UvA-DARE ( Digital Academic Repository ) Bench-to-bedside review : preventive measures for contrast-induced nephropathy in critically ill patients

An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) isoosmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. Administration of N-acetylcysteine, theophylline, or fenoldopam, sodium bicarbonate infusion, and periprocedural haemofiltration/haemodialysis have been investigated as preventive measures in recent years. This review addresses the literature on these newer strategies. Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of Nacetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions. Introduction Contrast-induced nephropathy, defined as an increase in serum creatinine by more than 25% or 44 μmol/l from baseline within 3 days after administration of contrast agents in the absence of an alternative aetiology [1,2], is a major cause of hospital-acquired acute renal failure [3,4]. Indeed, the incidence of contrast-induced nephropathy is as high as 10–30% in high-risk patient groups [5–8]. Contrast-induced nephropathy increases morbidity, mortality and costs of medical care, and length of hospital stay, and not just for those patients who need renal replacement therapy because of this complication [3,5,7–9]. Risk factors for contrastinduced nephropathy include pre-existing renal failure (especially diabetic nephropathy and multiple myeloma), hypovolaemia, administration of (cumulative) high doses of (hyperosmolar) contrast media, and concomitant use of drugs that interfere with the regulation of renal perfusion [3,8, 10–13]. The Contrast Media Safety Committee of the European Society of Urogenital Radiology [14] has produced simple guidelines to prevent contrast-induced nephropathy. These guidelines emphasize the importance of patient selection (avoid the use of contrast media in high risk groups; i.e. use another imaging technique) and advises avoidance of the use (of large doses) of (hyperosmolar) contrast agents. Furthermore, the guidelines recommend ensuring that patients are well hydrated; cessation of diuretics (particularly loop-diuretics); and cessation of concurrent nephrotoxic drugs, such as nonsteroidal anti-inflammatory drugs, aminoglycosides, amfotericine B, and antiviral drugs like acyclovir and foscarnet. Critically ill patients are a group at high risk for the development of contrast-induced nephropathy because they frequently suffer from renal failure as a part of multiple organ failure, and they may have pre-existing diabetic nephropathy. Moreover, they are repeatedly administered contrast media intravenously, sometimes in large dosages. Unfortunately, the preventive measures described in the guidelines cited above Review Bench-to-bedside review: Preventive measures for contrast-induced nephropathy in critically ill patients Guido van den Berk1, Sanne Tonino1, Carola de Fijter2, Watske Smit3 and Marcus J Schultz4 1Resident, Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands 2Internist, Department of Nephrology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands 3Internist, Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands 4Internist, Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Corresponding author: Guido van den Berk, guidovdberk@hotmail.com Published online: 7 January 2005 Critical Care 2005, 9:361-370 (DOI 10.1186/cc3028) This article is online at http://ccforum.com/content/9/4/361 © 2005 BioMed Central Ltd