851
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Abstract
Contrast-induced nephropathy occurs in 2-10% of patients exposed to intravascular radiographic contrast agents and results in significant morbidity and mortality. Although the exact mechanism of this disorder has not been fully elucidated, contrast nephropathy is probably due to a combination of decreased renal medullary blood flow, resulting in medullary ischemia, and direct toxicity to renal tubules. Contrast nephropathy is most commonly defined as either a >25% increase or a >0.5 mg/dL rise in serum creatinine level within 48 hours of contrast medium exposure. Baseline characteristics associated with an increased risk for development of contrast nephropathy include the presence of baseline renal dysfunction, diabetes mellitus, congestive heart failure, volume depletion, and concomitant administration of nephrotoxic drugs. Many strategies have been investigated in an effort to prevent the occurrence of renal dysfunction following contrast media exposure. Intravenous hydration has been shown to significantly decrease the incidence of nephropathy in high-risk patients. However, trials of several prophylactic pharmacologic interventions have been mostly disappointing, including the administration of calcium channel antagonists, diuretics, dopamine, endothelin receptor antagonists and fenoldopam. The use of N-acetylcysteine has been shown in some trials to decrease the incidence of contrast nephropathy in patients with a baseline renal dysfunction, and should currently be strongly considered in this high-risk patient subgroup in addition to hydration. Our purpose is to review the contemporary literature regarding contrast-induced renal dysfunction and present an evidence-based approach for prevention of this complication.
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Affiliation(s)
- David E Kandzari
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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852
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Sharp JC, Baron DW. Salvage stenting for acute renal failure secondary to renal artery stenosis. Heart Lung Circ 2003; 12:189-92. [PMID: 16352131 DOI: 10.1046/j.1444-2892.2003.00220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present two cases of successful, emergency renal artery stenting in the setting of acute renal failure requiring dialysis secondary to renal artery stenosis. Early reopening of the stenotic renal artery led to the resolution of acute renal failure and obviated the need for further dialysis in both cases.
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Affiliation(s)
- Jason C Sharp
- Department of Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
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853
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Connolly PJ, Biller J, Pritz MB. Aneurysm observation versus intervention: a literature review. Neurol Res 2002; 24 Suppl 1:S84-95. [PMID: 12074444 DOI: 10.1179/016164102101199963] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating illness that affects persons at the peaks of their lives. The 1990s witnessed rapid growth in noninvasive vascular imaging technologies, which allowed safe diagnosis of unruptured saccular intracranial aneurysms. Presently, it is unclear who will benefit from screening. Mass screening is neither feasible nor cost-effective. The current literature suggests that persons in a family with two or more relatives with a history of SAH are most likely to benefit from screening. Individuals with a history of SAH, with aneurysms greater than 10 mm in diameter or with symptomatic aneurysms are clearly at increased risk for SAH. These aneurysms should be treated, though the method of treatment remains open to question. Treatment of older patients or those with smaller aneurysms has been modeled by decision analysis, but has yet to be verified in a prospective clinical trial. Future directions for aneurysm management are explored.
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Affiliation(s)
- Patrick J Connolly
- Section of Neurosurgery, Indiana University School of Medicine, Indianapolis 46202, USA.
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854
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Harbarth S, Burke JP, Lloyd JF, Evans RS, Pestotnik SL, Samore MH. Clinical and economic outcomes of conventional amphotericin B-associated nephrotoxicity. Clin Infect Dis 2002; 35:e120-7. [PMID: 12471588 DOI: 10.1086/344468] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2002] [Accepted: 07/11/2002] [Indexed: 11/03/2022] Open
Abstract
A retrospective 9-year cohort study was conducted to identify the hospitalization costs, length of hospital stay, and mortality associated with nephrotoxicity (NT) among 494 inpatients who were treated with conventional amphotericin B (CAB). Survival regression methods were used to model the effect of NT. The rate of NT was 12%; the overall in-hospital mortality rate was 22%. After adjustment for confounding, NT was associated with a 2.7-fold higher risk of death (P<.001). Although the unadjusted effects of NT on length of hospital stay and hospitalization costs after the initiation of CAB were consistent with small increases, such effects were not significant in multivariate models (time ratio, 1.2 [P=.2]; cost ratio, 1.1 [P=.8]). The greater the number of days before the onset of NT that were included in the analysis, the greater the apparent effect of NT on costs. CAB-associated NT was associated with increased mortality, but it did not impact the costs and length of hospital stay.
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Affiliation(s)
- Stephan Harbarth
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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855
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856
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Miscellaneous medications for the management of atherosclerosis: Mayhem or miracle? Semin Vasc Surg 2002. [DOI: 10.1016/s0895-7967(02)70027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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857
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Durham JD, Caputo C, Dokko J, Zaharakis T, Pahlavan M, Keltz J, Dutka P, Marzo K, Maesaka JK, Fishbane S. A randomized controlled trial of N-acetylcysteine to prevent contrast nephropathy in cardiac angiography. Kidney Int 2002; 62:2202-7. [PMID: 12427146 DOI: 10.1046/j.1523-1755.2002.00673.x] [Citation(s) in RCA: 188] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Contrast nephropathy (CN) is a common cause of renal dysfunction after cardiac angiography. Recently, N-acetylcysteine (NAC) has been found to reduce the risk of CN after CT imaging with contrast enhancement. The purpose of the current study was to evaluate the efficacy of NAC for the prevention of CN in the setting of cardiac angiography. METHODS Eligible patients were those undergoing cardiac angiography with serum creatinine>1.7 mg/dL. Patients were randomized to one of two groups: Group 1, IV hydration and NAC, 1200 mg one hour before angiography, and a second dose 3 hours after; Group 2, IV hydration and placebo. CN was defined as an increase of 0.5 mg/dL in serum creatinine. RESULTS Seventy-nine patients completed the study. There were no significant differences between the groups in baseline characteristics, duration of angiography, mean volume of dye infused or mean IV hydration. Contrast nephropathy developed in 24.0% of subjects, 26.3% NAC, and 22.0% placebo (P = NS). Among subjects with diabetes mellitus, there was no significant difference in the rate of CN between the groups (42.1% NAC, 27.8% placebo; P = 0.09). The independent predictors of CN risk were diabetes mellitus and preexisting chronic renal insufficiency. CONCLUSIONS NAC was not effective for the prevention of CN after cardiac angiography.
