Contrast-induced kidney failure

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Classification according to ICD-10
N99.0 Kidney failure after medical measures
ICD-10 online (WHO version 2019)

In medicine, acute kidney failure after the use of X-ray contrast media is referred to as contrast medium- induced kidney failure . A direct toxic damage to the renal tubule cells by the contrast medium, but also a narrowing of the renal vessels (vasoconstriction) , which leads to a decrease in the oxygen supply in the renal medulla , is discussed as the cause of the contrast medium- induced kidney failure .

However, there is increasing discussion as to whether contrast media are really causally involved in kidney damage. Instead of the term “contrast agent-induced”, the term “contrast agent-associated” kidney failure is proposed (see English version).

Frequency and risk groups

Relevant kidney damage in patients with normal kidney function from the administration of X-ray contrast media is extremely rare or does not occur.

However, the risk of contrast medium-induced kidney failure is increased in patients with pre-existing renal impairment . Other risk factors include age over 75, the presence of diabetes , previous cardiovascular diseases, or heart failure . In addition, the risk increases even if generalized inflammatory reactions are present, which can be seen from the CRP . Various scoring systems are available to assess the individual risk. According to data from the US National Cardiovascular Data Register, around 7% of all patients develop contrast- medium- induced kidney failure after PTCA .

diagnosis

The decrease in kidney function is usually expressed in an increase in serum creatinine 24 to 48 hours after administration of the contrast agent. A decrease in the amount of urine ( oliguria ) is usually not observed. The decline in kidney function is usually temporary. Dialysis treatment may only be necessary in rare cases , usually if the kidney function was already severely impaired at the time the contrast medium was administered.

In the differential diagnosis , acute tubular necrosis or the infiltration of a blood clot (embolism) into the renal vessels must be considered.

treatment

An optimal treatment of contrast medium-induced kidney failure is not known. A lack of volume at the time of the examination should be avoided.

In the case of moderate or severe renal impairment (glomerular filtration rate <45 ml / min / 1.73 m² with intravenous contrast agent administration or <60 ml / min / 1.73 m² with intra-arterial contrast agent administration), preventive measures should be taken, especially if there is also diabetes mellitus . Investigations without contrast agent should be considered, for example an ultrasound examination (sonography) , magnetic resonance imaging without gadolinium or computed tomography without contrast agent administration can be carried out without restrictions. If the administration of contrast medium cannot be avoided in patients with impaired kidney function, the risk of kidney failure can be reduced by the following measures:

The best is the benefit of a prophylactic intravenous hydration . The repeatedly recommended administration of sodium bicarbonate solutions or acetylcysteine ​​can now be viewed as obsolete according to the PRESERVE study. The semi-electrolyte solution originally used is also no longer in use. Therapy regimens in use at present are e.g. B .:

  • Physiological saline solution 1 ml / kg / hour, 6–12 hours before the examination to 6–12 hours after the examination. A possible, but not formally evaluated alternative for outpatients or emergency examinations: 3 ml / kg / hour one hour before the examination and 1–1.5 ml / kg / hour for 4–6 hours after the examination.
  • Avoid high- osmolar contrast media, if possible use low-osmolar or iso-osmolar contrast media. Iso-osmolar contrast media show no additional benefit.
  • Give the smallest possible amount of contrast medium
  • Avoid repeated administration of contrast media within 48 hours
  • Avoid the simultaneous administration of kidney-damaging drugs such as RAAS inhibitors or non-steroidal anti-inflammatory drugs , which include the most widely used pain medication ( diclofenac , ibuprofen, etc.).
  • Furosemide and mannitol have an unfavorable effect .
  • Prophylactic dialysis treatment is currently not recommended.

forecast

In patients with contrast medium-induced renal failure after cardiac catheter examinations, the mortality is increased in the further course . It has not been clarified whether the increased mortality is due to contrast-medium-induced kidney failure or whether the frequency of contrast-medium-induced kidney failure and mortality are simultaneously increased in high-risk patients.

