Auswirkungen einer intravasalen Röntgenkontrastmittelgabe auf die Nierenfunktion - Risiken und Prävention

Zusammenfassung.

Das durch Röntgenkontrastmittelgabe initiierte Nierenversagen, die sogenannte Kontrastmittelnephropathie (KMN), stellt - insbesondere bei Patienten mit eingeschränkter Nierenfunktion - nach wie vor ein erhebliches medizinisches Problem dar, dessen Auftreten mit einer deutlich erhöhten Krankenhausmortalität verbunden ist. Die Genese der KMN ist nach wie vor nicht eindeutig geklärt. Neben hämodynamischen Veränderungen durch die Kontrastmittel spielen tubulotoxische Schäden eine Rolle. Die vorliegende Übersicht beschreibt die zur Zeit bekannten pathophysiologischen Vorgänge bei der KMN und die möglichen Präventivmaßnahmen mit besonderem Augenmerk auf die klinisch relevanten Themen der Hydratation, der prophylaktischen Gabe vasoaktiver Substanzen, den Einsatz alternativer Kontrastmittel und die Entfernung von Röntgenkontrastmitteln (KM) mittels Hämodialyse.

Contrast media in renal insufficiency - risk and prevention.

The use of iodinated contrast media (CM) continues to be a common cause of hospital-acquired acute renal failure (ARF) and its development increases the in-hospital mortality significantly. Alterations in renal hemodynamics and direct tubular toxicity by contrast media are the primary factors believed to be responsible for contrast media-associated nephrotoxicity. We review recent insights into the pathogenesis of this complication and summarize prophylactic strategies focussing on hydration, vasoactive pharmacological agents, alternative contrast media and “prophylactic hemodialysis”.

Kontrastmittelnephropathie - Hämodialyse - Atrialer Natriuretischer Faktor - Hydratation - Theophyllin - Dopamin

Contrast media nephropathy - Theophylline - Hemodialysis - Natriuretic peptide - Hydration - Dopamine