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Affiliation(s)
- John D Durham
- Division of Nephrology, Department of Pharmacy, and Division of Cardiology, Winthrop-University Hospital, Mineola, New York, USA
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858
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Ahmadi R, Ugurluoglu A, Schillinger M, Katzenschlager R, Sabeti S, Minar E. Duplex ultrasound-guided femoropopliteal angioplasty: initial and 12-month results from a case controlled study. J Endovasc Ther 2002; 9:873-81. [PMID: 12546590 DOI: 10.1177/152660280200900622] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate initial technical success, procedural complications, and 12-month patency of duplex-guided angioplasty compared to conventional fluoroscopically-guided procedures. METHODS One hundred four patients (65 men; mean age 69 years) who underwent duplex-guided femoropopliteal angioplasty were compared to 104 patients undergoing fluoroscopically-guide procedures who were matched for age, sex, baseline ankle-brachial index (ABI), and length and grade of lesion. Patients were followed for 12 months, and restenosis was assessed by ABI and duplex sonography. RESULTS Technical success was achieved in 88 (84.6%) patients from the duplex-guided group and in 102 (98.1%) control patients (p=0.001). Periprocedural complications occurred in 12.5% (n=13) and 18.3% (n=19), respectively (p=0.4). Contrast-induced transient renal impairment was observed in 7 (6.7%) patients in the fluoroscopic group. One hundred (96.1%) patients in the duplex and 102 (98.1%) patients in the fluoroscopic group completed the 12-month follow-up. Restenosis was found in 35 (39.8%) patients of the duplex group and in 38 (37.2%) patients of the fluoroscopic group (p=0.8). CONCLUSIONS Technical success of duplex-guided procedures was significantly lower compared to fluoroscopic angioplasty; complications and 12-month patency were similar with both techniques. Duplex-guided angioplasty may be a feasible alternative, particularly for patients at high risk for contrast-induced complications.
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Affiliation(s)
- Ramazanali Ahmadi
- Department of Angiology, Vienna General Hospital, University of Vienna Medical School, Vienna, Austria
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859
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Murray PT, Le Gall JR, Dos Reis Miranda D, Pinsky MR, Tetta C. Physiologic endpoints (efficacy) for acute renal failure studies. Curr Opin Crit Care 2002; 8:519-25. [PMID: 12454536 DOI: 10.1097/00075198-200212000-00007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute renal failure research has been hampered by the lack of useful physiologic surrogate endpoints. Acute renal failure prevention and therapy studies using variables such as urine output and serum and urine chemistries have not yielded interventions proven to decrease the morbidity and mortality associated with acute renal dysfunction. Of those interventions that have been successful in smaller, phase II-level efficacy studies, none subsequently decreased the incidence of clinical (effectiveness) endpoints such as dialysis requirement or mortality in larger phase III trials. Suitable physiologic endpoints are needed to test the efficacy of new proposed therapies for the prevention and management of acute renal failure. Candidate endpoints for efficacy studies in acute renal failure prevention and management include glomerular filtration rate markers, renal blood flow, urine markers, and urine output. Possible endpoints for efficacy studies of renal replacement therapy in acute renal failure include serum markers of renal function and a variety of nonrenal markers. In this article, we present an approach to the choice of physiologic endpoints to determine the efficacy of interventions in acute renal failure.
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Affiliation(s)
- Patrick T Murray
- Department of Medicine, University of Chicago, Chicago, Illinois, USA.
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860
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861
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Ahmadi R, Ugurluoglu A, Schillinger M, Katzenschlager R, Sabeti S, Minar E. Duplex Ultrasound–Guided Femoropopliteal Angioplasty:Initial and 12-Month Results From a Case Controlled Study. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0873:dugfai>2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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862
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Freeman RV, O'Donnell M, Share D, Meengs WL, Kline-Rogers E, Clark VL, DeFranco AC, Eagle KA, McGinnity JG, Patel K, Maxwell-Eward A, Bondie D, Moscucci M. Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose. Am J Cardiol 2002; 90:1068-73. [PMID: 12423705 DOI: 10.1016/s0002-9149(02)02771-6] [Citation(s) in RCA: 237] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml x body weight (kilograms)/serum creatinine (milligrams per deciliter). Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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863
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Fernández-Fúnez A, Polo FJ, Broseta L, Valer J, Zafrilla L. Effects of N-acetylcysteine on myoglobinuric-acute renal failure in rats. Ren Fail 2002; 24:725-33. [PMID: 12472195 DOI: 10.1081/jdi-120015676] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Oxygen metabolites play an important role in renal injury during myoglobinuric acute renal failure (ARF). This study was designed to determine the protective influence of N-acetylcysteine (NAC), a hydroxyl radical scavenger, and treatment in an experimental model of myoglobinuric-ARF induced by intramuscular injection of hypertonic glycerol in rats. The rats were randomly distributed into five groups: Group 0 (n = 10), was assigned to receive 2mL saline (0,9%) intraperitoneally (ip); Group 1 (n = 10), NAC ip in a dose of 0 mg/100 g of body weight 30 min before the intramuscular (im) injection of 50% glycerol (10 mg/kg); Group 2 (n = 10), received saline 0,9% ip in a equivalent volume of NAC in Group I before the im injection of glycerol; Group 3 (n = 10), received NAC ip in a dose of 10 mg/100 g after im injection of glycerol; Group 4 (n = 10), saline 0,9% ip in a equivalent volume of NAC of the Group 3 after im administration of glycerol. After 24 h rats were sacrificed and kidney morphology and renal function were determined. A severe renal failure was produced by glycerol injection in the Groups 1, 2, 3, and 4, with significant tubular proximal necrosis and cast formation, and creatinine and urea concentrations were elevated in these groups without significant differences among groups, but Group 0 where the values were significantly lower. The results of this study suggests that ip administration of NAC in rats before or after glycerol injection do not confer protection against impairment of renal function under these conditions in this model of myoglobinuric-ARF.
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Affiliation(s)
- Angel Fernández-Fúnez
- Department of Medicine, General Hospital of Albacete, University of Castilla La Mancha, Albacete, Spain.
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864
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Muramatsu Y, Tsujie M, Kohda Y, Pham B, Perantoni AO, Zhao H, Jo SK, Yuen PST, Craig L, Hu X, Star RA. Early detection of cysteine rich protein 61 (CYR61, CCN1) in urine following renal ischemic reperfusion injury. Kidney Int 2002; 62:1601-10. [PMID: 12371960 DOI: 10.1046/j.1523-1755.2002.00633.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute renal failure (ARF) has a high morbidity and mortality. Many therapies have worked in animals but were unsuccessful in clinical trials. The inability to diagnose ARF early may have impaired the success of these trials. METHOD We screened a subtraction library to search for potential disease markers that would be induced rapidly after renal injury. Mice and rats were subjected to 30 to 40 minutes of bilateral ischemia. RESULTS mRNA for Cyr61, a secreted growth factor-inducible immediate early gene, was markedly up-regulated at two hours in the kidney but not other organs following renal ischemia. In situ hybridization studies suggested Cyr61 was synthesized in the proximal straight tubule. Cyr61 protein was analyzed by capture with heparin beads followed by Western blotting. Induction of Cyr61 protein could be detected in the kidney within one hour, peaked at four to eight hours, and remained elevated for at least 24 hours following ischemia. Cyr61 protein was detected in urine at three to six hours and peaked at six to nine hours after renal injury. Cyr61 was not detected after volume depletion, which is often difficult to differentiate from ARF. CONCLUSIONS The secreted, cysteine-rich, heparin binding protein Cyr61 is rapidly induced in proximal straight tubules following renal ischemia, and excreted in the urine where it might serve as an early biomarker of renal injury.
