1.
造影剤腎症
造影してもいいっすか？

2.
造影剤による腎障害
 造影剤投与3日以内に,
Crが>25%上昇 or >0.5mg/dL上昇
– 他に原因となる物が無い
– 腎機能正常の患者では頻度は0-10%程度
 腎機能障害や, リスクがある患者では25%
– 糖尿病, 心不全, 高齢者, 他に腎毒性のある薬剤
– 蛋白尿, 腎手術, 痛風もリスクとなり得る

3.
造影剤腎症 予測スコア NEJM 2006;354:379-86
Risk Factor Score
sBP < 80mmHgが> 1hr持続 + IABP or 昇圧剤の使用 5
IABPの使用 5
心不全(NYHA III or IV), 肺水腫 5
年齢 > 75歳 4
Ht < 39%(男性), Ht < 36%(女性) 3
糖尿病(+) 3
造影剤の量 100ml毎に1pt
Cr > 1.5mg/dL 4
or 予測GFR < 60 (40-60, 20-39, <20) (2, 4, 6)
Total Score 造影剤腎症リスク 透析リスク
=< 5 7.5% 0.04%
評価 6-10 14.0% 0.12%
11-15 26.1% 1.09%
>=16 57.3% 12.6%

4.
腹部造影CT後の腎症予測Nomogram
American Journal of Emergency Medicine (2011) 29, 412–417
 ERにおいて緊急造影腹部CTを撮影した
750名のRetrospective study
– 34/750(4.5%)で造影剤腎症(+).
– 年齢と基礎のSCr値が有意に造影剤腎症発症に関連.
年齢1yr毎 OR1.04[1.02-1.07], Cr値1mg/dL毎 2.51[1.67-3.78]
– リスクに応じたNomogramを作成.(次ページ)
4

5.
Previous studies have shown that CIN is associated with a 5. Limitations
prolonged hospital length of stay and an increase in hospital
and long-term mortality [2,9,13,16]. It is for this reason that
This study has several limitations. First, the selection of
we need to identify patients at high risk of CIN to seek
patients might be biased because only patients with both
alternative diagnostic procedures. However, the clinical
baseline and follow-up SCr levels were included in the
needs for diagnostic imaging may outweigh the potential
analysis. Although the model may be biased, the nomogram
risks of CIN in many emergency situations. In these cases,
was internally validated. This problem can be solved by
efforts should be devoted to reducing the risk of CIN by
external validation; however, we could not perform it. Second,
reducing the volume of contrast media, providing preventive
the number of cases with nephropathy was modest because the
measures such as N-acetyl cysteine or normalizing the
risk of nephropathy in patients with normal renal function is
physiologic deterioration caused by underlying disease. The
low (only 2.6%) and most study patients (86.3%) had normal
most important and first step is the identification of the
renal function. This modest number of cases could expose the
patients with risk of nephropathy.
model to the risk of overfitting. However, that risk was
Nomograms are a useful bedside tool for clinical decision
minimized by performing internal validation in this study.
making [17,18] without the need for complex computer
software for the calculation of individualized probability.
This is similar to scoring system used in pneumonia severity
index [19]. Though it looks more complex than scoring 6. Conclusions
system, this graphical presentation has some advantages over
scoring system. For example, continuous variable such as
Fig. 1 Nomogram to predict nephropathy after receiving emergency A-CECT. SCr indicates initial SCr emergency
The individual risk of nephropathy following
(mg/dL).
log-transformed scales should be converted to categorical if A-CECT can be predicted by an internally validated
American Journal of Emergency Medicine (2011) 29, 412–417
ractice. Therefore, we treated the variables of renal function with advancing age but also du
a
Table 4 etiologies as risk factors for nephropathy. presence of more comorbidities. Prior studies in
lternative Diagnostic performances at each level of predicted probabilities
ally intravenous administration of contrast media
Sensitivity Specificity undergoingPositivehave shown that diabetes LR o
PCI LR Negative with
ered as having lesser(89.7-100) the development of
1% 100 risk for 18.2 (15.4-21.2) diabetic chronic renal failure (CRF) were related
1.22 (1.18-1.26) NA
pared with intra-arterial administration. In 74.0 (70.6-77.2) [9,13,14]. However, diabetes was not an indepen
5% 67.6 (49.5-82.6) contrast 2.60 (2.00-3.39) 0.44 (0.27-0.71)
15% 20.6 (8.7-37.9) 96.6 (95.1-97.8)
studies involving intra-arterial administration of factor in this study. This difference 0.82 (0.69-0.98) t
6.14 (2.85-13.2)
may be due
LR indicates likelihood ratio; NA, not applicable.
media, there presented few studies ratio with 95% confidence intervals.that although the prevalence of diabetes in PCI st
a
Values are
are a as percentages or involving intrave-
inistration of contrast media [10]. In the subgroup been at least 20%, the prevalence of diabetes in

