Copyright
©The Author(s) 2017.
World J Nephrol. May 6, 2017; 6(3): 86-99
Published online May 6, 2017. doi: 10.5527/wjn.v6.i3.86
Published online May 6, 2017. doi: 10.5527/wjn.v6.i3.86
Table 1 Common indications for contrast media use in medical imaging
| Diagnosis and treatment of vascular diseases such as coronary artery disease, pulmonary thromboembolism, arteriovenous malformations, aneurysms, arterial dissections and thrombosis |
| Diagnosis and staging of neoplastic diseases and mass lesions |
| Diagnosis of inflammatory and infectious diseases such as multiple sclerosis, meningitis, pancreatitis, diverticulitis |
Table 2 Types, osmolalities and molecular structures of iodinated-contrast media
| Osmolality | High osmolal (> 1400 mosm/kg) | Low osmolal (500-850 mosm/kg) | Iso-osmolal (290 mosm/kg) | |
| Molecular structure | Ionic/monomer | Ionic/dimer | Non-ionic/monomer | Non-ionic/dimer |
| Name of molecule | Diatrizoate (Hypaque) | Ioxaglate (Hexabrix) | Iohexol (Omnipaque) | Iodixanol (Visipaque) |
| Iopamidol (Isovue) | ||||
| Ioversol (Optiray) | ||||
| Iopromide (Ultravist) | ||||
| Iopentol (Imagopaque) | ||||
| Iomeprol (Iomeron) | ||||
Table 3 Major studies comparing low-osmolal and iso-osmolal contrast media in terms of renal safety
| Ref. | Baseline renal functions/patient population | Procedure/administration route | Compared drugs | Aim of the study/primary end points | Results |
| Feldkamp et al[94] | Normal GFR | PTCA (intra-arterial) | Iodixanol (IOCM) vs Iopromide (LOCM) | ≥ 25% increase in SCr at 48 h | No difference |
| Hardiek et al[95] | Normal GFR, diabetic patients | PTCA (intra-arterial) | Iodixanol (IOCM) vs Iopamidol (LOCM) | ≥ 25% increase in SCr days 1, 3 and 7 | No difference |
| Aspelin et al[96] (NEPHRIC) | CKD, diabetic patients | PTCA (intra-arterial) | Iodixanol (IOCM) vs Iohexol (LOCM) | Peak increase in SCr day 0–3 | Iso-osmolal safer than low-osmolal CM |
| Jo et al[97] (RECOVER) | CKD | PTCA (intra-arterial) | Iodixanol (IOCM) vs Ioxaglate (LOCM) | Increase in SCr ≥ 25% or ≥ 0.5 mg/dL within 2 d | Iso-osmolal safer than low-osmolal CM |
| Solomon et al[98] (CARE) | CKD | PTCA (intra-arterial) | Iodixanol (IOCM) vs Iopamidol (LOCM) | Increase in SCr > 0.5 mg/dL at 45-120 h | No difference |
| Rudnick et al[99] (VALOR) | CKD | PTCA (intra-arterial) | Iodixanol (IOCM) vs Ioversol (LOCM) | Increase in SCr > 0.5 mg/dL within 72 h | No difference |
| Barrett et al[8] (IMPACT) | CKD | CT (intravenous) | Iodixanol (IOCM) vs Iopamidol (LOCM) | Increase in SCr > 0.5 mg/dL or ≥ 25% at 48–72 h | No difference |
| Kuhn et al[100] (PREDICT) | CKD | CT (intravenous) | Iodixanol (IOCM) vs Iopamidol (LOCM) | Increase in SCr > 0.5 mg/dL within 48-72 h | No difference |
| Thomsen et al[101] (ACTIVE) | CKD | CT (intravenous) | Iodixanol (IOCM) vs Iomeprol (LOCM) | Increase in SCr > 0.5 mg/dL at 48-72 h | Low-osmolal safer than iso-osmolal CM |
| Nguyen et al[102] | CKD | CT (intravenous) | Iodixanol (IOCM) vs Iopromide (LOCM) | Peak rise in SCr days 1-3 | Iso-osmolal safer than low-osmolal CM |
| Wessely et al[103] | CKD | PTCA (intra-arterial) | Iodixanol (IOCM) vs İomeprol (LOCM) | Peak increase in SCr | No difference |
Table 4 Meta-analyses comparing iso-osmolal and low-osmolal contrast media in terms of renal safety
| Metaanalyses | Baseline renal functions | Procedure/administration route | Compared drugs | Results |
| McCullough et al[104] (16 trials) | Both normal GFR and CKD | PTCA (intra-arterial) | Iodixanol (IOCM) vs various LOCM | Iodixanol safer than LOCM, e.p. in patients with CKD or CKD + diabetes mellitus |
| Reed et al[23] (16 trials) | Both normal GFR and CKD | PTCA + CT (intra-arterial + intravenous) | Iodixanol (IOCM) vs various LOCM | Overall, no difference. However, iodixanol safer than ioxaglate and iohexol |
| Heinrich et al[48] (25 trials) | Both normal GFR and CKD | PTCA + IV urography + CT (intra-arterial + intravenous) | Iodixanol (IOCM) vs various LOCM | Overall, no difference. However, iodixanol safer than iohexol in CKD patients when CM used via intra-arterial route |
| From et al[105] (36 trials) | Both normal GFR and CKD | PTCA + CT (intra-arterial + intravenous) | Iodixanol (IOCM) vs various LOCM | Overall, no difference. Iodixanol safer than iohexol |
| Eng et al[24] (29 trials) | Both normal GFR and CKD | PTCA + IV urography + CT (intra-arterial + intravenous) | Iodixanol (IOCM) vs various LOCM | Iodixanol slightly safer than LOCM but the lower risk did not exceed a minimally important clinical difference |
