabetes mellitus. Studies on CIAKI present considerable complexity because of differences in CM type and dose, controversies in definition and baseline comorbidities. Despite that, it should be noted that CIAKI poses a serious health problem because it is a very common cause of hospitalacquired AKI, linked to increased morbidity and mortality and utilizing growing healthcare resources. The pathogenesis of CIAKI is heterogeneous and, thus, is incompletely understood. Three basic mechanisms appear to simultaneously occur for CIAKI development: Renal vasoconstriction and medullary hypoxia, tubular cell toxicity and reactive oxygen species formation. The relative contribution of each one of these mechanisms is unknown but they ultimately lead to epithelial and endothelial cell apoptosis and GFR reduction. Further research is needed in order to better clarify CIAKI pathophysiology and accordingly introduce effective preventive and therapeutic strategies.

Quercetin, a Promising Clinical Candidate for The Prevention of Contrast-Induced Nephropathy

Iodinated contrast media (CM) are the leading cause of acute renal failure of toxic origin. Between 21% and 50% of patients that receive them develop contrast-induced nephropathy (CIN). All prophylactic measures used so far have failed to provide effective prevention. Since oxidative stress is involved in the damage, a possible preventive strategy could be the administration of antioxidant substances, such as quercetin. This compound has shown renoprotective effects in experimental studies. The aim of this study was to evaluate whether quercetin may be helpful in preventing CIN in patients undergoing coronary catheterization. A clinical phase II study was conducted. Patients were distributed in two groups, namely, CM (patients who only received contrast media) and CM+Q (patients who were pretreated with quercetin orally for 3-5 days). Results showed less incidence of CIN in the CM+Q group, possibly due to glomerular protection, evidenced by a lower increase in serum creatinine and albuminuria; and a lower decrease in the glomerular filtration rate (GFR). Furthermore, in this group, the relative risk of developing CIN observed in patients that received a high dose of contrast media was inferior. In conclusion, this is the first study that demonstrates that quercetin is a promising safe candidate in preventing CIN.

Fusion Imaging Reduces Radiation and Contrast Medium Exposure During Endovascular Revascularization of Iliac Steno-Occlusive Disease

INTRODUCTION

To evaluate feasibility, safety and efficacy of fusion imaging in order to guide endovascular revascularization of iliac steno-occlusive disease.

MATERIALS AND METHODS

Retrospectively, we identified twenty-six patients (20 male, mean age 63 ± 8y; Rutherford II-V) who underwent revascularization of a chronic total occlusion (n = 6; 23%) or severe stenosis (n = 20; 77%) of the common and/or external iliac artery. Median lesion length was 33 mm (IQR 20-60). In one group of patients (NEW; n = 11), fusion imaging with 2-D/3-D registration was used to guide revascularization. No baseline digital subtraction angiography (DSA) had been acquired in these patients. In another group of patients (OLD; n = 15), no fusion imaging had been utilized and at least one DSA run had been performed to guide the procedure. In both groups, final DSA of the treated lesions was performed. Number of DSA runs, radiation and contrast medium exposure, technical success (residual stenosis < 30%) and complications were analyzed.

RESULTS

Median DSA runs needed in OLD for guidance were n = 2 (IQR 2-3) and in NEW n = 0 (IQR 0-0; p = 0.001). Compared to OLD, median dose area product (DAP) was reduced by 17,118 mGy*cm² (IQR 10,407-23,614; p = 0.016) if fusion imaging guidance had been used (NEW). Based on the median DAP of the final angiogram in NEW, median DAP reduction was 6007 mGy*cm² (IQR 5012-16,105; p = 0.1). Median total contrast medium volume injected in NEW was 45 ml (IQR 30-90) and in OLD 120 ml (IQR 100-140; p = 0.001). Technical success was 100% for both groups. In 1/27 patients (3.7%) a minor complication (embolism) occurred.

CONCLUSION

Fusion imaging proved to be feasible as well as safe and significantly reduces radiation and contrast medium exposure during endovascular revascularization of iliac steno-occlusive disease.

Effectiveness of contrast-associated acute kidney injury prevention methods; a systematic review and network meta-analysis

BACKGROUND

Different methods to prevent contrast-associated acute kidney injury (CA-AKI) have been proposed in recent years. We performed a mixed treatment comparison to evaluate and rank suggested interventions.

METHODS

A comprehensive Systematic review and a Bayesian network meta-analysis of randomised controlled trials was completed. Results were tabulated and graphically represented using a network diagram; forest plots and league tables were shown to rank treatments by the surface under the cumulative ranking curve (SUCRA). A stacked bar chart rankogram was generated. We performed main analysis with 200 RCTs and three analyses according to contrast media and high or normal baseline renal profile that includes 173, 112 & 60 RCTs respectively.

RESULTS

We have included 200 trials with 42,273 patients and 44 interventions. The primary outcome was CI-AKI, defined as ≥25% relative increase or ≥ 0.5 mg/dl increase from baseline creatinine one to 5 days post contrast exposure. The top ranked interventions through different analyses were Allopurinol, Prostaglandin E1 (PGE1) & Oxygen (0.9647, 0.7809 & 0.7527 in the main analysis). Comparatively, reference treatment intravenous hydration was ranked lower but better than Placebo (0.3124 VS 0.2694 in the main analysis).

