Contrast-induced nephropathy (CIN) is a significant cause of acute kidney injury, particularly in hospitalized patients undergoing endovascular procedures. Defined by specific criteria related to serum creatinine levels, CIN may be influenced by various risk factors, including baseline renal function and certain medications. Management focuses on prevention through hydration and appropriate contrast media usage, with the effectiveness of various pharmacological agents still under investigation.

1. Contrast Induce Nephropathy
Collage Of Medicine – Al-Qadisiya University
Iraq
Done By :- Ziyad Salih

2. Index :
• Introduction
• Definition
• Epidemiology
• Pathophysiology
• Risk markers
• Risk score
• Contrast agents
• Management

3. INTRODUCTION
• CIN (CI -AKI ) it’s a leading cause of acute
kidney injury in hospitalized patients.
• Most frequent renal complication of
endovascular interventional procedures.
• Increases short and long term morbidity and
mortality.
• Treatment is limited to supportive measures
while awaiting the resolution of renal
impairement

4. QUESTIONS IN MIND
• How CIN occurs ?
• What is the definition of CIN ?
• Are contrast agents directly nephrotoxic ?
• How can it be prevented ?
• Will CIN be never having an effective
treatment ?

5. Historical view about contrast
• In 1906,Von Lichtenberg and Voelcker used
2% colloidal silver solution,for retrograde
pyelography studies.(toxic to kidneys,death).
• In 1920, Osborne and colleagues ,10% “NaI”
for Rx of syphilis, fortuiously found it to be
radiopaque ,excreted by kidneys.--first
pyelogram.
• 1924,Brooks – first angiogram (under GA).

6. Definition
• CI-AKI is defined by the Kidney Disease
Global Outcomes (KDIGO) guidelines as an :-
“…increase in serum creatinine of 0.5 mg/dL or
greater within 48 hours of contrast use or a
25% or greater increase from baseline serum
creatinine within 7 days”.
The serum creatinine usually increases within 24 -
48hrs after contrast administration, peaks at 3 to 5
days,and returns to baseline in 1 -3 weeks.

7. Epidemiology
• According to the US FDA, the incidence of
renal failure after contrast administration
,ranged from 0.6%to2.3%.
• However, rates of CIN maybe 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.

8. Risk Factors
•Systolic blood pressure <80 mm Hg - 5 points
•Intraarterial balloon pump– 5 points
•Congestive heart failure (history of pulmonary edema .
– 5 points
•Age >75 y - 4 points
•Hematocrit level <39% for men and <35% for women -
3 points
•Diabetes - 3 points
•Contrast media volume - 1 point for each 100 mL
•Renal insufficiency - 4 points

9. Risk Factors
• Scoring:
5 or less points
• Risk of CIN - 7.5
• Risk of Dialysis - 0.04%
6–10 points
• Risk of CIN - 14.0
• Risk of Dialysis - 0.12%
11–16 points
• Risk of CIN - 26.1*
• Risk of Dialysis - 1.09%
>16 points
• Risk of CIN - 57.3
• Risk of Dialysis - 12.8%

10. Risk Factors
Or the CIN can be classified on the basis of GFR
• Low Risk: GFR> 60 ml/min
• Moderate Risk: GFR 30-59 ml/min
• High Risk: GFR < 30ml/min

11. Pathophysiology
• Not well understood until now , but
there's theoretical explanation :-
1- tubular toxicity
2- microvascular alteration
3- oxidative stress
4- inflammation
5- protein precipitation
6- Regional Hypoxia

12. Pathophysiology

13. Important considerations in choosing a
contrast agent
• Its an important factor is to choose the
appropriate contrast media depending on
its harmful or beneficial effect

14. Types Of Contrast Media
A decreased incidence of contrast nephropathy
appears to be associated with nonionic agents
,which, are either low osmolal or iso-osmolal
• SOLUBILITY Classified into ionic and nonionic
groups based on water solubility.
• OSMOLALITY ( High – Iso – Low )
• VISCOSITY ( High – Low )

15. How could hyperosmolality
cause nephropathy ?

16. How could hyperosmolality
cause nephropathy ?

17. Types Of Contrast Media
• So, recommended to use of either Isosmolar
or Low Osmolar iodinated contrast media,
rather than High Osmolar iodinated contrast
media in patients at increased risk of CI-AKI.

18. Why we use Iso-Osmolar ?
• ISOSMOLAR Iodinated contrast media is
recommended for the following groups of
patients:
• –All high risk patients (eGFR<30 mL/min)
• –Dialysis patients
• –Moderate Risk (eGFR<60 mL/min) patients
for intra-arterial procedures

19. Is there any role for drugs in CIN ?
• The use of some drugs that had been found
to increase the posibility of Contrast induced
nephropthy , through , their mechanism of
action ..

