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Prevention of contrast-induced nephropathy through a knowledge of its pathogenesis and risk factors. ScientificWorldJournal 2014; 2014:823169. [PMID: 25525625 PMCID: PMC4266998 DOI: 10.1155/2014/823169] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 09/30/2014] [Indexed: 12/13/2022] Open
Abstract
Contrast-induced nephropathy (CIN) is an iatrogenic acute renal failure (ARF) occurring after the intravascular injection of iodinated radiographic contrast media. During the past several years, in many patients undergoing computed tomography, iodinated contrast media have not been used for the fear of ARF, thereby compromising the diagnostic procedure. But recent studies have demonstrated that CIN is rarely occurring in patients with normal renal function and that preexisting chronic renal failure and/or diabetes mellitus represent(s) predisposing condition(s) for its occurrence. After the description of CIN and its epidemiology and pathophysiology, underlying the important role played by dehydration and salt depletion, precautions for prevention of CIN are listed, suggested, and discussed. Maximum priority has to be given to adequate hydration and volume expansion prior to radiographic procedures. Other important precautions include the need for monitoring renal function before, during, and after contrast media injection, discontinuation of potentially nephrotoxic drugs, use of either iodixanol or iopamidol at the lowest dosage possible, and administration of antioxidants. A long list of references is provided that will enable readers a deep evaluation of the topic.
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52
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Lauver DA, Carey E.G, Bergin IL, Lucchesi BR, Gurm HS. Sildenafil citrate for prophylaxis of nephropathy in an animal model of contrast-induced acute kidney injury. PLoS One 2014; 9:e113598. [PMID: 25426714 PMCID: PMC4245209 DOI: 10.1371/journal.pone.0113598] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/29/2014] [Indexed: 01/08/2023] Open
Abstract
Contrast-induced acute kidney injury (CIAKI) is one of the commonest complications associated with contrast media (CM). Although the exact etiology of CIAKI remains unclear, one hypothesis involves vasoconstriction of afferent arterioles resulting in renal ischemia. Increased renal blood flow, therefore, might represent an attractive target for the treatment of CIAKI. In this study we evaluated the protective effects of the phosphodiesterase type 5 (PDE5) inhibitor, sildenafil citrate, in a rabbit model of CIAKI. New Zealand white rabbits were used due to their susceptibility to CIAKI. To evaluate the effects of sildenafil, the drug was administered before CM infusion and repeatedly throughout the remainder of the experiment (6 mg/kg, p.o.). Animals were sacrificed after 48 hours and kidneys were prepared for histological evaluation. Intravenous administration of CM produced marked kidney injury. Serum creatinine concentrations were elevated within two hours of the infusion and remained elevated for the duration of the experiment. Histological evaluation of the kidneys revealed significant tubular necrosis. The effects of the CM were dose dependent. Treatment with sildenafil was associated with lesser degree of histological injury, attenuation in markers of acute kidney injury (48 hour creatinine 1.54±0.21 versus 4.42±1.31 mg/dl, p<0.05) and reduction in electrolyte derangement (percent change in serum K+ at 48 hours 2.55±3.80% versus 15.53±4.47%, p<0.05; serum Na+ at 48 hours −0.14±0.26% versus −1.97±1.29%, p = 0.20). The results suggest a possible role for PDE5 inhibitors in the treatment of CIAKI and warrant further evaluation to determine the exact mechanism of protection.
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Affiliation(s)
- D. Adam Lauver
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, United States
- * E-mail:
| | - E . Grant Carey
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, United States
| | - Ingrid L. Bergin
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Benedict R. Lucchesi
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, United States
| | - Hitinder S. Gurm
- Department of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States
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53
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The Choice of the Iodinated Radiographic Contrast Media to Prevent Contrast-Induced Nephropathy. ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/691623] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In patients with preexisting renal impairment, particularly those who are diabetic, the iodinated radiographic contrast media may cause contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury (CI-AKI), that is, an acute renal failure (ARF), usually nonoliguric and asymptomatic, occurring 24 to 72 hours after their intravascular injection in the absence of an alternative aetiology. Radiographic contrast media have different osmolalities and viscosities. They have also a different nephrotoxicity. In order to prevent CIN, the least nephrotoxic contrast media should be chosen, at the lowest dosage possible. Other prevention measures should include discontinuation of potentially nephrotoxic drugs, adequate hydration with i.v. infusion of either normal saline or bicarbonate solution, and eventually use of antioxidants, such as N-acetylcysteine, and statins.
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54
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Hassan K, Fadi H. Is hypoalbuminemia a prognostic risk factor for contrast-induced nephropathy in peritoneal dialysis patients? Ther Clin Risk Manag 2014; 10:787-95. [PMID: 25328394 PMCID: PMC4199564 DOI: 10.2147/tcrm.s70665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective Residual renal function (RRF) is an important predictor of outcome in peritoneal dialysis (PD) patients. Hypoalbuminemia was found to be an independent risk factor for the development of acute kidney injury. We investigated the possibility of an association between serum albumin levels and the development of iodine contrast media-induced nephropathy (CIN) in PD patients. Methods A total of 103 PD patients who underwent invasive angiographies with exposure to iodine contrast media (ICM) were reviewed retrospectively. All patients received 0.9% saline intravenously at a rate of 75 mL per hour for 12 hours prior, during, and 12 hours after exposure to ICM. Acetylcysteine was given orally at a dose of 600 mg twice daily, on the day before and on the day of exposure to ICM. The nonionic, low-osmolar contrast agent iopromide was used at a mean dose of 75.0±15.2 mL. The changes in RRF from baseline to 1 week and 4 weeks after exposure to ICM were recorded. Outcomes of patients with serum albumin levels <3.8 g/dL and those with serum albumin levels ≥3.8 g/dL were compared. A reduction >30% in RRF at 7 days after exposure to ICM was considered CIN. Results CIN developed in 27.2% (28/103) of patients. Of the 103 patients, 59.2% (61) had serum albumin levels <3.8 g/dL. Of those, 37.7% (23/61) developed CIN, compared with 11.9% (5/42) of those with serum albumin levels ≥3.8 g/dL (P=0.004). After adjustment for all tested variables in a logistic regression with a stepwise selection model, serum albumin level at exposure to ICM was found to be the most powerful predictor of the development of CIN (odds ratio =4.5; confidence interval =1.5–13.0; P=0.006). Conclusion PD patients with serum albumin levels <3.8 g/dL should be monitored carefully when exposed to ICM. Serum albumin level may be considered a potential therapeutic target in the prevention of CIN and preservation of RRF in PD patients.
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Affiliation(s)
- Kamal Hassan
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel ; Peritoneal Dialysis Unit, Galilee Medical Center, Nahariya, Israel
| | - Hassan Fadi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Andreucci M, Faga T, Pisani A, Sabbatini M, Michael A. Acute kidney injury by radiographic contrast media: pathogenesis and prevention. BIOMED RESEARCH INTERNATIONAL 2014; 2014:362725. [PMID: 25197639 PMCID: PMC4150431 DOI: 10.1155/2014/362725] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 07/07/2014] [Indexed: 12/14/2022]
Abstract
It is well known that iodinated radiographic contrast media may cause kidney dysfunction, particularly in patients with preexisting renal impairment associated with diabetes. This dysfunction, when severe, will cause acute renal failure (ARF). We may define contrast-induced Acute Kidney Injury (AKI) as ARF occurring within 24-72 hrs after the intravascular injection of iodinated radiographic contrast media that cannot be attributed to other causes. The mechanisms underlying contrast media nephrotoxicity have not been fully elucidated and may be due to several factors, including renal ischaemia, particularly in the renal medulla, the formation of reactive oxygen species (ROS), reduction of nitric oxide (NO) production, and tubular epithelial and vascular endothelial injury. However, contrast-induced AKI can be prevented, but in order to do so, we need to know the risk factors. We have reviewed the risk factors for contrast-induced AKI and measures for its prevention, providing a long list of references enabling readers to deeply evaluate them both.