CONCLUSION

Multiple CA-AKI preventive interventions have been tested in RCTs. This network evaluates data for all the explored options. The results suggest that some options (particularly allopurinol, PGE1 & Oxygen) deserve further evaluation in a larger well-designed RCTs.

Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed!

Background/Summary

Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is "preferable."

Key Messages

This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.

Safe and Appropriate Use of lodinated Radiographic Contrast Agents: Is There a Reason to Use High-Osmolality lodinated Contrast Agents?

The improved safety profile of low-osmolality compared with high-osmolality iodinated radiographic contrast agents supports the use of low-osmolality iodinated contrast agents in patients with a high risk for adverse reactions to contrast agents. Current pressures in the health care industry to minimize costs may warrant the continued use of high-osmolality agents in patients with relatively low risk for contrast reactions. Health-system management and pharmacists should continue to review the clinical and pharmacoeconomic issues surrounding the use of high-osmolality agents, because market factors have caused the prices of high-osmolality agents and second-generation low-osmolality agents to fluctuate. Moreover, the introduction of new agents will continue to change the risk—benefit–cost relationship.

Administration guidelines and appropriate patient monitoring are important, because both low-osmolality and high-osmolality agents carry the risk of adverse reactions. Pharmacologic pretreatment to alleviate adverse reactions to contrast agents when high-osmolality agents are used should be encouraged. Pharmacists—in cooperation with diagnostic imaging departments—should ensure that the use of iodinated radiographic contrast agents conforms to accepted guidelines.

Contrast-induced nephropathy in urological imaging: A comparison with cardiology interventions

Introduction:

Published studies about contrast-induced nephropathy (CIN) mainly focus on cardiac intervention and rarely focus on patients undergoing urological contrast investigations. We aimed to determine the association and effect of intravenous (IV) iodinated contrast material on the incidence of CIN in a group of patients undergoing urology investigation and compare the results with that of cardiology interventions.

Methods:

This prospective study was performed in patients undergoing IV contrast studies in Urology and those undergoing coronary interventions, in our institution for 1 year. Association between the occurrence of CIN and the risk factors such as age (≥60 years), sex, diabetes mellitus, hypertension, anemia, left ventricular ejection fraction <40%, estimated glomerular filtration rate (eGFR), and volume of contrast used were studied using Chi-square tests or Fisher exact test and Student's t-test.

Results:

A total of 339 cases (168 urology and 171 cardiology) were studied. CIN was noted in 8.3% of urology patients whereas it was 29.8% in cardiology patients. In urology patients, statistically significant association was noted between CIN and eGFR <60 ml/min/1.73 m² and volume of contrast used. In cardiology patients, statistically significant association (P < 0.05) was noted for diabetes, hypertension, eGFR <60 ml/min/1.73 m², volume of contrast used.

Conclusion:

Although CIN was found to occur with contrast studies, the deleterious effects of contrast in urological procedures were lower than cardiology patients. The association between the occurrence of CIN and patient factors were also different in the two groups.

Sodium Bicarbonate-Ascorbic Acid Combination for Prevention of Contrast-Induced Nephropathy in Chronic Kidney Disease Patients Undergoing Catheterization

BACKGROUND

Sodium bicarbonate and ascorbic acid have been proposed to prevent contrast-induced nephropathy (CIN). The present study evaluated the effect of their combined use on CIN incidence.

METHODS AND RESULTS

We prospectively enrolled 429 patients with chronic kidney disease (CKD: baseline estimated glomerular filtration rate <60 mL/min/1.73 m2) prior to elective coronary catheterization. CIN was defined as absolute (≥0.5 mg/dL) or relative (≥25%) increase in serum creatinine within 72 h. In the saline hydration (n=218) and combined sodium bicarbonate+ascorbic acid (n=211) groups, a total of 1,500-2,500 mL 0.9% saline was given before and after the procedure. In addition, the combination group received 20 mEq sodium bicarbonate and 3 g ascorbic acid i.v. before the procedure, followed by 2 g ascorbic acid after the procedure and a further 2 g after 12 h. There were no significant differences between the basic characteristics and contrast volume in the 2 groups. CIN occurred in 19 patients (8.7%) in the saline group, and in 6 patients (2.8%) in the combined treatment group (P=0.008).

CONCLUSIONS

Combined sodium bicarbonate and ascorbic acid could prevent CIN following catheterization in CKD patients.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Pre-operative Simulation of the Appropriate C-arm Position Using Computed Tomography Post-processing Software Reduces Radiation and Contrast Medium Exposure During EVAR Procedures

OBJECTIVE/BACKGROUND

The aim was to evaluate the feasibility and efficacy of a new method for pre-operative calculation of an appropriate C-arm position for iliac bifurcation visualisation during endovascular aortic repair (EVAR) procedures by using three dimensional computed tomography angiography (CTA) post-processing software.