Literatur

• 1 Abizaid A S, Clark C E, Mintz C S, Dosa S, Popma J J, Pichard A D, Satler L F, Harvey M, Kent K M, Leon M B. Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency.  Am J Cardiol. 1999;  83 (A5) 260-263
• 2 Arakawa K, Suzuki H, Naitoh M, Matsumoto A, Hayashi K, Matsuda H, Ichihara A, Kubota E, Saruta T. Role of adenosine in the renal responses to contrast medium.  Kidney Int. 1996;  49 1199-1206
• 3 Arend L J, Bakris G L, Burnett J CJ, Megerian C, Spielman W S. Role for intrarenal adenosine in the renal hemodynamic response to contrast media.  J Lab clin Med. 1987;  110 406-411
• 4 Arsenault T M, King B F, Marsh JW J, Goodman J A, Weaver A L, Wood C P, Ehman R L. Systemic gadolinium toxicity in patients with renal insufficiency and renal failure: retrospective analysis of an initial experience.  Mayo Clin Proc. 1996;  71 1150-1154
• 5 Bakris G L, Burnett J CJ. A role for calcium in radiocontrast-induced reductions in renal hemodynamics.  Kidney Int. 1985;  27 465-468
• 6 Barrett B J, Carlisle E J. Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media.  Radiology. 1993;  188 171-178
• 7 Barrett B J, Parfrey P S, McDonald J R, Hefferton D M, Reddy E R, McManamon P J. Nonionic low-osmolality versus ionic high-osmolality contrast material for intravenous use in patients perceived to be at high risk: randomized trial.  Radiology. 1992;  183 105-110
• 8 Barrett B J, Parfrey P S, Vavasour H M, McDonald J, Kent G, Hefferton D, O'Dea F, 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
• 9 Berns A S. Nephrotoxicity of contrast media.  Kidney Int. 1989;  36 730-740
• 10 Bettmann M A. The evaluation of contrast-related renal failure.  Am J Roentgenol. 1991;  157 66-68
• 11 Bohle A, Christensen J, Kokot F, Osswald H, Schubert B, Kendziorra H, Pressler H, Marcovic Lipkovski J. Acute renal failure in man: new aspects concerning pathogenesis. A morphometric study.  Am J Nephrol. 1990;  10 374-388
• 12 Brezis M, Heyman S N, Dinour D, Epstein F H, Rosen S. Role of nitric oxide in renal medullary oxygenation. Studies in isolated and intact rat kidneys.  J Clin Invest. 1991;  88 390-395
• 13 Brooks D P, DePalma P D. Blockade of radiocontrast-induced nephrotoxicity by the endothelin receptor antagonist, SB 209670.  Nephron. 1996;  72 629-636
• 14 Byrd L, Sherman R L. Radiocontrast-induced acute renal failure: a clinical and pathological review.  Medicine. 1979;  58 270-279
• 15 Caldicott W J, Hollenberg N K, Abrams H L. Characteristics of response of renal vascular bed to contrast media. Evidence for vasoconstriction induced by renin-angiotensin system.  Invest Radiol. 1970;  5 539-547
• 16 Cantley L G, Spokes K, Clark B, McMahon E G, Carter J, Epstein F H. Role of endothelin and prostaglandins in radiocontrast-induced renal artery constriction.  Kidney Int. 1993;  44 1217-1223
• 17 Carraro M, Mancini W, Artero M, Stacul F, Grotto M, Cova M, Faccini L. Dose effect of nitrendipine on urinary enzymes and microproteins following non-ionic radiocontrast administration.  Nephrol Dial Transplant. 1996;  11 444-448
• 18 Carraro M, Stacul F, Collari P, Toson D, Zucconi F, Torre R, Faccini L, Dalla Palma L. Contrast media nephrotoxicity: urinary protein and enzyme pattern in patients with or without saline infusion during digital subtracting angiography.  Contrib Nephrol. 1993;  101 251-254
• 19 Chertow G M, Lazarus J M, Sayegh M H, Allgren R L. Is the administration of dopamine associated with adverse outcomes in severe acute renal failure?.  J Am Soc Nephrol. 1995;  6 460
• 20 Davidson C J, Hlatky M, Morris K G, Pieper K, Skelton T N, Schwab S J, Bashore T M. Cardiovascular and renal toxicity of a nonionic radiographic contrast agent after cardiac catheterization. A prospective trial.  Ann Intern Med. 1989;  110 119-124
• 21 Deray G, Jacobs C. Radiocontrast nephrotoxicity. A review.  Invest Radiol. 1995;  30 221-225
• 22 Donadio C, Tramonti G, Giordani R, Lucchetti A, Calderazzi A, Sbragia P, Bianchi C. Glomerular and tubular effects of ionic and nonionic contrast media (diatrizoate and iopamidol).  Contrib Nephrol. 1988;  68 212-219
• 23 Donaldson I ML. Comparison of the renal clearance of insulin and radioactive diatrizoate as measures for glomerular filtration rate in man.  Clin Sci. 1968;  35 513-519
• 24 Erley C M, Duda S H, Rehfuss D, Scholtes B, Bock J, Müller C, Osswald H. Prevention of Radiocontrast-Media-Induced Nephropathy in Patients with Preexisting Renal Insufficiency by Hydration in Combination with the Adenosine Antagonist Theophylline.  Nephrol Dial Transplant. 1999;  14 1146-1149
• 25 Erley C M, Duda S H, Schlepckow S, Koehler J, Huppert P E, Strohmaier W L, Bohle A, Risler T, Osswald H. Adenosine antagonist theophylline prevents the reduction of glomerular filtration rate after contrast media application.  Kidney Int. 1994;  45 1425-1431
