Contrast Nephropathy

Intern

 1.

Kandzari DE. Contrast nephropathy : an

evidence-based approach to prevention. American
Journal of Cardiovascular Drugs. 3(6):395-405,
2003.
2. Murphy SW. Contrast nephropathy. Journal of
the American Society of Nephrology. 11(1):177-82,
2000 Jan.
3. Birck R. Acetylcysteine for prevention of
contrast nephropathy: meta-analysis. Lancet.
362(9384):598-603, 2003 Aug 23. 805 cases
4. Curhan GC. Prevention of contrast nephropathy.
JAMA. 289(5):606-8, 2003 Feb 5.

 5.

Guitterez NV. Determinants of serum creatinine

trajectory in acute contrast nephropathy. Journal
of Interventional Cardiology. 15(5):349-54, 2002
Oct. 95 cases
6. Durham JD. A randomized controlled trial of Nacetylcysteine to prevent contrast nephropathy in
cardiac angiography. Kidney International.
62(6):2202-7, 2002 Dec. 79 cases
7. Kini AS. Changing trends in incidence and
predictors of radiographic contrast nephropathy
after percutaneous coronary intervention with use
of fenoldopam. American Journal of Cardiology.
89(8):999-1002, 2002 Apr 15. 260 cases

 8.

Kini AS. A protocol for prevention of radiographic

contrast nephropathy during percutaneous coronary
intervention: effect of selective dopamine receptor agonist
fenoldopam. Catheterization & Cardiovascular
Interventions. 55(2):169-73, 2002 Feb. 150 cases
9. McCullough PA. Prediction and prevention of contrast
nephropathy. Journal of Interventional Cardiology.
14(5):547-58, 2001 Oct. 150 cases
10. Tepel M. Prevention of radiographic-contrast-agentinduced reductions in renal function by acetylcysteine. New
England Journal of Medicine. 343(3):180-4, 2000 Jul 20. 83
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Cardiology. 33(2):403-11, 1999 Feb

Contrast
Oil-soluble:

Dionosil: bronchogram
Lipiodol: TAE, lymphangiography
Water-soluble:
Ionic high-osmolarity: 900 osmo/kg
Ionic low-osmolarity: 500 osmo/kg
Non-ionic: 300 osmo/kg

Contrast
Excretion:

100% from kidney

80% by glomerular filtration
20% by excretion from renal tubule
Half life: 20 min (Ccr > 70 ml/min)

Contrast Nephropathy
Diagnosis:

A rise in serum creatinine of at least 0.5

(1) mg/dL within 48 h of contrast
administration
Other causes of acute renal failure must
be excluded

Clinical Feature
Prerenal type acute renal failure
Onset: within 24 to 48 h
Peak: 3rd to 5th days
Resolution: within 7~14 days
Transient

Risk Factor
Advanced

age (> 65 y/o 1,9)

Preexisting renal disease (CRI: CT:
8%~28% 3, Angio: 15~40% 8)
DM (20~50% 7,10)
Dehydration 2,9
High contrast dose (neg:3 )
Ionic, high-osmolar contrast media 1,2,4

Pathophysiology
Vasoconstriction:

Endothelin-1
Immune response
Nephrotoxicity: free radicle

Prevention
Calcium

channel blocker 4
Atrial natiuretic peptide (ANP)
Furosemide 4,5,11
Mannitol 5,11
Dopamine 5
Endothelin-receptor antagonist
Dialysis 4

Prevention
0.45%

saline 3,9,11
N-Acetylcysteine (NAC) 3,10
Acetylcysteine + hydration in chronic
renal insufficiency 10

0.45% Saline
Slightly

Volume-expanded
High urine output (>150 ml/hr 11)
Mannitol, crystalloid 11

N-Acetylcysteine (NAC)
Anti-oxidant
NAC

+ NO ---> S-nitrothiol (a potent

vasodilator)
Increase the expression of NO synthase

Fenoldopam (Corlopam)
Selective

dopamine-1 (DA-1) receptor

agonist Fenoldopam: Cr>2
(incidence<4% 7, 4.7% vs. 19% 8)
0.1 mcg/kg/minute 1~2 days
Vasodilation
Anti-hypertension

Conclusion
Risk of contrast nephropathy could be
reduced by
Selection
Preparation

Selection
No! Wait!
Age > 65 y/o
Preexisting renal disease: Cr > 2.5
Uncontrolled DM
Dehydration
Previous contrast nephropathy

Selection
It depends
Heart failure, hypoalbuminemia, liver failure
Uncontrolled hypertension
Ongoing infection
Discuss with -- Lower contrast dose
Nonionic, low-osmolar contrast media

Preparation
0.45% saline, 1ml/kg/hr
12~24 hr

12 hr

Mannitol, crystalloid
N-Acetylcysteine,600mg bid po*2 days
Fenodolpam,0.1 mcg/kg/min

Preparation
Follow

up BUN, Cr for 3~5 days

Control hypertension, infection
Dialysis: can NOT prevent contrast
nephropathy

Thanks!