This document provides information on contrast induced nephropathy (CIN), including its definition, pathogenesis, risk factors, incidence, prevention, and management. CIN is a form of acute kidney injury caused by radiocontrast media administration that results in an increase in serum creatinine levels within 3 days. Prevention focuses on hydration, using low- or iso-osmolar contrast agents, avoiding repetitive procedures, and discontinuing nephrotoxic drugs. Treatment is supportive as CIN is generally reversible with hydration and supportive care.

1. Your presentation begins here
contrast induced
nephropathy

2. How to manage
Drugs to avoid
Risk factors
Studied to discuss
risk benefit of
pretreatent of cin
TABLE OF CONTENTS
01
03
02
04

3. CONTRAST
INDUCED
NEPHROPATHY

4. CONTENTS OF THIS
TEMPLATE
• Contrast-induced nephropathy (CIN) is a generally reversible form of acute kidney
injury (AKI) that occurs soon after the administration of radiocontrast media.
• After intravascular CM injection, immediate renal toxicity may occur, and in most
cases it remains fortunately free of significant clinical consequences.

5. Late Time Line..
These occur
within 1 hour to
1 week
•Skin Reactions
 Mild
• N ,V,
• urticaria,Itching
 Moderate
• Vasovagal Reaction
• Bronchospasm
• Laryngeal Edema
 Sever
• Hypotensive Shock
• Pulmonary Edema
• Respiratory Arrest
• Cardiac Arrest
• Convulsions .
• Thrombosis
Very Late Time Line..
These occur after
one week
•Thyrotoxicosis ( due
to iodine related)
•Nephrogenic
Systemic Fibrosis
( Gadolinium
related)
Acute
Time
Line;
These
occur
with
1
hour
of
contrast
administration
ADVERSE EFFECTS OF CONTRAST MEDIA

6. in the absence of alternative
causes for acute kidney injury
at 48–72 hours after exposure
to contrast agent, peaks at 3–5
days
an absolute increase in serum creatinine
of ≥0.5 mg/dL or a ≥25% relative
increase in serum creatinine from the
baseline value
Definition
of CIN
includes

7. 1 2 3 4 Weeks
Serum
Creatinine
Some patients have
a persistent decline
in renal function and
require RRT
(in patients with CIN
risk factors)
S. Cr. usually returns
to the baseline value
after 1–3 weeks
In most cases, the decline in
renal function is mild and
transient

8. Incidence
of CIN
Risk
Incidence of CIN
Contrast
Dose
Type of
Radiologic
procedure
Contrast
Type

9. • According to the US FDA, the incidence of renal failure after
contrast administration, ranged from 0.6% to 2.3%.
• However, rates of CIN may be as high as 50%, depending on
the presence of well characterized risk factors, the most
important of which are baseline chronic renal insufficiency
and DM.

10. The Pathogenesis of CIN is multifactorial

11. Risk factors
for the
development
of CIN

12. • A decreased incidence of contrast nephropathy appears to be
associated with nonionic agents, which, are either low osmolal
(500 to 850 mosmol/kg) or iso-osmolal (approximately 290 mosmol/kg).
Contrast media type

13.  Iodixanol, the only currently available iso-osmolal nonionic contrast agent
(approximately 290 mosmol/kg), may be associated with a lower risk of nephropathy
than some low-osmolal agents, particularly iohexol
Contrast media type

14. • Most of the studies indicate that the higher volume of CM is
especially deleterious in the presence of other risk factors , with
lower doses of contrast being safer, but not free of risk.
• Even relatively low doses of contrast (less than 100 ml) can induce
permanent renal failure and the need for dialysis in patients with
chronic kidney disease.
Contrast media dose

15. • In this study, low dose was defined by a formula as:
• However, diabetic patients with a serum creatinine concentration
>5 mg/dL (440 micromol/L) may be at risk from as little as 20 to
30 mL of contrast.
Contrast media dose

16. CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, and infographics
& images by Freepik
To assess the cumulative risk of several
variables on renal function, a simple CIN
risk score that could be readily applied
was developed.