• 26 Erley C M, Heyne N, Burgert K, Langanke J, Risler T, Osswald H. Prevention of radiocontrast induced nephropathy by adenosine antagonists in rats with chronic nitric oxide deficiency.  J Am Soc Nephrol. 1997;  8 1125-1132
• 27 Erley C M, Heyne N, Rossmeier S, Vogel T, Risler T, Osswald H. Adenosine and extracellular volume in radiocontrast media-induced nephropathy.  Kidney Int. 1998;  54 (67) S192-S194
• 28 Fenves A Z, Allgren R L. Radiocontrast dye-induced acute tubular necrosis (ATN): atrial natriuretic peptide (ANP) versus placebo.  J Am Soc Nephrol. 1995;  6 431
• 29 Golman K, Cederholm C. Contrast medium-induced acute renal failure. Can it be prevented?.  Invest Radiol. 1990;  25 (1) S127-S128
• 30 Hall K A, Wong R W, Hunter G C, Camazine B M, Rappaport W A, Smyth S H, Bull D A, McIntyre K E, Bernhard V M, Misiorowski R L. Contrast-induced nephrotoxicity: the effects of vasodilator therapy.  J Surg Res. 1992;  53 317-320
• 31 Hammer F D, Goffette P P, Malaise J, Mathurin P. Gadolinium dimeglumine: an alternative contrast agent for digital subtraction angiography.  Eur Radiol. 1999;  9 128-136
• 32 Hawkins I F, Wilcox C S, Kerns S R, Sabatelli F W. CO₂ digital angiography: a safer contrast agent for renal vascular imaging?.  Am J Kidney Dis. 1994;  24 685-694
• 33 Heyman S N, Brezis M, Epstein F H, Spokes K, Rosen S. Effect of glycine and hypertrophy on renal outer medullary hypoxic injury in ischemia reflow and contrast nephropathy.  Am J Kidney Dis. 1992;  19 578-586
• 34 Heyman S N, Brezis M, Epstein F H, Spokes K, Silva P, Rosen S. Early renal medullary hypoxic injury from radiocontrast and indomethacin.  Kidney Int. 1991;  40 632-642
• 35 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
• 36 Heyman S N, Clark B A, Kaiser N, Spokes K, Rosen S, Brezis M, Epstein F H. Radiocontrast agents induce endothelin relase in vivo and in vitro.  J AM Soc Nephrol. 1992;  3 58-65
• 37 Hunter J V, Kind P RN. Nonionic iodinated contrast media: potential renal damage assessed with enzymuria.  Radiology. 1992;  183 101-104
• 38 Jakobsen J A. Renal effects of iodixanol in healthy volunteers and patients with severe renal failure.  Acta Radiol Suppl. 1995;  399 191-195
• 39 Jakobsen J A. Renal experience with Visipaque.  Eur Radiol. 1996;  6 (2) S16-S19
• 40 Kapoor A, Sinha N, Sharma R K, Shrivastava S, Radhakrishnan S, Goel P K, Bajaj R. Use of dopamine in prevention of contrast induced acute renal failure - a randomised study.  Int J Cardiol. 1996;  53 233-236
• 41 Katholi R E, Taylor G J, McCann W P, Woods W T, Womack K A, McCoy C D, Katholi C R, Moses H W, Mishkel G J, Lucore C L, Holloway R M, Miller B D, Woodruff R C, Dove J T, Mikell F L, Schneider J A. Nephrotoxicity from contrast media: attenuation with theophylline.  Radiology. 1995;  195 17-22
• 42 Katholi R E, Taylor G J, Woods W T, Womack K A, Katholi C R, McCann W P, Moses H W, Dove J T, Mikell F L, Woodruff R C. Nephrotoxicity of nonionic low-osmolality versus ionic high-osmolality contrast media: a prospective double-blind randomized comparison in human beings.  Radiology. 1993;  186 183-187
• 43 Kaufman J A, Geller S C, Waltman A C. Renal insufficiency: gadopentetate dimeglumine as a radiographic contrast agent during peripheral vascular interventional procedures.  Radiology. 1996;  198 579-581
• 44 Kummer K D, Kloess W, Marienhoff N, Schutz R M, Zwaan M, Weiss H D. Angiography during interventional procedures with carbon dioxide (CO₂) (carbo-angiography) in patients with increased contrast media risk.  Zentralbl Chir. 1997;  122 725-729
• 45 Kurnik B R, Weisberg L S, Cuttler I M, Kurnik P B. Effects of atrial natriuretic peptide versus mannitol on renal blood flow during radiocontrast infusion in chronic renal failure.  J Lab Clin Med. 1990;  116 27-36
• 46 Larson T S, Hudson K, Mertz J I, Romero J C, Knox F G. Renal vasoconstrictive response to contrast medium. The role of sodium balance and the renin-angiotensin system.  J Lab Clin Med. 1983;  101 385-391
• 47 Lautin E M, Freeman N J, Schoenfeld A H, Bakal C W, Haramati N, Friedman A C, Lautin J L, Braha S, Kadish E G, Sprayregen S. Radiocontrast-associated renal dysfunction: incidence and risk factors.  Am J Roentgenol. 1991;  157 49-58
• 48 Lehnert T, Gondolf K, Schäffner T, Schollmeyer P, Keller E. Effect of hemodialysis after contrast media application in adults with renal insufficiency.  J Am Soc Nephrol. 1995;  6 469
• 49 Levy E M, Viscoli C M, Horwitz R I. The effect of acute renal failure on mortality: A cohort analysis.  J Am Med Ass. 1996;  275 1489-1494