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Affiliation(s)
- Yasunari Muramatsu
- Renal Diagnostic and Therapeutic Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
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865
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866
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Allaqaband S, Tumuluri R, Malik AM, Gupta A, Volkert P, Shalev Y, Bajwa TK. Prospective randomized study of N-acetylcysteine, fenoldopam, and saline for prevention of radiocontrast-induced nephropathy. Catheter Cardiovasc Interv 2002; 57:279-83. [PMID: 12410497 DOI: 10.1002/ccd.10323] [Citation(s) in RCA: 196] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of this study was to compare the efficacy of N-acetylcysteine (NAC), fenoldopam, and saline in preventing radiocontrast-induced nephropathy (RCIN) in high-risk patients undergoing cardiovascular procedures. We prospectively enrolled 123 patients who were scheduled for cardiovascular procedures and had a baseline creatinine > 1.6 mg/dl or creatinine clearance of < 60 ml/min. Patients were randomly assigned to receive either saline (0.45% normal saline at 1 cc/kg) for 12 hr before and 12 hr after the procedure, or fenoldopam (0.1 microg/kg/min) plus saline for 4 hr prior and 4 hr after the procedure, or NAC orally (600 mg) plus saline every 12 hr for 24 hr prior and 24 hr after the procedure. All the patients received low-osmolality nonionic contrast. RCIN was defined as an increase in creatinine level > 0.5 mg/dl after 48 hr. The incidence of RCIN was 17.7% in the NAC group, 15.3% in the saline group, and 15.7% in the fenoldopam group (P = 0.919). Of the 20 patients who developed RCIN, 2 required dialysis. Serum creatinine decreased after 48 hr (vs. baseline) in 38% patients in the NAC group, 18% in the fenoldopam group, and 15% in the saline group. In patients with chronic renal insufficiency, NAC or fenoldopam offered no additional benefit over hydration with saline in preventing RCIN.
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Affiliation(s)
- Suhail Allaqaband
- Department of Cardiology, University of Wisconsin Medical School, Milwaukee Clinical Campus, Aurora-Sinai Medical Center, Milwaukee, Wisconsin 53201, USA.
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867
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Soma VR, Cavusoglu E, Vidhun R, Frishman WH, Sharma SK. Contrast-associated nephropathy. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:372-9. [PMID: 12441014 DOI: 10.1097/00132580-200211000-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Contrast-associated nephropathy (CaN) has become a major cause of iatrogenic acute renal failure, especially with the increasing use of radiographic contrast media in both diagnostic and interventional procedures. CaN is the third most common cause of iatrogenic acute renal failure, and is associated with increased morbidity and in-hospital mortality. CaN typically presents as an acute rise in serum creatinine levels, usually within 48 hours after exposure to contrast media. Renal medullary ischemia secondary to contrast-induced vasoconstriction is now believed to be the most likely cause of CaN, although direct renal tubular cytotoxicity does appear to play a role. The occurrence of CaN is directly related to the number of coexisting clinical risk factors. Among the many risk factors, preexisting renal impairment, the presence of diabetes mellitus and the volume of the contrast agent administered are the most important. The most effective means of reducing the incidence of CaN is through prevention, by first identifying the risk factors and then attempting to correct for them before the administration of contrast material. Although the earliest and most well-tested preventive measure, namely intravenous hydration, continues to be the most effective way to prevent CaN, recent studies have provided many new preventive modalities. The growing use of these new agents, such as acetylcysteine, endothelin blockers, and most recently fenoldopam, has increased the options available for the prevention of CaN.
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Affiliation(s)
- Vikas R Soma
- Department of Medicine, Bronx VA Medical Center, Bronx, New York, USA
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868
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Shyu KG, Cheng JJ, Kuan P. Acetylcysteine protects against acute renal damage in patients with abnormal renal function undergoing a coronary procedure. J Am Coll Cardiol 2002; 40:1383-8. [PMID: 12392825 DOI: 10.1016/s0735-1097(02)02308-2] [Citation(s) in RCA: 212] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES We sought to evaluate the efficacy of the antioxidant acetylcysteine in limiting the nephrotoxicity after coronary procedures. BACKGROUND The increasingly frequent use of contrast-enhanced imaging for diagnosis or intervention in patients with coronary artery disease has generated concern about the avoidance of contrast-induced nephrotoxicity (CIN). Reactive oxygen species have been shown to cause CIN. METHODS We prospectively studied 121 patients with chronic renal insufficiency (mean [+/-SD] serum creatinine concentration 2.8 +/- 0.8 mg/dl) who underwent a coronary procedure. Patients were randomly assigned to receive either acetylcysteine (400 mg orally twice daily) and 0.45% saline intravenously, before and after injection of the contrast agent, or placebo and 0.45% saline. Serum creatinine and blood urea nitrogen were measured before, 48 h and 7 days after the coronary procedure. RESULTS Seventeen (14%) of the 121 patients had an increase in their serum creatinine concentration of at least 0.5 mg/dl at 48 h after administration of the contrast agent: 2 (3.3%) of the 60 patients in the acetylcysteine group and 15 (24.6%) of the 61 patients in the control group (p < 0.001). In the acetylcysteine group, the mean serum creatinine concentration decreased significantly from 2.8 +/- 0.8 to 2.5 +/- 1.0 mg/dl (p < 0.01) at 48 h after injection of the contrast medium, whereas in the control group, the mean serum creatinine concentration increased significantly from 2.8 +/- 0.8 to 3.1 +/- 1.0 mg/dl (p < 0.01). CONCLUSIONS Prophylactic oral administration of the antioxidant acetylcysteine, along with hydration, reduces the acute renal damage induced by a contrast agent in patients with chronic renal insufficiency undergoing a coronary procedure.
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Affiliation(s)
- Kou Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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869
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Stamatakis MK. Strategies for Treatment and Prevention of Acute Renal Failure. J Pharm Pract 2002. [DOI: 10.1177/089719002237255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute renal failure (ARF) is a potentially life-threatening medical condition that often complicates the hospitalization of critically ill patients. A variety of therapeutic strategies has been studied for both preventing ischemic and nephrotoxic injury to the kidney and improving renal function in established ARF. This article summarizes the role of pharmacologic therapy in the treatment of ARF. Strategies to reduce extracellular fluid volume and preserve renal function with loop diuretics, low-dose dopamine, and renal replacement therapy will be discussed. The value of preventative therapy has increased, and identifying patients at high risk for development of ARF is critical. Modification of drug regimens, administration of less nephrotoxic medications, and volume expansion prior to nephrotoxin administration can minimize toxicity to the kidney. The search for new agents that can improve survival, decrease the need for renal replacement therapy, and hasten the recovery of renal function in ARF is ongoing.
