9.9.08 williams. contrast-induced nephropathy

8/2/2019 9.9.08 Williams. Contrast-Induced Nephropathy

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Post PCI Contrast InducedNephropathy

Brandon M. Williams M.D.

A.M. Report 9/9/08


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Acute Renal Failure Post Cath/PCI

Renal atheroemboli

Hemodynamic instability with decreasedrenal perfusion

Contrast induced nephropathy


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Renal Atheroemboli

Other signs of embolization (blue toes,livedo reticularis, Hollenhorst plaques,abdominal pain)

Transient eosinophilia andhypocomplementemia

Renal failure which persists greater than 7days


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Evidence of Renal Atheroemboli


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Renal Hypoperfusion

Oliguria/anuria

Postischemic acute tubular necrosis(increasing Cr, normal to reduced uop,granular casts, FeNa > 1


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Contrast Induced Nephropathy(CIN)

Definition: new-onset or an exacerbationof renal dysfunction after contrastadministration in the absence of othercauses

Cr Increase of >25% or absolute increaseof >0.5mg/dl


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CIN Timeline

Symptoms initially seen 24-48 hours afterexposure

Cr peaks at 5-7 days

Normalizes usually within 7-10 days

Mehran, 2007


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CIN Incidence

3rd most common hospital acquired renalfailure

>5% of patients with cath experiencetransient increase Cr > 1.0 from baseline

Up to Date Complications of diagnostic cardiac catheterization


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Outcomes of CIN

Prognosis of patients with CIN significantlyworse than those without

Case control study 1600 pts with contrast,

mortality rate with CIN (n=183) 5.5 timesof matched controls (n=174)

Increased risk of mortality if require

hemodialysis Increase in cost of $10,345 for hospital

stay


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CIN and Coronary Procedures

Higher mortality than other types of CIN 3% primary PCI for ACS (Marenzi et al 2004)

McCullough et al. 19971800 pts with coronary interventions withcontrast- ARF 14%, dialysis 0.8%

- In house mortality for those to HD 36% (1% forthose without HD)- 2 yr survival 19% in those needing HD


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Patient CIN Risk Factors

RENAL INSUFFICIENCY

DIABETES MELLITUS WITH CRI

Volume depletion

Age > 75 Hypotension

CHF

Other renal toxins Renal transplant

Hypoalbuminemia


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Procedure CIN Risk Factors

Multiple studies in 72 hour period

Intra-arterial injection site

High volume of contrast

High osmolality of contrast1st generation: ionic monomers, 14-18Kmosmol/kg

2nd generation: nonionic monomers, 500-850mosmol/kg3rd generation: nonionic dimers, ~290mosmol/kg


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Pathogenesis of CIN

In animal models, some evidence of ATNbut mechanism is not fully understood.

Theories:

Renal vasoconstriction

Cytotoxic effect of contrast agent


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Renal Vasoconstriction

Contrast induced release of endothelin (?importance) and adenosine

High osmolality of contrast can cause areduction of medullary blood flowsecondary to increased viscosity of theblood flowing through the vasa recta

(usually low viscosity)


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Vasa Recta


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Direct Tubular Injury

Direct cytotoxic effects

Oxygen free radicals


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McCullough et al.


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Prevention

Contrast: low or iso-osmolar (similar results)Omnipaque (iohexol) 844mOsm/kg

Hold nephrotoxic drugs (NSAIDs, calcineurininhibitors, diuretics, aminoglycosides, metformin)

Hydration: NS better than NS, ?sodiumbicarbonate, ascorbic acid, and N-acetylcysteine

Continue statin Hemofiltration (Cr 3-4) 6hr before and 12-18hr

post ? IV antioxidants, renal vasodilators, forced

hydration


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McCullough et al.


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At UNC

Hydration: NS at 1mL/kg/hr for 12 hours prior tocath

Acetylcystein 600-1200mg po BID x 4 doses (2doses the day prior and 2 the day of)

Na Bicarb: 150mEq in 1L D5W at

3mL/kg/hour(max 110kg) x 1 hour on call toprocedure, then 1mL/kg/hour (max 110kg) x 6hours


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References

Marenzi et al. Contrast-induced nephropathy in patients undergoingprimary angioplasty for acute myocardial infarction. J Am CollCardiol, 44, 2004. pp 1780-1785

McCullough et al. Contrast-Induced Acute Kidney Injury. J Am CollCardiol, 51, 2008, 1419-1428

Mehran. Contrast-Induced Nephropathy Remains a Seriouscomplication of PCI. J Interven Cardiol 20. 2007 236-240

Plueger et al. Role of adenosine in contrast media-induced acuterenal failure in diabetes mellitus. Mayo Clin Proc 2000, Dec 70 (12)1275-83

Medic8 Drug Information (omnipaque)

Up to Date Google Images

9.9.08 williams. contrast-induced nephropathy

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