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Radiocontrast Nephropathy

Radiocontrast Nephropathy. Jason S. Finkelstein, M.D. Tulane University HSC Division of Cardiology 3/2/04. Outline. Incidence and Clinical Features of RCN Risk Factors Pathophysiology Agents used for Prevention of RCN. Incidence.

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Radiocontrast Nephropathy

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  1. Radiocontrast Nephropathy Jason S. Finkelstein, M.D. Tulane University HSC Division of Cardiology 3/2/04

  2. Outline • Incidence and Clinical Features of RCN • Risk Factors • Pathophysiology • Agents used for Prevention of RCN

  3. Incidence • In the year 2000, an estimated 1.8 million caths were performed in the US • Two studies looked at 1826/1196 patients and the incidence of RCN was 14.4% & 11.1% respectively • 0.3-4% of patients required short-term dialysis • Approx 60,000 cases of RCN occur each year

  4. Definition • Absolute increase of Cr > 0.5 mg/dl or relative increase of 25-50% from baseline within 48 hours of contrast exposure in absence of other causes • Third most common cause of acute renal failure

  5. Definition • Typically occurs within 24-48 hours of contrast exposure • Creatinine typically peaks in 3-5 days and returns to baseline in 1-3 weeks • RCN is non-oliguric in most patients

  6. Outcome • Causes increased length of hospital stay and costs • Significant in-hospital morbidity • 5-10% require transient dialysis; <1% require long term dialysis

  7. Increased mortality • 3.8% -- Increase in Cr 0.5-0.9 mg/dl • 64% -- Increase in Cr > 3.0 mg/dl

  8. Osmolality • Contrast media are water soluble structures composed of triiodobenzene ring with varying numbers of iodine molecules • Increased iodine content results in increased osmolality • Pooled data from 25 randomized trials have shown that high osmolality agents pose a greater risk of CN than low-osmolality agents

  9. Risk Factors for RCN • Pre-existing renal insufficiency (37%) • Diabetes (risk is 4.1%) • Contrast volume • Dehydration • Advanced Age • Nephrotoxic drugs (ACE, NSAIDS) • CHF, Liver disease

  10. Pathophysiology • Medullary ischemia • Direct tubular toxicity • Tubular obstruction

  11. Medullary Ischemia • Contrast agents cause a selective renal medullary vasoconstriction • Shunting of blood to the renal cortex • Also known as the “steal phenomenon” • This leads to tubular injury

  12. Tubular obstruction • Possible role in pathogenesis of RCN • Precipitation of Dye crystals in the renal tubules • In presence of dehydration, precipitation of urate or dye crystals could lead to tubular obstruction

  13. Direct Tubular Toxicity • Toxic ATN • Oxygen Free Radicals • Leads to apoptosis in renal tubular and glomerular cells

  14. Iohexol Cooperative Study • Objective • To compare the incidence of contrast nephrotoxicity between nonionic “Iohexol” and the ionic contrast agent “diatrizoate” in a large population of low and high risk patients undergoing angiogram • 1196 pts, randomized trial

  15. Conclusion • The incidence of RCN depends on the presence of risk factors • Pts with CRI and DM are at highest risk • RCN can be associated with significant morbidity and mortality • There are preventive interventions to decrease the risk of toxicity

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