6.
induced AKI, it is not without its limitations. First, rates than those without contrast-induced AKI. There-
patients were in the study according to a single-center fore, it is necessary to study whether withholding
design. Second,造影剤腎症のリスクをPropensity-matched cohortで評価 the inci-
 the study is an observational study ACE inhibitors/ARBs before CAG decreases
rather than a controlled interventional trial; random dence of contrast-induced AKI and improves long-
allocation to either ACE/ARB阻害薬は造影剤腎症のリスクとなり得る.
– the RAAS treatment group or term survival rates.
untreated group was not performed. To address these Despite these limitations, our study is the only large
issues, we used propensity score matching to mini- 利尿薬はリスクファクター.
– 他には貧血, 低アルブミン, observational cohort analysis with propensity score
mize the differences in baseline characteristics. Never- matching that provides evidence that RAAS blockade
theless, the propensity score approach has limitations exacerbates contrast-induced AKI in patients undergo-
in terms of determining whether the comparison groups ing CAG.
are truly matched; the propensity score may meet In conclusion, although the role of RAAS blockade
statistical criteria but there still may be important in the development of contrast-induced AKI is de-
Am J Kidney Dis. 60(4):576-582
Table 3. Risk Factors for Contrast-Induced AKI on Multivariable Logistic Regression Analysis in the Matched Cohort
Variable Unadjusted OR (95% CI) P Adjusted OR (95% CI) P
ACEi/ARB use 1.93 (1.46-2.55) Ͻ0.001 1.43 (1.06-1.94) 0.02
CKD 2.21 (1.68-2.92) Ͻ0.001 1.54 (1.15-2.08) 0.004
Hemoglobin Ͻ10 g/dL 2.72 (1.89-3.92) Ͻ0.001 1.74 (1.16-2.63) 0.008
Albumin Ͻ3.5 g/dL 3.03 (2.26-4.05) Ͻ0.001 2.14 (1.54-2.97) Ͻ0.001
Contrast volume (per 100-mL increase) 1.27 (1.10-1.46) Ͻ0.001 1.38 (1.19-1.61) Ͻ0.001
Diuretic use 3.76 (2.85-4.94) Ͻ0.001 2.89 (2.14-3.90) Ͻ0.001
LVEF Ͻ40% 1.79 (1.05-3.05) 0.006 1.68 (0.95-2.97) 0.08
Age (per 10-y increase) 1.26 (1.13-1.42) Ͻ0.001 1.07 (0.95-1.07) 0.3
Diabetes 1.49 (1.01-2.22) 0.05 1.22 (0.80-1.87) 0.4
Male sex 1.02 (0.78-1.34) 0.9
Statin use 0.80 (0.59-1.07) 0.1
Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; CI,
6
confidence interval; CKD, chronic kidney disease; LVEF, left ventricular ejection fraction; OR, odds ratio.

