Download Guidelines for the Prevention of Contrast

Saint Joseph Mercy Health System
Guidelines for the Prevention of Contrast-Induced Nephropathy (CIN)
1
Definition of CIN
Absolute increase in serum creatinine of at least 0.5 mg/dL in patients with a baseline serum creatinine less
than or equal to 2 mg/dL
Increase in serum creatinine of at least 25% from baseline
Decrease in GFR greater than 25%
Prevalence of CIN
Contrast-induced nephropathy occurs in approximately 15% of radio-contrast procedures, with less than
1% requiring dialysis
1
Characteristics of CIN
Serum creatinine typically peaks on the second or third day after exposure to the contrast medium
Usually reversible and returns to baseline within two weeks.
1,2,3
Predisposing Risk Factors for CIN (Use Contrast With Caution)
Pre-existing renal insufficiency (e.g., Scr greater than 1.5 mg/dL, GFR less than 60 ml/min)
Diabetes mellitus
Dehydration (reduced effective arterial volume)
Hypotension
Nephrotic syndrome
Chronic heart failure (class III or IV)
Multiple myeloma
Drugs adversely affecting renal function (e.g., NSAIDs, ACE inhibitors, aminoglycosides, cyclosporine, or
chemotherapy)
Repeat exposure to contrast agents within a 48-hour period
High dose of contrast media, intra-arterial injection of contrast, or use of high osmolar contrast media
Intra-aortic counter-pulsation
Chronic liver disease
Older age (e.g., greater than 75 years old)
3
Monitoring Parameters
Serum creatinine evaluation recommended at 48 hours for patients with a GFR or CrCl less than 60 ml/min
*Typically serum creatinine starts rising 24-48 hours after exposure and peaks at 4-7 days. Creatinine
3
values tend to return to normal within 7-14 days.
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1,5,6,7,8,9,10
Recommendations to Prevent Contrast Induced Nephropathy
GFR or CrCl greater than 60 ml/min
Hold metformin until 48 hours post-procedure
GFR or CrCl 30-60 ml/min
Hydrate the night before the procedure
o At least 4-6 glasses of water up to 4 hours pre-procedure
Hold ACE inhibitors, angiotensin receptor blockers, diuretics, NSAIDs, and COX-2 inhibitors 24
hours before the procedure
o Aforementioned medications may be resumed 24 hours after the procedure
Hold metformin until 48 hours post-procedure or until creatinine is stable
Minimize contrast use (biplane imaging in the Cath Lab, if possible)
Consider using a nonionic, isosmolar contrast
Check serum creatinine at 48 hours post-procedure
GFR or CrCl less than 30 ml/min
IV hydration recommendations (50 mEq NaHCO3 in 1 Liter NaCl 0.45%)
o For inpatient cases: 1
- Pre-procedure: 1 ml/kg/hr x 12 hours2
- Post-procedure: 1 ml/kg/hr x 12 hours2
o For same-day cases: 1
- Pre-procedure: 3 ml/kg/hr x 1 hour (maximum rate = 330 ml/hr)
- Post-procedure: 1 ml/kg/hr x 6 hours
Consider acetylcysteine (Mucomyst®) 600 mg orally every 12 hours the day before and the day of
the procedure (total of 4 doses)3
Hold ACE inhibitors, angiotensin receptor blockers, diuretics, NSAIDs, and COX-2 inhibitors 24
hours before the procedure
o Aforementioned medications may be resumed 24 hours after the procedure
Hold metformin until 48 hours post-procedure or until creatinine is stable
Minimize contrast use (biplane imaging in the Cath Lab, if possible)
Use a nonionic, isosmolar contrast
Check serum creatinine at 48 hours post-procedure
1
Monitor for signs of heart failure in patients who are at risk for development of fluid overload
IV hydration for 6-12 hours pre-procedure and/or for 6-12 hours post-procedure can be considered.
3
Emergent procedure: one dose before and three doses post-procedure is acceptable
2
Caution:
Patients who are at risk for development of fluid overload should be given less IV hydration and observed
carefully for development of heart failure
Avoid repeat contrast exposure. Delay angiography until serum creatinine level has peaked and stabilized.
o In patients with diabetes and renal disease, delay angiography greater than 72 hours
o In patients with no risk factors, delay angiography greater than 48 hours
Acetylcysteine (Mucomyst®) Prescriptions:
Acetylcysteine (Mucomyst®) is not commonly stocked in community pharmacies. The following
pharmacies are aware of our guidelines and maintain an adequate supply of acetylcysteine.
o
o
o
o
SJMHS Ann Arbor: Towers Pharmacy
SJMHS Ann Arbor: Reichert Pharmacy
SJMHS Livingston Pharmacy
SJMHS Saline Pharmacy
734-712-3333
734-712-2222
517-545-6666
734-429-1666
Note: If a patient wishes to obtain their prescription from their local pharmacy, it is recommended that
either the physician office or the patient call three days prior to needing the prescription to ensure that the
pharmacy can supply the medication.
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References:
1. Ferrone, Marcus. Pharmacotherapeutic Options to Prevent Radiocontrast-induced Acute Renal Failure.
Formulary. 2004;39:163-185.
2. Brenner, Z. et al. Acetylcysteine and Nephropathy: An Option for High-Risk Patients Receiving
Intravascular Contrast Agents. American Journal of Nursing. 2003;103(3):64AA-64EE.
3. Narang, R. et al. Contrast Induced Nephropathy. Indian Heart Journal. 2004;56(1):1-12.
4. Liistro, F. et al. The Clinical Burden of Contrast Media-Induced Nephropathy. Italian Heart Journal.
2004;4:668-676.
5. Nephrology Angiogram Hydration Protocol and Creatinine/GFR Guidelines.
6. Shyu, K. et al. Acetylcysteine Protects Against Acute Renal Damage In Patients with Abnormal Renal
Function Undergoing a Coronary Procedure. American Journal of Cardiology. 2002;40:1383-1388.
7. Kay, C. et al. Acetylcysteine for Prevention of Acute Deterioration of Renal Function Following Elective
Coronary Angiography and Intervention: A Randomized Controlled Trial. Journal of the American
Medical Association. 2003;289:553-558
8. Bigouri, C. et al. Acetylcysteine and Contrast Agent-Associated Nephrotoxicity. Journal of the American
College of Cardiology. 2002;40:298-303.
9. Allaqaband, S. et al. Prospective Randomized Study of Acetylcysteine, Fenoldopam, and Saline for
Prevention of Radio-Contrast-Induced Nephropathy. Catheterization and Cardiovascular Interventions.
10. Merten GJ. Et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized
controlled trial. JAMA. 291(19):2328-34, 2004 May 19.
CN 12/9/05