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Dtsch Med Wochenschr 2005; 130(42): 2391-2396
DOI: 10.1055/s-2005-918582
Übersichten
Nephrologie / Radiologie
© Georg Thieme Verlag Stuttgart · New York

Kontrastmittel-induzierte Nephropathie

Klinik und PräventionContrast-media-induced nephrotoxicityClinic and preventionE. Adolph1 , T. Chatterjee1 , H. Ince1 , H. Eckard1 , T. Rehders1 , S. Kische1 , S. Drawert1 , M. Petzsch1 , C. A. Nienaber1
  • 1Universität Rostock, Klinik und Poliklinik für Innere Medizin, Abteilung für Kardiologie
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Publikationsverlauf

eingereicht: 1.2.2005

akzeptiert: 22.7.2005

Publikationsdatum:
19. Oktober 2005 (online)

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Zusammenfassung

Weltweit wird ein Zuwachs an diagnostischen und therapeutisch-angiologischen oder kardiologischen Katheteruntersuchungen unter Verwendung von Röntgenkontrastmitteln beobachtet, die erwartungsgemäß von einer Zunahme an Fällen von Röntgenkontrastmittel-induzierter Nephropathie begleitet wird. In diesem Artikel wird eine Übersicht über Pathogenese, Klinik und prophylaktischen Maßnahmen zur Prävention der Röntgenkontrastmittel-induzierten Nephropathie gegeben. Die wichtigsten prophylaktischen Maßnahmen bestehen in der Identifizierung von Risikopatienten, in einer strengen Indikationsstellung für den Einsatz von Kontrastmitteluntersuchungen und Prüfung alternativer diagnostischer Verfahren wie z. B. Angio-MRT, die Verwendung nicht-ionischer, niedrig-osmolarer oder - neuerdings - iso-osmolarer Kontrastmittel, und eine großzügige Hydrierung mit 0,9 %iger NaCl-Lösung vor/während der Intervention mit additiver Gabe von Acetylcystein.

Summary

The use of diagnostic and therapeutic catheterization is increasing and so is the exposure to radiocontrast media. As a consequence, an increasing incidence of contrast media-associated nephropathy is being observed. This article reviews pathogenesis, clinical symptoms and preventive measures of contrast media-associated nephropathy. Most important prophylactic measures is identification of high-risk patients, careful selection to be exposed to contrast media, application of non-ionic low osmolality or - most recently - iso-osmolality contrast media, adjusted hydration with isotonic saline before/during catheter interventions, and potentially the administration of acetylcysteine.