METHODS

Post-processing software was used to simulate C-arm angulations in two dimensions (oblique, cranial/caudal) for appropriate visualisation of distal landing zones at the iliac bifurcation during EVAR. Retrospectively, 27 consecutive EVAR patients (25 men, mean ± SD age 73 ± 7 years) were identified; one group of patients (NEW; n = 12 [23 iliac bifurcations]) was compared after implementation of the new method with a group of patients who received a historic method (OLD; n = 15 [23 iliac bifurcations]), treated with EVAR before the method was applied.

RESULTS

In the OLD group, a median of 2.0 (interquartile range [IQR] 1-3) digital subtraction angiography runs were needed per iliac bifurcation versus 1.0 (IQR 1-1) runs in the NEW group (p = .007). The median dose area products per iliac bifurcation were 11951 mGy*cm² (IQR 7308-16663 mGy*cm²) for the NEW, and 39394 mGy*cm² (IQR 19066-53702 mGy*cm²) for the OLD group, respectively (p = .001). The median volume of contrast per iliac bifurcation was 13.0 mL (IQR: 13-13 mL) in the NEW and 26 mL (IQR 13-39 mL) in the OLD group (p = .007).

CONCLUSION

Pre-operative simulation of the appropriate C-arm angulation in two dimensions using dedicated computed tomography angiography post-processing software is feasible and significantly reduces radiation and contrast medium exposure.

The effects of contrast media volume on acute kidney injury after transcatheter aortic valve replacement: a systematic review and meta-analysis

OBJECTIVE

The goal of this systematic review was to assess the effects of contrast media volume on transcatheter aortic valve replacement-related acute kidney injury.

METHODS

A literature search was performed using Medline, EMbase, the Cochrane Database of Systematic Reviews, and clinicaltrials.gov from the inception of these databases through December 2015. Studies that reported relative risk, odds ratio, or hazard ratio comparing the risks of acute kidney injury following transcatheter aortic valve replacement in patients who received high contrast media volume were included. Pooled risk ratio (RR) and 95% confidence intervals (95% CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Four cohort studies composed of 891 patients were included in the analyses to assess the risk of acute kidney injury after transcatheter aortic valve replacement in patients who received high contrast media volume. The pooled RR of acute kidney injury after transcatheter aortic valve replacement in patients who received a large volume of contrast media was 1.41 (95% CI, 0.87 to 2.28) compared with low contrast media volume. The meta-analysis was limited to studies using standard acute kidney injury definitions, and the pooled RR of acute kidney injury in patients who received high contrast media volume is 1.12 (95% CI, 0.78 to 1.62).

CONCLUSION

Our meta-analysis shows no significant association between contrast media volume and risk of acute kidney injury after transcatheter aortic valve replacement.

Radiocontrast-Induced Acute Renal Failure

The intravascular administration of iodinated radiocontrast media can lead to acute renal dysfunction. Even small changes in renal function have been associated with increased morbidity and mortality, making the prevention of radiocontrast nephropathy of paramount importance. This review summarizes the principal risk factors for radiocontrast nephropathy and evidence-based preventive strategies that should be used to limit its occurrence. Risk factors for radiocontrast nephropathy include preexistent kidney disease, diabetes mellitus, dose of radiocontrast used, advanced congestive heart failure, and intravascular volume depletion. Proven preventive measures include volume expansion with intravenous saline or sodium bicarbonate and the use of low-osmolar or iso-osmolar radiocontrast media. Studies evaluating N-acetylcysteine have been conflicting, with meta-analyses suggesting a small beneficial effect. Studies of other pharmacologic agents have not demonstrated clinical benefit.

Iodixanol in Femoral Arteriography

Two contrast media, iodixanol (Visipaque, Nycomed) 270 mg I/ml and iohexol (Omnipaque, Nycomed) 300 mg I/ml, were compared in femoral arteriography, in 147 patients. Both contrast media were diagnostically effective for use in femoral arteriography, without any significant difference. Pain was reported in connection with injection of iohexol by 36% of the patients, after injection of iodixanol none reported pain. Seventy-two percent of the patients in the iodixanol group reported a sensation of warmth in connection with contrast injection versus 90% in the iohexol group. The average intensity of the warmth was greater with iohexol than with iodixanol. Fourteen percent of patients in the iodixanol group and 1% in the iohexol group reported one or more subjective adverse events.

Effects of Femoral Arteriography and Low Osmolar Contrast Agents on Renal Function

The contrast media-induced renal effects of 3 different low osmolar contrast agents were prospectively evaluated with creatinine, beta-2-microglobulin, and urea in serum before and after femoral arteriography in 110 consecutive patients. Forty-two patients (38%) had at least one of the 2 major risk factors for contrast media-induced nephropathy; diabetes mellitus or renal dysfunction. Six patients (5%) had both risk factors. There were statistically significant increases of S-creatinine (6.5%, p < 0.001) and S-beta-2-microglobulin (7.4%, p < 0.001) but no increase of S-urea, in the total patient material. This effect was independent of preexaminatory renal function, the presence of diabetes mellitus and type of low osmolar contrast agent used in these patients who were properly hydrated before the examination. The amount of administered contrast medium did not correlate with the degree of contrast agent-induced renal function impairment.

