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Contrast-induced nephropathy after computed tomography

Nefropatia induzida por contraste após tomografia computadorizada

Abstracts

Introduction:

Contrast induced nephropathy is the third most prevalent preventable cause of acute kidney injury in hospitalized patients. It defined as an absolute increase in serum creatinine ≥ 0.5 mg/dL and relative ≥ 25% increase.

Objective:

We studied the risk factors to intravenous injection contrast nephropathy after computed tomography.

Methods:

We studied 400 patients prospectively.

Results:

The incidence of contrast induced nephropathy, with an absolute or a relative increase were 4.0% and 13.9%, respectively. Diabetes and cardiac failure were independent risk factors for CIN a relative increase de serum creatinine (O.R.: 3.5 [95% CI: 1.92-6.36], p < 0.01, 2.61 [95% CI: 1.14-6.03%], p < 0.05, respectively).

Conclusions:

We showed association between uses of intravenous injection contrast after computed tomography with acute injury renal, notably with diabetes and heart failure.

contrast media; risk factors; tomography


Introdução:

Nefropatia induzida por contraste é a terceira causa de lesão renal aguda em pacientes hospitalizados. Ela é definida como: um aumento absoluto da creatinina sérica ≥ 0,5 mg/dL e relativo em ≥ 25%.

Objetivo:

Nós estudamos os fatores de risco associados à nefropatia do contraste após tomografia computadorizada.

Métodos:

Analisamos prospectivamente 400 pacientes submetidos ao contraste endovenoso na tomografia computadorizada.

Resultados:

A incidência de nefropatia por contraste variou de 4 a 13,9%, conforme o critério de aumento da creatinina sérica. Diabetes e insuficiência cardíaca foram associados significativamente no aumento absoluto da creatinina sérica (O.R.: 3,5 [95% CI: 1,92-6,36], p < 0,01, 2,61 [95% CI: 1,14-6,03%], p < 0,05, respectivamente).

Conclusão:

Encontramos uma relação direta da infusão de contraste endovenoso na tomografia computadorizada e injúria renal, notadamente com diabetes e insuficiência cardíaca.

fatores de risco; nefropatia induzida por contraste; tomografia


Introduction

Contrast-induced nephropathy (CIN) is an important cause of acute kidney injury (AKI) in hospitalized patients. There are several risk factors associated with CIN after arterial infusion: high doses of iodine; diabetes mellitus (DM); old-age, chronic renal failure (CKD); female gender, heart failure (HF), association with nephrotoxic drugs, etc.1Barrett BJ, Katzberg RW, Thomsen HS, Chen N, Sahani D, Soulez G, et al. Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a double-blind comparison of iodixanol and iopamidol. Invest Radiol 2006;41:815-21. PMID: 17035872 DOI: http://dx.doi.org/10.1097/01.rli.0000242807.01818.24
http://dx.doi.org/10.1097/01.rli.0000242...

Elicker BM, Cypel YS, Weinreb JC. IV contrast administration for CT: a survey of practices for the screening and prevention of contrast nephropathy. AJR Am J Roentgenol 2006;186:1651-8. PMID: 16714655 DOI: http://dx.doi.org/10.2214/AJR.05.0407
http://dx.doi.org/10.2214/AJR.05.0407...

Haveman JW, Gansevoort RT, Bongaerts AH, Nijsten MW. Low incidence of nephropathy in surgical ICU patients receiving intravenous contrast: a retrospective analysis. Intensive Care Med 2006;32:1199-205. DOI: http://dx.doi.org/10.1007/s00134-006-0198-2
http://dx.doi.org/10.1007/s00134-006-019...

Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006:S3-7. PMID: 16612398 DOI: http://dx.doi.org/10.1038/sj.ki.5000366
http://dx.doi.org/10.1038/sj.ki.5000366...

Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
http://dx.doi.org/10.1148/radiol.2392050...
-6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.

