A.Rasoolzadeh MD

Contrast induced nephropathy (CIN): A kind of reversible AKI as a rise in serum creatinine (by 25%) during of h after receipt iodinated contrast which return to or near previous base line during 7 days.

Risk Factors : -CKD : GFR< 60 cc/min -Diabetic Nephropathy -Advance CHF and other causes of renal hypo-perfusion -High dose of contrast or high-osmolar contrast media -PCI -Multiple myeloma -Age > 70 -Cirrhosis,Kidney allograft, proteinuria - Other risk factors: Metabolic syndrome, hyperuricemia, prediabetic situation,sepsis

Prevention: - Cr should be checked for all patients who are candidate for injection of radio-contrast - Patients with eGFR 1.5 mg/dl should receive pharmacologic and non-pharmacologic prophylaxis - At risk patients with eGFR>60 need only non- pharmacologic prophylaxis

Alternative imaging if possible : Ultrasonography,CT without contrast,MRI without gadolinium,CO2 as contrast Non ionic iso- osmolar or low-osmolar contrast are safer than high-osmolar Use lower doses of contrast and avoid to repeat contrast injection within h Avoid volume depletion and diuretics, NSAIDs, aminoglycoside, amphotericin B, Acyclovir,foscarnet, ACE-I, ARB, metformine ( metformin should be discontinued 24 h before to 48 h after procedure. ACE-I and ARB should be D/C at the same day of procedure if possible)

1- IV fluid therapy : If there is no contraindication A: inpatients : 1-Normal saline 1cc/kg/h for 6-12h before and 6-12 h after procedure OR 2- Isotonic bicarbonate : ( By adding 150 meq sodium bicarbonate (three 50 cc ampoules of 1 meq/ml sodium bicarbonate ) to 850 cc of DW5% ) 3 cc/kg /h for 1 hour prior to procedure and 1cc/kg/h for 6 h after procedure B: Outpatients: Isotonic saline : 3 cc/kg /h for 1 hour prior to procedure and 1cc/kg/h for 6 h after procedure 2- if available : Eff NAC 1200 mg/BID/PO the day before an the day of the procedure

Patients with stage 5 CKD (eGFR< 15cc/min) and a functioning hemodialysis access : Prophylactic hemodialysis after contrast exposure is suggested. But its not suggested to place a temporary access for prophylactic hemodialysis. For patients under hemodialysis or pritoneal dialysis who have residual renal function, nephrology counsultation is necessary.

Cr should be checked for all patients who are candidate for MRI with gadolinium Patients with eGFR < 30 cc/min who received gadolinium have a great risk for NSF (nephrogenic systemic fibrosis : a fibrosing disorder which involves skin, muscle, facia,lungs, heart with no proven therapy. )

Gadolinium should be avoided in patients with eGFR< 30 cc/min. If gadolinium must be given : 1.Patients should be informed of the risks 2. macrocyclic chelate preparation( gadoteriol, gadobutrol, gadotrate ) must be used (avoid linear chelates ) 3.Gadolinium should be given in the lowest doses( < 0.3 mMol/kg ) 4. Gadolinium should be avoided in patients with a diagnosis or suspicion of NSF

5. After exposure,hemodialysis should be done immediately and after 24 h for: Patients who are on maintenance hemodialysis If GFR< 15 cc/min : placement of temporary hemodialysis catheter should be performed If 15<eGFR < 30 cc/min : hemodialysis should be done if only there is a functioning hemodialysis catheter. for patients on peritoneal dialysis, placement of a temporary hemodialysis catheter for hemodialysis after procedure should be performed. If its not possible, more frequent peritoneal dialysis for at least 24 h after exposure is suggested with no periods of dry abdomen. -

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