Contrast-Induced Acute Kidney Injury

McCullough PA, Choi JP, Feghali GA, et al.
Contrast-Induced Acute Kidney Injury. J Am Coll Cardiol 2016;68:1465-1473.

The following are 10 key points to remember about the prognosis and management of contrast-induced acute kidney injury (CI-AKI), as it applies to the cardiac catheterization laboratory:

  1. Coronary angiography and percutaneous intervention rely on the use of iodinated intravascular contrast for vessel and chamber imaging.
  2. Despite advancements in imaging and interventional techniques, iodinated contrast continues to pose a risk of CI-AKI for a subgroup of patients at risk for this complication.
  3. There has been a consistent and graded signal of risk for associated outcomes including need for renal replacement therapy, rehospitalization, and death, according to the incidence and severity of CI-AKI.
  4. In general, estimated glomerular filtration rate <60 ml/min/1.73 m2 with diabetes elevates the risk of CI-AKI sufficiently above the baseline of approximately 5-10%; thus, appropriate counseling and preventive measures are warranted to mitigate this potential adverse consequence of angiography.
  5. Principles of management include using volumes of contrast that are as low as reasonably achievable (ALARA) and selection of the least-toxic iodinated contrast agent.
  6. Low-osmolar contrast agents are reasonable for moderate-risk patients and iso-osmolar contrast is indicated for the highest-risk patients.
  7. CI-AKI is responsive to intravascular administration of isotonic crystalloid solutions to enhance renal elimination of contrast via the urine. There have been numerous randomized trials comparing isotonic bicarbonate solutions to intravenous saline, with no differences in the rates of renal outcomes. Hence, either isotonic crystalloid solution is recommended.
  8. Although no adjunctive therapy is prophylactic or therapeutic for CI-AKI, statin use appears to reduce the incidence and severity of AKI, whereas continuation of renin-angiotensin system inhibitors appears to increase the risk for CI-AKI.
  9. Further research is needed in the development of less toxic contrast agents, as well as therapies that can reduce cardiorenal complication of interventional cardiovascular procedures.
  10. Such agents hold the promise of improving long-term outcomes by minimizing the hazards of intercurrent events, such as acute coronary syndrome, and urgent and planned catheterization procedures.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Bicarbonates, Cardiac Catheterization, Contrast Media, Coronary Angiography, Counseling, Diabetes Mellitus, Diagnostic Imaging, Isotonic Solutions, Primary Prevention, Prognosis, Renal Replacement Therapy, Renin-Angiotensin System

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