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Affiliation(s)
- Michele Andreucci
- Nephrology Unit, Department of Health Sciences, “Magna Graecia” University, Campus “Salvatore Venuta”, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
| | - Teresa Faga
- Nephrology Unit, Department of Health Sciences, “Magna Graecia” University, Campus “Salvatore Venuta”, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
| | - Antonio Pisani
- Nephology Unit, Department of Public Health, “Federico II” University, Via Pansini no. 5, 80131 Naples, Italy
| | - Massimo Sabbatini
- Nephology Unit, Department of Public Health, “Federico II” University, Via Pansini no. 5, 80131 Naples, Italy
| | - Ashour Michael
- Nephrology Unit, Department of Health Sciences, “Magna Graecia” University, Campus “Salvatore Venuta”, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
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56
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Andreucci M, Faga T, Russo D, Bertucci B, Tamburrini O, Pisani A, Sabbatini M, Fuiano G, Michael A. Differential activation of signaling pathways by low-osmolar and iso-osmolar radiocontrast agents in human renal tubular cells. J Cell Biochem 2014; 115:281-9. [PMID: 24023012 DOI: 10.1002/jcb.24662] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 08/19/2013] [Indexed: 11/10/2022]
Abstract
Radiocontrast media (RCM)-induced nephrotoxicity (CIN) is a major clinical problem accounting for 12% of all hospital-acquired cases of acute kidney injury (AKI). The pathophysiology of AKI due to RCM is not well understood, but direct toxic effects on renal cells have been postulated as contributing to CIN. It is believed that iso-osmolar RCM (IOCM) are less nephrotoxic than low-osmolar RCM (LOCM) but clinical data have been controversial. We have investigated the intracellular signaling pathways that may be affected by the LOCM iomeprol (IOM) and the IOCM iodixanol (IOD). Both IOM and IOD caused a dramatic decrease in phosphorylation of the kinase Akt at Ser473 and Thr308 in human renal tubular (HK-2) cells, with IOM having a greater effect; IOM also caused a greater decrease in cell viability. IOM also had a greater effect on phosphorylation of p38 MAP kinases, JNKs, and NF-kB (Ser276), and caused a marked decrease in the phosphorylation of forkhead box O3a (FOXO3a) and signal transducer and activator of transcription 3 (STAT3). However, IOD caused a greater decrease in the phosphorylation of mTOR (Ser2448) and phospho-ERK 1/2 while both RCM caused a similar decrease in the phosphorylation of phospho-p70S6 kinase (Ser371). In vivo studies showed that both IOM and IOD caused a significant decrease in both pAkt (Ser473) and pERK 1/2 in rat kidneys. Our study gives an insight into the possible mechanism of toxicity of RCM via their action on intracellular signaling pathways and may help in developing pharmacological interventions for their side-effects.
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Affiliation(s)
- Michele Andreucci
- Chair of Nephrology, Department of Health Sciences, "Magna Graecia" University, Catanzaro, I-88100, Italy
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57
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Goel SS, Shishehbor MH. Renal Complications in Patients Undergoing Peripheral Artery Interventions. Interv Cardiol Clin 2014; 3:441-448. [PMID: 28582228 DOI: 10.1016/j.iccl.2014.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical or endovascular revascularization procedures for severe peripheral artery disease (PAD) are typically performed in patients with lifestyle-limiting symptoms or evidence of end-organ ischemia secondary to PAD. The role of endovascular therapy in the treatment of PAD is expanding. Contrast-induced nephropathy is the most important and most frequent renal complication of endovascular interventional procedures. Knowledge about complications and their prevention and management is essential for successful outcomes. This article focuses on renal complications during peripheral artery interventions.
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Affiliation(s)
- Sachin S Goel
- Interventional Cardiology, Department of Cardiovascular Medicine, Heart & Vascular Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Mehdi H Shishehbor
- Endovascular Services, Heart & Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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58
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Rojkovskiy I, Solomon R. Intravenous and Oral Hydration: Approaches, Principles, and Differing Regimens. Interv Cardiol Clin 2014; 3:393-404. [PMID: 28582224 DOI: 10.1016/j.iccl.2014.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Prevention of contrast-induced nephropathy is founded on minimizing the pathophysiologic consequences of contrast media (CM) interacting with a vulnerable kidney. In this article, the rationale for administering fluid (oral or intravenous) is discussed, and the clinical trials exploring different protocols are reviewed. A benefit from administration of fluids before CM exposure, which corrects volume depletion and increases urine output, can be expected. Forced diuresis without adequate volume replacement is deleterious.
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Affiliation(s)
- Igor Rojkovskiy
- Division of Nephrology and Hypertension, Fletcher Allen Health Care, University of Vermont College of Medicine, UHC 2309, 1 South Prospect Street, Burlington, VT 05401, USA
| | - Richard Solomon
- Division of Nephrology and Hypertension, Fletcher Allen Health Care, University of Vermont College of Medicine, UHC 2309, 1 South Prospect Street, Burlington, VT 05401, USA.
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59
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Andreucci M. Side effects of radiographic contrast media. BIOMED RESEARCH INTERNATIONAL 2014; 2014:872574. [PMID: 24991572 PMCID: PMC4060789 DOI: 10.1155/2014/872574] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 05/04/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Michele Andreucci
- Department of Health Sciences, Magna Graecia University, Campus Salvatore Venuta, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
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60
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Abstract
OBJECTIVE The objective of our study was to exposit the shifting perspectives on contrast-induced nephropathy (CIN) for IV low-osmolar iodinated contrast media. CONCLUSION The historically inflated risk of CIN reflects logistic and intellectual pitfalls that continue to confound the study of this disease. Recent advances have clarified that the incidence of CIN is much lower than previously thought, but there are lingering questions. We suggest that CIN is likely real but is rare and offer directions for future study.
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61
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Andreucci M, Solomon R, Tasanarong A. Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention. BIOMED RESEARCH INTERNATIONAL 2014; 2014:741018. [PMID: 24895606 PMCID: PMC4034507 DOI: 10.1155/2014/741018] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 03/03/2014] [Indexed: 12/18/2022]
Abstract
Radiocontrast media (RCM) are medical drugs used to improve the visibility of internal organs and structures in X-ray based imaging techniques. They may have side effects ranging from itching to a life-threatening emergency, known as contrast-induced nephropathy (CIN). We define CIN as acute renal failure occurring within 24-72 hrs of exposure to RCM that cannot be attributed to other causes. It usually occurs in patients with preexisting renal impairment and diabetes. The mechanisms underlying CIN include reduction in medullary blood flow leading to hypoxia and direct tubule cell damage and the formation of reactive oxygen species. Identification of patients at high risk for CIN is important. We have reviewed the risk factors and procedures for prevention, providing a long list of references enabling readers a deep evaluation of them both. The first rule to follow in patients at risk of CIN undergoing radiographic procedure is monitoring renal function by measuring serum creatinine and calculating the eGFR before and once daily for 5 days after the procedure. It is advised to discontinue potentially nephrotoxic medications, to choose radiocontrast media at lowest dosage, and to encourage oral or intravenous hydration. In high-risk patients N-acetylcysteine may also be given.
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Affiliation(s)
- Michele Andreucci
- Nephrology Unit, Department of “Health Sciences”, Campus “Salvatore Venuta”, “Magna Graecia” University, Loc. Germaneto, 88100 Catanzaro, Italy
| | - Richard Solomon
- University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT, USA
| | - Adis Tasanarong
- Nephrology Unit, Department of Medicine, Faculty of Medicine, Thammasat University, Rangsit Campus, Khlong Luang, Pathum Thani 12121, Thailand
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62
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Morales H, Lu A, Kurosawa Y, Clark JF, Leach J, Weiss K, Tomsick T. Decreased infarct volume and intracranial hemorrhage associated with intra-arterial nonionic iso-osmolar contrast material in an MCA occlusion/reperfusion model. AJNR Am J Neuroradiol 2014; 35:1885-91. [PMID: 24812016 DOI: 10.3174/ajnr.a3953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Infarct volume and intracranial hemorrhage after reperfusion with nonionic low-osmolar and iso-osmolar iodinated IRCM has not been previously compared. We postulated that iso-osmolar and low-osmolar iodinated contrast media exert varied effects on cerebral infarct after intra-arterial injection. We compared infarct volume and hemorrhagic changes following intra-arterial infusion of iodixanol, iopamidol, or normal saline in a rat MCA occlusion/reperfusion model. MATERIALS AND METHODS Infarct was induced in 30 rats by a previously validated method of MCA suture occlusion. Reperfusion was performed after 5 hours with either iodixanol (n = 9), iopamidol (n = 12), or saline (n = 9). MR images were obtained at both 6 and 24 hours after ischemia, followed by sacrifice. Infarct volume was measured with T2WI and DWI by semiautomatic segmentation. Incidence and area of hemorrhage were measured on brain sections postmortem. RESULTS T2WI mean infarct volumes were 242 ± 89, 324 ± 70, and 345 ± 92 mm(3) at 6 hours, and 341 ± 147,470 ± 91, and 462 ± 71 mm(3) at 24 hours in the iodixanol, iopamidol, and saline groups, respectively. Differences in infarct volume among groups were significant at 6 hours (P < .03) and 24 hours (P < .05). In the iodixanol, iopamidol, and saline groups, mean areas for cortical intracranial hemorrhage were 0.8, 18.2, and 25.7 mm(2); and 28, 31, and 56.7 mm(2), respectively, for deep intracranial hemorrhage. The differences in intracranial hemorrhage area among groups were statistically significant for cortical intracranial hemorrhage (P < .01). CONCLUSIONS Intra-arterial infusion of nonionic iso-osmolar iodixanol showed reduced infarct volume and reduced cortical intracranial hemorrhage areas in comparison with nonionic low-osmolar iopamidol and saline. Our results may be relevant in the setting of intra-arterial therapy for acute stroke in humans, warranting further investigation.
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Affiliation(s)
- H Morales
- From the Departments of Radiology (H.M., J.L., T.T.)
| | - A Lu
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - Y Kurosawa
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - J F Clark
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - J Leach
- From the Departments of Radiology (H.M., J.L., T.T.)
| | - K Weiss
- Department of Radiology (K.W.), University of Mississippi, Oxford, Mississippi
| | - T Tomsick
- From the Departments of Radiology (H.M., J.L., T.T.)