7.
造影剤は 5xWt/Cr mL以下とすべし
 561名のSTEMI患者に対するPCIを解析
– Maximum Contrast Doseを5 x Wt/Cr mLとしたときの
造影剤腎症, 予後に関する前向きコホート
(Ann Intern Med 2009;150:170-7)
– 20.5%が造影剤腎症を併発
– MCDを超える量の造影剤を用いた患者では, 有意に腎症併発が多い
– 使用造影剤量/MCD とContrast Induced Nephropathyの頻度
40.00% 31.70%
30.00%
20.00% 16.70%
10.30% 13.20%
10.00%
0%
0.1-0.5 0.5-0.7 0.7-1.0 1.0-4.7

8.
Ann Intern Med 2008;148:284-94
造影剤腎症の予防; NAC
 造影CT前後12hrの補液(1ml/kg/hr)は
飲水よりも予防効果が大きい
 NAC(Nアセチルシステイン) vs 輸液のみ
– NACのDIV投与(国内には製剤なし)
– 400-600mg bid, 造影の前日と当日
– 輸液は1-1.5ml/kg/hr 造影の前後数時間(8hr)
– RR 0.62[0.44-0.88]
 NAC経口; 600mg q12hrで4回投与, 初回は造影前に
(NEJM 2006;354:379-86)

9.
 Meta-analysisでは,
High-dose NACは造影剤腎症予防効果があるとの結果
– High-dose; 1200mg/24hr or 造影前<4hrに600mg投与.
投与経路は経口, 経静脈投与.
– 16 trials, N=1677のMeta-analysisでは
(Am J of Med 2009;122:874.e9-e15)
– High-dose NACの造影剤腎症予防効果は RR 0.46[0.33-0.63]
– Funnel plotにてPublication biasも指摘されず.

10.
NEJM 2006;354:379-86
造影剤腎症の予防; Bicarbonate
 Bicarbonate
– 3ml/kg/hrを造影前, 1ml/kg/hrを造影後に6hr
– 生食負荷と比較し, 腎障害予防効果は有意差無し
(CCr 25%減少がOutcome, RR 0.94[0.55-1.60])
(JAMA 2008;300:1038-46)
 Bicarbonate + 生理食塩水 vs 生理食塩水のみで比較
– Cr >=1.5の患者で待機的冠動脈造影を行う265名
– 8.4% Bicarbonate 75ml + NS 1L vs NSを,
造影前1hrより3mL/kg/hrで開始, 造影後は1mL/kg/hr 6hr投与
– 造影剤腎症発症率は 7.4% vs 5.9%, OR 1.36[0.45-3.50]
(Am J Kidney Dis 2009;54:610-8)

11.
 冠動脈造影直前のBicarbonate 1回投与は腎症を予防する
– 軽度腎障害(Cr 1.1-2.0)のある待機的冠動脈造影患者144名
– 造影剤投与5分前のBicarbonate 20mEq bolus
vs 通常の輸液負荷(0.5-1mL/kg/hr 12hr前~12hr後)で比較
(RCT, Single-blind, 大分のStudy) (Am J Cardiol 2009;104:921-5)
– 造影剤腎症発症率は1.4% vs 12.5%(p=0.017)
– 心不全などの合併症は有意差無し.
 BicarbonateのMeta-analysis (Ann Intern Med 2009;151:631-8)
– 23 RCT, N=3563, 内造影剤腎症は396名(11.1%)
– Bicarbonateの造影剤腎症RR 0.62[0.45-0.86]と, 予防効果あり
– N, Jaded Scoreが高いものでは有意差無く,
結論は出せないが, 行う価値はあるかもしれない予防法.

12.
造影しながらの透析は無意味
The American Journal of Medicine (2012) 125, 66-78
 造影剤腎症予防目的の透析療法を評価したRCTのMeta.
– 9 RCTsと2 non-RCTs, N=1010. (8 trialsがHD, 3 trialsがHDF, HF)
透析は殆どのStudyで造影直後∼2時間後までに開始.
造影前から開始が1 trial, 造影中に開始するのが2 trials.
– 透析療法群の造影剤腎症合併率は23.3%,
通常の内科的予防群では21.2%, RR 1.02[0.54-1.93].
– HDのみに限定すると, 造影剤腎症リスクはRR 1.61[1.13-2.28]と,
むしろ造影剤腎症が増加する.
– 基本的に造影剤腎症は透析してもダメ.
12

