Risk Factors and Therapy Strategies for Contrast-Induced Nephropathy

Figures & data

Figure 1. Pathogenesis of contrast-induced nephropathy. NO: nitric oxide.

Table 1. Risk factors for the development of contrast-induced nephropathy

Kidney-related risk factors	Odds ratio (95% CI)	p value
Pre-existing renal failure
Periprocedural creatinine 2.0–2.9 mg/dL[8]	7.37 (4.78–11.39)	<0.0001
Periprocedural creatinine ≥3 mg/dL[8]	12.82 (8.01–20.54)	<0.0001
Diabetes mellitus—diabetic nephropathy
Periprocedural creatinine ≤1.1 mg/dL[8]	1.86 (1.20–2.89)	0.005
Periprocedural creatinine 1.2–1.9 mg/dL[8]	2.42 (1.54–3.79)	<0.001
Use of nephrotoxic drugs^34[,35]
Low effective circulatory volume[8]	1.19 (0.72–1.95)	0.05
Cardiovascular system-related risk factors
Class III–IV congestive heart failure[33]	2.20 (1.60–2.90)	<0.0001
Left ventricle ejection fraction <40%[14]	1.57 (1.14–2.16)	0.005
Acute myocardial infarction ≤ 24 h^8	1.85 (1.31–2.63)	0.0006
Hypertension[33]	2.00 (1.40–2.80)	0.0001
Periprocedural hypotension[14]	2.50 (1.70–3.69)	<0.00001
Peripheral vascular disease[33]	1.90 (1.40–2.70)	<0.0001
Preprocedure shock[8]	1.19 (0.72–1.96)	0.05
Using intra-aortic balloon pump[15]	15.51 (4.65–51.64)	<0.0001
Bypass graft intervention[55]	4.94 (1.16–20.9)	0.03
Time to reperfusion ≥6 h[15]	2.51 (1.01–6.16)	0.04
Pulmonary edema[14]	2.56 (1.42–4.52)	0.001
Demographic risk factors
Age >75 years[15]	5.28 (1.98–14.05)	0.0009
Female gender^30	1.4 (1.25–1.60)	0.0001
Contrast media-related risk factors
High total dose of contrast agent (>300 ml)[15]	2.8 (1.17–6.68)	0.02
Osmolality (Low- vs. high-osmolality)[109]	0.50 (0.36–0.68)
Short duration of two contrast administration, urgent/emergency procedure[33]	4.4 (2.9–6.5)
Other possible risk factors
Procedural success[8]	0.27 (0.19–0.38)	<0.0001
Baseline hematocrit[8]	0.95 (0.92–0.97)	<0.00001
Hyperuricemia[57]
Hypoalbuminemia[7]
Multi-vessel coronary involvement[18]
Hypercholesterolemia[59]
Renal transplant[63]
Multiple myeloma[64]
Diuretics[19]
ACE inhibitors[96]
Intra-arterial contrast administration[61]
Sepsis, cirrhosis[2]

Table 2. Prevention strategies for contrast-induced nephropathy in high-risk patients

Clinical evidence advocating their use	Don't use	With conflicting or limited evidence
Extracellular volume expansion	NSAIDs, COX-2 inhibitors, aminoglycoside, cisplatin	Acetylcystein
Saline or sodium bicarbonate	Loop diuretics	Theophylline
Low or iso-osmolar contrast	Mannitol	Calcium channel blockers
Minimizing the dose of contrast	Multiple use of contrast within 72 h	Fenoldopam
Alternative imaging techniques	Large doses of contrast	Captopril
Monitoring serum creatinine	High-osmolar contrast	Ascorbic acid
Delaying contrast procedures until hemodynamic status is corrected	Metformin usage especially in patients with renal failure	Atrial natriuretic peptide
≥48 h between contrast procedures		Endothelin antagonist
		PGE1
		Hemofiltration

*NSAIDs: nonsteroidal anti-inflammatory drugs.