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870
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Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, Rosenfield K, White C, Bettmann M, Cortell S, Puschett J, Clair DG, Cole P. Guidelines for the reporting of renal artery revascularization in clinical trials. J Vasc Interv Radiol 2002; 13:959-74. [PMID: 12397117 DOI: 10.1016/s1051-0443(07)61860-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Although the treatment of atherosclerotic renal artery stenosis with use of percutaneous angioplasty, stent placement, and surgical revascularization has gained widespread use, there exist few prospective randomized controlled trials (RCTs) comparing these techniques to each other or against the standard of medical management alone. To facilitate this process as well as help answer many important questions regarding the appropriate application of renal revascularization, well-designed and rigorously conducted trials are needed. These trials must have clearly defined goals and must be sufficiently sized and performed so as to withstand intensive outcomes assessment. Toward this end, this document provides guidelines and definitions for the design, conduct, evaluation, and reporting of renal artery revascularization RCTs. In addition, areas of critically necessary renal artery revascularization investigation are identified. It is hoped that this information will be valuable to the investigator wishing to conduct research in this important area.
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Affiliation(s)
- John H Rundback
- Columbia Presbyterian Medical Center, Milstein Pavilion, Vascular and Interventional Radiology, New York, NY 10032, USA.
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871
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Zeller T, Müller C, Frank U, Bürgelin K, Sinn L, Horn B, Flügel PC, Roskamm H. Gadodiamide as an Alternative Contrast Agent During Angioplasty in Patients With Contraindications to Iodinated Media. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0625:gaaaca>2.0.co;2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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872
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Zeller T, Müller C, Frank U, Bürgelin K, Sinn L, Horn B, Flügel PC, Roskamm H. Gadodiamide as an alternative contrast agent during angioplasty in patients with contraindications to iodinated media. J Endovasc Ther 2002; 9:625-32. [PMID: 12431148 DOI: 10.1177/152660280200900514] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate gadodiamide as an alternative contrast agent for peripheral and renal angioplasty in patients with contraindications to iodinated contrast media. METHODS Seventeen patients (10 men; mean age 74 years, range 68-83) with contraindication to iodinated contrast media were given gadodiamide as the contrast agent during peripheral and renal intra-arterial digital subtraction angiography (DSA) and subsequent percutaneous interventions (balloon angioplasty, stent placement). RESULTS The mean volume of gadodiamide used was 136 +/- 46 mL (range 60-200). No serious side effects were observed, especially no change in renal or thyroid function; no exanthema or other allergic reactions were noted. In patients without renal artery intervention, serum creatinine at discharge remained unchanged (2.57 +/- 1.43 mg/dL to 2.40 +/- 1.28 mg/dL, p=NS). In patients undergoing angioplasty/stenting of renal artery stenoses, serum creatinine decreased significantly from 3.53 +/- 1.75 mg/dL to 2.36 +/- 1.15 mg/dL (p<0.01). All but 1 intervention was successful. Using a simple scoring system, 2 judges blinded to the contrast agent graded the quality of the peripheral DSAs as "good," whereas renal DSA images were only "sufficient." CONCLUSIONS For patients with contraindications to iodinated materials, gadodiamide may be a suitable alternative for renal or peripheral DSA followed by angioplasty.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Herz-Zentrum Bad Krozingen, Germany.
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873
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Affiliation(s)
- Jose M Wiley
- Section of Invasive Cardiology, Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana 70121, USA
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874
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Le Blanche AF, Tassart M, Deux JF, Rossert J, Bigot JM, Boudghene F. Gadolinium-enhanced digital subtraction angiography of hemodialysis fistulas: a diagnostic and therapeutic approach. AJR Am J Roentgenol 2002; 179:1023-8. [PMID: 12239059 DOI: 10.2214/ajr.179.4.1791023] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the feasibility, safety, and potential role of the contrast agent gadoterate meglumine for digital subtraction angiography as a single diagnostic procedure or before percutaneous transluminal angioplasty of malfunctioning native dialysis fistulas. MATERIALS AND METHODS Over a 20-month period, 23 patients (15 women, eight men) with an age range of 42-87 years (mean, 63 years) having end-stage renal insufficiency and with recent hemodialysis fistula surgical placement underwent gadoterate-enhanced digital subtraction angiography with a digital 1024 x 1024 matrix. Opacification was performed on the forearm, arm, and chest with the patient in the supine position using an injection (retrograde, n = 14; anterograde, n = 8; arterial, n = 1) of gadoterate meglumine into the perianastomotic fistula segment at a rate of 3 mL/sec for a total volume ranging from 24 to 32 mL. Percutaneous transluminal angioplasty was performed in three patients and required an additional 8 mL per procedure. Examinations were compared using a 3-step confidence scale and a two-radiologist agreement (Cohen's kappa statistic) for diagnostic and opacification quality. Tolerability was evaluated on the basis of serum creatinine levels and the development of complications. RESULTS No impairment of renal function was found in the 15 patients who were not treated with hemodialysis. Serum creatinine level change varied from -11.9% to 11.6%. All studies were of diagnostic quality. The presence of stenosis (n = 14) or thrombosis (n = 3) in arteriovenous fistulas was shown with good interobserver agreement (kappa = 0.71-0.80) in relation to opacification quality (kappa = 0.59-0.84). No pain, neurologic complications, or allergiclike reactions occurred. Three percutaneous transluminal angioplasty procedures (brachiocephalic, n = 2; radiocephalic, n = 1) were successfully performed. CONCLUSION Gadoterate-enhanced digital subtraction angiography is an effective and safe method to assess causes of malfunction of hemodialysis fistulas. It can also be used to plan and perform percutaneous transluminal angioplasty.
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875
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Rundback JH, Weintraub JL. Renal vascular interventions. Semin Roentgenol 2002; 37:312-26. [PMID: 12455129 DOI: 10.1016/s0037-198x(02)80008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- John H Rundback
- New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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876
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877
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Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, Rosenfield K, White C, Bettmann M, Cortell S, Puschett J, Clair D, Cole P. Guidelines for the reporting of renal artery revascularization in clinical trials. American Heart Association. Circulation 2002; 106:1572-85. [PMID: 12234967 DOI: 10.1161/01.cir.0000029805.87199.45] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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878
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Affiliation(s)
- Pinak B Shah
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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879
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Abstract
PURPOSE OF REVIEW Radiographic contrast media are used at an increasing rate for several diagnostic and therapeutic applications. Therefore, contrast agent-induced nephropathy will become more important, including the risk of patient impairment and costs. The prevention of radiographic contrast-induced nephropathy is mandatory. Radiographic contrast agent-induced nephropathy is caused by vasoconstriction-mediated renal medullary ischaemia and direct toxic damage to renal tubular epithelial cells. These effects may be partly mediated by the generation of reactive oxygen species. Data from experimental studies indicate that antioxidants, e.g. acetylcysteine, may prevent radiocontrast-induced nephropathy. RECENT FINDINGS Two prospective, randomized, placebo-controlled studies in patients with moderate renal insufficiency confirmed that the prophylactic oral administration of acetylcysteine, at a dose of 600 mg twice a day along with hydration, prevents the reduction in renal function after radiocontrast administration. SUMMARY The use of acetylcysteine together with hydration is the treatment of choice to protect against radiographic contrast media-induced nephropathy.