13.
Table 5 Selected Sensitivity Analysis
Effect Size Heterogeneity
No. of No. of
Studies Patients Risk Ratio (95% CI) P Value I2* P Value
RCIN
All 9 827 1.02 (0.54-1.93) .96 80% Ͻ.001
RCT 7 738 1.00 (0.48-2.11) 1.0 84% Ͻ.001
N Ն20 6 750 0.77 (0.54-1.11) .16 88% Ͻ.001
N Ն50 3 569 0.79 (0.17-3.59) .76 93% Ͻ.001
HD 6 572 1.61 (1.13-2.28) .008 8% .37
HF/HDF 3 255 0.46 (0.12-1.70) .24 87% Ͻ.001
CKD St 4-5 7 455 0.81 (0.37-1.76) .59 79% Ͻ.001
CKD St 3 2 372 1.98 (0.94-4.17) .07 52% .15
Acute RRT
All 6 864 0.48 (0.12-1.95) .31 76% Ͻ.001
RCT 5 813 0.39 (0.09-1.74) .22 19% Ͻ.001
N Ն20 6 864 0.48 (0.12-1.95) .31 76% Ͻ.001
N Ն50 4 731 0.57 (0.11-2.92) .50 81% .001
HD 3 607 0.78 (0.07-8.43) .84 83% .003
HF/HDF 3 257 0.22 (0.06-0.74) .01 36% .21
CKD St 4-5 5 452 0.37 (0.08-1.73) .21 78% .001
Chronic RRT/ESRD
All 5 366 0.87 (0.33-2.29) .78 19% .30
RCT 4 326 0.66 (0.17-2.55) .55 31% .22
N Ն20 4 349 0.69 (0.19-2.48) .57 33% .21
HD 4 252 1.04 (0.34-3.13) .95 25% .26
CKD St 4-5 5 366 0.87 (0.33-2.29) .78 19% .30
Mortality
All 5 794 0.65 (0.17-2.49) .52 53% .07
RCT 4 743 0.52 (0.12-2.30) .39 59% .06
N Ն20 5 794 0.65 (0.17-2.49) .52 53% .07
N Ն50 3 639 0.74 (0.09-6.24) .79 66% .05
HF/HDF 3 257 0.29 (0.07-1.10) .07 28% .25
CKD St 4-5 4 370 0.34 (0.11-1.07) .06 18% .30
The pooled risk ratio (RR) for outcomes is estimated only when there are Ͼ2 studies included (see Methods).
Abbreviations: CI ϭ confidence interval; CKD ϭ chronic kidney disease; ESRD ϭ end-stage renal disease; HD ϭ hemodialysis; HDF ϭ hemodiafiltration;
HF ϭ hemofiltration; RCIN ϭ radiocontrast-induced nephropathy; RCT ϭ randomized controlled trial; RRT ϭ renal replacement therapy.
* The I2 statistic13-14 is a measure of heterogeneity, expressed as the approximate percentage of total variation (within and between studies) due to
between-study variation.

14.
Ann Intern Med 2008;148:284-94
造影剤腎症の予防; その他
 他の薬剤はイマイチ
– テオフィリン: RR0.49[0.23-1.06]
– ドパミン, スタチン, マンニトール,
Fenoldopam(ドーパミンα1 agonist),
iloprost(prostaglandin製剤) は有意差なし
 フロセミドは増悪因子: RR3.27[1.48-7.26]
 造影剤は低浸透圧性が最も侵襲が大きい
– 等浸透圧, 高浸透圧と比較し, OR 0.50[0.36-0.68]
– 造影剤の量が5ml x Wt(kg) /Crを超える場合もHigh Riskとなる

15.
造影剤腎症予防のテオフィリン
Meta-analysis Am J Kidney Dis. 60(3):360-370.
 16 RCTs (N=1412)のMeta-analysis.
– テオフィリン投与方法は,
Gandhi 1992 125mg po 2回/d, 前日~48hr後まで Huber 2003 200mg IV 30分前
Erley 1994 5mg/kg IV, 45分前 Dussol 2006 5mg/kg po, 1時間前
Katholi 1995 2.88mg/kg po q12hr, 1h前∼48hr後まで Huber 2006 200mg IV, 30分前 + NAC
Kolonko 1998 165mg IV 30分前 Baskurt 2009 200mg po, 2回/d, 1日前∼当日
Abizaid 1999 4mg/kg IV, 0.4mg/kg/h. 2hr前より Matejka 2010 205.7mg IV, 1時間前
Erley 1999 270mg 朝, 540mg 夕を2日前∼3日後 Kinbara 2010 250mg IV 30分前
Huber 2002 200mg IV, 30分前 Malhis 2010 200mg po, 2回/d, 24h前∼48h後
or 200mg IV 30分前,
200mg po bid 48hr後まで
Kapoor 2002 200mg po, 1日2回, 24hr前∼48hr後 Rohani 2010 250mg IV 30分前
15

