Radiocontrast nephropathy
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Radiocontrast Nephropathy. Jason S. Finkelstein, M.D. Tulane University HSC Division of Cardiology 3/2/04. Outline. Incidence and Clinical Features of RCN Risk Factors Pathophysiology Agents used for Prevention of RCN. Incidence.

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Radiocontrast nephropathy

Radiocontrast Nephropathy

Jason S. Finkelstein, M.D.

Tulane University HSC

Division of Cardiology

3/2/04


Outline
Outline

  • Incidence and Clinical Features of RCN

  • Risk Factors

  • Pathophysiology

  • Agents used for Prevention of RCN


Incidence
Incidence

  • In the year 2000, an estimated 1.8 million caths were performed in the US

  • Two studies looked at 1826/1196 patients and the incidence of RCN was 14.4% & 11.1% respectively

  • 0.3-4% of patients required short-term dialysis

  • Approx 60,000 cases of RCN occur each year


Definition
Definition

  • Absolute increase of Cr > 0.5 mg/dl or relative increase of 25-50% from baseline within 48 hours of contrast exposure in absence of other causes

  • Third most common cause of acute renal failure


Definition1
Definition

  • Typically occurs within 24-48 hours of contrast exposure

  • Creatinine typically peaks in 3-5 days and returns to baseline in 1-3 weeks

  • RCN is non-oliguric in most patients


Outcome
Outcome

  • Causes increased length of hospital stay and costs

  • Significant in-hospital morbidity

  • 5-10% require transient dialysis; <1% require long term dialysis


Increased mortality
Increased mortality

  • 3.8% -- Increase in Cr 0.5-0.9 mg/dl

  • 64% -- Increase in Cr > 3.0 mg/dl


Osmolality
Osmolality

  • Contrast media are water soluble structures composed of triiodobenzene ring with varying numbers of iodine molecules

  • Increased iodine content results in increased osmolality

  • Pooled data from 25 randomized trials have shown that high osmolality agents pose a greater risk of CN than low-osmolality agents


Risk factors for rcn
Risk Factors for RCN

  • Pre-existing renal insufficiency (37%)

  • Diabetes (risk is 4.1%)

  • Contrast volume

  • Dehydration

  • Advanced Age

  • Nephrotoxic drugs (ACE, NSAIDS)

  • CHF, Liver disease


Pathophysiology
Pathophysiology

  • Medullary ischemia

  • Direct tubular toxicity

  • Tubular obstruction


Medullary ischemia
Medullary Ischemia

  • Contrast agents cause a selective renal medullary vasoconstriction

  • Shunting of blood to the renal cortex

  • Also known as the “steal phenomenon”

  • This leads to tubular injury


Tubular obstruction
Tubular obstruction

  • Possible role in pathogenesis of RCN

  • Precipitation of Dye crystals in the renal tubules

  • In presence of dehydration, precipitation of urate or dye crystals could lead to tubular obstruction


Direct tubular toxicity
Direct Tubular Toxicity

  • Toxic ATN

  • Oxygen Free Radicals

    • Leads to apoptosis in renal tubular and glomerular cells


Iohexol cooperative study
Iohexol Cooperative Study

  • Objective

    • To compare the incidence of contrast nephrotoxicity between nonionic “Iohexol” and the ionic contrast agent “diatrizoate” in a large population of low and high risk patients undergoing angiogram

    • 1196 pts, randomized trial


Conclusion
Conclusion

  • The incidence of RCN depends on the presence of risk factors

  • Pts with CRI and DM are at highest risk

  • RCN can be associated with significant morbidity and mortality

  • There are preventive interventions to decrease the risk of toxicity


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