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Affiliation(s)
- Martin Tepel
- Medizinische Klinik IV, Universitätsklinikum Benjamin-Franklin, Freie Universität, Berlin, Germany.
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880
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Chamsuddin AA, Kowalik KJ, Bjarnason H, Dietz CA, Rosenberg MS, Gomes MD, McDermott CM, Hunter DW. Using a dopamine type 1A receptor agonist in high-risk patients to ameliorate contrast-associated nephropathy. AJR Am J Roentgenol 2002; 179:591-6. [PMID: 12185025 DOI: 10.2214/ajr.179.3.1790591] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The objective of our study was to evaluate the effects of fenoldopam mesylate, a dopamine type 1A receptor agonist and a potent renal vasodilator that markedly increases renal blood flow, on kidney function of patients who were receiving iodinated contrast material for an interventional procedure and thought to be at high risk of contrast-associated nephropathy. MATERIALS AND METHODS We retrospectively reviewed the records of all patients who received fenoldopam mesylate to determine the acute and, when possible, the longer term effects on kidney function. RESULTS Twenty-nine cases were reviewed. The average serum creatinine value before contrast administration was 2.55 mg/dL (range, 1.3-5.8 mg/dL) [corrected]. Twenty-four hours after contrast administration, serum creatinine was measured in 28 of the 29 patients. The serum creatinine values had decreased in 16 of the 28 patients by an average of 0.55 mg/dL [corrected]. In nine patients, the serum creatinine value had not changed. Two of the three increases in the serum creatinine value appear to have been caused primarily by problems that did not involve the contrast material. CONCLUSION The use of fenoldopam mesylate at appropriate doses offers patients at high risk for contrast-associated nephropathy a chance to avoid this complication. To learn the extent and true nature of the effect of fenoldopam mesylate in this patient population requires a rigorous scientific trial, which is currently underway.
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Affiliation(s)
- Abbas A Chamsuddin
- Department of Radiology, Cardiovascular and Interventional Radiology, University of Tennessee, 865 Jefferson Ave., Ste. 121C, Memphis, TN 38163, USA
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881
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Brophy DF. Role of N-acetylcysteine in the prevention of radiocontrast-induced nephropathy. Ann Pharmacother 2002; 36:1466-70. [PMID: 12196069 DOI: 10.1345/aph.1a482] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the role of N-acetylcysteine (NAC) in the prevention of radiocontrast-induced nephropathy (RIN). DATA SOURCES A literature search of MEDLINE (1966-December 2001) was performed using the following search terms: N-acetylcysteine, nephropathy, acute renal failure, and radiocontrast. STUDY SELECTION Pertinent English-language animal and human studies were reviewed. DATA SYNTHESIS Few small animal trials have demonstrated that NAC significantly prevents the development or reduces the severity of acute renal failure. Two human studies demonstrated NAC significantly reduces the occurrence of RIN. CONCLUSIONS NAC may reduce the occurrence of RIN in high-risk patients. Further large-scale studies are needed to corroborate findings from earlier trials.
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Affiliation(s)
- Donald F Brophy
- Department of Pharmacy, Virginia Commonwealth University/Medical College of Virginia School of Pharmacy, PO Box 980533, Richmond, VA 23298-0533, USA.
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882
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Abstract
BACKGROUND Acute renal failure (ARF) is a common condition in hospitalized patients. Research has been unable to identify the optimal target for therapeutic intervention; hence, effective prevention of and/or treatment for ARF remain elusive. OBJECTIVE To examine the usefulness of current and potential pharmacologic treatments in seriously ill, hospitalized patients. DATA SOURCES A MEDLINE search (1996-June 2002) was conducted using the search terms kidney (drug effects) and acute kidney failure (drug therapy). Bibliographies of selected articles were also examined to include all relevant investigations. STUDY SELECTION AND DATA EXTRACTION Review articles, meta-analyses, and clinical trials describing prevention of and treatment for hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available. CONCLUSIONS Appropriate management of ARF includes prospective identification of at-risk patients, fluid administration, and optimal hemodynamic support. Drug treatments, including low-dose dopamine and diuretics, have demonstrated extremely limited benefits and have not been shown to improve patient outcome. Experimental agents influence cellular processes of renal dysfunction and recovery; unfortunately, relatively few drugs show promise for the future.
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Affiliation(s)
- Maria C Pruchnicki
- Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University, Columbus, OH 43210-1291, USA.
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883
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884
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Sabeti S, Schillinger M, Mlekusch W, Ahmadi R, Minar E. Reduction in renal function after renal arteriography and after renal artery angioplasty. Eur J Vasc Endovasc Surg 2002; 24:156-60. [PMID: 12389239 DOI: 10.1053/ejvs.2002.1655] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the incidence and risk factors for renal function deterioration after renal angiography and angioplasty or stenting. METHODS A retrospective study of 85 consecutive patients undergoing selective renal artery arteriography (n = 53) or renal artery angioplasty % (PTRA) stenting (n = 32) for renal artery stenosis. Multivariate logistic regression analysis was used to determine independent predictors of deterioration of renal function, defined as an increase of serum creatinine by at least one third within 24 h. RESULTS Deterioration of renal function occurred in 13 patients (15%), [8/53 (15%) after angiography and 5/32 (16%) after PTRA/stenting]. Only pre-existing renal impairment (se-creatinine > or = 177 mumol/l) (Odds ratio: 40; 95% confidence interval 1.2-72, p = 0.02) and administered dosage of contrast agent (more than 225 ml) (OR 67; 95% CI 11.8-100, p = 0.02) were independently associated with renal function deterioration. CONCLUSION Transient renal dysfunction after renal artery angiography or PTRA/stenting occurs in about 15% of patients, but persistent renal failure is uncommon. Pre-existing renal impairment and amount of contrast agent are independent risk factors. Endovascular treatment of renal artery stenosis is not associated with a higher risk of renal deterioration compared to selective renal angiography.