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63
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Golshahi J, Nasri H, Gharipour M. Contrast-induced nephropathy; A literature review. J Nephropathol 2014; 3:51-6. [PMID: 24772397 PMCID: PMC3999584 DOI: 10.12860/jnp.2014.12] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/04/2014] [Accepted: 01/18/2014] [Indexed: 12/19/2022] Open
Abstract
CONTEXT Contrast-induced nephropathy (CIN) is a common cause of acute kidney dysfunction. EVIDENCE ACQUISITIONS Directory of Open Access Journals, Google Scholar, PubMed, EBSCO and Web of Science have been searched. RESULTS It is necessary to identify at risk patients at early stages to implement preventive strategies to decrease the incidence of this nephropathy. However, mechanisms of CIN have not fully explained yet. It seems that mechanisms which mediated by nitric oxide and prostaglandin-induced vasodilatation have been played a crucial role in the CIN. Hemodynamic changes of renal blood flow, which causes hypoxia in the renal medulla and direct toxic effects of contrast media on renal cells, are thought to contribute to the pathogenesis of CIN. Contrast media is normally divided into iso-osmolar, low-osmolar, and high-osmolar. N-acetylcysteine is considered as one of the best choices to prevent CIN in high-risk groups. CONCLUSIONS The first aim to prevent CIN is identifying high-risk subjects and controlling associate risk factors. As significant differences existed between contrasts agents due to their physicochemical properties, low-osmolar or iso-osmolar contrast media should be used to prevent CIN in at-risk patients. The volume of contrast media should be as low as possible.
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Affiliation(s)
- Jafar Golshahi
- Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Nasri
- Department of Nephrology, Division of Nephropathology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mojgan Gharipour
- Isfahan Cardiovascular Research Centre, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Bucher AM, De Cecco CN, Schoepf UJ, Meinel FG, Krazinski AW, Spearman JV, McQuiston AD, Wang R, Bucher J, Vogl TJ, Katzberg RW. Is contrast medium osmolality a causal factor for contrast-induced nephropathy? BIOMED RESEARCH INTERNATIONAL 2014; 2014:931413. [PMID: 24800254 PMCID: PMC3988854 DOI: 10.1155/2014/931413] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/27/2014] [Accepted: 02/15/2014] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Andreas M. Bucher
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
- Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, 60590 Frankfurt am Main, Germany
| | - Carlo N. De Cecco
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
- Department of Radiological Sciences, Oncology and Pathology, University of Rome “Sapienza”-Polo Pontino, Latina, Italy
| | - U. Joseph Schoepf
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
| | - Felix G. Meinel
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Aleksander W. Krazinski
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
| | - James V. Spearman
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
| | - Andrew D. McQuiston
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
| | - Rui Wang
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Judith Bucher
- Heidelberg Kidney Center, Department of Nephrology, University Hospital Heidelberg, INF 162, 69120 Heidelberg, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, 60590 Frankfurt am Main, Germany
| | - Richard W. Katzberg
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive MSC 226, Charleston, SC 29425, USA
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65
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Michael A, Faga T, Pisani A, Riccio E, Bramanti P, Sabbatini M, Navarra M, Andreucci M. Molecular mechanisms of renal cellular nephrotoxicity due to radiocontrast media. BIOMED RESEARCH INTERNATIONAL 2014; 2014:249810. [PMID: 24745009 PMCID: PMC3976916 DOI: 10.1155/2014/249810] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/09/2013] [Accepted: 12/24/2013] [Indexed: 11/29/2022]
Abstract
Modern iodinated radiocontrast media are all based on the triiodinated benzene ring with various chemical modifications having been made over the last few decades in order to reduce their toxicity. However, CIN remains a problem especially in patients with pre-existing renal failure. In vitro studies have demonstrated that all RCM are cytotoxic. RCM administration in vivo may lead to a decrease in renal medullary oxygenation leading to the generation of reactive oxygen species that may cause harmful effects to renal tissue. In addition, endothelin and adenosine release and decreased nitric oxide levels may worsen the hypoxic milieu. In vitro cell culture studies together with sparse in vivo rat model data have shown that important cell signalling pathways are affected by RCM. In particular, the prosurvival and proproliferative kinases Akt and ERK1/2 have been shown to be dephosphorylated (deactivated), whilst proinflammatory/cell death molecules such as the p38 and JNK kinases and the transcription factor NF- κ B may be activated by RCM, accompanied by activation of apoptotic mediators such as caspases. Increasing our knowledge of the mechanisms of RCM action may help to develop future therapies for CIN.
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Affiliation(s)
- Ashour Michael
- Department of Health Sciences, Nephrology Unit, “Magna Graecia” University, I-88100 Catanzaro, Italy
| | - Teresa Faga
- Department of Health Sciences, Nephrology Unit, “Magna Graecia” University, I-88100 Catanzaro, Italy
| | - Antonio Pisani
- Department of Nephrology, “Federico II” University, I-80131 Naples, Italy
| | - Eleonora Riccio
- Department of Nephrology, “Federico II” University, I-80131 Naples, Italy
| | | | - Massimo Sabbatini
- Department of Nephrology, “Federico II” University, I-80131 Naples, Italy
| | - Michele Navarra
- Department of Drug Sciences and Health Products, University of Messina, I-98168 Messina, Italy
| | - Michele Andreucci
- Department of Health Sciences, Nephrology Unit, “Magna Graecia” University, I-88100 Catanzaro, Italy
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Netti GS, Prattichizzo C, Montemurno E, Simone S, Cafiero C, Rascio F, Stallone G, Ranieri E, Grandaliano G, Gesualdo L. Exposure to low- vs iso-osmolar contrast agents reduces NADPH-dependent reactive oxygen species generation in a cellular model of renal injury. Free Radic Biol Med 2014; 68:35-42. [PMID: 24300339 DOI: 10.1016/j.freeradbiomed.2013.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 11/13/2013] [Accepted: 11/15/2013] [Indexed: 01/21/2023]
Abstract
Contrast-induced nephropathy represents the third cause of hospital-acquired acute renal failure. This study investigated the effects of low- vs iso-osmolar contrast medium (CM) exposure on NADPH-dependent reactive oxygen species (ROS) generation by tubular cells. X-ray attenuation of iohexol, iopamidol, and iodixanol was assessed at equimolar iodine concentrations and their effects on human renal proximal tubular cells (PTCs) were evaluated with equally attenuating solutions of each CM. Cytotoxicity, apoptosis, and necrosis were investigated by trypan blue exclusion, MTT assay, and annexin V/propidium iodide assay, respectively. ROS production was assessed by DCF assay, NADPH oxidase activity by the lucigenin-enhanced chemiluminescence method, and Nox4 expression by immunoblot. Yielding the same X-ray attenuation, CM cytotoxicity was assessed in PTCs at equimolar iodine concentrations. More necrosis was present after incubation with iohexol and iopamidol than after incubation with equal concentrations of iodixanol. Iohexol and iodixanol at low iodine concentrations induced less cytotoxicity than iopamidol. Moreover, both iohexol and iopamidol induced more apoptosis than iodixanol, with a dose-dependent effect. ROS generation was significantly higher with iopamidol and iohexol compared to iodixanol. NADPH oxidase activity and Nox4 protein expression significantly increased after exposure to iopamidol and iohexol, with a dose-dependent effect, compared with iodixanol. CM-induced Nox4 expression and activity depended upon Src activation. In conclusion, at angiographic concentrations, iodixanol induces fewer cytotoxic effects on cultured tubular cells than iohexol and iopamidol along with a lower induction of Nox4-dependent ROS generation. This enzyme may, thus, represent a potential therapeutic target to prevent iodinated CM-related oxidative stress.
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Affiliation(s)
- Giuseppe Stefano Netti
- Department of Medical and Surgical Sciences, Section of Clinical Pathology, University of Foggia, Foggia 71122, Italy
| | - Clelia Prattichizzo
- Department of Medical and Surgical Sciences, Section of Clinical Pathology, University of Foggia, Foggia 71122, Italy
| | - Eustacchio Montemurno
- Department of Medical and Surgical Sciences, Section of Nephrology, University of Foggia, Foggia 71122, Italy
| | - Simona Simone
- Department of Emergency and Organ Transplantation, Section of Nephrology, University of Bari "Aldo Moro," Bari 70124, Italy
| | - Cesira Cafiero
- Department of Emergency and Organ Transplantation, Section of Nephrology, University of Bari "Aldo Moro," Bari 70124, Italy
| | - Federica Rascio
- Department of Medical and Surgical Sciences, Section of Nephrology, University of Foggia, Foggia 71122, Italy
| | - Giovanni Stallone
- Department of Medical and Surgical Sciences, Section of Nephrology, University of Foggia, Foggia 71122, Italy
| | - Elena Ranieri
- Department of Medical and Surgical Sciences, Section of Clinical Pathology, University of Foggia, Foggia 71122, Italy
| | - Giuseppe Grandaliano
- Department of Medical and Surgical Sciences, Section of Nephrology, University of Foggia, Foggia 71122, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Section of Nephrology, University of Bari "Aldo Moro," Bari 70124, Italy.
