Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update

Abstract

Background Despite tremendous improvement in molecular properties over the last century, intravascular injection of iodinated contrast material may still have systemic and hemodynamic consequences. Patients with pre-existing renal insufficiency may be at risk for acute kidney injury, which may be associated with an increased risk of the need for dialysis and mortality in the long term. Many questions as to the physiological pathways, optimal definition, and incidence of contrast-induced acute kidney injury remain open. These uncertainties are reflected in the changing landscape of this field in terms of nomenclature, research, and clinical practice.

Methods Clinical practice guidelines for the prevention of post-contrast acute kidney injury all recommend giving prophylaxis in the form of intravenous hydration to high-risk patients. Solid evidence for this strategy is lacking. This article gives an overview of the changing landscape of post-contrast acute kidney injury and prophylactic intravenous hydration, with the aim of supporting informed decision-making in clinical practice.

Results Recent data have caused a shift in guideline recommendations: 90 % of patients formerly considered high-risk for contrast-induced acute kidney injury no longer qualify for prophylaxis. The remaining high-risk patients, with severe chronic kidney disease, represent a vulnerable population for whom intravenous hydration may provide some benefits but also carries risk.

Conclusion Intravenous hydration may benefit ‘new’ high-risk patients. However, it also confers risk. A dual approach to screening patients will help avoid this risk in clinical practice.

Key Points: 

• Intravenous hydration is the cornerstone for preventing contrast-induced acute kidney injury

• Solid evidence is lacking; recent data caused a shift in guideline recommendations

• Intravenous hydration may benefit ‘new’ high-risk patients with severe chronic kidney disease; however, it also confers risk

• A dual approach to screening patients will help avoid this risk in clinical practice

Citation Format

• Nijssen E, Rennenberg R, Nelemans P et al. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. Fortschr Röntgenstr 2021; 193: 151 – 159

Zusammenfassung

Hintergrund Die intravaskuläre Applikation jodhaltiger Kontrastmittel kann, trotz kontinuierlicher Verbesserung ihrer pharmakologischen Eigenschaften, systemische bzw. hämodynamische Nebenwirkungen haben. Insbesondere Patienten mit eingeschränkter Nierenfunktion sind gefährdet. Ein akutes Nierenversagen im Nachgang einer intravaskulären Kontrastmittelgabe hat für betroffene Patienten im Langzeitverlauf ein erhöhtes Dialyse- und Mortalitätsrisiko. Weder ist der zugrunde liegende Pathomechanismus vollständig geklärt, noch ist die wirkliche Inzidenz eines akuten Nierenversagens im Rahmen einer kontrastmittelinduzierten Nephropathie bekannt. Diese Unsicherheiten spiegeln sich in vielen weiteren Aspekten wider: so fehlt beispielsweise eine allgemein verbindliche Definition und ist der Umgang in der klinischen Praxis uneinheitlich.

Methode Klinische Leitlinien zur Prävention einer kontrastmittelinduzierten Nierenschädigung empfehlen klassischerweise eine prophylaktische intravenöse Hydrierung von Hochrisikopatienten. In der vorliegenden Übersicht werden die gültigen Empfehlungen zur intravenösen Prophylaxe in diesem Kontext zusammengefasst und ein 2-stufiger Praxisleitfaden auf Basis der letzten Leitlinienempfehlungen vorgestellt.

Ergebnisse Jüngere Forschungsergebnisse haben zu einer weitreichenden Anpassung der klinischen Leitlinienempfehlungen geführt: 90 % der bis dato als Hochrisiko für kontrastmittelinduzierte Nephropathie eingestuften Patienten gehören nicht länger in diese Risikokategorie, eine diesbezügliche Prophylaxe vor Kontrastmittelgabe wird nicht mehr empfohlen. Für eine kleine Patientengruppe kann diese Prophylaxe sehr wohl hilfreich sein, unter sorgfältiger Abwägung im Rahmen einer Nutzen-Risiko-Analyse. Dies betrifft insbesondere Patienten mit chronischer Niereninsuffizienz im Stadium CKD 4 und 5.

Schlussfolgerung Intravenöse Hydratation kann einen positiven Effekt haben für Hochrisikopatienten gemäß der „neuen” Definition; eine Risikoabwägung bleibt notwendig. Ein 2-stufiger Screening-Ansatz bietet Hilfestellung für die praktische Implementierung in der Klinik.

Kernaussagen: 

• Prophylaktische Prähydrierung ist ein wesentlicher Baustein, um eine kontrastmittelinduzierte Nephropathie zu vermeiden.

• Jüngere Publikationen haben zu einer Anpassung der gegenwärtigen Leitlinienempfehlungen beigetragen.

• Intravenöse Hydratation kann einen positiven Effekt haben für Hochrisikopatienten gemäß der „neuen” Definition; eine Risikoabwägung bleibt notwendig.

• Ein 2-stufiger Screening-Ansatz bietet Hilfestellung für die praktische Implementierung in der Klinik.

Key words

contrast agents - acute kidney injury - preventive measures - clinical practice guideline

Publication History

Received: 10 March 2020

Accepted: 20 August 2020

Article published online:
16 December 2020

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