High-Osmolar and Low-Osmolar Contrast Media

During the past 3 years a great number of papers about adverse drug reactions to intravascular injection of high-osmolar and low-osmolar iodinated contrast media (CM) have been published. They include observational studies, randomized trials, meta-analyses and committee reports. Thorough analysis of this material substantiates an improvement in safety of at least 6-fold using nonionic low-osmolar CM compared with ionic high-osmolar CM. The point where only a small minority is continuing to argue effectively that low-osmolar CM are not better than conventional high-osmolar CM has now been reached. High-osmolar CM are used less and less for intravascular purposes, and, in fact, have been totally replaced by low-osmolar CM in 4 countries.

Contrast Medium Exposure During Computed Tomography and Risk of Development of End-Stage Renal Disease in Patients With Chronic Kidney Disease: A Nationwide Population-Based, Propensity Score-Matched, Longitudinal Follow-Up Study

The aim of the study was to investigate the long-term association between contrast medium exposure during computed tomography (CT) and the subsequent development of end-stage renal disease (ESRD) in patients with chronic kidney disease (CKD). We conducted a population-based cohort study using Taiwan's National Health Insurance Research Database. A total of 7100 patients with nonadvanced CKD who underwent contrast medium-enhanced CT were identified and served as the study cohort. To avoid selection bias, we used the propensity score to match 7100 nonadvanced CKD patients, who underwent noncontrast medium-enhanced CT to serve as the comparison cohort. The age, sex, index year, and frequency of undergoing CTs were also matched between the study and comparison cohorts. Participants were followed until a new diagnosis of ESRD or December 31, 2011. Hazard ratios (HRs) with 95% confidence interval (95% CI) were calculated using the Cox proportional hazards regression. Contrast medium exposure was not identified as a risk factor for developing ESRD in nonadvanced CKD patients after confounders adjustment (adjusted HR = 0.91; 95% CI, 0.66-1.26; P = 0.580). We further divided the patients who underwent CTs with contrast medium use into ≤1 exposure per year on average, >1 and <2 exposure per year on average, and ≥2 exposure per year on average. After adjusting for confounders, we identified a much higher risk for developing ESRD in the 2 groups of >1 and <2 exposure per year on average and ≥2 exposure per year on average (adjusted HR = 8.13; 95% CI, 5.57-11.87 and adjusted HR = 12.08; 95% CI, 7.39-19.75, respectively) compared with the patients who underwent CTs without contrast medium use. This long-term follow-up study demonstrated that contrast medium exposure was not associated with an increased risk of ESRD development in nonadvanced CKD patients.

Adverse effects of drugs on the kidney

The number of drugs presently marketed is countless, their prescription is relentlessly growing, such that the likelihood of adverse effects is strikingly increasing. As many drugs are cleared by the body through kidney excretion, renal adverse events are likely. In this review we shall concisely describe the pathophysiologic mechanisms of renal damage by drugs, the different clinical presentations outlining renal toxicity in the course of pharmacologic treatment, and the main offending agents.

Contrast induced nephropathy among patients with normal renal function undergoing coronary angiography

INTRODUCTION

Although contrast induced nephropathy (CIN) is a well-known complication of radiocontrast media administration among patients with underlying renal insufficiency, however the data about CIN among patients with normal renal function are few and it seems that CIN often remained under-diagnosed among these patients.

OBJECTIVES

The aim of present study was evaluation of CIN in diabetic and nondiabetic patients with normal renal function undergoing coronary angiography.

PATIENTS AND METHODS

This cross-sectional and prospective study has conducted on patients with normal renal function candidate for diagnostic coronary angiography at Imam hospital, Ahvaz, Iran from October 2010 to February 2011. CIN defined as an increase in serum creatinine (sCr) >0.5 mg/dL after two days of contrast administration. A standardized questionnaire was used to collect demographics, clinical and laboratory data.

RESULTS

A total of 254 patients (140 males and 114 Females with mean age of 56.6 ± 11.9 years) were included in the study. Of them, 60 patients (23.6%) had congestive heart failure (CHF) and 57 patients (22.4%) had diabetes mellitus (DM). The mean sCr levels before contrast administration in men and women were 1.05 ± 0.22 and 0.93 ± 0.17 mg/dL respectively. In overall CIN occurred in 27 patients (10.6%) with no difference between males and females (P = 0.386) and in patients with or without CHF (P = 0.766). There was a significant association between CIN and DM (P = 0.001) and mean volume of contrast administration (P = 0.001).

CONCLUSION

Although CIN is a common problem in patients with diabetic nephropathy undergoing coronary angiography, diabetic patients without diabetic nephropathy and also patients without DM who had normal renal function are also at risk of contrast nephropathy.