CIN pathogenesis is related to direct toxic effect of contrast medium on the tubular epithelial cells and results from direct hemodynamic disturbances in renal blood flow. Renal tubules are less prone to injury when isosmotic contrast medium is used as compared to low-osmolality contrast media. Intravascular contrast administration effects on renal blood flow were biphasic. The initial vasodilatation turns into the longest lasting phase of reduced renal blood flow, consequent to vasoconstriction and hypoxia. Moreover, there is a release of endogenous factors such as endothelin, adenosine, free radicals, Ca2+ ions, and the glomerular filtration rate issue.6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.,7Geenen RW, Kingma HJ, van der Molen AJ. Contrast-induced nephropathy: pharmacology, pathophysiology and prevention. Insights Imaging 2013;4:811-20. DOI: http://dx.doi.org/10.1007/s13244-013-0291-3

However, the CIN incidence in computed tomography (CT) is quite complex. The use of intravenous contrast to enhance imaging has increased substantially in recent years. Studies have described a CIN incidence between 5 and 13% in outpatients after venous contrast injection to enhance CT scan images. These studies are limited by their retrospective design and patient selection bias.3Haveman JW, Gansevoort RT, Bongaerts AH, Nijsten MW. Low incidence of nephropathy in surgical ICU patients receiving intravenous contrast: a retrospective analysis. Intensive Care Med 2006;32:1199-205. DOI: http://dx.doi.org/10.1007/s00134-006-0198-2
http://dx.doi.org/10.1007/s00134-006-019...
,5Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
http://dx.doi.org/10.1148/radiol.2392050...
,8Kooiman J, Pasha SM, Zondag W, Sijpkens YW, van der Molen AJ, Huisman MV, et al. Meta-analysis: serum creatinine changes following contrast enhanced CT imaging. Eur J Radiol 2012;81:2554-61. PMID: 22177326 DOI: http://dx.doi.org/10.1016/j.ejrad.2011.11.020
http://dx.doi.org/10.1016/j.ejrad.2011.1...
,9Krol AL, Dzialowski I, Roy J, Puetz V, Subramaniam S, Coutts SB, et al. Incidence of radiocontrast nephropathy in patients undergoing acute stroke computed tomography angiography. Stroke 2007;38:2364-6. DOI: http://dx.doi.org/10.1161/STROKEAHA.107.482778
http://dx.doi.org/10.1161/STROKEAHA.107....

This study evaluated CIN incidence in hospitalized patients after CT scan with intravenous contrast injection, its relation with classic risk factors (DM, HF, old age, etc.) and contrast volume with variations in serum creatinine (SCr) levels.

Methods

Study population

Our cohort study allocated 400 hospitalized patients from a single center (Hospital São Lucas PUCRS) between January 01, 2007 and March 31, 2008. All patients underwent CT scan with hyperosmolar intravenous contrast (59.285 g, meglumine 15.1 g/100 mL, iodine content of 300 mg/mL, osmolality of 1650 mOsm/kg H2O, Telebrix 30 Laboratory Guebert).

Inclusion criteria for this study were: age over 18 years and hospitalization.

Exclusions criteria were: drugs that can interfere with the SCr assay (e.g.: cephalosporins, barbiturates, chemotherapeutic agents) and its secretion (e.g.: trimethoprim, cimetidine).

All patients signed consent forms. The local ethics committee approved this study.

Study execution

SCr values were obtained from a kinetic colorimetric compensated Jaffe technique (Roche Modular, Meylan; compensation according to manufacturer's recommendations). We evaluated the assay method's inaccuracy (intra-assay coefficient was 0.7%; interassay coefficients were 4.0% at low SCr (0.51 - 0.71 mg/dL) and 1.5% at high SCr concentrations (6.5 mg/dL), respectively. SCr was tested before and 48 hours after intravenous contrast injection.

To estimate GFR (eGFR), we used the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula:6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.

We did not divide our sample into CKD groups according to the KIDGO criteria because of the small number of patients with eGFR < 60 mL/min/1.73 m2.

Potential risk factors for CIN were considered based on the concepts and terminology from the American College of Radiology (ACR):5Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
http://dx.doi.org/10.1148/radiol.2392050...
DM, neoplasia, HF, CKD, female gender, low mean arterial blood pressure upon examination (MBP < 80 mmHg), CKD (eGFR < 60 mL/min/1.73 m2), old-age (≥ 65 years), obesity (BMI ≥ 30 kg/m2), anemia (Hematocrit < 36%). We defined CIN prophylaxis as the use of parenteral hydration with saline solution at a dose of 1 mL/kg/h 6 hours prior to the procedure, and continued up to 12 hours after it.

