Contrast-Induced Nephropathy in PCI: An Evidence-Based Approach to Prevention

Asad Shabbir; Jamie Kitt; Omar Ali

Br J Cardiol. 2015;21(4)

Introduction

Contrast-induced nephropathy is the third most common cause of in-hospital acute kidney injury and accounts for 10% of total cases. It is commonly encountered following coronary angiography and this systematic review aims to use current evidence to ascertain which treatment modalities are most effective in the prevention of the disease.

A PubMed literature search was conducted in March 2014 using search terms, 'contrast nephropathy and coronary angiography'. The data analysed included 15 trials and two meta-analyses in order to determine whether patients given N-acetylcysteine (NAC), sodium chloride or sodium bicarbonate had better clinical outcomes. Study data were reviewed and quality of data discussed.

Current data indicate that sodium bicarbonate is as effective as sodium chloride when used in patients with estimated glomerular filtration rate (eGFR) <60 ml/min. NAC adds no statistically significant benefit in mild-to-moderate renal disease regardless of whether it is used in isolation or as an adjunct therapy with fluid.

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Next Section

Introduction
Pathogenesis
Clinical Significance
Treatment Strategies to Reduce the Risk of CIN
Conclusion
References
Sidebar

Table 1. The Mehran risk score and associated risk of progression to CIN
Risk factor	Score
Hypotension	5
Intra-aortic balloon pump	5
Congestive cardiac failure	5
Age >75 years	4
Anaemia	3
Diabetes mellitus	3
Contrast media volume use	1 per 100 cc³
Serum creatinine	4
eGFR <60 ml/min/1.73 cm²	2
Risk score	CIN risk
<6	7.5%
6 to 10	14%
11 to 16	26.1%
>16	57.3%

Adapted from Mehran R et al. ⁶
Key: CIN = contrast-induced nephropathy; eGFR = estimated glomerular filtration rate

Table 2. General guidance for prevention of CIN
	eGFR >60 ml/min	eGFR <60 ml/min	eGFR unknown and high-risk features for CIN (emergency procedure)
Avoid dehydration, encourage oral fluids	✓	✓	✓
Include risk of CIN in consent	✓	✓	✓
Minimise volume of contrast used		✓	✓
Intravenous hydration with sodium bicarbonate 1.26% as per protocol*		✓	✓ (if large volumes are required, sodium chloride 0.9% or colloids can be used)
Check U&E prior to discharge		✓	✓
Where appropriate, arrange repeat U&E after 48–72 hours (at hospital or via GP)		✓	✓

* Prescribe sodium bicarbonate 1.26% (500 ml polyfusor) as below:
3 ml/kg/hr for 1 hour pre-procedure (for emergency procedures 0.5 ml/kg bolus) 1 ml/kg/hr for 6 hours post-procedure
Key: CIN = contrast-induced nephropathy; eGFR = estimated glomerular filtration rate; U&E = urea and electrolytes