Risk Prediction of Contrast-Induced Nephropathy

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In order to make appropriate decisions about clinical management, it is important for physicians to be able to stratify patients according to their risk for contrast-induced nephropathy (CIN). The most important risk marker for nephropathy after exposure to iodinated contrast media is preexisting renal impairment. The risk of CIN is elevated and becomes clinically important in patients with chronic kidney disease characterized by an estimated glomerular filtration rate <60 mL/min per 1.73 m2. In patients with renal impairment, diabetes mellitus amplifies the risk of CIN and complicates postprocedure management. Other markers associated with an increased risk of CIN include cardiovascular disease, periprocedural hemodynamic instability, use of nephrotoxic drugs, and anemia. The effect of risk factors is additive, and the presence of multiple risk factors in the same patient can create a very high risk for CIN and acute renal failure requiring dialysis. Risk models incorporating baseline and periprocedural characteristics have been developed using data from large databases of percutaneous coronary intervention patients. These schemes are potentially valuable, but at present the most practical approach to risk prediction is based on a simple model incorporating renal function and diabetes mellitus.

Section snippets

Consensus statement 2

The risk of CIN is elevated and of clinical importance in patients with chronic kidney disease (particularly when diabetes is also present), recognized by an estimated glomerular filtration rate <60 mL/min/1.73 m2.

Consensus statement 5

The presence of multiple CIN risk factors in the same patient or high-risk clinical scenarios can create a very high risk for CIN (∼50%) and acute renal failure (∼15%) requiring dialysis after contrast exposure.

Overview of Major Risk Markers

Table 1 summarizes the main risk predictors for CIN that have been reported in the literature, with impaired renal function and diabetes cited consistently. The CIN Consensus Working Panel preferred the use of the term risk marker to risk factor because many of these indicators are nonmodifiable patient characteristics that are not necessarily directly causative.

Additive risk

The effect of risk factors is additive, and the likelihood of CIN rises sharply as number of risk factors increases. This was first documented by Cochran and colleagues29 in a study of renal angiography that showed that the risk of CIN was 50% in patients with 5 risk factors. Others have consistently shown a relation between multiple risk factors and an increased risk of CIN, both in peripheral angiography4, 22, 23 and in PCI.12, 16, 17 One study in patients undergoing angiography for

Review of main scoring schemes

A risk model combines ≥2 characteristics to help clinicians to make predictions about future health outcomes. The identification of major risk markers for CIN and quantification of the effect of these baseline and periprocedural characteristics on the likelihood of a CIN event among patients undergoing various radiologic procedures have allowed the development of risk models. The predictors used in published risk models are summarized in Table 2.12, 16, 17, 19, 39, 79 As already discussed, the

Practical approaches to risk prediction

The consensus view of the Panel was that the most appropriate approach to risk prediction is a simple one that focuses on renal dysfunction and diabetes as the most important risk markers. Figure 2 shows the result of modeling the risk of CIN according to the eGFR for the total population and according to the presence or absence of diabetes.9, 15, 47, 49, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111,

References (119)

  • R.V. Freeman et al.

    Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose

    Am J Cardiol

    (2002)
  • J.A. D’Elia et al.

    Nephrotoxicity from angiographic contrast material: a prospective study

    Am J Med

    (1982)
  • C.P. Taliercio et al.

    A randomized comparison of the nephrotoxicity of iopamidol and diatrizoate in high risk patients undergoing cardiac angiography

    J Am Coll Cardiol

    (1991)
  • S. Sabeti et al.

    Reduction in renal function after renal arteriography and after renal artery angioplasty

    Eur J Vasc Endovasc Surg

    (2002)
  • M.R. Rudnick et al.

    Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trialThe Iohexol Cooperative Study

    Kidney Int

    (1995)
  • R. Birck et al.

    Acetylcysteine for prevention of contrast nephropathy: meta-analysis

    Lancet

    (2003)
  • D.H. Kang et al.

    Uric acid and chronic renal disease: possible implication of hyperuricemia on progression of renal disease

    Semin Nephrol

    (2005)
  • G. Marenzi et al.

    Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction

    J Am Coll Cardiol

    (2004)
  • R. Dumaine et al.

    Prognostic significance of renal insufficiency in patients presenting with acute coronary syndrome (the Prospective Multicenter SYCOMORE study)

    Am J Cardiol

    (2004)
  • P.A. McCullough et al.

    Slowing the progression of diabetic nephropathy and its cardiovascular consequences

    Am Heart J

    (2004)
  • S. Khanal et al.