Literatur

  • 1 Agmon Y, Peleg H, Greenfield Z. Nitric oxide and prostanoids protect the renal outer medulla from radiocontrast toxicity in the rat.  J Clin Invest. 1994;  94 1069-1073
    Google Scholar
  • 2 Andrale L, Campos S B, Seguro A C. Hypercholesterolemia aggravates radiocontrast nephrotoxicity: protective role of L-arginine.  Kidney Int. 1998;  15 43-49
    Google Scholar
  • 3 Aspelin P, Aubry P, Fransson S -G, Strasser R, Willenbrock R, Berg K J. Nephrotoxic effetcs in high-risk patients undergoing angiography.  N Engl J Med. 2003;  348 491-499
    Google Scholar
  • 4 Bach R, Jung F. Optimales Röntgenkontrastmittel für die ambulante Koronarangio-graphie aus mikrozirkulatorischer Sicht.  Herz. 1998;  23 35-41
    Google Scholar
  • 5 Bakris G L, Lass N A, Glock D. Renal hemodynamics and radiocontrast medium-induced renal dysfunction: A role for dopamin-1 receptors.  Kidney Int. 1999;  56 206-210
    Google Scholar
  • 6 Baliga R, Ueda N, Walker P D, Shah S V. Oxidant mechanisms in toxic acute renal failure.  Am J Kidney Dis. 1997;  29 465-477
    Google Scholar
  • 7 Barrett B J. Contrast nephrotoxicity.  J Am Soc Nephrol. 1994;  5 125
    Google Scholar
  • 8 Barrett B J, Carlisle E J. Nephrotoxocity of high- and low-osmolality contrast media: a meta-analysis.  Radiology. 1993;  188 171-178
    Google Scholar
  • 9 Barrett B J, Parfrey P S, Vasosour H M, O’Dea F, Kent G, Stone E, Reddy R, McManamon P J. Contrast nephropathy in patients with impaired renal function: high versus low osmolar media.  Kidney Int. 1992;  41 1274-1279
    Google Scholar
  • 10 Berns A S. Nephrotoxicity of contrast media.  Kidney Int. 1989;  36 730-740
    Google Scholar
  • 11 Briguori C, Manganelli F, Scarpato P, Elia P P, Briviezzo G, Lepore S, Librera M, Villari B, Colombo A, Ricciardelli B. Acetylcysteine and contrast agent-associated nephrotoxicity.  J Am Coll Cardiol. 2002;  40 298-303
    Google Scholar
  • 12 Cantley L G, Spokes K, Clark B, McMahon E G, Carter J, Epstein F H. Role of endo-thelin and prostaglandins in radioconstrast-induced renal artery constriction.  Kidney Int. 1993;  44 1217-1223
    Google Scholar
  • 13 Chamsuddin A A, Kowalik K J, Bjarnason H. Using a dopamine type 1A receptor agonist in high-risk patients to ameliorate contrast-associated nephropathy.  Am J Roentgenol. 2002;  179 591-595
    Google Scholar
  • 14 Chu V L, Cheng J W. Fenoldopam in the prevention of contrast media-induced acute renal failure.  Ann Pharmacother. 2001;  35 1278-1282
    Google Scholar
  • 15 Cigarroa R G, Lange R A, Williams R H, Hillis L D. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease.  Am J Med. 1989;  86 649-652
    Google Scholar
  • 16 Conlon P J, Schwab S J. Time to abandon nonionic contrast?.  J Am Soc Nephrol. 1994;  5 123-125
    Google Scholar
  • 17 Diaz-Sandoval L J, Kosowsky B D, Losordo D W. Acetylcysteine to prevent angiography related renal tissue injury (The APART trial).  Am J Cardiol. 2002;  89 356-360
    Google Scholar
  • 18 Duan S B, Liu F Y, Luo J A, Wu H W, Liu R H, Peng Y H, Yang X L. Nephrotoxicity of high- and low-osmolar contrast media. The protective role of amlodipine in a rat mo-del.  Acta Radiol. 2000;  41 503-507
    Google Scholar
  • 19 Erley C M, Duda S H, Schlepckow S, Koehler C M, Huppert P E, Strohmaier W L, Bohle A, Risler T, Osswald H. Adenosine antagonist theophylline prevents the re-duction of glomerular filtration rate after contrast media application.  Kidney Int. 1994;  45 1425-1431
    Google Scholar
