Contrast-induced acute kidney injury and its contemporary prevention

Abstract

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Keywords: PCI; acute kidney injury; chronic renal insufficiency; contrast-induced acute kidney injury; nephrotoxicity; prevention.

FIGURE 1

Incidence of Cl-AKI reported in selected recent studies. Tsai et al. (21); McDonald et al. (23); Wilhelm-Leen et al. (24); Schönenberger et al. (27); Ward et al. (29); Kiss and Hamar (30). CI-AKI, contrast induced acute kidney injury; PTCA, percutaneous transluminal coronary angioplasty; CTA, computed tomography angiography; CTP, computed tomography perfusion; NCCT, noncontrast computed tomography; CTCM, compute tomography with contrast; CATH, coronary vessels catheterisation; AKI-C, acute kidney injury control; CA-AKI-V, venous contrast application as the causative factor of CA-AKI, CA-AKI-A, arteria contrast application as the causative factor of CA-AKI.

FIGURE 2

Diagram for Cl-AKI prevention and patient approach.LVDEP, left ventricle end-diastolic pressure; RAP, right atrial pressure; IABP, intra-aortic balloon pump; CM, contrast media; CA-AKI, contrast associated acute kidney injury.