16.
Am J Kidney Dis. 60(3):360-370.
 テオフィリンは造影剤腎症リスクを軽減する
RR 0.48[0.26-0.89] Am J Kidney Dis. 60(3):360-370.
Theophylline and Contrast-Induced Acute Kidney Injury
Study Events, Events, %
ID RR (95% CI) Treatment Control Weight
Gandhi (1992) 1.23 (0.13, 11.48) 2/13 1/8 5.46
Abizaid (1999) 1.17 (0.48, 2.86) 7/20 6/20 13.61
Erley (1999) 1.66 (0.16, 17.37) 2/35 1/29 5.07
Huber (2002) 0.25 (0.06, 1.12) 2/50 8/50 8.98
Kapoor (2002) 0.09 (0.01, 0.67) 1/35 11/35 6.39
Huber (2003) 0.20 (0.05, 0.87) 2/50 10/50 9.19
Huber (2006) 0.34 (0.07, 1.60) 2/49 6/50 8.66
Dussol (2006) 1.44 (0.42, 4.92) 6/80 4/77 10.90
Baskurt (2009) 0.07 (0.00, 1.16) 0/72 7/73 3.78
Kinbara (2010) 0.11 (0.01, 1.90) 0/15 4/15 3.79
Malhis (2010) 0.20 (0.05, 0.87) 2/128 12/152 9.12
Rohani (2010) 0.67 (0.21, 2.13) 4/30 6/30 11.41
Matejka (2010) 5.69 (0.31, 105.21) 3/31 0/25 3.63
Overall (I−squared = 44.3%, p = 0.043) 0.48 (0.26, 0.89) 33/608 76/614 100.00
NOTE: Weights are from random effects analysis
16 .1 1 10

17.
 ただし, Jadad score >3のstudyでは有意差は認められず,
デザインがイマイチなStudyでのみ有効性が認められている
Theophylline and Contrast-Induced Acute Kidney Injury
Am J Kidney Dis. 60(3):360-370.
Study Events, Events, %
ID RR (95% CI) Treatment Control Weight
Jadad<3
Gandhi (1992) 1.23 (0.13, 11.48) 2/13 1/8 5.46
Huber (2002) 0.25 (0.06, 1.12) 2/50 8/50 8.98
Kapoor (2002) 0.09 (0.01, 0.67) 1/35 11/35 6.39
Huber (2003) 0.20 (0.05, 0.87) 2/50 10/50 9.19
Huber (2006) 0.34 (0.07, 1.60) 2/49 6/50 8.66
Baskurt (2009) 0.07 (0.00, 1.16) 0/72 7/73 3.78
Kinbara (2010) 0.11 (0.01, 1.90) 0/15 4/15 3.79
Malhis (2010) 0.20 (0.05, 0.87) 2/128 12/152 9.12
Rohani (2010) 0.67 (0.21, 2.13) 4/30 6/30 11.41
Subtotal (I−squared = 0.0%, p = 0.505) 0.29 (0.16, 0.50) 15/442 65/463 66.79
.
Jadad>=3
Abizaid (1999) 1.17 (0.48, 2.86) 7/20 6/20 13.61
Erley (1999) 1.66 (0.16, 17.37) 2/35 1/29 5.07
Dussol (2006) 1.44 (0.42, 4.92) 6/80 4/77 10.90
Matejka (2010) 5.69 (0.31, 105.21) 3/31 0/25 3.63
Subtotal (I−squared = 0.0%, p = 0.769) 1.39 (0.71, 2.73) 18/166 11/151 33.21
.
Overall (I−squared = 44.3%, p = 0.043) 0.48 (0.26, 0.89) 33/608 76/614 100.00
17
NOTE: Weights are from random effects analysis
.1 1 10