  • 20 Forbes J M, Hewitson T D, Becker G J, Jones C L. Simultaneous blockade of endothelin A and B receptors in ischemic acute renal failure is detrimental to long-term kidney function.  Kidney Int. 2001;  59 1333-1341
    Google Scholar
  • 21 Harris K G, Smith T P, cragg A H, Lemke J H. Nephrotoxicity from contrast material in renal insufficiency: Ionic versus nonionic agents.  Radiology. 1991;  179 849-533
    Google Scholar
  • 22 Haylor J L, Morcos S K. Endothelin antagonism and contrast nephropathy.  Kidney Int. 2000;  58 2239
    Google Scholar
  • 23 Hentschel M, Gildein P, Brandis M, Zimmerhackl L B. Endothelin (ET-1) is involved in the contrast media induced nephrotoxicity in children with congenital heart disease.  Clin Nephrol. 1995;  43 12-15
    Google Scholar
  • 24 Hess B. Nephrologie im Alltag.  Primary Care Medicine. 2003;  3 1051-1054
    Google Scholar
  • 25 Heyman S N, Brezis M, Epstein F H, Spokes K, Silva P, Rosen S. Early renal medul-lary hypoxic injury from radiocontrast and indomethacin.  Kidney Int. 1991;  40 632-642
    Google Scholar
  • 26 Heyman S N, Brezis M, Greenfeld Z, Rosen S. Protective role of furosemide and saline in radiocontrast-induced acute renal failure in the rat.  Am J Kidney Dis. 1989;  14 377-385
    Google Scholar
  • 27 Hunter D. Fenoldopam: A dopamine type-1 receptor agonist in the prevention of re-nal injury associated with the administration of intravenous contrast.  J Vasc Interv Radiol. 2000;  11 396-398
    Google Scholar
  • 28 Ide J M, Lancelot E, Pines E, Corot C. Prophylaxis of iodinated contrast media-induced nephropathy: a pharmacological point of view.  Invest Radiol. 2004;  39 155-170
    Google Scholar
  • 29 Kay J, Chow W H, Chan T M, Lo A K, Kwok O H, Yip A, Fan K, Lee C H, Lam W F. Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention.  JAMA. 2003;  289 553-608
    Google Scholar
  • 30 Koch J A, Plum J, Grabesee B, Modder U. Prostaglandin E1: a new agent for pre-vention to renal dysfunction in high risk patients caused by radiocontrast media? PGE1 Study Group.  Nephrol Dial Transplant. 2000;  15 43-49
    Google Scholar
  • 31 Kolonko A, Wiecek A, Kokot F. The nonselective adenosine antagonist theophylline does prevent renal dysfunction induced by radiographic contrast agents.  J Nephrol. 1998;  11 151-156
    Google Scholar
  • 32 Kramer B K, Kammerl M, Schweda F, Schreiber M. A primer in radiocontrast-induced nephropathy.  Nephrol Dial Trasnplnat. 1999;  14 2830-2835
    Google Scholar
  • 33 Kshirsagar A V, Poole C, Mottl A, Shoham D, Franceschini N, Tudor G, Agrawal M, Denu-Ciocca C, Ohman E M, Finn W E. N-acetylcysteine for the prevention of radiocontrats induced nephropathy: a meta-analysis of prospective controlled trials.  J Am Soc Nephrol. 2004;  15 761-769
    Google Scholar
  • 34 Kurnik B R, Allgren R L, Genter F C, Solomon R J, Bates E R, Weisberg L S. Pro-spective study of atrial natriuretic peptide for the prevention of radiocontrast- induced nephropathy.  Am J Kidney Dis. 1998;  31 674-680
    Google Scholar
  • 35 Lehnert T, Keller E, Gondolf K, Schaffner T, Pavenstadt H, Schollmeyer P. Effect of haemodialysis after contrast medium administration in patients with renal insufficiency.  Nephrol Dial Transplant. 1998;  13 358-362
    Google Scholar
  • 36 Liss P, Nygren A, Erikson U, Ulfendahl H R. Injection of low and iso-osmolar contrast medium decreases oxygen tension in the renal medulla.  Kidney Int. 1998;  53 698-702
    Google Scholar
  • 37 Liss P, Nygren A, Hansell P. Hypoperfusion in the renal outer medulla after injec-tion of contrast media in rats.  Acta Radiol. 1999;  40 521-527
