Contrast nephropathy in patients with impaired renal function: High versus low osmolar media

Abstract

Prescription of low osmolar contrast to prevent nephrotoxicity in subjects with pre-existing renal impairment is costly and has not been clearly shown to be effective. We entered 249 subjects with a pre-contrast serum creatinine greater than 120 mumol/liter (1.35 mg/dl) having cardiac catheterization or intravenous contrast into a randomized controlled trial comparing high and low osmolar contrast. The outcome assessed was a rise in serum creatinine repeated 48 to 72 hours after contrast. A further 117 patients entered the non-randomized prospective arm of the study. In the randomized study the serum creatinine rose by at least 25% after contrast in 8 of 117 (6.8%) given high and in 5 of 132 (3.8%) given low osmolar contrast (P greater than 0.05, one-tailed 95% confidence interval for the difference 3 to 7.8%). More severe renal failure (greater than 50% increase in serum creatinine) after contrast was uncommon (3.4% with high and 1.5% with low osmolar contrast). A rise in serum creatinine after contrast was significantly associated with the severity of the pre-contrast renal impairment and the presence of diabetes mellitus, but not with type of contrast. Diabetics with a serum creatinine greater than 200 mumol/liter (2.25 mg/dl) pre-contrast had a highest risk of deterioration in renal function after contrast. We conclude that in patients with pre-existing renal impairment the incidence of contrast nephropathy was not significantly different comparing high osmolar and nonionic contrast. The potential benefit of nonionic contrast in moderate renal impairment is likely to be small, but trials in diabetics with severe renal impairment should be undertaken urgently.

Comparison of Iodixanol and Iohexol in Patients Undergoing Intravenous Pyelography: A Prospective Controlled Study

“…Moreover, data from animal studies have suggested that nonionic CM is less nephrotoxic than ionic CM. [8][9][10][11][12] CN can be defined as an acute impairment of renal function following the exposure of radiocontrast medium. [1] The clinical presentation of CN is distinct, having a temporal relation between the performance of the contrast study in the high-risk patient and the onset of an increase in serum creatinine levels within the next 24 hours to 5 days.…”

“…Until now, several pathophysiological mechanisms have been proposed, including disturbed renal perfusion/hypoxia, direct toxicity to renal tubular epithelium, apoptosis, altered glomerular function, and immunologic mechanisms. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Histamine is a well-known mediator of inflammation and a very important modulator of cytokine production. [23] Previous studies have reported on the elevation of plasma histamine levels after conventional CM.…”

Incidence and Outcomes of Contrast-Induced AKI Following Computed Tomography

“…Clinical factors that increase the risk for contrast-induced acute kidney injury (CIAKI) include preexistent kidney disease, diabetes mellitus in the setting of underlying renal impairment, advanced congestive heart failure, intravascular volume depletion, administration of large volumes of contrast, and the use of high-osmolal contrast media (1,(5)(6)(7)(8). Much of our understanding of the risk factors for, incidence of, and outcomes associated with CIAKI emanate from clinical studies of patients undergoing angiography, particularly coronary angiography.…”

The Risk Factors for Developing Contrast-induced Nephropathy after the Evaluation of Trauma Patients at a Regional Trauma Center in Korea

“…This rate is slightly higher than in similar studies of trauma patients, which reported a range of CIN rates from 1.9% to 6.6%. (11)(12)(13) We found that contrast volume, sCr at presentation, hypotension at presentation, and ISS were all risk factors for CIN in univariate analyses. In the multivariate analysis, only sCr at presentation and ISS remained independently associated with the development of CIN.…”

“…(10)(11)(12) Procedures that use intravascular contrast medium such as coronary angiography and contrast-enhanced CT are being used more frequently for both diagnostic and therapeutic purposes. In addition, the major risk factors for CIN, i.e., chronic kidney disease and diabetes mellitus, are also increasing in prevalence.…”