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Seeliger E, Lenhard DC, Persson PB. Contrast media viscosity versus osmolality in kidney injury: lessons from animal studies. BIOMED RESEARCH INTERNATIONAL 2014; 2014:358136. [PMID: 24707482 PMCID: PMC3950904 DOI: 10.1155/2014/358136] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 12/29/2013] [Indexed: 01/01/2023]
Abstract
Iodinated contrast media (CM) can induce acute kidney injury (AKI). CM share common iodine-related cytotoxic features but differ considerably with regard to osmolality and viscosity. Meta-analyses of clinical trials generally failed to reveal renal safety differences of modern CM with regard to these physicochemical properties. While most trials' reliance on serum creatinine as outcome measure contributes to this lack of clinical evidence, it largely relies on the nature of prospective clinical trials: effective prophylaxis by ample hydration must be employed. In everyday life, patients are often not well hydrated; here we lack clinical data. However, preclinical studies that directly measured glomerular filtration rate, intrarenal perfusion and oxygenation, and various markers of AKI have shown that the viscosity of CM is of vast importance. In the renal tubules, CM become enriched, as water is reabsorbed, but CM are not. In consequence, tubular fluid viscosity increases exponentially. This hinders glomerular filtration and tubular flow and, thereby, prolongs intrarenal retention of cytotoxic CM. Renal cells become injured, which triggers hypoperfusion and hypoxia, finally leading to AKI. Comparisons between modern CM reveal that moderately elevated osmolality has a renoprotective effect, in particular, in the dehydrated state, because it prevents excessive tubular fluid viscosity.
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Affiliation(s)
- Erdmann Seeliger
- Institute of Physiology and Center for Cardiovascular Research, Charité-University Medicine Berlin, Campus Mitte, Hessische Straße 3-4, 10115 Berlin, Germany
| | - Diana C. Lenhard
- Institute of Physiology and Center for Cardiovascular Research, Charité-University Medicine Berlin, Campus Mitte, Hessische Straße 3-4, 10115 Berlin, Germany
| | - Pontus B. Persson
- Institute of Physiology and Center for Cardiovascular Research, Charité-University Medicine Berlin, Campus Mitte, Hessische Straße 3-4, 10115 Berlin, Germany
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68
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Thomsen HS, Stacul F, Webb JAW. Contrast Medium-Induced Nephropathy. MEDICAL RADIOLOGY 2014. [DOI: 10.1007/174_2013_902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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69
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Kim KH, Kim YS, Kuh SU, Park HS, Park JY, Chin DK, Kim KS, Cho YE. Time- and dose-dependent cytotoxicities of ioxitalamate and indigocarmine in human nucleus pulposus cells. Spine J 2013; 13:564-71. [PMID: 23406968 DOI: 10.1016/j.spinee.2013.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 10/11/2012] [Accepted: 01/13/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Ioxitalamate (Telebrix 300) is an ionic iodinated contrast medium commonly used for discography or percutaneous endoscopic lumbar discectomy (PELD), though it has side effects such as anaphylactic shock and renal toxicity. Indigocarmine is an organic compound dye with a distinctive blue color that is commonly used during PELD to stain the acidic, degenerated nucleus pulposus (NP). Although ioxitalamate and indigocarmine are widely used in spinal surgery, there have been no reports on their effects on NP cells. We studied the toxicities of both ioxitalamate and indigocarmine to NP cells. PURPOSE To determine the toxicities of both ioxitalamate and indigocarmine to NP cells in vitro. STUDY DESIGN In vitro, controlled study of the toxicities of both ioxitalamate and indigocarmine to human NP cells. METHODS Nucleus pulposus cells were obtained via discectomy from lumbar disc patients and isolated. Nucleus pulposus cells were cultured in three-dimensional (3D) alginate beads with 0.001, 0.1, 10, and 100 mg/mL ioxitalamate, 0.00001, 0.001, 0.1, and 10 mg/mL indigocarmine, or a mixture of both for 1, 2, or 3 days. The living cells were analyzed with trypan blue staining. Fluorescence Activated Cell Sorting analysis using Annexin V and propidium iodide and 3D alginate bead immunostaining was performed to identify live, apoptotic, and necrotic cells. RESULTS Ioxitalamate, indigocarmine, and their combination induced statistically significant NP cell injury that was both time- and dose dependent (p<.05). Also, at the same concentration, ioxitalamate was more cytotoxic than was indigocarmine or the combination (p<.05). All three treatments also showed dose-dependent cytotoxicity according to flow cytometry and immunostaining. CONCLUSIONS Ioxitalamate and indigocarmine are toxic to human NP cells in vitro in a time- and dose-dependent manner. We assume that ioxitalamate and indigocarmine may have similar effects in patients undergoing discography and PELD. Thus, we suggest that ioxitalamate and indigocarmine should be used carefully at low concentrations.
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Affiliation(s)
- Kyung-Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 712 Eonjuro, Gangnam-gu, Seoul 135-720, South Korea
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Tehrani S, Laing C, Yellon DM, Hausenloy DJ. Contrast-induced acute kidney injury following PCI. Eur J Clin Invest 2013; 43:483-90. [PMID: 23441924 DOI: 10.1111/eci.12061] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/03/2013] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, University College London, London, UK
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71
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Song JS, Kim SI, Kim W, Park DW, Kwak HJ, Moon JY, Kim SH, Kim TH, Sohn JW, Shin DH, Park SS, Yoon HJ. Incidence and risk factors of contrast-induced nephropathy after bronchial arteriography or bronchial artery embolization. Tuberc Respir Dis (Seoul) 2013; 74:163-8. [PMID: 23678357 PMCID: PMC3651926 DOI: 10.4046/trd.2013.74.4.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/04/2012] [Accepted: 04/24/2013] [Indexed: 11/24/2022] Open
Abstract
Background In uncontrolled hemoptysis patient, bronchial arteriography and bronchial artery embolization (BAE) is a important procedure in diagnosis and treatment. The aim of this study is to assess the incidence of contrast-induced nephropathy and the risk factors of contrast-induced nephropathy (CIN) after bronchial arteriography and BAE. Methods We retrospectively reviewed the medical records of the patients who underwent bronchial arteriography and BAE in two university hospitals from January 2003 to December 2011. CIN was defined as rise of serum creatinine more than 25% of baseline value or 0.5 mg/dL at between 48 hours and 96 hours after bronchial arteriography and BAE. We excluded patients who already had severe renal insufficiency (serum creatinine≥4.0) or had been receiving dialysis. Results Of the total 100 screened patients, 88 patients met the enrollment criteria. CIN developed in 7 patients (8.0%). The mean duration between the exposure and development of CIN was 2.35±0.81 days. By using multivariate analysis, serum albumin level was found to be significantly associated with the development of CIN (p=0.0219). Conclusion These findings suggest that the incidence of CIN was higher than expected and patients with hypoalbuminemia should be monitored more carefully to prevent the development of CIN after bronchial arteriography and BAE.
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Affiliation(s)
- June Seok Song
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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72
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The Effect of Iodinated Contrast Agent Properties on Renal Kinetics and Oxygenation. Invest Radiol 2013; 48:175-82. [DOI: 10.1097/rli.0b013e31827b70f9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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73
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Yang D, Yang D, Jia R, Ding G. Selective inhibition of the reverse mode of Na(+)/Ca(2+) exchanger attenuates contrast-induced cell injury. Am J Nephrol 2013; 37:264-73. [PMID: 23485664 DOI: 10.1159/000348526] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/28/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The precise mechanisms underlying radiocontrast nephropathy (RCN) are not well understood. Intracellular Ca(2+) overload is considered to be a key factor in RCN. The Na(+)/Ca(2+) exchanger (NCX) system is one of the main pathways of intracellular Ca(2+) overload. We investigated whether intracellular Ca(2+) overload via the NCX system was involved in contrast-induced renal tubular cytotoxicity. METHODS NRK-52E cells were exposed to ioversol (100 mg iodine/ml) for 4 h. KB-R7943 (inhibitor of reverse mode of NCX, 4 × 10(-5), 4 × 10(-6)M) was added 1 h before incubation with ioversol. Cell viability and permeability were determined by 3-(4,5-dimethyldiazol-2-yl)-2,5-diphenyl tetrazolium bromide and lactate dehydrogenase assay. Apoptosis was determined by flow cytometry. Intracellular Ca(2+) concentration ([Ca(2+)](i)] and reactive oxygen species (ROS) were detected by confocal microscopy. The expression of NCX1 mRNA and caspase-3 protein was evaluated by reverse transcription-polymerase chain reaction and Western blot, respectively. RESULTS Ioversol exposure induced significantly increased lactate dehydrogenase release and decreased 3-(4,5-dimethyldiazol-2-yl)-2,5-diphenyl tetrazolium bromide conversion in NRK-52E cells. Significantly increased apoptosis and caspase-3 protein expression were observed in the NRK-52E cells exposed to ioversol for 4 h. Ioversol treatment induced a significant increase in [Ca(2+)](i) and intracellular ROS. KB-R7943 dose-dependently and significantly suppressed the increase in [Ca(2+)](i), intracellular ROS and caspase-3 overexpression induced by ioversol and attenuated the contrast-induced NRK-52E cell apoptosis. No significant changes in NCX1 mRNA expression were observed following contrast exposure. CONCLUSION Intracellular Ca(2+) overload via the reverse mode of NCX, followed by ROS overproduction and caspase-3 overexpression played an important role in the contrast-induced renal tubular cytotoxicity. The reverse mode of the NCX inhibitor KB-R7943 attenuated contrast-induced renal tubular cytotoxicity.