    Google Scholar
  • 38 Liss P, Nygren A, Olsson U, Ulfendahl H R, Erikson U. Effects of contrast media and mannitol on the renal medullary blood flow and red cell aggregations in the rat kidney.  Kidney Int. 1996;  49 1268-1275
    Google Scholar
  • 39 Manske C L, Sprafka J M, Strong J H, Wang Y. Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography.  Am J Med. 1990;  89 615-620
    Google Scholar
  • 40 Mehran R, Aymong E D, Nikolsky E. et al . A simple risk score for prediction of contrast-induced nephorpathy after percutaneous coronary intervention: development and initial validation.  J Am Coll Cardiol. 2004;  44 1393-1399
    Google Scholar
  • 41 Merten G J, Burgess W P, Gray L V, Hollemann J H, Roush T S, Kowalehuk G J, Bersin R M, Moore A V, Simonton C A, Rittase R A, Norton H J, Kennedy T P. Prevention of contrast-induced nephropathy with sodium bicarbonat.  JAMA. 2004;  291 2328-2334
    Google Scholar
  • 42 Moore R D, Steinberg E P, Rowe N R. Nephrotoxicity of high-osmolality versus low-osmolality contrast media: Randomized clinical trial.  Radiology. 1992;  182 649-652
    Google Scholar
  • 43 Morcos S K, Thomsen H S, Webb J A. Contrast-media-induced nephrotoxicity: a consensus report. Contrast Media Safty Commitee, European Society of Urogenital Radiology.  Eur Radiol. 1999;  9 1602-1613
    Google Scholar
  • 44 Morcos S K, Thomsen H S. Adverse reaction to iodinated contrast media.  Eur Radiol. 2001;  11 1267-1279
    Google Scholar
  • 45 Müller C, Buerkle G, Buettner H J, Petersen J, Perruchoud A P, Erikson U, Marsch S, Roskamm H. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty.  Arch Intern Med. 2002;  162 329-336
    Google Scholar
  • 46 Neumayer H H, Junge W, Kufner A, Wenning A. Prevention of radiocontrast-media-induced nephrotoxicity by the calcium channel blocker nitrendipine: a prospective randomised clinical trial.  Nephrol Dial Transplant. 1989;  4 1030-1036
    Google Scholar
  • 47 Newaz M A, Oyekan A O. Vascular responses to endothelin-I, angiotensin-II, and u46619 in glycerol induced acute renal failure.  J Cardiovasc Pharmacol. 2001;  38 569-577
    Google Scholar
  • 48 O’Meare J J, Dehmer G J. Care of patients and mangement of complications after percutaneous coronary artery interventions.  Ann Int Med. 1997;  127 458-471
    Google Scholar
  • 49 Oldemeyer J B, Cichowski E K, Wurdeman R L, Packard K, Biddle W, Mooss A. Prophylactic acetylcysteine is not effective in preventing contrast-induced nephro-pathy following coronary angiography [abstract].  J Am Coll Cardiol. 2003;  41 328A
    Google Scholar
  • 50 Pannu N, Manns B, Lee H, Tonell M. Systematic review of the impact of N-acetylcysteine on contrast nephropathy.  Kidney Int. 2004;  65 1366-1374
    Google Scholar
  • 51 Pflueger A, Larson T S, Nath K A, King B F, Gross J M, Knox F G. Role of adenosine in contrast media-induced acute renal failure in diabetes mellitus.  Mayo Clin Proc. 2000;  75 1275-1283
    Google Scholar
  • 52 Rudnick M R, Berns J S, Cohen R M, Goldfarb S. Nephrotoxic risks of renal angiography: Contrast-media associated nephrotoxicity and atheroembolism. A critical review.  Am J Kidney Dis. 1994;  24 713-716
    Google Scholar
  • 53 Rudnick M R, Goldfarb S, Wexler L, Ludbrook P A, Murphy M J, Halpern E F, Hill J A, Winniford M, Cohen M B, van Fosen D B. Nephrotoxicity of ionic and nonionic con-trast media in 1196 patients: a randomized trial.  Kidney Int. 1995;  47 254-261
    Google Scholar
  • 54 Safirstein R. Endothelin: the yin and yang of ischemic acute renal failure.  Kidney Int. 2001;  59 1590-1591