The role of medications and their management in acute kidney injury

Prior to 2002, the incidence of acute renal failure (ARF) varied as there was no standard definition. To better understand its incidence and etiology and to develop treatment and prevention strategies, while moving research forward, the Acute Dialysis Quality Initiative workgroup developed the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification. After continued data suggesting that even small increases in serum creatinine lead to worse outcomes, the Acute Kidney Injury Network (AKIN) modified the RIFLE criteria and used the term acute kidney injury (AKI) instead of ARF. These classification and staging systems provide the clinician and researcher a starting point for refining the understanding and treatment of AKI. An important initial step in evaluating AKI is determining the likely location of injury, generally classified as prerenal, renal, or postrenal. There is no single biomarker or test that definitively defines the mechanism of the injury. Identifying the insult(s) requires a thorough assessment of the patient and their medical and medication histories. Prerenal injuries arise primarily due to renal hypoperfusion. This may be the result of systemic or focal conditions or secondary to the effects of drugs such as nonsteroidal anti-inflammatory drugs, calcineurin inhibitors (CIs), and modulators of the renin-angiotensin-aldosterone system. Renal, or intrinsic, injury is an overarching term that represents complex conditions leading to considerable damage to a component of the intrinsic renal system (renal tubules, glomerulus, vascular structures, inter-stitium, or renal tubule obstruction). Acute tubular necrosis and acute interstitial nephritis are the more common types of intrinsic renal injury. Each type of injury has several drugs that are implicated as a possible cause, with antiinfectives being the most common. Postrenal injuries that result from obstruction block the flow of urine, leading to hydronephrosis and subsequent damage to the renal parenchyma. Drugs associated with tubular obstruction include acyclovir, methotrexate, and several antiretrovirals. Renal recovery from drug-induced AKI begins once the offending agent has been removed, if clinically possible, and is complete in most cases. It is uncommon that renal replacement therapy will be needed while recovery occurs. Pharmacists can play a pivotal role in identifying possible causes of drug-induced AKI and limit their toxic effect by identifying those most likely to cause or contribute to injury. Dose adjustment is critical during changes in renal function, and the pharmacist can ensure that optimal therapy is provided during this critical time.

Relative and absolute changes in urinary neutrophil gelatinase-associated lipocalin and correlation with small increases in serum creatinine levels after coronary angiography: an observational study

INTRODUCTION/AIMS

The Acute Kidney Injury Network classification is based on small increases in serum creatinine (sCr) for stage 1. This study investigated whether changes in the urinary concentration of neutrophil gelatinase-associated lipocalin (uNGAL) could predict small increases in sCr in patients undergoing coronary angiography.

METHODS

The uNGAL was measured before contrast infusion and 2 and 4 h afterwards. Patients were divided into 2 subgroups: G1 (n = 103), where sCr increased by <0.3 mg/dl, and G2 (n = 22), where sCr increased by ≥0.3 mg/dl 48 h after the angiography. To determine the sensitivity and specificity for the absolute and relative variations of uNGAL, a receiver operating characteristic curve analysis was performed.

RESULTS

In G2, the uNGAL concentration increased over baseline values (15.9 vs. 9.2 ng/dl; p < 0.05), and it was also 2-fold higher in G2 versus G1 (15.9 vs. 8.0 ng/dl; p < 0.001). The uNGAL remains an independent predictor of the small increases in sCr, and, for an increase of 50% over baseline levels, it showed 60% sensitivity and 81% specificity.

CONCLUSION

Changes in uNGAL concentration 2 h after the infusion of contrast media showed marginal sensitivity to predict small increases in sCr.

Relative Nephrotoxicity of Different Contrast Media

Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury among hospitalized patients. High-osmolar contrast agents are associated with increased risk of CIN. Low-osmolar (LOCM) and iso-osmolar (IOCM) agents show no difference in the incidence of CIN, even among high-risk patients. This finding suggests that factors other than osmolality may play a role in the pathogenesis of CIN. The use of either LOCM or IOCM agents is recommended in high-risk patients.

Is contrast medium osmolality a causal factor for contrast-induced nephropathy?

The exact pathophysiology of contrast-induced nephropathy (CIN) is not fully clarified, yet the osmotic characteristics of contrast media (CM) have been a significant focus in many investigations of CIN. Osmotic effects of CM specific to the kidney include transient decreases in blood flow, filtration fraction, and glomerular filtration rate. Potentially significant secondary effects include an osmotically induced diuresis with a concomitant dehydrating effect. Clinical experiences that have compared the occurrence of CIN between the various classes of CM based on osmolality have suggested a much less than anticipated advantage, if any, with a lower osmolality. Recent animal experiments actually suggest that induction of a mild osmotic diuresis in association with iso-osmolar agents tends to offset potentially deleterious renal effects of high viscosity-mediated intratubular CM stagnation.

Glomerular filtration rate in evaluation of the effect of iodinated contrast media on renal function

OBJECTIVE

The purpose of this study was to use measured glomerular filtration rate (GFR), the reference standard of renal function, to assess the deleterious effect of iodinated contrast media on renal function. Such an effect has been traditionally defined as a greater than 0.5-mg/dL increase in serum creatinine concentration or a 25% or greater increase 24-72 hours after the injection of iodinated contrast medium.

SUBJECTS AND METHODS

This pilot investigation was focused on the consequences of clinically indicated IV injection of iodinated contrast media; intraarterial injection was excluded. One hundred thirteen patients with normal serum creatinine concentrations were enrolled in an approved protocol. At random, as chosen by one of the investigators, patients underwent imaging with one of three monomeric agents (iopamidol 300, iopromide 300, iohexol 300) and one dimeric agent (iodixanol 320). Measured GFR was determined immediately before CT and approximately 3 and 72 hours after the contrast injection for the CT examination. Iodinated contrast medium, a glomerular filtrate with no tubular excretion or reabsorption, was the GFR marker. Measured GFR was determined by x-ray fluorescence analysis with nonisotopic iodinated contrast media.

