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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • The peak rise in serum creatinine occurs within 2–5 days after the diagnostic procedure using IV contrast, and it returns to baseline in most cases

  • Increase in serum creatinine of > 50% represents clinically important acute renal failure

GENERAL CONSIDERATIONS

  • Most commonly seen after cardiac catheterization, especially if left ventricular angiography is carried out

  • May be seen after CT scans or other diagnostic tests using contrast agents

  • Hypoxic tubular injury due to vasoconstriction with release of free oxygen radicals is the likely mechanism

  • Major risk factors:

    • – Prior renal insufficiency

    • – Diabetes mellitus

  • Minor risk factors:

    • – Congestive heart failure

    • – Dehydration

    • – Hypotension

    • – Hypoxia

    • – Large amount of contrast

    • – Ionic and high osmolar contrast

    • – Repeated examinations at short intervals

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • No specific symptoms or signs

PHYSICAL EXAM FINDINGS

  • No specific findings

DIFFERENTIAL DIAGNOSIS

  • Atheroembolic renal failure

  • Prerenal azotemia secondary to low cardiac output

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Increased serum creatinine over baseline before procedure using contrast

  • Serum electrolytes: may be abnormal

ELECTROCARDIOGRAPHY

  • Nonspecific ST-T–wave changes can occur

  • Signs of hyperkalemia may occur

TREATMENT

HOSPITALIZATION CRITERIA

  • Rising creatinine following procedure

MEDICATIONS

  • When contrast nephropathy occurs, treatment is similar to that for any other cause of acute renal insufficiency

  • Most patients improve spontaneously with conservative management

THERAPEUTIC PROCEDURES

  • A few patients require temporary dialysis

  • Need for long-term dialysis purely for contrast nephropathy is rare

SURGERY

  • Shunt placement if long-term dialysis is needed

MONITORING

  • ECG monitoring in hospital

DIET AND ACTIVITY

  • As appropriate for renal and cardiac condition

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Falling serum creatinine

  • Resolution of the problem

FOLLOW-UP

  • Visit in 4–8 weeks to confirm stable renal function

COMPLICATIONS

  • Persistent renal dysfunction

  • Chronic dialysis

PROGNOSIS

  • Good if renal function returns to normal

  • Persistent renal dysfunction decreases survival

PREVENTION

  • Adequate hydration (0.45% normal saline at 1 mL/kg/hour for 12 hours before and 12 hours after the procedure): the most important therapy for preventing contrast nephropathy in high-risk patients

  • Statin drugs combined with fluids and N-acetylcysteine may be useful

  • An iso-osmolar contrast agent may be useful for prevention in high-risk patients

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