Patients given contrast media for angiography may develop contrast-media induced nephrotoxicity. It is one of the iatrogenic conditions which may require dialysis at times. There are several strategies to prevent this from happening. What is the best possible approach to prevent or treat this condition?
1- 1st check if there is an absolute need to do this contast study or it can be replaced by other safe imaging studies like us or MRI.
2- discuss with the patient at high risk the risk of developing AKI and get high risk consent
3- stop all medications that could augment AKI if given with the contrast such as : ACEI, NSAID, Diuretics
4- use isoosmolar non ionic minimal dose of contrast as possible
5- give mucomyst 600 mg po bid 48 hours before the the study
6- isotonic sodium bicarbonate (150 mmol sodium bicarb + 1 litre of d5w) at a rate of 3 ml / kg/ hour one hour before the procedure then 1 ml/ kg/ hour for 6 hours after the contrast or can be given 1 ml/ kg / hour 12 hour pre and 12 hour post the procedure
7- 1 gm ascorbic acid can be given ( weak evidence)
Thank you Hossam for mentioning these interesting strategies to prevent contrast media induced nephropathy. Interestingly, contrast media besides causing nephropathy also have adverse hematological effects.
Off course all the the previously mentioned measures to be taken in high risk groups, adequate hydration is essential in preventing contrast induced nephropathy (CIN) but the issue you can not give all patients such big volume of i v fluids considering their renal impairment and most likely poor cardiac function in those group of patients.
one more thing, steroids and antihistamines are not given to prevent CIN but to prevent any hypersensitivity reaction from the contrast
best regards
Thanks Sengottuvelu.
Perhaps the best preventive aspect would be to avoid the use of contrast media if possible. Is giving contrast media absolutely necessary? Can we instead resort to using safer imaging approaches such as the use of ultrasound or MRI? Please see even Hossam has the same views. One important point one should bear in mind is that in addition to the nephrotoxicity, there may be adverse hematological adverse effects especially coagulation activation, and platelet activation. These may trigger release of several biomarkers which may have diverse effects. There could be release of TNF-alpha, TGFbeta, MCP-1 and various other cytokines. These biomarkers have significant effects on various systems such as hematological, cardiovascular, and cerebrovascular system in addition to renal system.
Physicians should realize that by using contrast media just for diagnostic purposes, they are causing damage to the kidneys and other hematological effects. There should be no reason that a patient who undergoes diagnostic tests should have unnecessary adverse effects such as nephropathy which might lead to dialysis. The patient at first did not come to the physician for dialysis. Thrombotic or bleeding complications may be associated with contrast-media mediated nephrotoxicity and may require treatment but foremost prevention. Physicians have a great role to play in reducing the incidence of iatrogenic conditions.
You can prevent CIN when performing rotational coronary angiography (RA) instead of conventional one. Approx 1/3 of contrast dose is needed for RA vs. conventional coronary angiography.
Article Rotational angiography in cardiological diagnostics nowadays.
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