1
|
Danışan G, Taydaş O, Özdemir M, Ateş ÖF, Küpeli A, Öğüşlü U, Erkin A, Neşelioğlu S, Eren F. Dynamic thiol-disulphide homeostasis as a biomarker for predicting the development of contrast medium-associated acute kidney injury in the endovascular treatment of peripheral arterial disease: should intravenous N-acetylcysteine be given before the procedure? Clin Radiol 2023; 78:466-472. [PMID: 36941180 DOI: 10.1016/j.crad.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/15/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
AIM To determine the predictive ability of serum thiol-disulphide levels for contrast medium-associated acute kidney injury (CA-AKI) after endovascular treatment (EVT) of peripheral arterial disease (PAD) and evaluate the efficacy of intravenous N-acetylcysteine (NAC) in preventing CA-AKI. MATERIAL AND METHODS This double-blind, randomised controlled study included 85 consecutive adult patients who underwent EVT for PAD. Patients were divided into NAC negative (NAC-) and positive (NAC+) groups. While the NAC- group received only 500 ml saline, the NAC + group received 500 ml saline plus intravenous 600 mg NAC before the procedure. Intra- and intergroup patient characteristics, procedural details, preoperative thiol-disulphide levels, and ischaemia-modified albumin (IMA) levels were recorded. RESULTS There was a significant difference between NAC- and NAC + groups regarding native thiol, total thiol, disulphide/native thiol ratio (D/NT), and disulphide/total thiol ratio (D/TT). There was also a significant difference between the NAC- (33.3%) and NAC+ (13%) groups in CA-AKI development. Logistic regression analysis showed that the D/TT (OR 2.463) and D/NT (OR 2.121) were the most influential parameters for CA-AKI development. In the receiver operating characteristic (ROC) curve analysis, the sensitivity of native thiol to detect the development of CA-AKI was 89.1%. The negative predictive values of native thiol and total thiol were 95.6% and 94.1%, respectively. CONCLUSION The serum thiol-disulphide level can be used as a biomarker to detect CA-AKI development and reveal patients with a low risk for CA-AKI development before EVT of PAD. Furthermore, thiol-disulphide levels allow for the indirect quantitative monitoring of NAC. Preprocedural intravenous NAC administration significantly inhibits CA-AKI development.
Collapse
Affiliation(s)
- G Danışan
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey.
| | - O Taydaş
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - M Özdemir
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - Ö F Ateş
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - A Küpeli
- Kanuni Training and Research Hospital, Department of Radiology, Trabzon, Turkey
| | - U Öğüşlü
- Medicana International Hospital, Department of Radiology, Istanbul, Turkey
| | - A Erkin
- Sakarya University Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya, Turkey
| | - S Neşelioğlu
- Ankara City Hospital, Department of Biochemistry, Ankara, Turkey
| | - F Eren
- Ankara City Hospital, Department of Biochemistry, Ankara, Turkey
| |
Collapse
|
2
|
Kraft WK. Clinical Pharmacology and the Best Use of Public Research Investment. Clin Pharmacol Ther 2022; 111:1185-1188. [PMID: 35586960 DOI: 10.1002/cpt.2590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Barrios López A, García Martínez F, Rodríguez JI, Montero-San-Martín B, Gómez Rioja R, Diez J, Martín-Hervás C. Incidence of contrast-induced nephropathy after a computed tomography scan. RADIOLOGIA 2021; 63:307-313. [PMID: 34246421 DOI: 10.1016/j.rxeng.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 02/13/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS The term contrast-induced nephropathy is used to describe acute deterioration of renal function after the intravenous administration of iodinated contrast material. We aimed to estimate the incidence of contrast-induced nephropathy and to analyze the evolution of different biomarkers of renal function in patients who underwent computed tomography with intravenous contrast administration after premedication with oral hydration and N-acetylcysteine. MATERIAL AND METHODS This prospective observational study included 112 patients with chronic renal failure (glomerular filtration rate (GFR) 30ml-60ml/min/1.73m2) scheduled for computed tomography with intravenous iodinated contrast material. We recorded demographic variables, dose of contrast material, diabetes mellitus, hypertension, and serum hemoglobin. We measured serum creatinine and GFR after premedication and after the CT examination. We summarized variables as means, standard deviations, and percentages. We used the Wilcoxon and Mann-Whitney tests to compare pre- and post-CT values and Pearson's r to analyze correlations. RESULTS Incidence acute kidney injury: 0.9%; 95%CI: 0.36-1.4. Mean difference between pre- and post-CT creatinine: 0.04; 95%CI: 0.002-0.09, p<0.004. Mean difference between pre- and post-CT GFR: -3.06; 95%CI: -4.66 to -1.47), p<0.001. CONCLUSIONS The incidence of contrast-induced nephropathy in patients with chronic renal failure and GFR 30ml-60ml/min/1.73m2 is low. The biomarkers of renal function analyzed improve in patients who receive premedication and the minimum dose of contrast material.