    Google Scholar
  • 55 Schwab S J, Hlatky M A, Pieper K S, Davidson C J, Morris K G, Skelton T N, Bashore T M. Contrast nephrotoxicity: a randomized control trial of a nonionic and an ionic radiographic contrast agent.  N Engl J Med. 1989;  320 149-153
    Google Scholar
  • 56 Shyu K G, Cheng J J, Kuan P. Acetylcysteine protects against acute renal damage in patients with abnormal renal function undergoing a coronary procedures.  J Am Coll Cardiol. 2002;  40 1383-1387
    Google Scholar
  • 57 Solomon R, Werner C, Mann D, D’Elia J, Silva P. Effects of saline, mannitol, and furosemide to prevent acute decrease in renal function induced by radiocontrast agents.  N Engl J Med. 1994;  331 1416-1420
    Google Scholar
  • 58 Taylor A J, Hotschkiss D, Morse R W, McCabe J. PREPARED: Preparation for angio-graphy in renal dysfunction: a randomized trial of inpatients vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction.  Chest. 1998;  114 1570-1574
    Google Scholar
  • 59 Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast agent-induced reductions in renal function by acetyl-cysteine.  N Engl J Med. 2000;  343 180-184
    Google Scholar
  • 60 Trivedi H S, Moore H, Nasr S, Aggarwal K. A randomized prospective trial to assess the role of saline hydration on the deveolpemt of contrast nephrotoxicity.  Nephron. 2003;  93 C29
    Google Scholar
  • 61 Tumlin J, Mathur V. Prophylactic efficacy of feoldapam in radiocontrast nephropathy: A randomized, doubleblind, placebo-controlled trial.  J Vasc Interv Radiol. 2000;  11 175-178
    Google Scholar
  • 62 Visweswaran P, Massin E K, DuBose T D. Mannitol-induced acute renal failure.  J Am Soc Nephrol. 1997;  8 1028-1033
    Google Scholar
  • 63 Vogt B, Ferrari P, Schönholzer C, Marti H P, Mohaupt M, Wiederkehr M, Cereghetti C, Serra A, Huynh Do U, Uehlinger D, Frey F J. Prophylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful.  Am J Med. 2001;  111 692-698
    Google Scholar
  • 64 Wang A, Holcslaw T, Bashore T M, Freed M I, Miller D, Rudnick M R, Szerlip H, Thames M D, Davidson C J, Shustermann N, Schwab S J. Exacerbation of radio-contrast nephrootoxicity by endothelin receptor antagonism.  Kidney Int. 2000;  59 1590-1591
    Google Scholar
  • 65 Weinrauch L A, Healy R W, Leland O S. Coronary angiography and acute renal failure in diabetic azotemic nephropathy.  Ann Intern Med. 1977;  86 56-59
    Google Scholar
  • 66 Weinstein J M, Heymann S, Brezis M. Potential deleterious effect of furosemide in radiocontrast nephropathy.  Nephron. 1992;  62 413-415
    Google Scholar
  • 67 Weisberg L S, Kurnik P B, Kurnik B R. Radiocontrast-induced nephropathy in humans. Role of renla vasoconstriction.  Kidney Int. 1992;  41 1408-1413
    Google Scholar
  • 68 Yao K, Heyne N, Erley C M, Risler T, Osswald H. The selective adenosine A1 receptor antagonist KW-3902 presents radiocontrast media-induced nephropathy in rats with chronic nitric oxide defeiciency.  Eur J Pharmacol. 2001;  414 99-104
    Google Scholar
  • 69 Yoshioka T, Fogo A, Beckman J K. Reduced activity of antioxidant enzymes underlies contrast media-induced renal injury in volumen depletion.  Kidney Int. 1992;  41 1008-1011
    Google Scholar

Prof. Christoph A. Nienaber

Universität Rostock, Klinik und Poliklinik für Innere Medizin, Abteilung Kardiologie

Ernst-Heydemannstraße 6

18057 Rostock

Telefon: +49/0381/4947342

Fax: +49/0381/4947702

eMail: christoph.nienaber@med.uni-rostock.de

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