Summary
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 <30ml 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.
Zusammenfassung
Die Kontrastmittel-induzierte Nephropathie ist eine häufige Komplikation, vor allem bei Hochrisikopatienten (z.B. bei Patienten mit chronischer Nierenerkrankung und Diabetes mellitus). Die überwiegende Zahl der Studien belegt eine erhöhte Mortalität im Krankenhaus und eine ungünstige Langzeitprognose nach Manifestation der Kontrastmittel-induzierten Nephropathie. Bei dieser Sonderform des akuten Nierenversagens sind der zeitliche Verlauf und die möglichen Risikofaktoren bekannt. Dadurch sollte sich eine effektive Prophylaxe herleiten lassen, dieser Komplikation zu begegnen. Bei Patienten mit geringem Risiko genügt vermutlich die orale oder intravenöse Flüssigkeitszufuhr vor Kontrastmittelgabe und das Absetzen nicht-sterodialer Antiphlogistika 48 Stunden davor. Bei Hochrisikopatienten sind zusätzliche Prophylaxemaßnahmen erforderlich, deren Effektivität nicht eindeutig definiert ist. Entsprechend heterogen sind die Empfehlungen. Die Hydratation reduziert (afferente) Renovasokonstriktoren, den tubuloglomerulären Feedback, die tubulotoxische Wirkung von Kontrastmittel (u.a. durch Verdünnung) und die Sauerstoffradikalbildung. Unklar sind die optimale Zusammensetzung, Timing und Menge der substituierten Flüssigkeit. In den meisten Studien ist die intravenöse Flüssigkeitszufuhr effektiver als die orale. Mehrheitlich wird ein Benefit isotoner Natriumbikarbonat- im Vergleich zu isotonen Salzlösungen gesehen, auch wenn Meta-Analysen durch die Heterogenität der Daten nur einen positiven Trend für Natriumbikarbonat ergeben. Kontrovers ist die Datenlage für N-Acetylcystein, Vitamin C, Fenoldopam, Theophyllin oder Statine. Aufgrund der niedrigen Kosten und geringen Nebenwirkungen hat N-Acetylcystein breite Anwendung gefunden. Theophyllin (intravenös 30 min vor Kontrastmittelgabe) hat sich vor allem bei Intensivpatienten als renoprotektiv erwiesen. Wichtig ist die Minimierung des Kontrastmittelvolumens (möglichst < 30ml bei diagnostischer, < 100 ml bei interventioneller Indikationsstellung). Iso-osmolare und niedrig-osmolare Kontrastmittel werden im Hinblick auf das Risiko der Kontrastmittel-induzierten Nephropathie meist ohne signifikanten Unterschied beurteilt. Das Risiko der Kontrastmittel-induzierten Nephropathie ist offensichtlich größer unter intra-arterieller als unter intravenöser Kontrastmittelinjektion. Kontrovers ist die Datenlage im Hinblick auf die Verhinderung der Kontrastmittel-induzierten Nephropathie und Reduktion der Mortalität bei prophylaktischer Hämodialyse/Hämofiltration. Ein möglicher Benefit dieser Verfahren besteht vermutlich für Patienten mit weit fortgeschrittener chronischer Nierenerkrankung (Stadium 5). Mit weiterer Zunahme der Kontrastmitteluntersuchungen und vaskulären Interventionen wird bei Zunahme der Überalterung und Komorbiditäten der betroffenen Patienten das Problem der Kontrastmittel-induzierten Nephropathie trotz aller Prophylaxemaßnahmen weiter zunehmen.
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Hörl, W. Kontrastmittel-induzierte Nephropathie. Wien Klin Wochenschr 121, 15–32 (2009). https://doi.org/10.1007/s00508-009-1145-3
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DOI: https://doi.org/10.1007/s00508-009-1145-3
Keywords
- Contrast media induced nephropathy
- Acute renal failure
- Volume expansion
- Sodium bicarbonate
- N-acetylcystein
- Theophylline
- Hemodialysis