Collapse
Affiliation(s)
- A Barrios López
- Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain.
| | - F García Martínez
- Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| | - J I Rodríguez
- Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| | | | - R Gómez Rioja
- Servicio de Análisis Clínicos, Hospital Universitario La Paz, Madrid, Spain
| | - J Diez
- Servicio de Bioestadística, IdiPAZ - Hospital Universitario La Paz, Madrid, Spain
| | - C Martín-Hervás
- Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| |
Collapse
|
4
|
|
5
|
Dósa E, Heltai K, Radovits T, Molnár G, Kapocsi J, Merkely B, Fu R, Doolittle ND, Tóth GB, Urdang Z, Neuwelt EA. Dose escalation study of intravenous and intra-arterial N-acetylcysteine for the prevention of oto- and nephrotoxicity of cisplatin with a contrast-induced nephropathy model in patients with renal insufficiency. Fluids Barriers CNS 2017; 14:26. [PMID: 28974245 PMCID: PMC5627439 DOI: 10.1186/s12987-017-0075-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/18/2017] [Indexed: 12/02/2022] Open
Abstract
Background Cisplatin neuro-, oto-, and nephrotoxicity are major problems in children with malignant tumors, including medulloblastoma, negatively impacting educational achievement, socioemotional development, and overall quality of life. The blood-labyrinth barrier is somewhat permeable to cisplatin, and sensory hair cells and cochlear supporting cells are highly sensitive to this toxic drug. Several chemoprotective agents such as N-acetylcysteine (NAC) were utilized experimentally to avoid these potentially serious and life-long side effects, although no clinical phase I trial was performed before. The purpose of this study was to establish the maximum tolerated dose (MTD) and pharmacokinetics of both intravenous (IV) and intra-arterial (IA) NAC in adults with chronic kidney disease to be used in further trials on oto- and nephroprotection in pediatric patients receiving platinum therapy. Methods Due to ethical considerations in pediatric tumor patients, we used a clinical population of adults with non-neoplastic disease. Subjects with stage three or worse renal failure who had any endovascular procedure were enrolled in a prospective, non-randomized, single center trial to determine the MTD for NAC. We initially aimed to evaluate three patients each at 150, 300, 600, 900, and 1200 mg/kg NAC. The MTD was defined as one dose level below the dose producing grade 3 or 4 toxicity. Serum NAC levels were assessed before, 5 and 15 min post NAC. Twenty-eight subjects (15 men; mean age 72.2 ± 6.8 years) received NAC IV (N = 13) or IA (N = 15). Results The first participant to experience grade 4 toxicity was at the 600 mg/kg IV dose, at which time the protocol was modified to add an additional dose level of 450 mg/kg NAC. Subsequently, no severe NAC-related toxicity arose and 450 mg/kg NAC was found to be the MTD in both IV and IA groups. Blood levels of NAC showed a linear dose response (p < 0.01). Five min after either IV or IA NAC MTD dose administration, serum NAC levels reached the 2–3 mM concentration which seemed to be nephroprotective in previous preclinical studies. Conclusions In adults with kidney impairment, NAC can be safely given both IV and IA at a dose of 450 mg/kg. Additional studies are needed to confirm oto- and nephroprotective properties in the setting of cisplatin treatment. Clinical Trial Registration URL: https://eudract.ema.europa.eu. Unique identifier: 2011-000887-92
Collapse
Affiliation(s)
- Edit Dósa
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Krisztina Heltai
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Gabriella Molnár
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Judit Kapocsi
- 1st Department of Internal Medicine, Semmelweis University, 26 Üllői Street, Budapest, 1085, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Rongwei Fu
- Public Health & Preventive Medicine, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, CB669, Portland, OR, 97329, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Gerda B Tóth
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Zachary Urdang
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA. .,Department of Neurosurgery, Oregon Health & Science University, 3184 S.W. Sam Jackson Park Rd, L603, Portland, OR, 97329, USA. .,Portland Veterans Affairs Medical Center, 3710 S.W. US Veterans Hospital Rd, Portland, OR, 97239, USA. .,Blood-Brain Barrier and Neuro-Oncology Program, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, L603, Portland, OR, 97239, USA.