RESULTS

Monomeric and dimeric contrast agents in diagnostic CT volumes (based on bodyweight and imaging protocol) did not induce a significant change in measured GFR (95% confidence by Wilcoxon test), suggesting that use of the evaluated contrast media will not lead to more than a 12% variation.

CONCLUSION

The three monomeric agents studied and the one dimeric agent were equivalent in terms of lack of a significant effect on measured GFR when administered to patients with a normal GFR.

Contrast-induced acute kidney injury following PCI

BACKGROUND

Coronary revascularization using percutaneous coronary intervention (PCI) is one of the major treatments for patients with stable coronary artery disease, with approximately 1.5 million patients undergoing PCI in the United States and Europe every year. An important neglected complication of PCI is contrast-induced acute kidney injury (CI-AKI).

DESIGN

In this article, we review the definition, pathogenesis and management of CI-AKI and highlight potential therapeutic options for preventing CI-AKI in post-PCI patients.

RESULTS

CI-AKI is an important but underdiagnosed complication of PCI that is associated with increased in-hospital morbidity and mortality. Patients with pre-existing renal impairment and diabetes are particularly susceptible to this complication post-PCI. Optimization of the patients' circulating volume remains the mainstay for preventing CI-AKI, although the best strategy for achieving this is still controversial.

CONCLUSION

Following PCI, CI-AKI is an overlooked complication which is associated with significant morbidity and mortality. In this article, we review the pathophysiology of CI-AKI in patients undergoing PCI and discuss the potential therapeutic options for preventing it.

An uninvestigated risk factor for contrast-induced nephropathy in chronic kidney disease: proteinuria

BACKGROUND

Contrast-induced nephropathy (CIN) is one of the most frequent causes of acute renal failure in hospitalized patients with the incremental use of contrast media. We aimed to investigate whether proteinuria may act as a risk factor for CIN in patients with chronic kidney disease.

METHODS

Seventy hospitalized patients (37 men, 33 women) with chronic kidney disease, proteinuria, and/or estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2, who were exposed to contrast media were investigated prospectively. Thirty patients were diabetic. All patients received prophylaxis against CIN with acetylcysteine and 0.9% intravenous saline. CIN is defined as either a 25% higher increase in serum creatinine (sCr) from the baseline levels or a 0.5 mg/dL increase in sCr at 72 h after contrast media exposure.

RESULTS

CIN was detected in 26 (37.1%) patients. Advanced age, diabetes, heart failure, anemia, baseline sCr of >1.5 mg/dL, baseline eGFR of <60 mL/min/1.73 m(2), proteinuria of ≥1 g/day, hypoalbuminemia, and the volume of contrast media of ≥100 mL correlated significantly with CIN. The frequency of CIN was significantly higher in patients with proteinuria of ≥1 g/day compared to patients with proteinuria of <1 g/day (p = 0.009).

CONCLUSION

Proteinuria may be a new risk factor for the development of CIN in patients with chronic kidney disease.

Radiographic assessment of splenic injury without contrast: is contrast truly needed?

INTRODUCTION

Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (i.v.) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to i.v. contrast. Little information exists concerning the repercussions of CT imaging without i.v. contrast, specifically for splenic injury.

METHODS

We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008-2010), where a CT of the abdomen without i.v. contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with i.v. contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or "suspicious" splenic injury findings and compared with CONTRAST imaging results or intraoperative findings.

RESULTS

During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. "Suspicious" splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury.

CONCLUSION

DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to i.v. contrast, DRY imagining may be able to select those who require close monitoring or intervention.

Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium-induced nephropathy: a randomized controlled trial

AIMS

The most effective regimen for the prevention of contrast-induced nephropathy (CIN) remains uncertain. Our purpose was to compare two regimens of sodium bicarbonate with 24 h sodium chloride 0.9% infusion in the prevention of CIN.

METHODS AND RESULTS

We performed a prospective, randomized trial between March 2005 and December 2009, including 258 consecutive patients with renal insufficiency undergoing intravascular contrast procedures. Patients were randomized to receive intravenous volume supplementation with either (A) sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure or (B) sodium bicarbonate (166 mEq/L) 3 mL/kg for 1 h before and 1 mL/kg/h for 6 h after the procedure or (C) sodium bicarbonate (166 mEq/L) 3 mL/kg over 20 min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). The primary endpoint was the change in estimated glomerular filtration rate (eGFR) within 48 h after contrast. Secondary endpoints included the development of CIN. The maximum change in eGFR was significantly greater in Group B compared with Group A {mean difference -3.9 [95% confidence interval (CI), -6.8 to -1] mL/min/1.73 m2, P = 0.009} and similar between groups C and B [mean difference 1.3 (95% CI, -1.7-4.3) mL/min/1.73 m(2), P = 0.39]. The incidence of CIN was significantly lower in Group A (1%) vs. Group B (9%, P = 0.02) and similar between Groups B and C (10%, P = 0.9).