Table 5 Proposed pathophysiological mechanisms of contrast-induced acute kidney injury
| Medullary vasoconstriction and hypoxia[27-29] |
| Direct cytotoxicity to renal tubular cells[30-33] |
| Release of vasoconstrictive mediators: Endothelin, adenosine, angiotensin II, vasopressin[28] |
| Reduction of vasodilatatory mediators: Nitric oxide, prostocyclin[28,32,34] |
| Increased oxidative stress[32,35,36] |
| Impairment of tubulo-glomerular feedback[32] |
| Increased blood and renal tubular viscosity[41] |
| Impairment of mitochondrial function and mitochondrial membrane potential[42] |
Table 6 Patient-related and contrast media-related risk factors for contrast-induced acute kidney injury
| Patient-related risk factors |
| Pre-existing CKD |
| Diabetes mellitus and diabetic nephropathy |
| Older age |
| Simultaneous use of nephrotoxic drugs |
| Multiple myeloma |
| States of reduced kidney perfusion |
| Dehydration |
| Congestive heart failure |
| Hemodynamic instability |
| Contrast-media related risk factors |
| High volume of CM |
| Use of hyperosmolal CM |
| Multiple exposure to CM in short-term |
| Intra-arterial administration |
Table 7 Strategies to reduce the risk of contrast-induced acute kidney injury
| Assess the risk of CI-AKI |
| Assess the need of contrast-enhancement, avoid unnecessary contrast administration |
| Avoid concomitant use of other nephrotoxic drugs |
| Hydrate the patient with isotonic saline and/or sodium bicarbonate before and after the procedure |
| N-acetyl-cysteine 1200 mg orally twice daily |
| Prefer iso-osmolal or hypo-osmolal CM |
| Use minimum amount of CM |
| Check renal functions within 1 wk of the procedure |
Table 8 Experimental drugs and procedures to prevent contrast-induced acute kidney injury
| Drugs |
| Hydration with isotonic saline[57-59] |
| N-acetyl-cysteine[69,106-110] |
| Sodium bicarbonate[58,68,108,109,111] |
| Theophylline[112-114] |
| Mannitol[115] |
| Furosemide[115-117] |
| Ascorbic acid (vitamin C)[118] |
| Tocopherol (vitamin E)[119] |
| Statins[120-124] |
| Mesna[125] |
| Dopamine[126] |
| Fenoldopam (dopamin agonist)[127] |
| Calcium channel blockers (verapamil, diltiazem)[128] |
| Adenosine[129] |
| Endothelin receptor antagonists[130] |
| Atrial natriuretic peptide[131] |
| Iloprost (PGI2 analogue)[132] |
| Misoprostol (PGE1 analogue)[133] |
| Trimetazidine[134] |
| Erythropoetin[135,136] |
| Nebivolol[137] |
| Sodium citrate[138] |
| Procedures |
| Remote ischemic preconditioning[72,73] |
| Prophylactic hemodialysis/hemofiltration/hemodiafiltration[71,139,140] |
Table 9 Alternative non-contrast enhanced imaging techniques
| Name of the technique | Clinical indications | Notes |
| TOF MR angiography | Cerebral aneurysm | No contrast agent is required |
| Stroke | ||
| Atherosclerotic carotid disease | ||
| Arteriovenous malformation | ||
| Peripheral artery disease (less frequently) | ||
| ECG-gated fast spin echo MR angiography | Peripheral artery disease | No contrast agent is required. |
| Thoraco-abdominal aortic aneurysm | Higher image quality compared to TOF MR angiography in peripheral arterial imaging | |
| SSFP MR imaging | Coronary artery disease | No contrast agent is required |
| Myocardial viability and function | ||
| Pericardial diseases | ||
| Renal artery stenosis | ||
| Congenital heart diseases | ||
| Arterial spin labeling with/without SSFP | Native and transplanted renal renal artery stenosis | No contrast agent is required. |
| Renal perfusion | Evaluation of organ perfusion | |
| Cerebral blood flow | When combined with SSFP, it can be used as an angiographic imaging | |
| Characterization of masses | ||
| Phase contrast MR imaging | Imaging of major thoroco-abdominal vascular structures | No contrast agent is required. |
| Congenital heart disease | Quantification of blood flow and velocity | |
| Renal artery stenosis | ||
| Carbon-dioxide angiography | Peripheral artery disease (mostly infra-diaphragmatic) | No contrast agent is required. |
| Non-allergenic, non-nephrotoxic, inexpensive. | ||
| Neurotoxic, risk of air trapping and distal ischemia |
- Citation: Ozkok S, Ozkok A. Contrast-induced acute kidney injury: A review of practical points. World J Nephrol 2017; 6(3): 86-99
- URL: https://www.wjgnet.com/2220-6124/full/v6/i3/86.htm
- DOI: https://dx.doi.org/10.5527/wjn.v6.i3.86