Goldenberg I, Matetzky S. Nephropathy induced by contrast media: pathogenesis, risk factors and preventive strategies. CMAJ. 2005; 172: 1461–1471, [INFOTRIEVE], [CSA]

 PubMed Web of Science ®Google Scholar

Katzberg RW. Contrast medium-induced nephrotoxicity: which pathway?. Radiology. 2005; 235: 752–755, [INFOTRIEVE], [CSA]

 PubMed Web of Science ®Google Scholar

Weisbord SD, Palevsky PM. Radiocontrast-induced acute renal failure. J Intensive Care Med. 2005; 20: 63–75, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMedGoogle Scholar

Detrenis S, Meschi M, Musini S, Savazzi G. Lights and shadows on the pathogenesis of contrast-induced nephropathy: state of the art. Nephrol Dial Transplant. 2005; 20: 1542–1550, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMed Web of Science ®Google Scholar

Heyman SN, Rosenberger C, Rosen S. Regional alterations in renal hemodynamics and oxygenation: a role in contrast medium-induced nephropathy. Nephrol Dial Transplant. 2005; 20(Suppl. 1)6–11, [CSA], [CROSSREF]

 PubMedGoogle Scholar

Mudge GH. Uricosuric action of cholecystographic agents: possible nephrotoxicity. N Engl J Med. 1971; 284: 929–933, [INFOTRIEVE], [CSA]

 PubMedGoogle Scholar

Thomsen HS. How to avoid CIN: guidelines from the European Society of Urogenital Radiology. Nephrol. Dial. Transplant. 2005; 20: 18–22, [CSA], [CROSSREF]

 Google Scholar

Perlstein TS, Gumieniak O, Hopkins PN, Murphey LJ, Brown NJ, Williams GH, Hollenberg NK, Fisher ND. Uric acid and the state of the intrarenal renin-angiotensin system in humans. Kidney Int. 2004; 66: 1465–1470, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMed Web of Science ®Google Scholar

Morcos SK, Thomsen HS. European Society of Urogenital Radiology guidelines on administering contrast media. Abdom Imaging. 2003; 28: 187–190, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMedGoogle Scholar

Dangas G, Iakovou I, Nikolsky E, Aymong ED, Mintz GS, Kipshidze NN, Lansky AJ, Moussa I, Stone GW, Moses JW, Leon MB, Mehran R. Contrast-induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol. 2005; 95: 13–19, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMed Web of Science ®Google Scholar

Yang DW, Jia RH, Yang DP, Ding GH, Huang CX. Dietary hypercholesterolemia aggravates contrast media-induced nephropathy. Chin Med J. 2004; 117: 542–546, [INFOTRIEVE], [CSA]

 PubMed Web of Science ®Google Scholar

Holland MD, Galla JH, Sanders PW, Luke RG. Effect of urinary pH and diatrizoate on Bence Jones protein nephrotoxicity in the rat. Kidney Int. 1985; 27: 46–50, [INFOTRIEVE], [CSA]

 PubMedGoogle Scholar

McCarthy CS, Becker JA. Multiple myeloma and contrast media. Radiology. 1992; 183: 519–521, [INFOTRIEVE], [CSA]

 PubMed Web of Science ®Google Scholar

Marenzi G, Lauri G, Assanelli E, Campodonico J, De Metrio M, Marana I, Grazi M, Veglia F, Bartorelli AL. Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 2004; 44: 1780–1785, [INFOTRIEVE], [CSA], [CROSSREF]

 PubMed Web of Science ®Google Scholar

Workman RJ, Shaff MI, Jackson RV, Diggs J, Frazer MG, Briscoe C. Relationship of renal hemodynamic and functional changes following intravascular contrast to the renin-angiotensin system and renal prostacyclin in the dog. Invest Radiol. 1983; 18: 160–166, [INFOTRIEVE], [CSA]

 PubMed Web of Science ®Google Scholar

Weber-Mzell D, Kotanko P, Schumacher M, Klein W, Skrabal F. Coronary anatomy predicts presence or absence of renal artery stenosis: a prospective study in patients undergoing cardiac catheterization for suspected coronary artery disease. Eur Heart J. 2002; 23: 1684–1691, [INFOTRIEVE], [CSA]

 PubMedGoogle Scholar

Gleeson TG, Bulugahapitiya S. Contrast-induced nephropathy. Am J Roentgenol. 2004; 183: 1673–1689, [CSA]

 PubMed Web of Science ®Google Scholar