| |
Collapse
|
6
|
Samarage CR, Carnibella R, Preissner M, Jones HD, Pearson JT, Fouras A, Dubsky S. Technical Note: Contrast free angiography of the pulmonary vasculature in live mice using a laboratory x-ray source. Med Phys 2017; 43:6017. [PMID: 27806595 PMCID: PMC5074996 DOI: 10.1118/1.4964794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose: In vivo imaging of the pulmonary vasculature in small animals is difficult yet highly desirable in order to allow study of the effects of a host of dynamic biological processes such as hypoxic pulmonary vasoconstriction. Here the authors present an approach for the quantification of changes in the vasculature. Methods: A contrast free angiography technique is validated in silico through the use of computer-generated images and in vivo through microcomputed tomography (μCT) of live mice conducted using a laboratory-based x-ray source. Subsequent image processing on μCT data allowed for the quantification of the caliber of pulmonary vasculature without the need for external contrast agents. These measures were validated by comparing with quantitative contrast microangiography in the same mice. Results: Quantification of arterial diameters from the method proposed in this study is validated against laboratory-based x-ray contrast microangiography. The authors find that there is a high degree of correlation (R = 0.91) between measures from microangiography and their contrast free method. Conclusions: A technique for quantification of murine pulmonary vasculature without the need for contrast is presented. As such, this technique could be applied for longitudinal studies of animals to study changes to vasculature without the risk of premature death in sensitive mouse models of disease. This approach may also be of value in the clinical setting.
Collapse
Affiliation(s)
| | - Richard Carnibella
- 4Dx Limited, Melbourne 3000, Australia and Department of Mechanical and Aerospace Engineering, Monash University, Melbourne 3800, Australia
| | - Melissa Preissner
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne 3800, Australia
| | - Heather D Jones
- Department of Medicine and the Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | - James T Pearson
- Department of Physiology, Monash University, Melbourne 3800, Australia; Monash Biomedical Imaging Facility Monash University, Melbourne 3800, Australia; and Australian Synchrotron, Melbourne 3168, Australia
| | - Andreas Fouras
- 4Dx Limited, Melbourne 3000, Australia and Department of Mechanical and Aerospace Engineering, Monash University, Melbourne 3800, Australia
| | - Stephen Dubsky
- 4Dx Limited, Melbourne 3000, Australia and Department of Mechanical and Aerospace Engineering, Monash University, Melbourne 3800, Australia
| |
Collapse
|
7
|
Mathur M, Weinreb JC. Imaging patients with renal impairment. Abdom Radiol (NY) 2016; 41:1108-21. [PMID: 27015867 DOI: 10.1007/s00261-016-0709-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Imaging with intravascular contrast media is generally considered safe, particularly in patients without renal failure. However, as renal function deteriorates, the potential risk of nonallergic-type adverse events increases. This presents a unique challenge, particularly when the use of intravenous contrast media is deemed essential for diagnostic purposes. Following a discussion regarding the definition and epidemiology of kidney injury, this review focuses on the evolving understanding of both contrast-induced nephropathy and nephrogenic systemic fibrosis and discusses preventative strategies aimed at minimizing the risk of developing these entities. Alternative non-contrast imaging techniques are also discussed.
