Abstract
An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) iso-osmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. Administration of N-acetylcysteine, theophylline, or fenoldopam, sodium bicarbonate infusion, and periprocedural haemofiltration/haemodialysis have been investigated as preventive measures in recent years. This review addresses the literature on these newer strategies. Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
Highlights
Contrast-induced nephropathy, defined as an increase in serum creatinine by more than 25% or 44 μmol/l from baseline within 3 days after administration of contrast agents in the absence of an alternative aetiology [1,2], is a major cause of hospital-acquired acute renal failure [3,4]
Risk factors for contrastinduced nephropathy include pre-existing renal failure, hypovolaemia, administration of high doses of contrast media, and concomitant use of drugs that interfere with the regulation of renal perfusion [3,8, 10,11,12,13]
Thereafter, we focus on contrast-induced nephropathy in critically ill patients and attempt to provide clear recommendations regarding whether/when these new preventive measures may be applied in critically ill patients
Summary
Contrast-induced nephropathy, defined as an increase in serum creatinine by more than 25% or 44 μmol/l from baseline within 3 days after administration of contrast agents in the absence of an alternative aetiology [1,2], is a major cause of hospital-acquired acute renal failure [3,4]. Five trials found a significant protective effect of NAC compared with standard treatment [22,25,27,30,32], eight found no beneficial effect of administration of NAC [13,23,24,26,28, 29,31,35] Possible explanations for these contrasting results are differences in applied hydration regimens, in the patient populations studied and in the volumes of contrast media administered, and variations in the timing and dosing of NAC. Studies on fenoldopam Five trials have been performed evaluating fenoldopam infusion as a preventive measure for contrast-induced nephropathy [23,36,47,48,49], four of which were randomized 363
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