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) iso-osmolar 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 N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
van den Berk
Guido
G
Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands. guidovdberk@hotmail.com
Tonino
Sanne
S
de Fijter
Carola
C
Smit
Watske
W
Schultz
Marcus J
MJ
D000111:Acetylcysteine / Q000627:therapeutic use; D003287:Contrast Media / Q000009:adverse effects*; D003422:Critical Care / Q000379:methods*; D018818:Fenoldopam / Q000627:therapeutic use; D016166:Free Radical Scavengers / Q000627:therapeutic use; D006440:Hemofiltration; D006801:Humans; D007674:Kidney Diseases / Q000139:chemically induced* / Q000503:physiopathology / Q000517:prevention & control*; D017693:Sodium Bicarbonate / Q000627:therapeutic use; D013806:Theophylline / Q000627:therapeutic use; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000627:therapeutic use
D003287:Contrast Media; D016166:Free Radical Scavengers; D014665:Vasodilator Agents; D017693:Sodium Bicarbonate; D013806:Theophylline; D018818:Fenoldopam; D000111:Acetylcysteine