Collapse
Affiliation(s)
- Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA.
| | - Jeffrey C Weinreb
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA
| |
Collapse
|
8
|
Sadat U. N-acetylcysteine in contrast-induced acute kidney injury: clinical use against principles of evidence-based clinical medicine! Expert Rev Cardiovasc Ther 2013; 12:1-3. [DOI: 10.1586/14779072.2014.852066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
9
|
Patel Y, Depta JP, DeMartini TJ. Complications of chronic total occlusion percutaneous coronary intervention. Interv Cardiol 2013. [DOI: 10.2217/ica.13.48] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
10
|
Failure rate and complications of angiography and embolization for abdominal and pelvic trauma. J Trauma Acute Care Surg 2012; 73:1208-12. [DOI: 10.1097/ta.0b013e318265ca9f] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Richenberg J. How to reduce nephropathy following contrast-enhanced CT: a lesson in policy implementation. Clin Radiol 2012; 67:1136-45. [PMID: 22717146 DOI: 10.1016/j.crad.2012.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 04/23/2012] [Accepted: 05/01/2012] [Indexed: 12/31/2022]
Abstract
In excess of 50 contrast-enhanced computed tomography (CT) examinations are typically undertaken in our tertiary hospital NHS Trust each weekday, approximately 13,000 each year. In the Department of Radiology alone, we inject more than 1300 l of iodinated contrast medium per annum. There is a real need to devise a policy to anticipate contrast medium-induced nephropathy (CIN) and minimize its effects, without disrupting the high-intensity CT service. Having written a comprehensive yet pragmatic policy to reduce the incidence of this iatrogenic condition, it seemed sensible to share it with the wider radiology community and share the experience and lessons learnt in engaging all the stakeholders, ushering in the change with as little fuss as possible. The ramifications on primary and secondary care had to be anticipated, resource implications managed, and staff trained. This review is therefore presented in four sections: framing the problem, assessing its size and nature; a succeeding section on the available guidelines and their uptake; the policy itself to reduce CIN in CT is presented in the third section; and crucially, a description of the policy introduction process in the last section.
Collapse
Affiliation(s)
- J Richenberg
- Radiology Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
| |
Collapse
|
12
|
Singh T, Lam KV, Murray C. Low volume contrast CTPA in patients with renal dysfunction. J Med Imaging Radiat Oncol 2011; 55:143-8. [PMID: 21501402 DOI: 10.1111/j.1754-9485.2011.02243.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The study aims to evaluate a method for and technical feasibility of performing CT pulmonary angiography (CTPA) with just 30 mL of contrast. METHODS Twenty-four patients with renal dysfunction suspected of having pulmonary embolus underwent CTPA using 30 mL of contrast. A modified acquisition protocol was employed where sequential monitoring of the central superior vena cava (SVC) was performed following injection of contrast. Scanning was triggered at the first visualised arrival of contrast within the SVC. Hounsfield unit (HU) measurements were performed at the main pulmonary artery to the subsegmental branches to determine the adequacy of each study. RESULTS The level of pulmonary arterial enhancement achieved was high, averaging 247 HU across all measured arteries. Average enhancement within more peripheral lobar, segmental and subsegmental arteries was also greater than 200. Only one study was considered non-diagnostic. CONCLUSION Low-volume CTPA is technically feasible and provides excellent enhancement of the pulmonary arterial tree.