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Affiliation(s)
- Dingping Yang
- Division of Nephrology, Department of Internal Medicine, Renmin Hospital of Wuhan University, Wuhan, China.
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74
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Zhang Y, Wang J, Yang X, Wang X, Zhang J, Fang J, Jiang X. The serial effect of iodinated contrast media on renal hemodynamics and oxygenation as evaluated by ASL and BOLD MRI. CONTRAST MEDIA & MOLECULAR IMAGING 2012; 7:418-25. [PMID: 22649048 DOI: 10.1002/cmmi.1468] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contrast-induced nephropathy is a prevalent cause of renal failure, and the mechanisms underlying this injury are not fully understood. We utilized noninvasive functional MRI in order to determine the serial effect of a single administration of iodinated contrast media (CM) on renal hemodynamics and oxygenation. Fifteen rabbits were randomized to receive an intravenous injection of CM (i.e. iopamidol-370; 6 ml kg(-1) body weight) or an equivalent amount of 0.9% saline. Both arterial spin-labeling and blood oxygen level-dependent imaging sequences were performed at 24 h before and at intervals of 1, 24, 48 and 72 h after injection to obtain serial renal blood flow (RBF) and relative spin-spin relaxation rate (R(2)*). Results showed that, in the iopamidol group, the mean cortical RBF decreased at 1 h (p = 0.04 vs baseline), reached its minimum at 24 h (p = 0.01) and gradually returned to baseline by 48 h (p = nonsignificant, NS). The outer medullary RBF decreased to its minimum by 24 h (p = 0.00) and remained less than baseline until 72 h. R(2)* in inner stripes was dramatically increased at 1 h (p = 0.00), remained elevated at 24 h (p = 0.05), but returned to baseline by 48 h (p = NS). R(2)* values within the cortex and outer stripes and inner medulla were slightly increased, but the changes did not reach a statistical significance (p = NS). Saline did not produce positive change in either RBF or R(2)* within different compartments of the kidney. We conclude that iopamidol is associated with a relatively longer-term hypoperfusion in whole kidney and decreased oxygen level in the inner stripes of the outer medulla.
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Affiliation(s)
- Yudong Zhang
- Department of Radiology, Peking University First Hospital, Beijing, China
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The Osmolality of Nonionic, Iodinated Contrast Agents as an Important Factor for Renal Safety. Invest Radiol 2012; 47:503-10. [DOI: 10.1097/rli.0b013e318258502b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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76
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Li LP, Franklin T, Du H, Papadopoulou-Rosenzweig M, Carbray J, Solomon R, Prasad PV. Intrarenal oxygenation by blood oxygenation level-dependent MRI in contrast nephropathy model: effect of the viscosity and dose. J Magn Reson Imaging 2012; 36:1162-7. [PMID: 22826125 DOI: 10.1002/jmri.23747] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 06/04/2012] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To compare the effects of osmolality versus viscosity of radio-contrast media on intra-renal oxygenation as determined by blood oxygenation level-dependent (BOLD) MRI in a model of contrast induced nephropathy (CIN). MATERIALS AND METHODS Twenty-four Sprague-Dawley rats were divided into five groups. Nitric oxide synthase inhibitor L-NAME (10 mg/kg), cyclooxygenase inhibitor indomethacin (10 mg/kg), or saline, and radio-contrast iodixanol (high viscosity, 784 or 1600 mg I/kg) or iothalamate (high osmolality, 1600 mg I/kg) were administered. BOLD MRI images were acquired on Siemens 3 Tesla (T) scanner using a multiple gradient recalled echo sequence at baseline, following L-NAME (or saline), indomethacin (or saline), and radio-contrast agents. R2* (=1/T2*) was used as the BOLD MRI parameter in renal medulla and cortex. Mixed-effects models with first order auto-regressive variance-covariance models were used to analyze the data. RESULTS The magnitude of change in medullary R2* (MR2*) with same dose of iodine was larger with iodixanol compared with iothalalmate both in pretreated groups (303% versus 225.6%, < 0.01) and the control group (191.6% versus -1.8%, P < 0.01). The MR2* change in high dose iodixanol was approximately twice compared with the low dose (303% versus 133%, P < 0.01). CONCLUSION The viscosity of radio-contrast seems to play a more significant role than osmolality in terms of renal oxygenation changes as evaluated by BOLD MRI. Additionally, iodixanol induced a dose-dependent increase in renal medullary hypoxia.
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Affiliation(s)
- Lu-Ping Li
- Department of Radiology/Center for Advanced Imaging, Northshore University Healthsystem, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA.
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CT Angiography of the Renal Arteries: Comparison of Lower-Tube-Voltage CTA With Moderate-Concentration Iodinated Contrast Material and Conventional CTA. AJR Am J Roentgenol 2012; 199:96-102. [PMID: 22733899 DOI: 10.2214/ajr.11.7450] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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78
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Choi H, Kim Y, Kim SM, Shin J, Jang HR, Lee JE, Huh W, Kim YG, Oh HY, Kim DJ. Intravenous albumin for the prevention of contrast-induced nephropathy in patients with liver cirrhosis and chronic kidney disease undergoing contrast-enhanced CT. Kidney Res Clin Pract 2012; 31:106-11. [PMID: 26889416 PMCID: PMC4715130 DOI: 10.1016/j.krcp.2012.04.317] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 01/15/2012] [Accepted: 02/02/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the incidence of contrast-induced nephropathy (CIN), and the effect of intravenous albumin for prophylaxis of CIN in patients with liver cirrhosis (LC) and chronic kidney disease (CKD). METHODS We conducted a retrospective study of 81 subjects with LC and CKD (estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m(2)) who underwent contrast-enhanced computed tomography (CT). Patients received either isotonic sodium bicarbonate solution (3 mL/kg for 1 h before CT and 1 mL/kg/h for 6 h after CT) or albumin (20% albumin, 25 mL for 1 h before CT and 75 mL for 6 h after CT). CIN was defined as an increase of ≥25% or ≥0.5 mg/dL in serum creatinine level. RESULTS Overall, CIN developed in three patients (3.7%). Of the 81 subjects, 43 received sodium bicarbonate solution and 38 received albumin. Both groups were comparable with regard to age, sex, diabetes mellitus, and baseline eGFR. The albumin group showed a significantly poorer liver function profile. CIN incidence did not differ significantly between the groups: it occurred in one (2.3%) of the 43 subjects receiving sodium bicarbonate and two (5.3%) of the 38 subjects receiving albumin (P=0.6). However, the albumin group showed a significantly smaller increase in body weight (P=0.03). CONCLUSION The incidence of CIN in patients with LC and CKD undergoing contrast-enhanced CT after preventive measures was relatively low. The incidence of CIN was not significantly different between sodium bicarbonate and albumin groups.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Dae Joong Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Cerebral computed tomography angiography using a low tube voltage (80 kVp) and a moderate concentration of iodine contrast material: a quantitative and qualitative comparison with conventional computed tomography angiography. Invest Radiol 2012; 47:142-7. [PMID: 22104960 DOI: 10.1097/rli.0b013e31823076a4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To investigate the feasibility of an 80-kVp protocol using a moderate concentration contrast material (MC-CM) for cerebral computed tomography angiography by comparison with a conventional 120-kVp protocol using a high concentration contrast material (HC-CM). MATERIALS AND METHODS Attenuation values and signal-to-noise ratios (SNRs) were determined in a head phantom for 2 tube voltages (80 and 120 kVp) and 2 different iodine concentration contrast materials (HC-CM and MC-CM). Among 90 consecutive patients, 45 patients were scanned with 120 kVp and 150 mAs(eff) after administration of 70 mL of HC-CM (370 mg iodine [mgI]/mL), whereas the other 45 patients were scanned with 80 kVp and 370 mAs(eff) after administration of 70 mL of MC-CM (300 mgI/mL). The Hounsfield units (HU) of the internal carotid artery T junction, SNR, contrast-to-noise ratio (CNR), subjective degree of arterial enhancement, image noise, sharpness of the cerebral arterial boundary, and overall diagnostic image quality were compared between the 2 groups. RESULTS The mean attenuation of the internal carotid artery T junction, SNR, and CNR was significantly higher in the 80 kVp with MC-CM group (379.2, 33.7, and 31.1 HU, respectively) than in the 120 kVp with HC-CM group (282.2, 31.1, and 27.2 HU, respectively). The 80-kVp protocol resulted in significantly higher score in arterial enhancement, sharpness of the cerebral arteries, and overall diagnostic image quality. The effective dose of 80 kVp (0.7 mSv) was 22.2% lower than that of 120 kVp (0.9 mSv). CONCLUSIONS The use of 80 kVp with MC-CM improved arterial enhancement, SNR, and CNR and provided superior quality images using a smaller amount of iodine and a lower radiation dose than the conventional protocol of 120 kVp with HC-CM.