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Affiliation(s)
- S Sabeti
- University of Vienna, Department of Angiology, Vienna General Hospital, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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885
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Lufft V, Hoogestraat-Lufft L, Fels LM, Egbeyong-Baiyee D, Tusch G, Galanski M, Olbricht CJ. Contrast media nephropathy: intravenous CT angiography versus intraarterial digital subtraction angiography in renal artery stenosis: a prospective randomized trial. Am J Kidney Dis 2002; 40:236-42. [PMID: 12148095 DOI: 10.1053/ajkd.2002.34501] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Spiral computed tomographic angiography (CTA) is a noninvasive method to diagnose renal artery stenosis (RAS). In digital subtraction angiography (DSA), contrast media (CM) is injected directly into the renal artery; in CTA, a greater amount of CM is injected intravenously, potentially leading to an increased incidence of CM nephropathy. METHODS We investigated 80 patients with suspected RAS randomized to either CTA or DSA prospectively. The following parameters were determined: serum creatinine level and single-shot inulin clearance for evaluation of renal function and urine alpha1-microglobulin and beta-N-acetyl-glucoseaminidase (beta-NAG) as markers for tubular toxicity. Data from 16 patients undergoing angioplasty in the same session were excluded. RESULTS In the CTA and DSA groups, 163 +/- 13 and 104 +/- 56 mL of CM (mean +/- SD; P < 0.0001) were administered, respectively. Mean serum creatinine levels increased from 1.78 +/- 1.61 to 1.92 +/-1.73 mg/dL (157 +/- 142 to 170 +/- 153 micromol/L; P = 0.00001) in the CTA group and from 1.52 +/- 1.23 to 1.60 +/- 1.28 mg/dL (134 +/- 109 to 141 +/- 113 micromol/L; P = 0.01) in the DSA group. Mean inulin clearance decreased from 63 +/- 28 to 58 +/- 23 mL/min (P = 0.01) and 65 +/- 26 to 62 +/- 26 mL/min (P < 0.01), median beta-NAG levels increased from 4.6 to 6.0 U/g creatinine (P = not significant) and 2.5 to 8.0 U/g creatinine (P < 0.001), and median alpha1-microglobulin levels increased from 13 to 17 microg/g creatinine (P < 0.025) and 11 to 21 microg/g creatinine (P = not significant) in the CTA and DSA groups, respectively. CM nephropathy occurred in 3 of 33 patients in the CTA group and 2 of 31 patients in the DSA group. The increase in creatinine level was reversible in all patients within 7 days. CONCLUSION On this study, CTA performed for the detection of RAS is not associated with an increased risk for CM nephropathy compared with intraarterial DSA despite a greater dose of CM.
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Affiliation(s)
- Volkmar Lufft
- Abteilung Nephrologie, Abteilung Diagnostische Radiologie, Klinik für Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Germany.
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886
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Hizoh I, Haller C. Radiocontrast-induced renal tubular cell apoptosis: hypertonic versus oxidative stress. Invest Radiol 2002; 37:428-34. [PMID: 12138358 DOI: 10.1097/00004424-200208000-00003] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES Radiocontrast-induced nephropathy (RCIN) is a major complication of intravascular radiocontrast administration. Renal tubular cell apoptosis is a feature of RCIN, which is related to hypertonicity of contrast agents. Because a hyperosmolal extracellular environment induces oxidative stress via reactive oxygen species, we tested the hypothesis that antioxidants decrease hypertonicity-induced apoptosis of renal epithelial cells. We analyzed the effects of the antioxidants N-acetylcysteine (NAC) and taurine on hypertonicity-induced apoptosis of renal epithelial cells in vitro. METHODS Madin Darby Canine Kidney (MDCK) cells were incubated with the highly hyperosmolal, ionic radiocontrast agent diatrizoate (20% vol/vol, 6 hours) or with equally hyperosmolal (640 mOsm/kg) NaCl solutions. DNA fragmentation, which is a hallmark feature of apoptosis, was assessed quantitatively using flow cytometry after propidium iodide staining and qualitatively using agarose gel electrophoresis. RESULTS Both diatrizoate and NaCl induced DNA fragmentation in MDCK cells. Taurine (10 mmol/L) reduced DNA degradation in both diatrizoate- [79.5 +/- 2.3% versus 72.2 +/- 3.0%; P = 0.0088] and NaCl- [49.5 +/- 4.0% versus 39.4 +/- 1.0%; P = 0.0271] treated cells. In contrast, NAC (10 mmol/L) failed to reduce the DNA breakdown in this model of hypertonicity-induced renal tubular cell apoptosis. CONCLUSIONS The radiocontrast/hypertonicity-induced DNA fragmentation of MDCK cells is attenuated by taurine but not by NAC. Because both agents are antioxidants, the antioxidant property is not sufficient for the observed cytoprotective effect. Hence, the antiapoptotic effect of taurine has to be attributed to other, yet to be defined mechanisms. Our results suggest that pharmacological doses of taurine may be particularly protective against RCIN.
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Affiliation(s)
- Istvan Hizoh
- Department of Cardiology and Internal Medicine, Semmelweis University, Budapest, Hungary
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887
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Briguori C, Manganelli F, Scarpato P, Elia PP, Golia B, Riviezzo G, Lepore S, Librera M, Villari B, Colombo A, Ricciardelli B. Acetylcysteine and contrast agent-associated nephrotoxicity. J Am Coll Cardiol 2002; 40:298-303. [PMID: 12106935 DOI: 10.1016/s0735-1097(02)01958-7] [Citation(s) in RCA: 263] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Prophylactic acetylcysteine along with hydration seems to be better than hydration alone in preventing the reduction in renal function induced by a contrast dye. BACKGROUND Contrast media can lead to acute renal failure that may occasionally require hemodialysis. METHODS One hundred eighty-three consecutive patients with impairment of renal function, undergoing coronary and/or peripheral angiography and/or angioplasty, were randomly assigned to receive 0.45% saline intravenously and acetylcysteine (600 mg orally twice daily; group A, n = 92) or 0.45% saline intravenously alone (group B, n = 91) before and after nonionic, low-osmolality contrast dye administration. RESULTS The baseline serum creatinine concentrations were similar (1.5 +/- 0.4 mg/dl in group A vs. 1.5 +/- 0.4 mg/dl in group B; p = 0.37). An increase of > or =25% in the baseline creatinine level 48 h after the procedure occurred in 6 (6.5%) of 92 patients in group A and in 10 (11%) of 91 patients in group B (p = 0.22). In the subgroup with a low (<140 ml) contrast dose, renal function deterioration occurred in 5 (8.5%) of 60 patients in group B and in 0 of 60 patients in group A (p = 0.02; odds ratio [OR] 0.44, 95% confidence interval [CI] 0.35 to 0.54). In the subgroup with a high contrast dose, no difference was found (5/31 vs. 6/32 patients, p = 0.78). By multivariate analysis, the amount of contrast agent, but not the treatment strategy, was a predictor of the occurrence of contrast dye-associated nephrotoxicity (OR 2.58, 95% CI 1.1 to 4.9; p = 0.035). CONCLUSIONS In patients with reduced renal function undergoing angiography and/or angioplasty, the amount of contrast agent, but not the administration of prophylactic acetylcysteine, was a predictor of renal function deterioration. Prophylactic acetylcysteine might provide better protection than hydration alone, only when a small volume of contrast agent is used.
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Affiliation(s)
- Carlo Briguori
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Via Orazio 2, I-80121 Naples, Italy.