Outcomes

The primary outcomes was CIN incidence and association with risk factors. Secondary outcome was SCr variation vis-à-vis contrast volume per 1.73 m2 of BSA.

Statistical analysis

Our data was submitted to double entry, checking for inconsistencies.

We used backward stepwise linear and multivariable logistic regression, comparing the new variable to those previously reported. A p value < 0.05 was considered statistically significant. The analyses were performed using R for Windows, version 3.1.1 (R-Cran project) with the MASS package for Windows.

Results

Baseline clinical characteristics

The baseline clinical characteristics of those 400 patients are show on the Table 1. Upon inclusion in the cohort, the participants' mean ages were 59.2 ± 14.8 years. Elderly patients and male gender accounted for 40.2% and 50.4% respectively, with Caucasian predominance at 80.5%. Mean BMI was 24.36 ± 1.74 kg/m2, with underweight and obesity prevalences of 14.8% and 13.6%, respectively.

Table 1
Demographic data set

Most intravenous contrast-enhanced CT examinations were associated with malignancies (n = 249, 62.25%) in the chest, and chest-abdomen (n = 289, 72.25%). See details on Table 2. Mean contrast volume was of 142.2 ± 37.7 mL/1.73 m2 of BSA.

Table 2
Type of computerized tomography and volume contrast

Of the entire sample, 25 patients (6.25%) took metformin on the contrast injection day. Only 97 (24.25%) patients received intravenous hydration (Table 1).

We found an increase in baseline SCr of 25% in 61 (15.25%) patients and an absolute increase of 0.5 mg/dL in only 15 (3.75%) patients in our sample (Table 3).

Table 3
Incidence of contrast nephropathy and markers of renal injury

Procedures and variation in renal function

Multivariable logistic regression

After using intravenous contrast for CT, we found an association between absolute increase in SCr ≥ 0.5 mg/dL (Table 4) and ≥ 25% (Table 5) and the following factors: old age, DM, female gender, obesity, HF, CKD, neoplasia and anemia.

Table 4
Risk factors to contrast nephropathy (SCr increases ≥ 0.5 mg/dl)
Table 5
Risk factors to contrast nephropathy (SCr increases ≥ 25%)

Multivariate analysis revealed a relationship between an absolute increase in SCr ≥ 0.5 mg/dL and DM (O.R.: 10.22 [95% CI: 3.37-30.92], p < 0.01); old-age (OR 6.27 [95% CI: 1.74-22.57], p < 0.05) and HF (3.9 [95% CI: 1.36-11.00], p < 0.01) (Table 4).

The relative variation (Table 5) of SCr was associated with diabetes (O.R.: 3.5 [95% CI: 1.92-6.36], p < 0.01) and HF (OR 2.61 [95% CI: 1.14-6.03%], p < 0.05). However, it was not significant vis-à-vis old age and CKD (Table 5).

Regardless of reports in the medical literature, we did not find associations between female gender, obesity, neoplasia, MBP < 80 mmHg, anemia and CIN (Tables 4 and 5).

Multivariate analysis regression model and the impact on renal function fluctuation

Table 6 depicts the impact of contrast volume in relation to SCr increase. In the entire sample there was no difference in SCr after 116 mL of venous contrast injection per 1.73 m2 of BSA (model Ϋ1). However, DM and HF had a significant increase of 22% and 23% (p < 0.01) per 112 and 114 mL of intravenously injected contrast agent per 1.73 m2 of BSA, respectively (model Ϋ2 and Ϋ3). Patients with eGFR < 60 mL/min/1.73 m2 and the elderly in the sample did not show significant variation vis-à-vis contrast agent dose (model Ϋ4 and Ϋ5).

Table 6
Impact on SCr variation (percentage per 100 ml/1.73 m2 of contrast)

Discussion

CIN-related papers have been published since the 50's, notably after arterial contrast injection started. However, only a handful of studies have investigated CIN with intravenous contrast injection for CT.1Barrett BJ, Katzberg RW, Thomsen HS, Chen N, Sahani D, Soulez G, et al. Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a double-blind comparison of iodixanol and iopamidol. Invest Radiol 2006;41:815-21. PMID: 17035872 DOI: http://dx.doi.org/10.1097/01.rli.0000242807.01818.24
http://dx.doi.org/10.1097/01.rli.0000242...

