Contrast Induced Nephropathy: September 2007
Contrast Induced Nephropathy: September 2007
Contrast Induced Nephropathy: September 2007
September 2007
Case discussion
67 female with
IHD and previous NSTEMI 2004
DM CKD stage 3 (Creatinine 206)
On Ramipril, ISMN, Atenolol and Gliclazide
Admitted for PCI
Prevention strategies for contrast induced nephropathy (CIN)
What is currently the best strategy to avoid CIN in medium to high risk patients?
1. Intravenous volume expansion with a saline solution
2. Use of a low- or iso-osmolality contrast agent
3. Limits on the volume of contrast agent
4. Use of N-acetylcysteine (NAC)
5. Avoidance of nephrotoxic drugs peri-procedure
6. None of the above
REMEDIAL TRIAL
Published in Circulation 2007
Renal insufficiency following contrast media
administration trial
a randomized comparison of three preventative
strategies
Briguori C (MD PhD) et al.
Laboratory of Interventional Cardiology, San Raffaele
Hospital, Milan
Institute of Medical Statistics and Biometry,
University of Milan, Milan, Italy
Introduction
CIN: acute reversible form of ARF presenting within 48 hours after the
administration of contrast media
NAC (all 3 arms) 1.2 g twice daily day before and day of the
procedure (2 days in total)
Scheme to define contrast-induced nephropathy (CIN) risk score
Optimal therapy to prevent contrast-induced acute renal failure remains uncertain. Patients
with near-normal renal function are at little risk and few precautions are necessary other than
avoidance of volume depletion.
Patients at increased risk of contrast nephropathy (serum creatinine 132 mmol/L or an
estimated glomerular filtration rate <60 ml/1.73 m2, particularly in patients with diabetes:
ultrasonography, MRI without gadolinium contrast, or CT scanning without radiocontrast agents.
use of iso-osmolal agents rather than low osmolal agents
Use lower doses of contrast and avoid repetitive, closely spaced studies (eg, <48 hours apart).
Avoid volume depletion and nonsteroidal antiinflammatory drugs.
Isotonic intravenous fluids prior to and continued for several hours after contrast administration
The optimal type of fluid and timing of administration are not well established. We suggest isotonic
bicarbonate rather than isotonic saline
Despite conflicting data, we suggest acetylcysteine, at a dose of 600 to 1200 mg orally twice daily,
administered the day before and the day of the procedure, based upon its potential for benefit and
low toxicity and cost.
Based upon the lack of convincing evidence of benefit and the potential risk of anaphylactoid
reactions, we suggest not routinely using intravenous acetylcysteine for the prevention of
contrast nephropathy
We suggest using diuretics only in patients who are volume overloaded.
We do not recommend routine use of hemofiltration or hemodialysis.