A primer in radiocontrast-induced nephropathy.

Despite recent medical progress in supportive medical absent, DM present (n=318); (iii) RI present, DM absent (n=298); (iv) both RI and DM present (n=216) therapy, the frequency of hospital-acquired acute renal failure has increased in recent years from ~5% to [14]. The frequency of RCIN, defined as an increase of serum creatinine 0.5 mg/dl, was 8.5% for iohexol (I ) 6.4% [1,2]. Even more distressing is the fact that mortality associated with acute renal failure has and 8.2% for diatrizoate (D) in group i, 7.2% (I) and 11.1% (D) in group ii, 12.2% (I) and 27.0% (D) in group remained high, i.e. on average ~60% in more recent reports [1–11]. Radiocontrast-induced nephropathy iii, and finally 33.3% (I) and 47.7% (D) in group iv. Obviously the risk of RCIN is increased considerably in (RCIN) is the third most common cause of hospitalacquired acute renal failure. When RCIN is defined as patients with pre-existing renal failure, particularly when diabetes mellitus is present. When the clinically more an increase in serum creatinine level of at least 25% to at least 2 mg/dl within 2 days, most disturbingly RCIN relevant criterion of an increase of serum creatinine of 1.0 mg/dl was used, the frequency of RCIN in group continues to be associated with death by an odds ratio of 5.5 even when adjustments are made for comorbid i was 0%, in group ii <1% each for I and D, in group iii 4% (I) and 7% (D), and finally in group iv 12% (I) factors, e.g. age, liver disease and physiological severity score [10]. It appears that renal failure increases the and 27% (D) [14]; possibly suggesting that nonionic ( low osmolar) contrast-media are beneficial in patients risk of death from pre-existing nonrenal conditions, but also that major nonrenal morbidity will develop with pre-existing renal failure, especially in diabetic patients. Davidson and colleagues [15] examined 1144 in patients with RCIN [10]. RCIN not only reduces survival, but is also costly. In a recent clinical trial, patients undergoing cardiac catheterization and found a low risk of RCIN (D S-creatinine 0.5 mg/dl ) in the mean cost of treating adverse reactions to contrast media, which occurred in 193 patients, was $459 [12]. patients with normal renal function. When baseline S-creatinine concentration was >1.2 mg/dl, however, The mean cost of treating adverse reactions increased to $2064 in patients with a history of renal failure, i.e. the risk of RCIN was higher and increased exponentially with S-creatinine concentration (i.e. 20% RCIN when serum creatinine >1.2 mg/dl. Among the 12 patients with adverse reactions causing excessive cost, 75% had baseline S-creatinine was 2.0 mg/dl ). Even irreversible renal failure may develop when radiocontrast media are either pre-existing renal failure or developed RCIN [12]. The mean cost of treating RCIN was $1950, administered to patients with advanced diabetic nephropathy and renal failure [16,17]. After intravenous pyelogwhich is probably even an underestimate [12]. raphy RCIN was seen in 93% of diabetic patients with baseline S-creatinine concentrations >5 mg/dl, and in Incidence of radiocontrast-induced nephropathy 56% it was irreversible [16]. Similarly, after coronary angiography 50% of patients with diabetic nephropathy (S-creatinine concentration 5.9 mg/dl ) developed RCIN, The proportion of hospital-acquired acute renal failure and in 21% dialysis treatment was required within 14 accounted for by RCIN has increased from 5% in 1977 days, although the median volume of nonionic contrast to 32% in 1987 [6,13], but exact figures are difficult to medium was only 30 ml [17]. obtain, since the definitions used by different researchers are not uniform. In the multicentre Iohexol Cooperative Study, 1196 patients were randomized to receive either Available modalities for prevention and treatment the nonionic contrast agent iohexol (I ) or the ionic agent of radiocontrast-induced nephropathy meglumine/sodium diatrizoate (D) for cardiac angiography [14]. Patients were stratified into four groups: Hydration (i) renal insufficiency (RI; serum creatinine 1.5 mg/dl ) and diabetes mellitus (DM) both absent (n=364); (ii) RI In 1981 Eisenberg et al. [18] studied 537 patients undergoing cerebral, abdominal or peripheral angiogCorrespondence and offprint requests to: Dr Bernhard K. Krämer, raphy with relatively large volumes of radiocontrast. Klinik und Poliklinik für Innere Medizin II, Klinikum der Universität Regensburg, D-93042 Regensburg, Germany. They received 550 ml of normal saline and 250 ml of