This document discusses contrast-induced nephropathy (CIN). It describes the types of contrast agents used, risk factors for CIN, methods for prevention including volume expansion with intravenous or oral hydration, and diagnostic criteria for CIN. The nephrotoxic effects of contrast agents increase with higher osmolality, larger volume, repeated or intra-arterial administration, and can be prevented through adequate hydration before and after exposure.

1. 22
Contrast-inducedContrast-induced
NephropathyNephropathy
Dr. MohamedAbbassDr. MohamedAbbass
NephrologistNephrologist
PGDD,CARDIFF,UKPGDD,CARDIFF,UK

8. Contrast agentContrast agent

10. Types of contrast agentsTypes of contrast agents
Osmolality
(mosm/kg)
High
(>1400)
Low
(600)
Low
(600-
1000)
Iso
(290)
Ionicity Ionic Ionic Nonionic Nonionic
Dimer or
Monomer
Monomer Dimer Monomer Dimer
Name Diatrizoate Ioxaglate Iohexol Iodixanol

11. The nephrotoxic effects of contrastThe nephrotoxic effects of contrast
agents are changed byagents are changed by
1-The osmolality1-The osmolality
2- The volume2- The volume
3- The types3- The types
4-The route of administration of4-The route of administration of
contrast agentscontrast agents

12. The nephrotoxic effectThe nephrotoxic effect
increase with :increase with :
1-1- The nonionic > the ionicThe nonionic > the ionic
2- The high osm >Low osm > Iso-2- The high osm >Low osm > Iso-
osmolalityosmolality
3- The large volume ( >100 mL)3- The large volume ( >100 mL)
4- The repeated dose (<72 hours ),4- The repeated dose (<72 hours ),
better two weeks between thebetter two weeks between the
contrast exposurecontrast exposure
5-The intra-arterial > intravenous5-The intra-arterial > intravenous

13. PathophysiologyPathophysiology

15. Risk FactorsRisk Factors

17. To identify the high risk patients use theTo identify the high risk patients use the
risk score predictionrisk score prediction

18. ConcomitantConcomitant
medicationsmedications

20. DiagnosisDiagnosis

21. Clinical diagnosisClinical diagnosis
Contrast agents usually cause rise
of creatinine within 24 to 48 hours
after exposure to contrast
if >72 hours another causes is
suspected
AKI due to CM is usually nonoliguric if oliguric another causes is suspected or
patient has underlying renal insufficiency
The peak of elevation of serum creatinine usually 3 to 5 days after contrast and
return to baseline within 7 to 10 days
1% of patients may need Renal
Replacement Therapy , this patients
will take long time for recovery
This patient mostly has another
coexisting disease like diabetes and will
presented with oliguria
Generally, the CIN is reversible If not reversible , means patient already
has significant renal disease or another
co excitant disease
Contrast agents may causes renal athroemboli ( livedo reticularis ) which cause
renal injury with prolonged course
Uremic symptoms and signs are very rare

22. Diagnostic testsDiagnostic tests
Urine analysis :
1-Fractional excretion of sodium is usually <1% (due to VC )This not
diagnostic
2-In urine sediment , the granular casts are rare  This test is not conclusive
,but essential to evaluate other causes
3-Contrast agents may causes elevate urine specific gravity
CBC Eosinophilia or low complement may suggest renal athroemboli
Renal imaging Not diagnose CIN only exclude other causes
(ultrasound to role out obstruction )
Kidney biopsy not recommended except for further evaluation

23. PreventionPrevention

26. Volume ExpansionVolume Expansion
Hydration is essential in preventing CIN by
decrease renal vasoconstriction, improve
medullary blood flow and decrease the serum
creatinine
•I.V hydration better than oral
•Normal saline better than ½ normal saline
1-IV hydration :
1mL/kg/hr NS for 12 hrs before AND 12 hrs
after contrast OR
3 ml/kg/hr NS for 1 - 3 hrs before, and for 6
hrs after contrast.
(Should receive at least 300-500 mLs before

27. 2-Oral regimen (mostly used for outpatients):
300 - 500 mLs at the evening day before
contrast and the morning of the contrast
study (up to 2 hrs before), then at least extra
300 – 500 mLs for the next 24 hrs.
(Isotonic fluid is better than other fluid )
3-Rehydration using NaHCO3:
•Isotonic NaHCO3 dose 3 mL/kg/hr for 1 hr
before contrast and 1 mL/kg/hr for 6 hr post
contrast administration
•To prepare the isotonic NaHCO3 (150 meq
in 850 mL D5W)
Sodium bicarbonate has not any advantage over
saline

28. 4-N-acetylcysteine (NAC)
•• It has antioxidant character
•• Mostly used in conjugation with
hydration
•• Rare side effects
•• Oral dose:600 – 1200mg capsulesOral dose:600 – 1200mg capsules
PO twice /day for one day beforePO twice /day for one day before
contrast and one day after contrastcontrast and one day after contrast
•• IV dose: 600-1200 mg IV one doseIV dose: 600-1200 mg IV one dose
over 15 minutes, then 600-1200 mgover 15 minutes, then 600-1200 mg
PO every 12h for 4 doses afterPO every 12h for 4 doses after
contrast.contrast.

30. ThanksThanks
Dr M AbbassDr M Abbass