17. Mehrane score
Post-pci nephropathy
MEDCALC

18. Predicting the Risk of CIN after PCI
CIN

19. • There is no specific treatment once CI-AKI develops, and
management must be as for any cause of ATN, with the focus on
maintaining fluid and electrolyte balance.
• The best treatment of contrast-induced kidney injury is
prevention.

20. The use of lower doses of low- or iso-osmolal nonio
contrast agents and avoidance of repetitive stud
that are closely spaced (within 48 to 72 hours).
Consider alternate Imaging studies not requiring
iodinated contrast medium.
• Avoidance of volume depletion.
Prevention
General
consideration

21. Metformin should be discontinued on the day of the
proposed CM administration and for the subsequ
48 hours.
Concomitant nephrotoxic drugs such as NSAID and
nephrotoxic antibiotics, ACEI and diuretics should
discontinued 48 hours prior to contrast
administration.
Prevention
General
consideration

23. Goals of Hydration
Maintenance of sufficient intravascular
volume to increase renal perfusion
Establishment of adequate diuresis prior to
contrast media
Avoidance of hypotension

24. The results were conflicting as some showed a
significantly lower rate of contrast-induced
nephropathy with sodium bicarbonate, while oth
found equivalent rates.
Since alkalinization may protect against free radica
injury, the possibility that sodium bicarbonate
be superior to isotonic saline has been examine
a number of randomized trials and meta-analy
Isotonic saline is
superior to one-half
isotonic saline since
isotonic saline is a
more effective
volume expander.

25. Hydration with Saline
IVF = 1 mL/kg/hr (MAX 100 ml/hr) 12 hours pre & 12 hours post
contrast
CHF or left ventricular ejection fraction (LVEF) < 40%?
0.5 ml/kg/hr (max 50 ml/hr) 12 hrs pre & post contrast
Emergent procedure? (suggested regimen):
Fluid bolus of 3ml/Kg prior to procedure. Hydration during
procedure and/or 12 hrs after if possible (dependent on clinical
status)

26. • Given that an increasing number of individuals receive contrast as
outpatients, this trial has evaluated the effectiveness of oral hydration in
preventing contrast nephropathy.
• 53 patients were randomly assigned to either unrestricted oral fluids or to
normal saline at 1 mL/kg per hour for 24 hours beginning 12 hours prior to
the scheduled catheterization . AKI was significantly more common with
oral hydration (35 versus 4 %).
Oral hydration

27. Bicarbonate Dosing
IVF = 150 meq of sodium bicarbonate in 850 ml of D5W
3 ml/kg bolus (MAX 300 ml) 1 hour prior to procedure and 1
mL/kg/hour (MAX 100 ml/hr) during and for 6 hours post-
procedure.
Glycemic control issues (including patients with diabetes)?
Consider mixing sodium bicarbonate in 1 liter of sterile water
instead of D5W

28. • There are great heterogeneity and conflicting
available clinical trials and meta-analyses examining
results in the
the
effectiveness of acetylcysteine in the prevention of contrast
nephropathy .
• Being a precursor for glutathione synthesis, NAC has the potential
to diminish oxidative stress by directly scavenging superoxide
radicals and increasing intracellular glutathione.
N-ACETYLCYSEINE NAC

29. Nephroprotective drugs

30. Prophylactic oral administration of
acetylcysteine, along with hydration,
prevents the reduction in renal
function induced by the contrast.
• This trial studied 83
patients with chronic
renal insufficiency who
were undergoing
computed tomography.
• Patients were randomly
assigned either to
receive the antioxidant
acetylcysteine (600 mg
orally twice daily) and
0.45 percent saline
intravenously, before
and after administration
of the contrast agent,
or to receive placebo
and saline.
Conclusion:

31. There was no difference in the
development of CI-AKI (12.7 percent
in both groups).
• 2308 patients
undergoing
angiography received
either acetylcysteine
(1200 mg orally
twice daily) or
placebo on the day
before and after
angiogram.
• Patients had at least one of
the following risk factors: age
>70 years, CKD, diabetes
mellitus, heart failure or LV
ejection fraction
<45 percent, or shock.