Elicker BM, Cypel YS, Weinreb JC. IV contrast administration for CT: a survey of practices for the screening and prevention of contrast nephropathy. AJR Am J Roentgenol 2006;186:1651-8. PMID: 16714655 DOI: http://dx.doi.org/10.2214/AJR.05.0407
http://dx.doi.org/10.2214/AJR.05.0407...

Haveman JW, Gansevoort RT, Bongaerts AH, Nijsten MW. Low incidence of nephropathy in surgical ICU patients receiving intravenous contrast: a retrospective analysis. Intensive Care Med 2006;32:1199-205. DOI: http://dx.doi.org/10.1007/s00134-006-0198-2
http://dx.doi.org/10.1007/s00134-006-019...

Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006:S3-7. PMID: 16612398 DOI: http://dx.doi.org/10.1038/sj.ki.5000366
http://dx.doi.org/10.1038/sj.ki.5000366...
-5Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
http://dx.doi.org/10.1148/radiol.2392050...
,1010 Nyman U, Almén T, Aspelin P, Hellström M, Kristiansson M, Sterner G. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005;46:830-42. PMID: 16392608 DOI: http://dx.doi.org/10.1080/02841850500335051
http://dx.doi.org/10.1080/02841850500335...
These studies described similar risk factors for patients undergoing CT and angiographic exams. Nyman et al.1010 Nyman U, Almén T, Aspelin P, Hellström M, Kristiansson M, Sterner G. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005;46:830-42. PMID: 16392608 DOI: http://dx.doi.org/10.1080/02841850500335051
http://dx.doi.org/10.1080/02841850500335...
reported a CIN incidence of 6.4% after CT and higher CIN incidences in patients with impaired GFR.

Our results show CIN incidence after CT of 3.75 and 15.75%, with CIN defined as the absolute or relative increase of SCr, respectively. Thomsen et al.1111 Thomsen HS, Morcos SK, Erley CM, Grazioli L, Bonomo L, Ni Z, et al.; Investigators in the Abdominal Computed Tomography: IOMERON 400 Versus VISIPAQUE 320 Enhancement (ACTIVE) Study. The ACTIVE Trial: comparison of the effects on renal function of iomeprol-400 and iodixanol-320 in patients with chronic kidney disease undergoing abdominal computed tomography. Invest Radiol 2008;43:170-8. DOI: http://dx.doi.org/10.1097/RLI.0b013e31815f3172
http://dx.doi.org/10.1097/RLI.0b013e3181...
described that these two definitions of CIN are not interchangeable, because SCr is not an adequate marker for CIN. Thus, > 50% of renal function must be lost before an elevation in SCr is detected. In addition, SCr does not accurately depict GFR until a steady state has been reached, which may require several days1212 Bruce RJ, Djamali A, Shinki K, Michel SJ, Fine JP, Pozniak MA. Background fluctuation of kidney function versus contrast-induced nephrotoxicity. AJR Am J Roentgenol 2009;192:711-8. PMID: 19234268 DOI: http://dx.doi.org/10.2214/AJR.08.1413
http://dx.doi.org/10.2214/AJR.08.1413...
- this could explain the different CIN incidence found in our study. The Acute Kidney Injury Network (AKIN) suggested two separate CIN endpoints using both absolute and relative SCr alterations.6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150. Their proposed diagnostic criteria for AKI include an absolute increase in the SCr level of ≥ 0.3 mg/dL. However, calculations by Waikar & Bonventre13 showed that increases in SCr of 0.3 mg/dL are only significant when they occur within 24 h; and 0.5 mg/dL at 48 h after CT may be a more appropriate cut-off point. Moreover, the medical literature is based on the concepts and terminology from the American College of Radiology (ACR) in reference to CIN studies, this report will do the same.5Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
http://dx.doi.org/10.1148/radiol.2392050...
However, we recognize that the clinical effects of slightly different definitions of CIN and AKI have yet to be clarified.6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.

