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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