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Kim IY, Lee SB, Lee DW, Song SH, Seong EY, Kwak IS. Long-term effect of radiocontrast-enhanced computed tomography on the renal function of chronic kidney disease patients. Clin Exp Nephrol 2012; 16:755-9. [DOI: 10.1007/s10157-012-0629-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 03/13/2012] [Indexed: 12/22/2022]
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Seeliger E, Sendeski M, Rihal CS, Persson PB. Contrast-induced kidney injury: mechanisms, risk factors, and prevention. Eur Heart J 2012; 33:2007-15. [PMID: 22267241 DOI: 10.1093/eurheartj/ehr494] [Citation(s) in RCA: 347] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In general, iodinated contrast media (CM) are tolerated well, and CM use is steadily increasing. Acute kidney injury is the leading life-threatening side effect of CM. Here, we highlight endpoints used to assess CM-induced acute kidney injury (CIAKI), CM types, risk factors, and CIAKI prevention. Moreover, we put forward a unifying theory as to how CIAKI comes about; the kidney medulla's unique hyperosmolar environment concentrates CM in the tubules and vasculature. Highly concentrated CM in the tubules and vessels increases fluid viscosity. Thus, flow through medullary tubules and vessels decreases. Reducing the flow rate will increase the contact time of cytotoxic CM with the tubular epithelial cells and vascular endothelium, and thereby damage cells and generate oxygen radicals. As a result, medullary vasoconstriction takes place, causing hypoxia. Moreover, the glomerular filtration rate declines due to congestion of highly viscous tubular fluid. Effective prevention aims at reducing the medullary concentration of CM, thereby diminishing fluid viscosity. This is achieved by generous hydration using isotonic electrolyte solutions. Even forced diuresis may prove efficient if accompanied by adequate volume supplementation. Limiting the CM dose is the most effective measure to diminish fluid viscosity and to reduce cytotoxic effects.
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Affiliation(s)
- Erdmann Seeliger
- Institute of Physiology, Center for Cardiovascular Research, Charité-Universitätsmedizin Berlin, CCM, Hessische Str. 3-4, Berlin D-10115, Germany.
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Jensen H, Doughty RW, Grant D, Myhre O. The effects of the iodinated X-ray contrast media iodixanol, iohexol, iopromide, and ioversol on the rat kidney epithelial cell line NRK 52-E. Ren Fail 2011; 33:426-33. [PMID: 21529272 DOI: 10.3109/0886022x.2011.568146] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nephrotoxicity, associated with the administration of iodinated X-ray contrast media (ICM), continues to be a major side effect in a significant number of vulnerable patients undergoing diagnostic X-ray imaging procedures. The molecular mechanisms underlying these adverse effects on the kidneys are unclear despite several decades of investigation. Side effects are more common after exposure to high-osmolar compared with low-osmolar ICM, suggesting that osmolality may be an important physical-chemical property related to nephrotoxicity. This investigation in cultured NRK 52-E cells, a cell line of renal origin, compares the in vitro toxicity of the iso-osmolal ICM iodixanol with the low-osmolal ICM iohexol, iopromide, and ioversol. The cellular toxicity was evaluated with the trypan blue exclusion assay, the MTT assay, and incidences of cell death. A qualitative assessment of vacuolation of the cultured NRK 52-E cells was taken as a measure of intracellular uptake of ICM. A difference in cell death incidence was observed between the iso-osmolal iodixanol and the low-osmolal iohexol, iopromide, and ioversol contrast media, with the iso-osmolal iodixanol having the least effect in each of the in vitro systems tested. The osmolality of the contrast media appeared to be the major cause for the observed in vitro toxicity.
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Affiliation(s)
- Hanne Jensen
- Research Biology, GE Healthcare AS, Oslo, Norway.
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83
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Abstract
1. The present review focuses on the cytotoxic effects of iodinated contrast media (CM) that are shared by all types of CM. 2. Although the clinical nephrotoxicity of CM has been progressively improved, all currently available CM still possess a level of cytotoxicity, which is probably caused by iodine. 3. The toxicity caused by specific CM properties, such as osmolarity, viscosity and ionic strength, can be differentiated from the cytotoxicity common to all CM in studies using cell culture, isolated blood vessels and isolated tubules. 4. The cytotoxicity induced by CM leads to apoptosis and cell death of endothelial and tubular cells and may be initiated by cell membrane damage, together with oxidative stress. 5. Cell damage may be aggravated by factors such as tissue hypoperfusion and hypoxia, properties of individual CM, such as ionic strength, high osmolarity and/or viscosity, and clinically unfavourable conditions. 6. Clinically detectable renal failure may result from the summation of all these factors.
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Affiliation(s)
- Mauricio M Sendeski
- Institute of Vegetative Physiology, Charité Medical University, Berlin, Germany.
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84
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Jost G, Lengsfeld P, Lenhard DC, Pietsch H, Hütter J, Sieber MA. Viscosity of iodinated contrast agents during renal excretion. Eur J Radiol 2011; 80:373-7. [PMID: 21376497 DOI: 10.1016/j.ejrad.2011.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Modern iodinated non-ionic contrast agents (CAs) can be classified based on their molecular structure into monomeric and dimeric CAs and have at comparable iodine concentrations a different viscosity and osmolality. During their renal excretion, CAs are concentrated in the renal tubuli which might enhance the viscosity difference between monomeric and dimeric CAs. The viscosity of a CA might have an underestimated importance for renal safety, as suggested by recent publications. In this study, we investigated the viscosities of CAs at the concentrations expected to be present in renal tubules. This concentration process was simulated in vitro using dialysis. Furthermore, we investigated urine viscosity and urine flow in rodents after administration of several non-ionic monomeric and dimeric CAs. MATERIALS AND METHODS To estimate the viscosity of the CAs in vivo, we performed an in vitro dialysis of monomeric and dimeric CAs at various physiological osmolalities of the renal tubulus (290, 400, 500, 700 and 1000 mOsm/kg H2O). Following the dialysis, the iodine concentrations and the viscosities of the CAs were determined. Furthermore, to investigate the concentration process in vivo, we measured the urine viscosity and the urine flow in Han Wister rats after the administration of Iopromide, Iohexol, Ioversol, Iomeprol, Iodixanol, and Iosimenol at comparable iodine concentrations. As a control, saline was injected at the same volume. RESULTS In vitro dialysis of the dimeric CA increased the iodine concentration and strongly increased the viscosity at all tested osmolalities. In contrast, for the monomeric agents an increase in concentration and viscosity was observed only at 700 as well 1000 mOsm/kg H2O but to a lesser extent. In summary, dialysis strongly enhanced the viscosity differences between the non-ionic monomeric and dimeric CAs. The administration of dimeric CAs leads to a strong increase in urine viscosity; this was not observed for the monomeric CAs. In contrast, a significantly higher urine flow was measured after the administration of the monomeric CAs as compared to the dimeric CAs. CONCLUSION We demonstrated that the viscosity differences between monomeric and dimeric CAs are strongly enhanced due to a concentration process of the CAs upon increasing osmolalities, a process which is likely to take place in a similar manner in the tubular system. This result suggests that the viscosity of the dimeric agents increases dramatically in vivo and gives a plausible explanation for measured enhancement of urine viscosity upon dimeric CA administration. On the other hand, the higher osmolality of the monomeric agents causes an osmodiuresis, indicated by a higher urine flow, which leads to a faster elimination of the CAs from the kidney.
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Affiliation(s)
- Gregor Jost
- TRG Diagnostic Imaging, Bayer Schering Pharma AG, Berlin, Germany.