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888
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Dwyer KM, Vrazas JI, Lodge RS, Humphery TJ, Schlicht SM, Murphy BF, Mossop PJ, Goodman DJ. Treatment of acute renal failure caused by renal artery occlusion with renal artery angioplasty. Am J Kidney Dis 2002; 40:189-94. [PMID: 12087578 DOI: 10.1053/ajkd.2002.33929] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Renovascular disease is a common cause of renal impairment and hypertension, particularly in the older population. Oligoanuric acute renal failure secondary to renal artery occlusion is not well recognized; however, it is potentially reversible if identified and treated. METHODS Five patients presented to our institution with oligoanuric acute renal failure. Each had evidence of vascular disease, and a prerenal insult was identified. They were investigated with renal artery Doppler ultrasound or nuclear imaging before proceeding to percutaneous angioplasty and stent placement. RESULTS The targeted kidney had relatively well-preserved renal size, and potential viability of the renal tissue was determined by nuclear scanning with parenchymal uptake of tracer. Percutaneous angioplasty and stent placement resulted in brisk reperfusion of the kidney and an immediate diuresis with improvement of renal function, avoiding supportive dialysis after the procedure. Contrast nephrotoxicity was identified in two of the five cases. CONCLUSION Renal artery occlusion should be considered as a cause of oliguric acute renal failure, particularly in patients at high risk who present with a sudden deterioration of renal function, with nuclear imaging showing potentially viable renal tissue with relatively well-preserved renal size. Percutaneous revascularization should be considered in this group.
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Affiliation(s)
- Karen M Dwyer
- Department of Nephrology, St.Vincent's Hospital, Melbourne, Australia.
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889
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Spinosa DJ, Angle JF, Hartwell GD, Hagspiel KD, Leung DA, Matsumoto AH. Gadolinium-based contrast agents in angiography and interventional radiology. Radiol Clin North Am 2002; 40:693-710. [PMID: 12171180 DOI: 10.1016/s0033-8389(02)00022-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gadolinium is useful as an alternative contrast agent for diagnostic angiographic and interventional procedures in patients with renal insufficiency or a history of a severe reaction to iodinated contrast material. Gadolinium usually is used as a "problem solver" to answer specific diagnostic questions or guide interventional procedures that cannot adequately be defined with CO2 angiography. Because of dose limitations with Gd, careful planning is required prior to its use with angiography or interventional procedures.
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Affiliation(s)
- David J Spinosa
- Department of Radiology, University of Virginia Health System, Charlottesville 22908, USA.
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890
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Huber W, Ilgmann K, Page M, Hennig M, Schweigart U, Jeschke B, Lutilsky L, Weiss W, Salmhofer H, Classen M. Effect of theophylline on contrast material-nephropathy in patients with chronic renal insufficiency: controlled, randomized, double-blinded study. Radiology 2002; 223:772-9. [PMID: 12034949 DOI: 10.1148/radiol.2233010609] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate whether the adenosine antagonist theophylline reduces the incidence of contrast material-induced nephropathy (serum creatinine level increase of at least 0.5 mg/dL [44.2 micromol/L] in 48 hours) in high-risk patients who have chronic renal insufficiency and have received at least 100 mL of contrast medium. MATERIALS AND METHODS One hundred patients with serum creatinine levels of 1.3 mg/dL (114.3 micromol/L) or greater were randomly assigned to intravenously receive 200 mg theophylline or saline 30 minutes before administration of 100 mL or more of low-osmolarity contrast medium arterially (72 [72%] patients) or intravenously (28 [28%] patients). RESULTS Patients receiving theophylline and control subjects were comparable with regard to risk factors for contrast-induced nephropathy such as mean serum creatinine level before contrast medium administration (2.07 mg/dL +/- 0.94 [SD] [182.9 micromol/L +/- 83.1] vs 1.92 mg/dL +/- 0.76 [169.7 micromol/L +/- 67.2], respectively), amount of contrast medium (196.5 mL +/- 84.1 vs 216.6 mL +/- 95.0, respectively), and diabetes prevalence. Theophylline prophylaxis significantly reduced the incidence of contrast material-induced nephropathy (4% vs 16%; P =.046). With theophylline, the mean serum creatinine level decreased nonsignificantly 12 (1.98 mg/dL +/- 0.77 [175.0 micromol/L +/- 68.1]; P =.09), 24 (1.97 mg/dL +/- 0.75 [174.1 micromol/L +/- 68.1]; P =.99), and 48 (1.94 mg/dL +/- 0.77 [171.5 micromol/L +/- 68.1]; P =.99)(1.94 mg/dL +/- 0.77 [171.5 micromol/L +/- 68.1]; P =.99) hours after contrast medium administration. With a placebo, serum creatinine level significantly increased 24 hours after contrast medium administration (2.01 mg/dL +/- 0.89 [177.7 micromol/L +/- 78.7]; P =.006). Urinary N-acetyl-beta-glucosaminidase level did not change with theophylline administration but significantly (P =.034) increased 24 hours after contrast medium administration with the placebo. CONCLUSION Prophylactic administration of 200 mg theophylline reduces the incidence of contrast material-induced nephropathy in patients with chronic renal insufficiency.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik, Klinische Chemie, Technical University of Munich, Germany.
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891
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Sochman J. N-acetylcysteine in acute cardiology: 10 years later: what do we know and what would we like to know?! J Am Coll Cardiol 2002; 39:1422-8. [PMID: 11985902 DOI: 10.1016/s0735-1097(02)01797-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
N-acetylcysteine (NAC) is known in a variety of branches of medicine. This paper addresses in detail the action of NAC as it is emerging from research and clinical trials over the past decade in cardiology, giving rise to new concepts. The result is a process resembling creation of a mosaic from individual pieces. Also, the role of NAC in acute cardiology, during acute reperfusion in particular, is defined.
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Affiliation(s)
- Jan Sochman
- Intensive care Unit, Institute for Clinical and Experimental Medicine, Prague, Czech
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892
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Agrawal M, Stouffer GA. Cardiology Grand Rounds from The University of North Carolina at Chapel Hill. Contrast induced nephropathy after angiography. Am J Med Sci 2002; 323:252-8. [PMID: 12018667 DOI: 10.1097/00000441-200205000-00004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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893
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Tumlin JA, Wang A, Murray PT, Mathur VS. Fenoldopam mesylate blocks reductions in renal plasma flow after radiocontrast dye infusion: a pilot trial in the prevention of contrast nephropathy. Am Heart J 2002; 143:894-903. [PMID: 12040355 DOI: 10.1067/mhj.2002.122118] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiocontrast nephropathy (RCN) is a common source of acute renal failure in hospitalized patients and is associated with increased morbidity and mortality rates. Fenoldopam mesylate is a dopamine A1 receptor agonist that augments renal plasma flow (RPF) in patients with normotensive and hypertensive conditions. To determine whether fenoldopam mesylate attenuates reductions in RPF after contrast infusion, we conducted a double-blind, randomized, placebo-controlled pilot trial of fenoldopam mesylate in patients who underwent contrast angiography. METHODS Fifty-one patients with chronic renal insufficiency (creatinine level, 2.0-5.0 mg/dL) who were undergoing contrast angiography were screened, and 45 patients were randomized to receive normal saline solution (1/2 NS) or 1/2 NS plus fenoldopam mesylate at 0.1 microg/kg/min at lease 1 hour before infusion with contrast dye. Serum creatinine level was measured at baseline and at 24, 48, and 72 hours after angiography. The primary endpoint was change in RPF 1 hour after contrast infusion. The secondary endpoint was incidence of RCN, defined as a 0.5 mg/dL or a 25% rise in serum creatinine level at 48 hours. RESULTS RPF at 1 hour after angiography was 15.8% above baseline in the fenoldopam mesylate group compared with 33.2% below baseline in the 1/2 NS group (P <.05). The incidence rate of RCN at 48 hours was 41.0% in the 1/2 NS group versus 21% in the fenoldopam mesylate group (P =.148). Among patients with diabetes, the incidence rate of RCN tended to be higher in the 1/2 NS group compared with the fenoldopam mesylate group (64% vs 33%; P =.14). The peak serum creatinine level at 72 hours after contrast infusion was significantly higher at in the 1/2 NS group (creatinine level, 3.6 +/- 1.0 mg/dL) compared with the fenoldopam mesylate group (creatinine level, 2.8 +/- 0.35 mg/dL; P <.05). RPF was significantly (P <.0001) reduced in patients with RCN compared with patients in whom RCN did not develop. CONCLUSION The results of this pilot trial suggest that fenoldopam mesylate is a promising prophylactic agent for RCN and that larger multicenter trials should be conducted to prove its efficacy.