Collapse
Affiliation(s)
- Tushar Singh
- Department of Radiology, Royal Perth Hospital, Perth, Western Australia, Australia.
| | | | | |
Collapse
|
13
|
Sadat U, Walsh SR, Norden AG, Gillard JH, Boyle JR. Does oral N-acetylcysteine reduce contrast-induced renal injury in patients with peripheral arterial disease undergoing peripheral angiography? A randomized-controlled study. Angiology 2010; 62:225-30. [PMID: 20682612 DOI: 10.1177/0003319710377078] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The nephroprotective role of N-acetylcysteine (NAC) against contrast-induced nephropathy (CIN) in patients undergoing peripheral arterial angiography remains unclear. A total of 40 patients undergoing peripheral arterial angiography were randomized to receive intravenous (iv) hydration only (group 1) or oral NAC in addition to iv hydration (group 2; ISRCTN: 35882618). Primary outcome was reduction in the elevation of urinary retinol binding protein (RBP), albumin-creatinine ratio (ACR), and serum creatinine (serC). Groups 1 and 2 had equivocal percentage reduction in RBP and ACR levels from baseline (P = .80 and .30). A significant reduction in serC was, however, observed with NAC by third postprocedure day (P = .04). One patient in the treatment arm developed CIN compared with 3 patients in the control group (P = .33). Equivocal changes in RBP and ACR levels by both treatments seem to indicate that either is equally effective in affording renal protection.
Collapse
Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, UK.
| | | | | | | | | |
Collapse
|
14
|
Abstract
BACKGROUND Computed tomography (CT) is the gold standard for the identification of occult injuries, but the intravenous (IV) contrast used in CT scans is potentially nephrotoxic. Because elderly patients have decreased renal function secondary to aging and chronic disease, we sought to determine the rate of acute kidney injury (AKI) in elderly trauma patients exposed to IV contrast. METHODS Medical records of patients older than 55 years evaluated at a level-one trauma center between January 2003 and July 2008 were reviewed. Contrast was nonionic, isosmolar, and administered in standard volumes. Groups were based on administration of contrast. AKI was defined as a 25% relative or 0.5 mg/dL absolute increase in serum creatinine within 72 hours of presentation [corrected]. RESULTS During the study period 1,371 patients older than 55 years were evaluated, and 1,152 met the inclusion criteria. CT was performed on 1,071 patients (96%); 71% of this group received IV contrast. There was no significant difference between the contrast and noncontrast groups in terms of baseline characteristics. Criteria for AKI were satisfied in 2.1% of all patients, including 1.9% the contrast group versus 2.4% in the noncontrast group. AKI diagnosed within 72 hours of patient presentation was an independent risk factor for in-hospital mortality and prolonged length of stay. CONCLUSIONS IV contrast media in elderly trauma patients is not associated with an increased risk of AKI. Development of AKI within 72 hours of admission is associated with mortality and increased length of stay.
Collapse
|
15
|
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
|
16
|
Abstract
Contrast media induced nephropathy is a common complication, particularly in high risk patients, such as patients with chronic kidney disease (CKD) and diabetes. The majority of studies show an increased in-hospital mortality and an unfavourable long-term prognosis after manifestation of contrast media induced nephropathy. The course and the potential risk factors of this type of acute renal failure are known. Therefore, an effective prophylaxis should allow to prevent this complication. In low risk patients oral or intravenous volume expansion is probably sufficient combined with the withdrawal of non-steroidal anti-inflammatory drugs. In high risk patients additional prophylactic measures are needed but their efficacy is not clearly defined. Therefore, heterogeneous recommendations exist. Hydration reduces (afferent) renovasoconstriction, the tubuloglomerular feedback, the tubulotoxic effects of contrast media (via dilution) and the oxygen radical formation. The optimal composition, timing and amount of fluid which should be administered to the patients remain unclear. Most studies show that intravenous administration of volume is more effective than oral fluid intake. The majority of studies found a benefit of isotonic sodium bicarbonate in comparison to isotonic saline solutions, even if meta-analyses displayed only a positive trend for sodium bicarbionate due to the heterogeneity of the data. Controversies exist for N-acetylcysteine, vitamin C, fenoldopam, theophylline or statins. Due to low cost and low side effects, N-Acetylcysteine is widely used. Theophyllin (given intravenously 30 minutes before contrast media injection) is renoprotective, particularly in intensive care unit patients. Very important is the reduction of contrast media volume (if possible <30 ml for diagnostic procedures and <100 ml for interventions). Iso-osmolar and low-osmolar contrast media may have a comparable low risk for the induction of contrast media induced nephropathy. This risk is probably higher after intra-arterial as compared to intravenous administration of contrast media. Controversies exist with respect to the reduction of contrast media induced nephropathy and mortality by prophylactic hemodialysis or hemofiltration. A possible benefit of these procedures consists probably for patients with advanced chronic kidney disease (stage 5). With the further increase of investigations using contrast media, with the further increase in vascular interventions, in age and comorbidities of the patients one may suggest that the problem of contrast media induced nephropathy will further increase, despite all prophylactic procedures so far recommended.
