Intravenous Contrast Related Acute Renal Failure

1. See Also
   1. Intravenous Contrast
   2. Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
   3. Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)
   4. Prevention of Kidney Disease Progression
   5. Chronic Kidney Disease
   6. Acute Kidney Injury
2. Risk Factors
   1. See Acute Renal Failure Risk
   2. See Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
3. Definition
   1. Contrast-Induced Nephropathy
      1. Serum Creatinine increased 25% over baseline (or increased 0.5 mg/dl) and
      2. Onset within 3 days of Intravenous Contrast exposure
4. Prevention (Indicated for Acute Renal Failure Risk)
   1. Avoid concurrent Nephrotoxic Drugs
      1. See Nephrotoxic Drugs
      2. Avoid NSAIDs
   2. Use low osmolality (non-ionic) or iso-osmolal Contrast Material
   3. Allow 2-5 days between IV contrast procedures
   4. Hydrate before and after procedure (most important measure)
      1. Adjust for Congestive Heart Failure
      2. Option 1: Isotonic Bicarbonate (preferred)
         1. Prepare 3 ampules of Sodium Bicarbonate (50 meq/ampule) in 850 cc D5W
         2. Give 3 ml/kg IV one hour before procedure and 1 ml/kg/hour for 6 hours post-procedure
         3. Reference
            1. Stuart (2007) Park Nicollet Primary Care Conference, Minneapolis, MN
      3. Option 2: Intravenous normal saline
         1. Infuse 100 ml/hour saline for 4 hours pre-contrast
         2. Infuse 100 ml/hour for the 24 hours post-contrast
      4. Alternative: Oral (non-caffeinated fluid)
         1. Take at least 500 ml before contrast
         2. Take 2500 ml over the 24 hours post-contrast
   5. Adjust IV contrast dose
      1. Contrast Dose: (5 cc/kg)/(Serum Creatinine)
      2. Maximum total dose: 300 cc
   6. Acetylcysteine (Mucomyst) for 3 days (questionable efficacy)
      1. Indications
         1. Safe and low cost prevention (consider in all at risk patients)
         2. Chronic Kidney Disease
         3. Acute Renal Failure Risk Factors
         4. Diabetes Mellitus
      2. Protocol
         1. Used in combination with hydration protocol above
         2. Start day before contrast exposure
      3. High dose protocol (replaces the older, ineffective 600 mg dose)
         1. Mucomyst 1200 mg orall twice daily
         2. Give on the day before and the day of contrast administration
      4. Efficacy
         1. Initial studies showed risk of nephropathy reduced by 56%
         2. Recent data suggests that standard dose ineffective; higher dose may be effective
         3. References
            1. Williams (2008) Mayo Selected Topics in Internal Medicine, Lecture
            2. Trivedi (2009) Am J Med 122(9): 874
      5. References
         1. Birck (2003) Lancet 362:598-603
         2. Isenbarger (2003) Am J Cardiol 92:1454-8
   7. Other agents to consider
      1. Calcium Channel Blocker for 24 hours before procedure
   8. Agents with no benefit
      1. Avoid Furosemide (Lasix)
      2. Avoid Mannitol
5. Monitoring
   1. Recheck the Serum Creatinine in patients with Acute Renal Failure Risk within the first 3 days following contrast exposure
6. References
   1. Mende (2001) CME Medicine Lecture, San Diego
   2. Maddox (2002) Am Fam Physician 66(7):1229-34
   3. Quader (1998) Ann Vasc Surg 12:612-20