20. The following drugs should be discontinued 24
hours before until 48 hours after contrast media
administration
–NSAIDs
–Aminoglycosides
–Metformin
–Anti-virals(Acyclovir and
Foscarnet)
–Amphotericin B
–High dose diuretics
–ACE-inhibitors
–ARBs

21. Clinical Manifestaion
• Contrast-induced nephropathy most
commonly manifests as a nonoliguric and
asymptomatic transient decline in renal
function.
• The serum creatinine level begins to rise
within 24 hr of contrast administration,
usually peaks within 3–5 days, and returns to
baseline within 10–14 day

22. Clinical Manifestaion
• Oliguric acute renal failure requiring
hemodialysis can also occur. This condition
presents with oliguria (24-hr urine volume <
400 mL) within 24 hr of contrast
administration and typically persists for 2–5
days.
• Morbidity and mortality rates are
significantly higher in this group of patients
when compared with those who have
nonoliguric renal failure

23. Investigations
o Urinary epithelial cell casts,
o debris,
o urate and calcium oxalate crystals
are nonspecific findings in contrast-induced
nephropathy.
o Low urinary sodium and fractional excretion
of sodium (< 1%) have been reported as being
distinctive characteristics of this condition.

24. Diagnostic criteria for CIN

25. Diagnostic criteria for CIN
Exposure to
contrast
Increase
Sr.Creatinin

26. Prevention ….
o Hydration ... Hydraion ... And Hyrdraion

27. Hydration
o correct any decreases in renal blood flow by
ensuring that intravascular volume is replete.

28. Hydration
• Simplest and most effective way of protecting
renal function.(decreases by 50% chance of
CI-AKI)
• Effect of contrast agents on kidney is
prolonged in dehydration.(RBF,GFR) … so
the hydration is very important .

29. Hydration
• How can I do a good hydration ?
• In which mean ?
• By any type of fluid ?

30. Hydration
ORAL: Low risk patients should be instructed to
take 1-2 liters of water 12 hours before the
procedure. Patients should be placed on NPO 4
hours before the procedure and IV fluids may be
started if additional hydration is needed

31. Hydration
• While in High Risk patients …
IV Hydration : ≥ 1.0–1.5 ml/kg/h of NSS has to
be administered for 3–12 hours before, and up
to 6–12 hours after contrast media exposure.
• –Example: For a 60 kg patient, 60 –90 cc/hour
for 3-12 hours prior to the procedure and up
to 6-12 hours after the procedure.

32. Hydration
• In patients with poor systolic function Or
Chronic Renal failure use lower dose ( 0.5
ml/kg/hr )

33. Hydration
• Which type of I.V Fluids ?

34. Hydration
• Isotonic saline is superior to other types of
fluids , since isotonic saline is a more
effective volume expander.

35. NaHCo3
• Since alkalinization may protect against free
radical injury, the possibility that sodium
bicarbonate may be so important
• 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.
• Prepare = 150 meq of sodium bicarbonate
in 850 ml of Dextrose

36. N-acetylcysteine
• There are great heterogeneity and
conflicting results in the available clinical
trials and study-analyses examining 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.

37. N-acetylcysteine
Acetylcysteine Dosing :-
• Tolerating PO intake?
600-1200 mg capsules PO Q12h.
4 doses :-
2 doses pre-contrast and
2 doses post-contrast is optimal
• Emergent Procedure?
1 dose before and 3 doses post procedure is
acceptable (Q12h x 4 doses total)

38. N-acetylcysteine
Acetylcysteine Dosing :-
For a high risk patient undergoing cardiac
catheterization or PE protocol CT scan with no
PO access
• IV Acetylcysteine?
600-1200 mg IV x 1 over 15 minutes, then
600-1200 mg PO q12h x 4 doses post-
procedure .

39. 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 for the prevention of contrast
nephropathy.

40. Statins

41. Statins
• 2998 patients with type2 diabetes and CKD
were assigned to receive rosuvastatin or to
a control group prior to adiagnostic
angiogram with or without percutaneous
intervention.
• Patients assigned to rosuvastatin received
10 mg daily two days prior and three days
after the scheduled procedure.
Contrast-induced was less common among
patients assigned to rosuvastat incompared
with control.

42. theophylline
• In a randomized study, prophylactic
intravenous administration of theophylline
200mg reduced the incidence of CIN in 100
patients at risk ,as compared with placebo .

43. Calcium Channel Blocker
• 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.

44. Hemodialysis
• Iodinated contrast agents
are readily dialyzable.
• The plasma clearance of most modern
contrast media is 50–70mL/min ,with more
than 80% removed from the plasma within
4–5 hours of hemodialysis.
• Subsequent removal of CM is unlikely to
stop the cascade of renal injury ,which
would have already begun.