CONCLUSION

Volume supplementation with 24 h sodium chloride 0.9% is superior to sodium bicarbonate for the prevention of CIN. A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen. ClinicalTrials.gov Identifier: NCT00130598.

The use of gadolinium in patients with contrast allergy or renal failure requiring coronary angiography, coronary intervention, or vascular procedure

Coronary artery angiography remains an important procedure for the assessment of coronary arteries. It requires injection of iodinated contrast for the opacification of coronary arteries. Severe allergy to iodine contrast and renal insufficiency are two main problems with iodine-based contrast media. Gadolinium (Gd) has different chemical structure with no cross reactivity with iodine-based contrast media in patients with iodine allergy. The use of Gd is commonly used in contrast-enhanced magnetic resonance imaging for image enhancement, making it a potential alternative in patients in whom iodine is contraindicated. The aim of this manuscript is to review the available literature on the use of Gd in patients with contraindication to iodine contrast due to allergy or in patients with severe renal failure requiring coronary or vascular procedures.

Incidence and risk factors for radiocontrast-induced nephropathy in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is an effective treatment for unresectable hepatocellular carcinoma (HCC); however, large volumes of radiocontrast agents are used for TACE and may induce renal dysfunction. Most patients with HCC have coexisting liver cirrhosis (LC) at the time of diagnosis. Advanced cirrhosis is characterized by peripheral vasodilatation associated with decreased renal perfusion due to the activation of vasoconstrictor systems. We retrospectively investigated patients with HCC who had undergone TACE to determine the incidence and risk factors for radiocontrast-induced nephropathy (RCIN).

METHODS

A total of 101 patients with HCC who underwent a combined 221 TACE treatment sessions were included. Follow-up serum creatinine levels within 96 h after TACE were confirmed in these patients. RCIN was defined as an increase of at least 25% in baseline serum creatinine levels between 48 and 96 h after TACE.

RESULTS

RCIN developed in 20 (9%) of the 221 treatment sessions after TACE. A univariate analysis showed that the Child-Pugh score (6.0 ± 1.3 vs. 6.7 ± 1.9, P = 0.005), ascites (14.4 vs. 40%, P = 0.008), contrast medium volume (257.3 ± 66.8 vs. 275.0 ± 44.0 ml, P = 0.009), total bilirubin (1.3 ± 1.7 vs. 3.4 ± 8.0 mg/dl, P < 0.001), basal serum creatinine levels (0.9 ± 0.3 vs. 1.0 ± 0.5 mg/dl, P < 0.001) and glomerular filtration rate using the modification of diet in renal disease formula (90.5 ± 21.8 vs. 88.4 ± 29.6 ml/min, P = 0.015) were significantly associated with the development of RCIN. A multivariate analysis revealed that the Child-Pugh score was associated with RCIN [odds ratio (OR) 1.5; P = 0.015]. Overall, in-hospital mortality after TACE was 4.07% (with RCIN, 30%; without RCIN, 1.5%; P < 0.001). The multivariate analysis also showed that the Child-Pugh score and the occurrence of RCIN were associated with in-hospital mortality after TACE (OR 2.8; P = 0.001; OR 26.7, P = 0.002, respectively).

CONCLUSIONS

RCIN after TACE was closely associated with the severity of LC. Effective preventive measures remain to be determined in patients with HCC and advanced LC who are undergoing TACE.

Defining Incidence and Outcome of Contrast-Induced Nephropathy Among Trauma: Is It Overhyped?

Contrast-induced nephropathy (CIN) in trauma patients is uncommon and the incidence is unknown. We studied the incidence of CIN and its outcome. A retrospective chart review of trauma patients 16 years of age and older who were admitted to our Level I trauma center during 2005 was performed. Patients who received the intravenous contrast CT scan and had their serum creatinine (Cr) monitored at admission and at 48 to 72 hours were identified. CIN was defined as a 0.5-mg/dL rise of serum Cr or a 25 per cent increase from the baseline if the baseline Cr was abnormal. We excluded patients transferred from an outside facility, patients without repeated serum Cr measurements, patients who had cardiac arrest or persistent hypotension, and patients who had received N-acetylcysteine (Mucomyst) before their CT scan. We compared CIN and non-CIN groups. During 2005, 543 fit our study criteria, of whom 19 (3.5%) had CIN. CIN (vs non-CIN) had a higher baseline serum Cr (1.48 + 0.23 vs 1.06 + 0.02, P < 0.001), a longer intensive care unit stay (17 vs 5 days, P < 0.001), and a longer hospital stay (19 vs 8 days, P < 0.001); the mortality rate was not different (10 vs 4%, P = 0.2). We found elevated baseline serum Cr (OR, 1.92; 95% CI, 1.13 to 3.27; P = 0.016) to be associated with increased risk for CIN. All but two serum Cr levels peaked within 48 hours; all returned to baseline. One patient with an underlying congenital kidney disease required temporary dialysis. CIN incidence in trauma is low and the clinical course is benign.

