Nephrology Book

Organ Failure

  • Intravenous Contrast Related Acute Renal Failure

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Intravenous Contrast Related Acute Renal FailureAka: IV Contrast Related Acute Renal Failure, Renal Failure due to Radiocontrast Material

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  1. See Also
    1. Intravenous Contrast
  2. Risk Factors
    1. See Acute Renal Failure Risk
  3. Prevention (Indicated for Acute Renal Failure Risk)
    1. Avoid concurrent Nephrotoxic Drugs
    2. Use low osmolality (non-ionic) Contrast Material
    3. Allow 2-5 days between IV contrast procedures
    4. Hydrate before and after procedure (most important measure)
      1. Adjust for Congestive Heart Failure
      2. Option 1: Isotonic Bicarbonate (preferred)
        1. Prepare 3 ampules of Sodium Bicarbonate (50 meq/ampule) in 850 cc D5W
        2. Give 3 ml/kg IV one hour before procedure and 1 ml/kg/hour for 6 hours post-procedure
        3. Reference
          1. Stuart (2007) Park Nicollet Primary Care Conference, Minneapolis, MN
      3. Option 2: Intravenous normal saline
        1. Infuse 100 ml/hour saline for 4 hours pre-contrast
        2. Infuse 100 ml/hour for the 24 hours post-contrast
      4. Alternative: Oral (non-caffeinated fluid)
        1. Take at least 500 ml before contrast
        2. Take 2500 ml over the 24 hours post-contrast
    5. Adjust IV contrast dose
      1. Contrast Dose: (5 cc/kg)/(Serum Creatinine)
      2. Maximum total dose: 300 cc
    6. Acetylcysteine (Mucomyst) for 3 days (questionable efficacy)
      1. Indications
        1. Chronic Renal Insufficiency
        2. Diabetes Mellitus
      2. Protocol
        1. Used in combination with hydration protocol above
        2. Start day before contrast exposure
      3. Dose: 600 mg PO bid (consider higher dose - see efficacy below)
        1. Continue until day after contrast exposure
      4. Efficacy
        1. Initial studies showed risk of nephropathy reduced by 56%
        2. Recent data suggests that standard dose ineffective; higher dose may be effective
        3. Reference
          1. Williams (2008) Mayo Selected Topics in Internal Medicine, Lecture
      5. References
        1. Birck (2003) Lancet 362:598
        2. Isenbarger (2003) Am J Cardiol 92:1454
    7. Other agents to consider
      1. Calcium Channel Blocker for 24 hours before procedure
    8. Agents with no benefit
      1. Avoid Furosemide (Lasix)
      2. Avoid Mannitol
  4. Diagnosis of contrast-associated Renal Failure
    1. Serum Creatinine rises 25% within 3 days of contrast
  5. References
    1. Mende (2001) CME Medicine Lecture, San Diego
    2. Maddox (2002) Am Fam Physician 66(7):1229
    3. Quader (1998) Ann Vasc Surg 12:612

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