“Contrast-induced nephropathy (CIN) is associated with a rapid and often irreversible decline in kidney function following the administration of iodinated contrast agents. CIN is the third leading cause of acute kidney injury (acute renal failure) in hospitalized patients, and substantially increases mortality, morbidity, and length of hospitalization. It follows a predictable time of onset and is potentially preventable. No consensus exists on the definition of CIN, but recent literature has defined it as an increase in serum creatinine ≥0.5 mg/dL, or more than 25% above baseline.”
Treatment / Prevention
-Acetylcysteine 1200mg PO BID on the day before and the day of the contrast exposure.
-Isotonic fluids, NS. IVFs are more protective than unrestricted oral intake of fluids.
“Acetylcysteine appears to be beneficial, with an odds ratio from pooled analyses of 0.53 to 0.57 (SOR B). Studies suggest that higher doses may provide significant protection against CIN; treatment with 1200 mg of acetylcysteine given orally twice daily on the day before and the day of contrast exposure was associated with a lower risk of CIN, compared with 600-mg doses (3.5% versus 11%).
Isotonic saline is favored over hypotonic solutions. Administration of intravenous isotonic saline is associated with a lower risk of CIN compared to unrestricted oral intake in the general population undergoing elective coronary angiography (SOR B). The use of furosemide, mannitol, or simvastatin to prevent CIN is not supported by current evidence (SOR B).” Theabfm.org
Prevention of Contrast Nephropathy
| Identify risk | • eGFR < 30 mL/min/1.73m2 • eGFR 30 – 60 mL/min/1.73m2 and risk factors |
| Manage risk | • Hydration – IV 1.4% sodium bicarbonate / 0.9% saline at 3 mL/kg/hr 1hr pre and 1 mL/kg/hr for 6hrs post procedure • Omit potentially nephrotoxic medications (ACEi/ARBs / NSAIDs / metformin on day of procedure and do not restart until renal function stable at 48 – 72 hrs • Use low osmolar agents in the lowest dose. • Recheck renal function 48 – 72 hrs following the procedure |
Resources
http://annals.org/aim/article/739567/meta-analysis-effectiveness-drugs-preventing-contrast-induced-nephropathy
http://onlinelibrary.wiley.com/doi/10.1002/clc.20687/pdf
Harty J. Prevention and Management of Acute Kidney Injury. The Ulster Medical Journal. 2014;83(3):149-157.