32. IVAcetylcysteine?
600-1200mgIVx1over15minutes,then600-1200mgPO/PTq12hx4dos
post-procedure:ForahighriskpatientundergoingcardiaccatheterizationorPEp
CTscanwithnoPOaccess
Since the agent is potentially
beneficial, well tolerated, and
relatively inexpensive, 2012
KDIGO guidelines that suggest
administration of
acetylcysteine to patients at
high risk.
Tolerating PO intake?
600-1200 mg capsules PO Q12h X 4 doses
2 doses pre-contrast and 2 doses post-contrast is optima
Acetylcysteine Dosing
EmergentProcedure?
1dosebeforeand3dosespostcathorprocedureisacceptable(Q12hx4dose

33. STATINS
Statins may improve
endothelial function,
reduce arterial
stiffness, and reduce
inflammation and
oxidative stress.
There are no sufficient
data to support the use of
statins solely for the
prevention of contrast
nephropathy.

34. Unfortunately it also fails to reduce CIN
incidence in CKD patients.
FENOLDOPAM
• Fenoldopam is a
specific dopamine-
1 receptor agonist
that augments renal
plasma flow while
decreasing systemic
vascular resistance.
A prospective randomized trial (CONTRAST) assesse
effectiveness of fenoldopam in 315 patients
undergoing a cardiovascular procedure who had
with an estimated creatinine clearance <60 mL/m

35. theophylline is debated.
However, in other randomized studies, administratio
theophylline did not provide any benefit in
reduction of CIN rates compared with placebo.
In a randomized study
by Huber et al,
prophylactic
intravenous
administration of
theophylline 200
mg reduced the
incidence of CIN in
100 patients at risk,
as compared with
placebo (4% versus
16%).

36. A 20 ng/kg/min PGE1
infusion has a
significant protective
effect on post-PCI
SCr elevation,
But higher infusion rates
are not associated
with increased
benefits, probably
due to the associated
decrease in systemic
blood pressure.
prostaglandin E1 (
ALPROSTADIL)
In patients with high-risk factors undergoing PCI, the
use of PGE1 for prevention of CIN is safe and
efficacious.

37. three other studies, the change in CIN did not differ
significantly with calcium antagonists. On the othe
hand we found that amlodipine treatment before
played a role in protecting hypertensive patients f
CI-AKI and prolonging survival.
In a small, randomized,
placebo controlled study of
35 patients, eGFR was
preserved in patients
treated with nitrendipine
but decreased in patients
that received placebo..
calcium channel
blockers

38. Hemodialysis
• Iodinated contrast agents are readily dialyzable.
• The plasma clearance of most modern contrast media is 50–70 mL/
min, with more than 80% removed from the plasma within 4–5 hours of
hemodialysis.
• However, Reduction of CIN with dialysis is also not biologically plausible
since the CM would reach the kidneys within one or two cardiac cycle.
• Subsequent removal of CM is unlikely to stop the cascade of renal
injury, which would have already begun.

39. Hemofiltration
• In patients with chronic renal failure who are undergoing
percutaneous coronary interventions,
• periprocedural hemofiltration given in an ICU setting appears to
be effective in preventing the deterioration of renal function due
to CIN
• and is associated with improved in-hospital and long-term
outcomes.

40. There is available evidence that
HEMOFILTRATION (not
hemodialysis) may be
beneficial for prevention of
contrast induced
nephropathy. But
hemofiltration should be
performed for 6 hours before
and for 18 to 24 hours after
contrast exposure.

41. CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, and infographics
& images by Freepik
THANK YOU