Our results confirmed significantly classical risk factors to CIN after CT as being: CKD, DM and HF. Mehran et al.1414 Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 2004;44:1393-9. PMID: 15464318 showed an incidence of 8.8% and 5.2%, after arterial injection in patients with CKD and DM, respectively. In patients with CKD, HF and the elderly, SCr rises more steeply when hemodynamic changes occur or contrast is administered.4Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006:S3-7. PMID: 16612398 DOI: http://dx.doi.org/10.1038/sj.ki.5000366
http://dx.doi.org/10.1038/sj.ki.5000366...
,7Geenen RW, Kingma HJ, van der Molen AJ. Contrast-induced nephropathy: pharmacology, pathophysiology and prevention. Insights Imaging 2013;4:811-20. DOI: http://dx.doi.org/10.1007/s13244-013-0291-3

Our study demonstrated a statistically significant association, although low, between contrast medium volume and CIN, notably in DM and HF. It is opposite to the findings reported by other publications.8Kooiman J, Pasha SM, Zondag W, Sijpkens YW, van der Molen AJ, Huisman MV, et al. Meta-analysis: serum creatinine changes following contrast enhanced CT imaging. Eur J Radiol 2012;81:2554-61. PMID: 22177326 DOI: http://dx.doi.org/10.1016/j.ejrad.2011.11.020
http://dx.doi.org/10.1016/j.ejrad.2011.1...
,1010 Nyman U, Almén T, Aspelin P, Hellström M, Kristiansson M, Sterner G. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005;46:830-42. PMID: 16392608 DOI: http://dx.doi.org/10.1080/02841850500335051
http://dx.doi.org/10.1080/02841850500335...
,1515 Katzberg RW, Newhouse JH. Intravenous contrast medium-induced nephrotoxicity: is the medical risk really as great as we have come to believe? Radiology 2010;256:21-8. PMID: 20574082

16 Karlsberg RP, Dohad SY, Sheng R; Iodixanol Peripheral Computed Tomographic Angiography Study Investigator Panel. Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium. J Vasc Interv Radiol 2011;22:1159-65. DOI: http://dx.doi.org/10.1016/j.jvir.2011.03.020
http://dx.doi.org/10.1016/j.jvir.2011.03...
-1717 Nyman U, Almén T, Jacobsson B, Aspelin P. Are intravenous injections of contrast media really less nephrotoxic than intra-arterial injections? Eur Radiol 2012;22:1366-71. Nyman et al.1010 Nyman U, Almén T, Aspelin P, Hellström M, Kristiansson M, Sterner G. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005;46:830-42. PMID: 16392608 DOI: http://dx.doi.org/10.1080/02841850500335051
http://dx.doi.org/10.1080/02841850500335...
suggested a dose in grams of iodine numerically equal to the eGFR value in mL/min during percutaneous coronary intervention. These authors described a CIN frequency of 12% at an iodine dose (in grams)/GFR ratio of 1.1. Our study demonstrated the risk of GFR reduction by checking SCr, especially among patients with diabetes, CKD and HF.

Other relevant information from our data was: lowest prescription of preventive hydration before TC (27.75%) and higher intake of biguanide (metformin) on the contrast injection day (6.25%). The European Guidelines to CIN described that 75% of CIN studies reported some form of hydration as a prevention approach.1818 Stacul F, van der Molen AJ, Reimer P, Webb JA, Thomsen HS, Morcos SK, et al.; Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 2011;21:2527-41. DOI: http://dx.doi.org/10.1007/s00330-011-2225-0
http://dx.doi.org/10.1007/s00330-011-222...
They recommended expansion volume before contrast with saline or bicarbonate solution. Biguanide (metformin) has the possibility of worsening CIN, with an associated increased risk of lactic acidosis. However, there are no direct studies on the subject.1818 Stacul F, van der Molen AJ, Reimer P, Webb JA, Thomsen HS, Morcos SK, et al.; Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 2011;21:2527-41. DOI: http://dx.doi.org/10.1007/s00330-011-2225-0
http://dx.doi.org/10.1007/s00330-011-222...
Prevention guidelines are based on the expert consensus about metformin pharmacokinetics and CIN pathophysiology.4Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006:S3-7. PMID: 16612398 DOI: http://dx.doi.org/10.1038/sj.ki.5000366
http://dx.doi.org/10.1038/sj.ki.5000366...
,6Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.,1818 Stacul F, van der Molen AJ, Reimer P, Webb JA, Thomsen HS, Morcos SK, et al.; Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 2011;21:2527-41. DOI: http://dx.doi.org/10.1007/s00330-011-2225-0
http://dx.doi.org/10.1007/s00330-011-222...
In this study, we did not find any association between CIN and the use of metformin or lack of expansion volume (data not shown in the study).