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85
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Van Linden A, Kempfert J, Rastan AJ, Holzhey D, Blumenstein J, Schuler G, Mohr FW, Walther T. Risk of acute kidney injury after minimally invasive transapical aortic valve implantation in 270 patients. Eur J Cardiothorac Surg 2010; 39:835-42; discussion 842-3. [PMID: 21186126 DOI: 10.1016/j.ejcts.2010.11.034] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 11/08/2010] [Accepted: 11/15/2010] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Contrast agent is a potential risk factor for acute kidney injury (AKI). Little is known about the incidence of contrast-induced nephropathy (CIN) after trans-apical aortic valve implantation (TA-AVI) and on the impact of contrast exposure during preoperative computed tomography (CT) scan and cardiac catheterization. METHODS A total of 270 consecutive high-risk patients received TA-AVI for symptomatic aortic valve stenosis during a 3-year period. Different preoperative, peri-procedural, and postoperative variables were analyzed by uni- and multivariate logistic regression concerning incidence of early (<7 days) AKI and need for renal replacement therapy (RRT). Nine patients on chronic preoperative dialysis were excluded. RESULTS Mean age was 82 ± 5.8 years, 71% were female. LogEuroSCORE (European System for Cardiac Operative Risk Evaluation) and STS Score were 31.4 ± 15.6% and 12.1 ± 7.4%, respectively. Preoperative estimated glomerular filtration rate (eGFR) <60 ml min(-1) was present in 35.2%. CT scan and cardiac catheterization within 7 days before TA-AVI were performed in 43.7% and 20.3% of the patients and were associated with a mean contrast-agent exposition of 110 ± 21 ml for CT scans and 91 ± 65 ml for cardiac catheterization. Regarding the postoperative renal outcome, an improved or at least stable eGFR was seen in more than 50% of the patients. Intra-operative contrast-agent application was 99 ± 64 ml and correlated significantly to the development of postoperative AKI and need for RRT (p=0.013 and p=0.003). Postoperative RRT was required in 15.7%. Chronic renal insufficiency (odds ratio (OR)=6.8, p=0.025) and number of blood transfusions (OR=8.8, p=0.009) were independent risk factors for RRT. Postoperative AKI occurred in 16.1% and intra-operative contrast-agent burden >99 ml (OR=2.3, p=0.038), new thrombocytopenia (OR=4.4, p=0.005) and pathological leucocyte count (OR=2.8, p=0.009) were independent risk factors for this event. Early (within 1-7 days before TA-AVI) preoperative CT and cardiac catheterization did not significantly increase incidence of RRT or AKI. Short-term and long-term survival was explicitly lower in the AKI and in the RRT groups (p<0.001 each). CONCLUSIONS GFR improves after TA-AVI. Postoperative AKI and RRT depend on the amount of intra-operative contrast agent. These results strongly support the need for intra-operative tools to reduce contrast-agent exposition during TA-AVI.
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Affiliation(s)
- Arnaud Van Linden
- Department of Cardiac Surgery, Heartcenter University of Leipzig, Leipzig, Germany
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86
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Nephrotoxicity of contrast media and protective effects of acetylcysteine. Arch Toxicol 2010; 85:165-73. [DOI: 10.1007/s00204-010-0626-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 11/16/2010] [Indexed: 01/27/2023]
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87
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Constriction of the Vasa Recta, the Vessels Supplying the Area at Risk for Acute Kidney Injury, By Four Different Iodinated Contrast Media, Evaluating Ionic, Nonionic, Monomeric and Dimeric Agents. Invest Radiol 2010; 45:453-7. [DOI: 10.1097/rli.0b013e3181d77eed] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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88
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İmge Ergüder B, Çetin M, Namuslu M, Kılıçoğlu S, Devrim E, Çetin R, Durak İ. High osmolar contrast medium causes mild oxidation in liver, bladder, and ovary tissues from rats: vitamin C has protective role. Med Chem Res 2010. [DOI: 10.1007/s00044-009-9207-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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89
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Krummel T, Faller AL, Bazin D, Hannedouche T. [Contrast-induced nephropathy]. Presse Med 2010; 39:807-14. [PMID: 20462732 DOI: 10.1016/j.lpm.2010.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 02/15/2010] [Accepted: 02/23/2010] [Indexed: 11/19/2022] Open
Abstract
Acute kidney injury is a common complication after contrast administration in radiology or cardiology. It increases morbidity and in-hospital but also long-term mortality. The pathophysiology is complex, there is an association of direct cellular toxicity of contrast agents and medullary ischemia secondary to alterations in intra-renal hemodynamics and to an increase in metabolic activity. Many risk factors have been identified and should be checked prior to injection, the most important being pre-existing renal failure which might be identified by calculating the estimated glomerular filtration rate with predictive equations such as Cockcroft-Gault or MDRD equations. When risk factors are present and contrast administration is really necessary, the only validated measure to reduce the risk of renal failure is still volume expansion. Other pharmacological interventions have interesting results, but a confirmation on a larger scale is necessary. The volume expansion is best performed intravenously by the isotonic saline or sodium bicarbonate.
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Affiliation(s)
- Thierry Krummel
- Hôpitaux universitaires de Strasbourg, service de néphrologie, 67091 Strasbourg cedex, France.
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90
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The Impact of the Viscosity and Osmolality of Iodine Contrast Agents on Renal Elimination. Invest Radiol 2010; 45:255-61. [DOI: 10.1097/rli.0b013e3181d4a036] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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Hsu SP, Tsai TJ, Chien CT. Ioxitalamate Induces Renal Tubular Apoptosis via Activation of Renal Efferent Nerve–Mediated Adrenergic Signaling, Renin Activity, and Reactive Oxygen Species Production in Rats. Toxicol Sci 2009; 114:149-58. [DOI: 10.1093/toxsci/kfp290] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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92
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Interventional procedures: best practice to avoid complications. J Perianesth Nurs 2009; 24:295-9. [PMID: 19853813 DOI: 10.1016/j.jopan.2009.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Revised: 04/24/2009] [Accepted: 07/14/2009] [Indexed: 11/21/2022]
Abstract
Technological advances have allowed treatment of patients using interventional radiological imaging including the performance of multiple procedures in almost any vessel, eg, angioplasty, stenting, embolization, and coilings. Patients undergoing any procedure are at risk for complications because of contrast media, radiation exposure, vessel injury, and prolonged time in one position during the procedure. Diagnostic-only procedures minimize use of contrast medium and radiation time, and generally take about one hour to complete. On the other hand, interventional procedures can take several hours and require larger volumes of contrast medium and radiation, as well as increased time lying supine on a procedure table. This article will discuss several potential and known risks associated with interventional procedures, how to monitor for these risks, and evidence-based measures to prevent or minimize their occurrence.
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93
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Abstract
BACKGROUND Anecdotal data suggest that intravenous contrast agents given to enhance the sensitivity of computed tomography (CT) can produce increases in serum osmolality, producing an osmolal gap. An unexplained osmolal gap often prompts extensive evaluation for the presence of unidentified toxins, particularly the toxic alcohols (methanol, ethanol, isopropyl alcohol, and ethylene glycol). The ability of intravenous contrast media to raise serum osmolality with a resulting osmolal gap has not been systematically investigated. METHODS We evaluated changes in serum osmolality and osmolal gap in a cohort of patients presenting to a pediatric emergency department with abdominal pain who necessitated a contrast-enhanced CT scan as part of their diagnostic evaluation. Inclusion criteria were age of 10 to 18 years and the ability to obtain blood samples 30 minutes after contrast administration. Before and 30 minutes after contrast administration, serum osmolality and Na, glucose, and serum urea nitrogen levels were obtained. Osmolal gap was calculated using the formula 2(Na) + serum urea nitrogen/2.8 + glucose/18. The contrast agent Optiray 320 (Tyco healthcare, Mallinkrodt, Hazelwood, Mo) (ioversol, 68%) was administered at a dose of 2 mL/kg (1.36 g/kg). The main outcomes of interest were precontrast versus postcontrast osmolality and osmolar gap. RESULTS Fourteen subjects were enrolled. The mean precontrast and postcontrast serum osmolalities were 292.75 and 292.875 mOsm/L (P = 0.93), respectively. The corresponding mean values for the precontrast and postcontrast osmolal gaps were 9.17 and 12.15 mOsm/L, respectively (P = 0.133). The mean difference between the precontrast and the postcontrast osmolal gaps was 0.125 mOsm/L. There was no statistically significant correlation between the dose of the contrast agent administered and the postcontrast osmolality or osmolal gap. CONCLUSIONS These data suggest that intravenous contrast agents, when administered at conventional doses, do not significantly increase serum osmolality or produce an osmolal gap. Patients who are found to have an osmolal gap after the performance of a contrast-enhanced CT scan should undergo thorough evaluation to identify its etiology rather than attributing the gap to contrast administration.
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94
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Retention of iodine and expression of biomarkers for renal damage in the kidney after application of iodinated contrast media in rats. Invest Radiol 2009; 44:114-23. [PMID: 19104440 DOI: 10.1097/rli.0b013e318190fbd2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Commercially available iodinated contrast media (CM) show significantly different physico-chemical properties. The relevance of the viscosity of CM may be underestimated as a contributing factor for clinically relevant renal failure as suggested by a large registry data analysis (Swedish registry study). The objective of this preclinical study is to assess differences of a low and high-viscous CM regarding their retention time in the kidney. Furthermore, we investigated the expression of marker genes for renal damage and hypoxia to evaluate a potential renal damage and hypoxia after application of iodinated CM. MATERIAL AND METHODS After application of Iopromide 300 and Iodixanol 320 CM, the iodine concentration over time was determined using computed tomography and x-ray fluorescence analysis in healthy Han Wistar and renally impaired ZSF1 rats. The latter served as a model for age and diabetes-related renal impairment. X-ray attenuation (Hounsfield units) in the renal cortex was analyzed by 2 independent blinded readers. Furthermore, the expression of kidney injury molecule 1 (Kim-1/Havcr1) and heme oxygenase I (HO-1/HMOX1) was measured by quantitative reverse transcription-polymerase chain-reaction. RESULTS Computed tomography and x-ray fluorescence analysis in the kidneys of animals treated with Iodixanol revealed significantly prolonged retention of iodine in the kidney as compared with animals treated with Iopromide. This difference was even more pronounced in renally impaired rats. Twenty-four hours after Iodixanol treatment, significantly increased levels of Kim-1/Havcr1 and HO-1/HMOX1 transcript levels were observed compared with the saline and Iopromide treatment. CONCLUSIONS A prolonged retention of contrast media in the kidney was observed after administration of dimeric CM (Iodixanol 320). One possible explanation for this effect could be the high viscosity of the dimeric CM (Iodixanol 320) and the lack of dilution by osmotic diuresis. This prolonged exposure is possibly associated with higher renal toxicity as indicated by the elevated expression of biomarkers for hypoxia and renal injury.