Collapse
|
17
|
Clinical significance and preventive strategies for contrast-induced nephropathy. Curr Opin Nephrol Hypertens 2008; 17:616-23. [PMID: 18941356 DOI: 10.1097/mnh.0b013e32830f45a3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Contrast-induced nephropathy continues to be a common cause of in-hospital acute kidney injury. Published studies on pathogenesis, clinical significance, diagnosis, and preventive measures have dramatically increased significantly in the past several years. This review will focus on new developments in contrast-induced nephropathy. RECENT FINDINGS Studies on the clinical significance of contrast-induced nephropathy are reviewed along with initial reports of biomarkers in diagnosing this complication of iodinated contrast administration. Emerging literature on the relative nephrotoxicity of iso-osmolar versus low-osmolar contrast media and the value of bicarbonate hydration are discussed. More recent preventive measures using prostacyclin, 'statins', and erythropoietin are also reviewed. SUMMARY Contrast-induced nephropathy is an increasing cause of acute kidney injury and is associated with significant mortality and morbidity. Future developments in this field will focus on refining the clinical significance of this complication, earlier diagnosis with biomarkers, clarifying the role for bicarbonate and iso-osmolar contrast agents as preventive strategies, and the introduction of new prophylactic techniques on the basis of an improved understanding of pathogenesis at the cellular level.
Collapse
|
18
|
Yano T. [Etiology of iodinated radiocontrast nephrotoxicity and its attenuation by beraprost]. YAKUGAKU ZASSHI 2008; 128:1023-9. [PMID: 18591870 DOI: 10.1248/yakushi.128.1023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Radiocontrast nephropathy (RCN) is a major complication after radiographical examination with iodinated contrast media (CM). Although little is known about the mechanism of RCN, a direct toxic action on renal cells and/or decrease in renal blood flow are considered to be implicated in the pathogenesis of the disease/the condition, A large number of vasodilatory agents, including endothelin antagonists, adenosine antagonists, atrial natriuretic peptide, calcium channel blockers, dopamine, dopamine D1 receptor agonist fenoldopam, and prostaglandin E1 have been tried clinically to prevent RCN, however, most of them have failed. Although prophylactic effects of antioxidant N-acetylcysteine have recently been reported by several investigators, only hydration is a universally accepted protocol to prevent it. In our recent in vitro and in vivo study, we have elucidated that CM induced apoptosis of renal tubular cells through the reduction in Bcl-2 expression and the subsequent activation of caspase-9 and caspase-3. Moreover, we found that CM caused an increase in ceramide content in renal tubular cells, which leads to apoptosis by inhibiting the phosphorylation of Akt and cAMP responsive element binding protein (CREB) and the subsequent reduction in Bcl-2 expression. The inhibitor of ceramide synthase, fumonisin B1, reversed both the elevation of ceramide content and renal cell injury induced by CM. On the other hand, a prostacyclin analog beraprost prevented RCN in mice by the increase of endogenous cAMP and subsequent CREB phosphorylation resulted in enhancement of Bcl-2 expression. These findings suggest that ceramide synthesis inhibitor or beraprost is potentially useful for the prophylaxis of RCN.
Collapse
Affiliation(s)
- Takahisa Yano
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan.
| |
Collapse
|