    Statin therapy reduces contrast-induced nephropathy: an analysis of contemporary percutaneous interventions

    Am J Med

    (2005)
  • A.S. Kini et al.

    Changing trends in incidence and predictors of radiographic contrast nephropathy after percutaneous coronary intervention with use of fenoldopam

    Am J Cardiol

    (2002)
  • I. Arany et al.

    Cisplatin nephrotoxicity

    Semin Nephrol

    (2003)
  • H.S. Thomsen et al.

    Chronic cisplatin nephropathy, contrast media, and creatinine

    Acad Radiol

    (1996)
  • W.H. Reinhart et al.

    Effect of high-dose intravenous immunoglobulin therapy on blood rheology

    Lancet

    (1992)
  • A.S. Abizaid et al.

    Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency

    Am J Cardiol

    (1999)
  • C.S. Baker et al.

    A rapid protocol for the prevention of contrast-induced renal dysfunction: the RAPPID study

    J Am Coll Cardiol

    (2003)
  • C. Briguori et al.

    Acetylcysteine and contrast agent-associated nephrotoxicity

    J Am Coll Cardiol

    (2002)
  • L.J. Diaz-Sandoval et al.

    Acetylcysteine to prevent angiography-related renal tissue injury (the APART trial)

    Am J Cardiol

    (2002)
  • S. Efrati et al.

    The effect of N-acetylcysteine on renal function, nitric oxide, and oxidative stress after angiography

    Kidney Int

    (2003)
  • J.W. Fung et al.

    Effect of N-acetylcysteine for prevention of contrast nephropathy in patients with moderate to severe renal insufficiency: a randomized trial

    Am J Kidney Dis

    (2004)
  • W. Huber et al.

    Effectiveness of theophylline prophylaxis of renal impairment after coronary angiography in patients with chronic renal insufficiency

    Am J Cardiol

    (2003)
  • S.E. Miner et al.

    N-acetylcysteine reduces contrast-associated nephropathy but not clinical events during long-term follow-up

    Am Heart J

    (2004)
  • P.A. McCullough et al.

    Epidemiology and prognostic implications of contrast-induced nephropathy

    Am J Cardiol

    (2006)
  • A. Kamdar et al.

    Acute renal failure (ARF) induced by radiographic contrast material

    Clin Res

    (1976)
  • F.A. Krumlovsky et al.

    Acute renal failure: association with administration of radiographic contrast material

    JAMA

    (1978)
  • A. Kamdar et al.

    Acute renal failure following intravenous use of radiographic contrast dyes in patients with diabetes mellitus

    Diabetes

    (1977)
  • J. Chanard et al.

    Nephrotoxicity of conventional and low osmolality radiocontrast media

    J Nephrol

    (1991)
  • C. Davidson et al.

    Contrast medium use

    Am J Cardiol

    (2006)
  • C.S. Rihal et al.

    Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention

    Circulation

    (2002)
  • I. Iakovou et al.

    Impact of gender on the incidence and outcome of contrast-induced nephropathy after percutaneous coronary intervention

    J Invasive Cardiol

    (2003)
  • C. Mueller et al.

    Female sex and risk of contrast nephropathy after percutaneous coronary intervention

    Can J Cardiol

    (2004)
  • E.M. Lautin et al.

    Radiocontrast-associated renal dysfunction: incidence and risk factors

    AJR Am J Roentgenol

    (1991)
  • M.J. Gussenhoven et al.

    Renal dysfunction after angiography: a risk factor analysis in patients with peripheral vascular disease

    J Cardiovasc Surg (Torino)

    (1991)
  • A.S. Gomes et al.

    Acute renal dysfunction after major arteriography

    AJR Am J Roentgenol

    (1985)
  • M.W. Rich et al.

    Incidence, risk factors, and clinical course of acute renal insufficiency after cardiac catheterization in patients 70 years of age or older: a prospective study

    Arch Intern Med

    (1990)
  • S.T. Cochran et al.

    Predicting angiography-induced acute renal function impairment: clinical risk model

    AJR Am J Roentgenol

    (1983)
  • E.P. Steinberg et al.

    Nephrotoxicity of low osmolality contrast media versus high osmolality media

    Invest Radiol

    (1991)
  • C.J. Davidson et al.

    Cardiovascular and renal toxicity of a nonionic radiographic contrast agent after cardiac catheterization: a prospective trial

    Ann Intern Med

    (1989)
  • J.L. Teruel et al.

    Renal function impairment caused by intravenous urography: a prospective study

    Arch Intern Med

    (1981)
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