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95
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Low osmolar contrast medium induces cellular injury and disruption of calcium homeostasis in rat glomerular endothelial cells in vitro. Toxicol Lett 2009; 185:124-31. [DOI: 10.1016/j.toxlet.2008.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 12/10/2008] [Accepted: 12/12/2008] [Indexed: 11/17/2022]
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96
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Heinrich MC, Häberle L, Müller V, Bautz W, Uder M. Nephrotoxicity of iso-osmolar iodixanol compared with nonionic low-osmolar contrast media: meta-analysis of randomized controlled trials. Radiology 2009; 250:68-86. [PMID: 19092091 DOI: 10.1148/radiol.2501080833] [Citation(s) in RCA: 239] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To compare the nephrotoxicity of iso-osmolar iodixanol with that of nonionic low-osmolar contrast media (CM) (LOCM) in randomized clinical trials. MATERIALS AND METHODS This meta-analysis was conducted with a systematic search of MEDLINE, EMBASE, BIOSIS, Web of Science, ISI Web of Knowledge, Current Contents Medizin, Cochrane Library (until August 2007), trial registers, conference proceedings, and reference lists to identify studies and with requests from all manufacturers of CM for unidentified studies. Randomized controlled trials assessing serum creatinine levels before and after intravascular application of iodixanol or LOCM were included. The primary outcome measures were the incidence of contrast medium-induced nephropathy (CIN) and change in serum creatinine levels. RESULTS Twenty-five trials were included. Iodixanol did not significantly reduce the risk of CIN (relative risk [RR], 0.80; 95% confidence interval [CI]: 0.61, 1.04; weighted mean difference in serum creatinine increase, 0.01 mg/dL [0.88 mumol/L]; 95% CI: -0.01, 0.03). There was no significant risk reduction after intravenous administration of the CM (RR, 1.08; 95% CI: 0.62, 1.89); subgroup with preexisting renal insufficiency (RR, 1.07; 95% CI: 0.56, 2.02) or after intraarterial administration (RR, 0.68; 95% CI: 0.46, 1.01); subgroup with preexisting renal insufficiency (RR, 0.59; 95% CI: 0.33, 1.07). However, in patients with intraarterial administration and renal insufficiency, the risk of CIN was greater for iohexol than for iodixanol (RR, 0.38; 95% CI: 0.21, 0.68), whereas there was no difference between iodixanol and the other (noniohexol) LOCM (RR, 0.95; 95% CI: 0.50, 1.78). CONCLUSION Iodixanol is not associated with a significantly reduced risk of CIN compared with the LOCM pooled together. However, in patients with intraarterial administration and renal insufficiency, iodixanol is associated with a reduced risk of CIN compared with iohexol, whereas no significant difference between iodixanol and other LOCM could be found.
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Affiliation(s)
- Marc C Heinrich
- Institute of Radiology, University Hospital of Erlangen, Maximiliansplatz 1, 91054 Erlangen, Germany
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97
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Treitl M, Rupprecht H, Wirth S, Korner M, Reiser M, Rieger J. Assessment of renal vasoconstriction in vivo after intra-arterial administration of the isosmotic contrast medium iodixanol compared to the low-osmotic contrast medium iopamidol. Nephrol Dial Transplant 2008; 24:1478-85. [DOI: 10.1093/ndt/gfn638] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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98
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Xu X, Wu T, Ding X, Zhu J, Zou J, He J. The role of nuclear factor-κB in rats of radiocontrast-media-induced nephropathy. J Biochem Mol Toxicol 2008; 22:416-21. [DOI: 10.1002/jbt.20256] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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99
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Harmon RC, Duffy SP, Terneus MV, Ball JG, Valentovic MA. Characterization of a novel model for investigation of radiocontrast nephrotoxicity. Nephrol Dial Transplant 2008; 24:763-8. [PMID: 18840895 DOI: 10.1093/ndt/gfn540] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Radiocontrast agents are one of the most common causes of acute renal failure in the world. These agents are required for both diagnostic and therapeutic modalities of medical intervention, including computed tomography (CT), angiography and cardiac catheterization. Publications over the past 40 years support three potential mechanisms of toxicity: oxidative stress, haemodynamics and hyperosmolar effects. An in vitro model provides a rapid evaluation of cellular toxicity without the complications of haemodynamics. This study evaluated the renal toxicity of radiocontrast agents at clinically relevant concentrations. METHODS This study investigated the toxicity of two radiocontrast agents, diatrizoic acid (DA) and iothalamic acid (IA), using an in vitro model. Renal cortical slices isolated from F344 rats were incubated with 0-111 mg I/ml DA or IA. RESULTS Renal slices exposed to DA and IA showed toxicity as measured by increased lactate dehydrogenase (LDH) leakage at concentrations lower than previously published using isolated cell models. These data indicate that DA and IA are toxic to renal cortical slices, and this is a more sensitive model than previously used cell culture systems. DA and IA treatment failed to cause a significant decrease in total cellular glutathione or increase in percent glutathione disulphide (GSSG), implying that oxidative stress may not be an initial mechanism of toxicity. Finally, the addition of exogenous glutathione did provide complete protection from DA- and IA-induced LDH leakage. CONCLUSION These data validate the renal cortical slice in vitro model for investigation of radiocontrast nephrotoxicity. These studies further showed that glutathione was cytoprotective. Future research using this model is aimed at further characterization of radiocontrast nephrotoxicity, which may allow for improved prevention and treatment of radiocontrast-induced acute renal failure.
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Affiliation(s)
- Robert C Harmon
- Department of Pharmacology, Marshall University School of Medicine, WV 25755-9388, USA
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100
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Nguyen SA, Suranyi P, Ravenel JG, Randall PK, Romano PB, Strom KA, Costello P, Schoepf UJ. Iso-osmolality versus low-osmolality iodinated contrast medium at intravenous contrast-enhanced CT: effect on kidney function. Radiology 2008; 248:97-105. [PMID: 18483232 DOI: 10.1148/radiol.2481071484] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To determine the effects of iso-osmolality contrast medium compared with a low-osmolality agent on renal function (serum creatinine [SCr] and glomerular filtration rate [GFR]) in high-risk patients undergoing intravenous contrast material-enhanced CT. MATERIALS AND METHODS This HIPAA-compliant study was IRB-approved; formal consent was obtained. One hundred seventeen patients (83 men, 34 women; mean age, 64.3 years; range, 18-86 years) with decreased renal function underwent contrast-enhanced CT with either iso-osmolality iodixanol (n = 61) or low-osmolality iopromide (n = 56). Outcome measures were of SCr increase or GFR decrease for 3 days after CT, a SCr increase (of >or=0.5 mg/dL [44.2 micromol/L, 25%] or >or=1.0 mg/dL [88.4 micromol/L, 50%]), a GFR reduction (of >or=5 mL/min), and patient outcome at 30- and 90-day follow-up. RESULTS Iodixanol decreased SCr (mean +/- standard deviation) from 1.77 mg/dL +/- 0.24 (156.47 micromol/L +/- 21.22) at baseline to 1.65 mg/dL +/- 0.35 (145.86 micromol/L +/- 30.94, P = .046) at day 1, 1.73 mg/dL +/- 0.53 (152.93 micromol/L +/- 46.85, not significant) at day 2, and 1.73 mg/dL +/- 0.55 (152.93 micromol/L +/- 48.62, not significant) at day 3 (not significant). Iopromide increased SCr from 1.75 mg/dL +/- 0.32 (154.7 micromol/L +/- 28.29) at baseline to 1.8 mg/dL +/- 0.42 (159.12 micromol/L +/- 15.59) at day 1, 1.77 mg/dL +/- 0.49 (156.47 micromol/L +/- 43.32) at day 2, and 1.77 mg/dL +/- 0.62 (156.47 micromol/L +/- 54.81) at day 3 (not significant). Iodixanol increased and iopromide decreased GFR on all 3 days after CT (not significant). Fewer patients in the iodixanol group (8.5%) than in the iopromide group (27.8%) had SCr increase 0.5 mg/dL or higher (>or=25%, P = .012). Two patients in each group had SCr increase of 1.0 mg/dL or more (not significant). More patients in the iopromide group (42.3%) than in the iodoxanol group (24.1%) had a GFR reduction of 5 mL/min or higher (P = .0426). No patient had a contrast material-related adverse event at 30- or 90-day follow-up. CONCLUSION Intravenous contrast material application in high-risk patients is unlikely to be associated with permanent adverse outcomes. SCr levels after contrast material administration are lower in iodixanol than iopromide groups.
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Affiliation(s)
- Shaun A Nguyen
- Department of Radiology, Medical University of South Carolina, PO Box 250322, 169 Ashley Ave, Charleston, SC 29425, USA
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