Kontrastmittel-induzierte Nephropathie

Abstract

Contrast media induced nephropathy is a common complication, particularly in high risk patients, such as patients with chronic kidney disease (CKD) and diabetes. The majority of studies show an increased in-hospital mortality and an unfavourable long-term prognosis after manifestation of contrast media induced nephropathy. The course and the potential risk factors of this type of acute renal failure are known. Therefore, an effective prophylaxis should allow to prevent this complication. In low risk patients oral or intravenous volume expansion is probably sufficient combined with the withdrawal of non-steroidal anti-inflammatory drugs. In high risk patients additional prophylactic measures are needed but their efficacy is not clearly defined. Therefore, heterogeneous recommendations exist. Hydration reduces (afferent) renovasoconstriction, the tubuloglomerular feedback, the tubulotoxic effects of contrast media (via dilution) and the oxygen radical formation. The optimal composition, timing and amount of fluid which should be administered to the patients remain unclear. Most studies show that intravenous administration of volume is more effective than oral fluid intake. The majority of studies found a benefit of isotonic sodium bicarbonate in comparison to isotonic saline solutions, even if meta-analyses displayed only a positive trend for sodium bicarbionate due to the heterogeneity of the data. Controversies exist for N-acetylcysteine, vitamin C, fenoldopam, theophylline or statins. Due to low cost and low side effects, N-Acetylcysteine is widely used. Theophyllin (given intravenously 30 minutes before contrast media injection) is renoprotective, particularly in intensive care unit patients. Very important is the reduction of contrast media volume (if possible <30 ml for diagnostic procedures and <100 ml for interventions). Iso-osmolar and low-osmolar contrast media may have a comparable low risk for the induction of contrast media induced nephropathy. This risk is probably higher after intra-arterial as compared to intravenous administration of contrast media. Controversies exist with respect to the reduction of contrast media induced nephropathy and mortality by prophylactic hemodialysis or hemofiltration. A possible benefit of these procedures consists probably for patients with advanced chronic kidney disease (stage 5). With the further increase of investigations using contrast media, with the further increase in vascular interventions, in age and comorbidities of the patients one may suggest that the problem of contrast media induced nephropathy will further increase, despite all prophylactic procedures so far recommended.

Perceptions and attitudes of bhutanese people on Sowa Rigpa, traditional bhutanese medicine: a preliminary study from Thimphu

“…This art of healing is therefore a holistic approach to healthcare [11]. Sowa rigpa in Bhutan is based on principles of Indian and Tibetan Medicine and has also incorporated some ancient local medical practices [12-14]. According to Kleinman, a healthcare system articulates illness as a cultural idiom, linking perceptions about disease causation, the experience of symptoms, decisions concerning treatment alternatives, and actual therapeutic practices [15].…”

ACE-I/ARB Therapy prior to Contrast Exposure: What Should the Clinician Do?

“…In a meta-analysis of 17 randomized trials, sodium bicarbonate prophylaxis reduced the incidence of CIN when compared to other preventive strategies for CIN but showed no significant difference in the requirement for renal replacement therapy (RRT) and mortality [15]. Although prophylactic hemodialysis or hemofiltration has been used to prevent CIN in one clinical trial, the majority of studies show no benefit or harm associated with this intervention [9, 16]. The most simple and cost effective method to prevent CIN is proper volume expansion with normal saline, avoiding nephrotoxic agents, and use of the lowest possible volume of contrast media.…”

“…Multiple interventions including N-acetylcysteine, utilization of lower osmolar agents, volume expansion with or without sodium bicarbonate, avoiding nephrotoxic medications, dialysis for contrast removal, felodipine, and dopamine have been used to prevent CIN [9]. ACE-I and angiotensin receptor blockers (ARBs) on the other hand are used extensively for patients with congestive cardiac failure, hypertension, proteinuric kidney disease, myocardial ischemia, and diabetic nephropathy.…”

Ist Nephroprotektion durch die Auswahl des Röntgen-Kontrastmittels im Rahmen von Gefäßinterventionen bei vorbestehender Niereninsuffizienz möglich?

“…Hiernach folgen der Diabetes mellitus, das Alter, die arterielle Hypertonie, ein erhöhter Hämatokrit mit steigender Blutviskosität, eine erniedrigte, linksventrikuläre Ejektionsfraktion und Notfallbedingungen als Patienten-bezogene Risikofaktoren [12][13][14][15]. Als Patienten-unabhängige Risikofaktoren werden die hochosmolaren und ionischen Kontrastmittel angesehen, als auch eine hohe Viskosität des Kontrastmediums und die Kontrastmittelmenge [15][16][17][18][19]. Diese lassen sich im klinischen Alltag iatrogen beeinflussen.…”

“…Bei bereits niereninsuffizienten Patienten sollte die ACC-Gabe sorgfältig mit einer Vor-und Nachhydratation mit isotoner Infusionslösung erfolgen[20,21,23]. ACC fungiert als Radikalfänger bei renalem Anfall an toxischen Substanzen[5,6,18]. Widersprechend dazu finden sich ältere Publikationen z.…”