Risk Factors and Clinical Outcomes for Contrast-induced Nephropathy After Percutaneous Coronary Intervention in Patients with Normal Serum Creatinine

Introduction: We aim to examine the risk predictors of contrast-induced nephropathy (CIN) in patients with normal baseline serum creatinine (Cr). CIN is an important complication post percutaneous coronary intervention (PCI). Previous studies examined CIN predictors in patients with chronic renal impairment. No large studies investigated patients with normal renal function which constitute the majority undergoing PCI. We aim to identify risk predictors in this cohort and examine the clinical outcomes. Materials and Methods: A total of 3036 patients with normal baseline Cr (<1.5 mg/dL) who did not receive prophylaxis while undergoing PCI were enrolled. We examined the occurrence of CIN and the mortality outcome at 1 and 6 months. Results: CIN occurred in 7.3% of patients. The median age was 59.5 years (range, 26 to 86), 78.7% men, 34.6% diabetics. Risk predictors for CIN include age [odds ratio (OR), 6.4; 95% CI, 1.01-13.3; P = 0.042], female gender (OR, 2.0; 95% CI, 1.5-2.7; P = 0.001), abnormal left ventricular ejection fraction (LVEF) <50%(OR,1.02; 95% CI, 1.01-1.04; P = 0.01), anaemia with haemoglobin <11 mg/dL (OR, 1.5; 95% CI, 1.01-2.4; P = 0.044) and systolic hypotension with blood pressure <100 mmHg (OR, 1.5; 95% CI, 1.01-2.2; P = 0.004). Diabetics on insulin therapy were at the highest risk compared with diabetics on oral hypoglycaemics and diet control (18.9% vs 6.8% vs 3.6%; P = 0.001). Patients who developed CIN had higher mortality at 1 month (14.5% vs 1.1%; P <0.001) and 6 months (17.8% vs 2.2%; P <0.001). Conclusions: Subgroups of patients with normal baseline Cr undergoing PCI are at risk of developing CIN with resultant higher mortality. Age, female gender, insulin dependent diabetes mellitus, presence of hypotension, anaemia and low LVEF are predictors of CIN. Prophylaxis may be considered in these patients. Key words: Anaemia, Female gender, Haemoglobin, Left ventricular ejection fraction

Preventing acute decrease in renal function induced by coronary angiography (PRECORD): a prospective randomized trial

BACKGROUND

Infusion of saline attenuates the decrease in renal function induced by radiographic contrast agents among patients with chronic renal insufficiency.

AIM

The Preventing Renal alteration in Coronary Disease (PRECORD) trial was a randomized trial to assess the effect on renal function of saline infusion during and after coronary angiography in 201 patients without severe chronic renal insufficiency (serum creatinine<140micromol/L).

METHODS

All patients received standard oral hydration: 2000mL of tap water within the 24 hours after coronary angiography. Patients were randomized before the procedure to intravenous hydration (1000mL of 0.9% saline infusion) or no additional hydration. The infusion was started in the catheterization laboratory and continued for 24 hours. The primary endpoint was the change in calculated creatinine clearance between baseline and 24 hours after coronary angiography. The same ionic low osmolar radiographic contrast agent (ioxaglate) was used in all patients.

RESULTS

Both groups had similar baseline characteristics, including age, serum creatinine, volume of contrast and proportion of patients undergoing ad hoc coronary angioplasty. The overall decrease in serum creatinine clearance 24 hours after the procedure was -3.44 (0.68)mL/min. The change in serum creatinine clearance 24 hours after the procedure was -2.81 (1.07)mL/min in the infusion group vs -4.09 (0.91)mL/min in the control group (p=0.38).

CONCLUSION

Renal function is altered only slightly 24 hours after coronary angiography with standard oral hydration alone and is not affected by saline infusion started at the beginning of coronary angiography, even in patients with mild-to-moderate renal dysfunction.

CT angiography for intracerebral hemorrhage does not increase risk of acute nephropathy

BACKGROUND AND PURPOSE

CT angiography (CTA) is receiving increased attention in intracerebral hemorrhage (ICH) for its role in ruling out vascular abnormalities and potentially predicting ongoing bleeding. Its use is limited by the concern for contrast induced nephropathy (CIN); however, the magnitude of this risk is not known.

METHODS

We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with ICH presenting to a single tertiary care hospital from 2002 to 2007. Demographic, clinical, and radiographic data were prospectively collected for all patients. Laboratory data and clinical course over the first 48 hours were retrospectively reviewed. Acute nephropathy was defined as any rise in creatinine of >25% or >0.5 mg/dL, such that the highest creatinine value was above 1.5 mg/dL.

RESULTS

539 patients presented during the study period and had at least 2 creatinine measurements. 348 (65%) received a CTA. Acute nephropathy developed in 6% of patients who received a CTA and in 10% of those who did not (P=0.1). Risk of nephropathy was 14% in those receiving no contrast (130 patients), 5% in those receiving 1 contrast study (124 patients), and 6% in those receiving >1 contrast study (244 patients). Neither CTA nor any use of contrast predicted nephropathy in univariate or multivariate analysis.

CONCLUSIONS

The risk of acute nephropathy after ICH was not increased by use of CTA. Studies of CIN that do not include a control group may overestimate the influence of contrast. Patients with ICH appear to have an 8% risk of developing "Hospital-Acquired Nephropathy."