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Affiliation(s)
- J A Tumlin
- Emory University School of Medicine, Atlanta, GA 30322, USA.
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894
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Anderson RJ. Recent advances and developments in the treatment of acute renal failure. Expert Opin Ther Pat 2002. [DOI: 10.1517/13543776.12.5.645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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895
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Spinosa DJ, Kaufmann JA, Hartwell GD. Gadolinium chelates in angiography and interventional radiology: a useful alternative to iodinated contrast media for angiography. Radiology 2002; 223:319-25; discussion 326-7. [PMID: 11997531 DOI: 10.1148/radiol.2232010742] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Gadolinium has physical properties that are well suited for radiographic imaging. Digital subtraction angiography with a gadolinium chelate as contrast medium can provide images of suitable quality for diagnosis and intervention. The overall safety profile of gadolinium-based contrast media is excellent. In particular, these contrast media are well tolerated in patients with renal insufficiency when administered intraarterially in doses of less than 0.3-0.4 mmol per kilogram body weight, with a decreased incidence of contrast medium-induced nephropathy, as compared with similar volumes of iodinated contrast material. The currently available formulations of gadolinium chelates can be injected safely into every arterial and venous structure. However, substantial data are lacking on the intraarterial use of gadolinium in patients with renal insufficiency, particularly at doses that exceed those routinely used in magnetic resonance angiography. Gadolinium chelates in appropriate volumes are useful alternative contrast media in selected high-risk patients undergoing angiographic studies.
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Affiliation(s)
- David J Spinosa
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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896
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Kini AS, Mitre CA, Kamran M, Suleman J, Kim M, Duffy ME, Marmur JD, Sharma SK. Changing trends in incidence and predictors of radiographic contrast nephropathy after percutaneous coronary intervention with use of fenoldopam. Am J Cardiol 2002; 89:999-1002. [PMID: 11950448 DOI: 10.1016/s0002-9149(02)02259-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Annapoorna S Kini
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA
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897
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Abstract
This article focuses on the epidemiology, pathogenesis, and prevention of the most common forms of acute renal failure encountered in the critically ill. These include pre-renal azotemia and acute tubular necrosis that occurs postoperatively, in patients with rhabdomyolysis, or as a complication of sepsis. In addition, some unusual causes of acute renal failure that occur predominantly in the intensive care unit are briefly discussed.
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Affiliation(s)
- Vivian E Abernethy
- Boston University School of Medicine, Renal Section, Evans Biomedical Research Center, 5th Floor, Room 537, 650 Albany Street, Boston, MA 02118, USA
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898
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Abstract
Malnutrition is common in severe liver disease. Assessment of malnutrition usually requires a subjective global assessment of the patient with a few additional tests that often include handgrip strength and arm-muscle circumference. The severity of liver disease correlates well with the severity of malnutrition, which has prognostic value. Malnutrition is multifactorial, is difficult to correct, and occurs in liver disease independently of the etiology of hepatic injury. Patients who have severe protein-calorie malnutrition require diets with high calorie and protein intake, even in the presence of hepatic encephalopathy. Some forms of complementary and alternative medicine are frequently used in patients with advanced liver disease, but supporting scientific data is needed. Obesity is detrimental to patients with advanced liver disease and is of greater concern in liver transplant candidates because it increases transplant-related morbidity. Data detailing the effects of aggressive nutritional support before transplantation are scarce, and more studies are needed.
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Affiliation(s)
- Luis S Marsano
- Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA.
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899
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Wu Z, Turner DR, Oliveira DBG. Antioxidants inhibit mercuric chloride-induced early vasculitis. Int Immunol 2002; 14:267-73. [PMID: 11867563 DOI: 10.1093/intimm/14.3.267] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the Brown Norway (BN) rat, mercuric chloride (HgCl(2)) induces a T(h)2-dominated autoimmune syndrome which includes an early phase of mast cell-dependent vasculitis. We have shown in vitro that oxidative stress up-regulates IL-4 in mast cells and predisposes to degranulation. The aim of this study was to determine whether administration of antioxidants inhibits HgCl(2)-induced early vasculitis in vivo, and, if so, to examine whether modulation of the oxidative/antioxidative balance influences IgE and IL-4 expression by mast cells in situ. Groups of rats were given HgCl(2) + saline, HgCl(2) + N-acetyl-L-cysteine (NAC), saline + saline or saline + NAC respectively and blood was taken and animals killed 48 h later. NAC significantly reduced both HgCl2-induced early vasculitis and HgCl(2)-enhanced IgE expression on mast cells with a trend to a decrease in HgCl(2)-enhanced IL-4 expression in these cells. In addition, there was an increased rat mast cell protease (RMCP) II concentration in the serum after HgCl(2) injection and the elevated levels of RMCP II stimulated by HgCl(2) were totally abolished by the administration NAC in the HgCl(2) + NAC group. However, there was no significant change in serum total IgE concentrations between the HgCl(2) + saline group and the HgCl(2) + NAC group. The non-sulphydryl-containing antioxidants desferrioxamine and pyruvate demonstrated a similar effect in inhibiting HgCl(2)-induced early vasculitis. Our data show that administration of an antioxidant to BN rats reduces HgCl(2)-induced early vasculitis, suggesting that oxidative stress plays a role in the pathogenesis of HgCl(2)-induced early vasculitis. This finding may have implications for the understanding of the initiation in this experimental model of T(h)2 cell-driven autoimmunity and possibly of analogous human diseases.
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Affiliation(s)
- Zhonglin Wu
- Division of Renal Medicine, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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900
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Kloner RA, Textor SC, Tavel ME. Renovascular hypertension: problems in evaluation and management. Chest 2002; 121:964-8. [PMID: 11888983 DOI: 10.1378/chest.121.3.964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Robert A Kloner
- Heart Institute, Good Samaritan Hospital and Section of Cardiology, University of Southern California, Los Angeles, CA, USA
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