The main strength of the meta-analysis is the large number of patients included (n = 400), resulting in an estimate of the CIN incidence after contrast-enhanced CT. Moreover, we have chosen a logistic model by default for all analyses to cope statistically with patient heterogeneity, resulting in a conservative incidence estimate compared to a fixed effects model.

The limitations of our study are mainly the facts that it was carried out in a single center and the impossibility of monitoring these patients to determine other possible outcomes such as death or dialysis.

Conclusion

Despite the difficulties due to the variability of this population, this study is one of the few prospective publications that have shown the use of intravenous contrast after CT as a variation factor associated with acute kidney injury. This condition is stronger in patients with diabetes and heart failure.

References

  • 1
    Barrett BJ, Katzberg RW, Thomsen HS, Chen N, Sahani D, Soulez G, et al. Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a double-blind comparison of iodixanol and iopamidol. Invest Radiol 2006;41:815-21. PMID: 17035872 DOI: http://dx.doi.org/10.1097/01.rli.0000242807.01818.24
    » http://dx.doi.org/10.1097/01.rli.0000242807.01818.24
  • 2
    Elicker BM, Cypel YS, Weinreb JC. IV contrast administration for CT: a survey of practices for the screening and prevention of contrast nephropathy. AJR Am J Roentgenol 2006;186:1651-8. PMID: 16714655 DOI: http://dx.doi.org/10.2214/AJR.05.0407
    » http://dx.doi.org/10.2214/AJR.05.0407
  • 3
    Haveman JW, Gansevoort RT, Bongaerts AH, Nijsten MW. Low incidence of nephropathy in surgical ICU patients receiving intravenous contrast: a retrospective analysis. Intensive Care Med 2006;32:1199-205. DOI: http://dx.doi.org/10.1007/s00134-006-0198-2
    » http://dx.doi.org/10.1007/s00134-006-0198-2
  • 4
    Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006:S3-7. PMID: 16612398 DOI: http://dx.doi.org/10.1038/sj.ki.5000366
    » http://dx.doi.org/10.1038/sj.ki.5000366
  • 5
    Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006;239:392-7. PMID: 16543592 DOI: http://dx.doi.org/10.1148/radiol.2392050413
    » http://dx.doi.org/10.1148/radiol.2392050413
  • 6
    Group KDIGOKCW. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.
  • 7
    Geenen RW, Kingma HJ, van der Molen AJ. Contrast-induced nephropathy: pharmacology, pathophysiology and prevention. Insights Imaging 2013;4:811-20. DOI: http://dx.doi.org/10.1007/s13244-013-0291-3
  • 8
    Kooiman J, Pasha SM, Zondag W, Sijpkens YW, van der Molen AJ, Huisman MV, et al. Meta-analysis: serum creatinine changes following contrast enhanced CT imaging. Eur J Radiol 2012;81:2554-61. PMID: 22177326 DOI: http://dx.doi.org/10.1016/j.ejrad.2011.11.020
    » http://dx.doi.org/10.1016/j.ejrad.2011.11.020
  • 9
    Krol AL, Dzialowski I, Roy J, Puetz V, Subramaniam S, Coutts SB, et al. Incidence of radiocontrast nephropathy in patients undergoing acute stroke computed tomography angiography. Stroke 2007;38:2364-6. DOI: http://dx.doi.org/10.1161/STROKEAHA.107.482778
    » http://dx.doi.org/10.1161/STROKEAHA.107.482778
  • 10
    Nyman U, Almén T, Aspelin P, Hellström M, Kristiansson M, Sterner G. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005;46:830-42. PMID: 16392608 DOI: http://dx.doi.org/10.1080/02841850500335051
    » http://dx.doi.org/10.1080/02841850500335051
  • 11
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Publication Dates

  • Publication in this collection
    Jan-Mar 2015

History

  • Received
    08 Apr 2014
  • Accepted
    04 Dec 2014
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