Contrast-induced Nephropathy - Just an Iatrogenic Kidney Disease?

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US Cardiology 2004;2004:1(1):1-4

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The Problem of Contrast-induced Nephropathy

Contrast-induced nephropathy (CIN) is an increasingly common cause of acute renal failure in both hospitalized patients and out-patients. The growth in contrast-enhanced imaging and interventional procedures is one cause of the increased incidence of CIN. An aging patient population, with more comorbidities such as reduced renal function, may be another reason for the higher incidence of CIN.

Definitions of CIN vary, but most investigators accept that a 25% or greater increase in serum creatinine, or decrease in calculated creatinine clearance in the appropriate clinical setting, defines CIN. The appropriate setting is:

  • exposure to intravenous or intra-arterial contrast;
  • a rise in creatinine within 24-48 hours of contrast exposure; and
  • the absence of other explanations for acute renal failure such as nephrotoxins, hypotension, urinary obstruction, or atheromatous emboli.

CIN is usually self-limited, with serum creatinine levels peaking in three to five days and gradually returning to baseline levels within seven to 10 days.2 Most CIN patients are non-oliguric and examination of the urinary sediment reveals only granular casts without red or white cells. Proteinuria is rarely present by dipstick testing. Urine sodium is often low, suggesting a prerenal physiology.3 A small percentage of patients with CIN (<5%) may require dialysis until renal function recovers.

Pathogenesis of CIN and Risk Factors

For the majority of patients with CIN, the transient rise in serum creatinine and eventual recovery to baseline mirrors the changes in renal function that are associated with volume depletion and pre-renal azotemia.This has led to important misunderstandings regarding the pathogenesis and prognosis associated with CIN. CIN represents a combination of toxic and ischemic injury to the kidney, predominately in the medulla. Decreases in medullary blood flow and medullary oxygen tension follow exposure to contrast. Increases in vasoconstrictor hormones, such as endothelin and adenosine, and loss of vasodilatory factors such as nitric oxide, may contribute to the vasoconstriction that reduces medullary blood flow. At the same time that medullary flow and oxygenation are reduced, an increase in sodium is delivered to the medullary tubules because of the osmotic effect of the contrast agent. The loop of Henle increases sodium reabsorption in response to this load (an oxygen-requiring process). The increase in oxygen requirements coupled with decreased oxygen availability results in ischemic injury.

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