literature

Individual evidence

  1. ↑ Samuel N. Heyman et al .: Renal Parenchymal Hypoxia, Hypoxia Adaptation, and the Pathogenesis of Radiocontrast Nephropathy . In: Clin J Am Soc Nephrol . No. 3 , 2008, p. 288-296 ( abstract ).
  2. ↑ Heinz Losse : Assessment of kidney disease , in: Herbert Schwiegk (ed.): Kidney Diseases , in: Handbook of Internal Medicine , 5th Edition, volume 8, Part 3, Springer-Verlag, Berlin / Heidelberg / New York 1968 P. 632.
  3. ↑ ACR Manual on Contrast Media v9 2013, p. 35 (Manual)
  4. ↑ H.-J. Herms: Pharmacology and Pharmacokinetics of Contrast Media , in: Walter Frommhold, Paul Gerhardt (Ed.): Clinical-Radiological Seminar , Volume 1: Diseases of the Kidney, Georg Thieme Verlag, Stuttgart 1972, ISBN 3-13-487901-8 , p. 55-61; Quotation on page 59: "Kidney damage during the usual intravenous urography has been described, but it is extremely rare."
  5. ↑ J. Wiora, R. Westenfeld: in: Der Internist (2019) 60: 996. https://doi.org/10.1007/s00108-019-0651-2
  6. ↑ Steven D. Weisbord et al .: PRESERVE Trial. Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine. In: New England Journal of Medicine . tape 378 , 2018, p. 603-614 , PMID 29130810 ( Article ).
  7. ↑ Prophylaxis of contrast medium-induced acute kidney failure . In: Ludwig WD, Schuler J (ed.): The drug letter . tape 52 , 2018, ISSN  1611-2733 , p. 29-30 .
  8. ^ C Mueller et al .: Prevention of contrast media-associated nephropathy: Randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty . In: Arch Intern Med . No. 162 , 2002, p. 329-336 ( Article ).
  9. ↑ Steven D. Weisbord, Paul M. Palevsky: Strategies for the prevention of contrast-induced acute kidney injury . In: Current Opinion in Nephrology and Hypertension . No. 19 , 2010, p. 539-549 ( abstract ).
  10. ^ Marc C. Heinrich et al .: Nephrotoxicity of Iso-osmolar Iodixanol Compared with Nonionic Low-osmolar Contrast Media: Meta-analysis of Randomized Controlled Trials . In: Radiology . No. 250 , 2009, p. 68-86 ( article ).
  11. ↑ Michael Reed et al .: The relative renal safety of iodixanol compared with low-osmolar contrast media: a meta-analysis of randomized controlled trials . In: JACC: Cardiovascular Interventions . No. 2 , 2009, p. 645–654 ( article [PDF]).
  12. ↑ Aaron M. From et al .: Iodixanol versus low-osmolar contrast media for prevention of contrast induced nephropathy: meta-analysis of randomized, controlled trials . In: Circ Cardiovasc Interv . No. 3 , 2010, p. 351-358 ( Article ).
  13. ↑ J. Wiora, R. Westenfeld: in Der Internist (2019) 60: 996. https://doi.org/10.1007/s00108-019-0651-2
  14. ↑ R. Solomon et al .: Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents . In: The New England Journal of Medicine . No. 331 , 1994, pp. 1416-1420 ( abstract ).
  15. ↑ Michael Rudnick, Harold Feldman: Contrast-Induced Nephropathy: What Are the True Clinical Consequences? In: Clin J Am Soc Nephrol . No. 3 , 2008, p. 263-272 ( abstract ).

Web links

  • ACCF / AHA Practice Guideline: 6.5.1. Angiography in Patients With CKD American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines: 2012 ACCF / AHA focused update incorporated into the ACCF / AHA 2007 guidelines for the management of patients with unstable angina / non-ST-elevation myocardial infarction . In: Circulation . No. 127 , 2013, p. e663–828 .
  • ESUR Guidelines European Society of Urogenital Radiology Guidelines on Contrast Media 8.1