• 50 Liss P, Nygren A, Olsson U, Ulfendahl H R, Erikson U. Effects of contrast media and mannitol on renal medullary blood flow and red cell aggregation in the rat kidney.  Kidney Int. 1996;  49 1268-1275
• 51 Margulies K B, McKinley L J, Cavero P G, Burnett J CJ. Induction and prevention of radiocontrast-induced nephropathy in dogs with heart failure.  Kidney Int. 1990;  38 1101-1108
• 52 McCarthy C S, Becker J A. Multiple myeloma and contrast media.  Radiology. 1992;  183 519-521
• 53 Miller D L, Chang R, Wells W T, Dowjat B A, Malinosky R M, Doppman J L. Intravascular contrast media: effect of dose on renal function.  Radiology. 1988;  167 607-611
• 54 Moore R D, Steinberg E P, Powe N R, Brinker J A, Fishman E K, Graziano S, Gopalan R. Nephrotoxicity of high-osmolality versus low-osmolality contrast media: randomized clinical trial.  Radiology. 1992;  182 649-655
• 55 Morcos S K, Thomsen H S, Webb J A. Contrast-media-induced nephrotoxicity: a consensus report. Contrast Media Safety Committee, European Society of Urogenital Radiology (ESUR).  Eur Radiol. 1999;  9 1602-1613
• 56 Moreau J F, Droz D, Sabto J, Jungers P, Kleinknecht D, Hinglais N, Michel J R. Osmotic nephrosis induced by water soluble triiodinated contrast media in man.  Radiology. 1975;  115 329-336
• 57 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
• 58 Oldroyd S D, Haylor J L, Morcos S K. Bosentan, an orally active endothelin antagonist: effect on the renal response to contrast media.  Radiology. 1995;  196 661-665
• 59 Osswald H, Gleiter C. Renal effects of adenosine: possible consequences for kidney transplantation.  Zentralbl Chir. 1993;  118 90-102
• 60 Parfrey P S, Griffiths S M, Barrett B J, Paul M D, Genge M, Withers J, Farid N, McManamon P J. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study.  N Engl J Med. 1989;  320 143-149
• 61 Pendergrass E P, Chamberlin G W, Godfrey E W, Burdick E D. A survey of deaths and unfavorable sequelae following administration of contrast media.  Am J Radiol. 1942;  48 741-762
• 62 Porter G A. Experimental contrast-associated nephropathy and its clinical implications.  Am J Cardiol. 1990;  66 18F-22F
• 63 Porter G A, Kloster F E, Bristow J D. Sequential effect of angiographic contrast agent on canine renal and systemic hemodynamics.  Am Heart J. 1971;  81 80-92
• 64 Rahman S N, Kim G E, Mathew A S, Goldberg C A, Allgren R, Schrier R W, Conger J D. Effects of atrial natriuretic peptide in clinical acute renal failure.  Kidney Int. 1994;  45 1731-1738
• 65 Rosovsky M A, Rusinek H, Berenstein A, Basak S, Setton A, Nelson K. High-dose administration on nonionic contrast media: a retrospective review.  Radiology. 1996;  200 119-122
• 66 Rudnick M R, Berns J S, Cohen R M, Goldfarb S. Contrast media-associated nephrotoxicity.  Curr Opin Nephrol Hypertens. 1996;  5 127-133
• 67 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 Fossen D B. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial.  Kidney Int. 1995;  47 254-261
• 68 Rudnicki M, Berns J S, Cohen R M, Goldfarb S. Contrast media-associated nephrotoxicity.  Curr Opin Nephrol Hypertens. 1996;  5 127-133
• 69 Russo D, Testa A, Volpe L D, Sansone G. Randomised prospective study on renal effects of two different contrast media in humans: protective role of a calcium channel blocker.  Nephron. 1990;  55 254-257
• 70 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 controlled trial of a nonionic and an ionic radiographic contrast agent.  N Engl J Med. 1989;  320 149-153
• 71 Seeger J M, Self S, Harward T R, Flynn T C, Hawkins I F. Carbon dioxide gas as an arterial contrast agent.  Ann Surg. 1993;  217 688-697
• 72 Shieh S D, Hirsch S R, Boshell B R, Pino J A, Alexander L J, Witten D M, Friedman E A. Low risk of contrast media-induced acute renal failure in nonazotemic type 2 diabetes mellitus.  Kidney Int. 1982;  21 739-743
• 73 Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents.  N Engl J Med. 1994;  331 1416-1420
• 74 Spangberg Viklund B, Berglund J, Nikonoff T, Nyberg P, Skau T, Larsson R. Does prophylactic treatment with felodipine, a calcium antagonist, prevent low-osmolar contrast-induced renal dysfunction in hydrated diabetic and nondiabetic patients with normal or moderately reduced renal function?.  Scand J Urol Nephrol. 1996;  30 63-68
• 75 Spinosa D J, Matsumoto A H, Angle J F, Hagspiel K D, McGraw J K, Ayers C. Renal insufficiency: usefulness of gadodiamide-enhanced renal angiography to supplement CO₂-enhanced renal angiography for diagnosis and percutaneous treatment.  Radiology. 1999;  210 663-672
• 76 Swan S K, Lambrecht L J, Townsend R, Davies B E, McCloud S, Parker J R, Bensel K, Lafrance N D. Safety and pharmacokinetic profile of gadobenate dimeglumine in subjects with renal impairment.  Invest Radiol. 1999;  34 443-448
• 77 Taylor A J, Hotchkiss D, Morse R W, McCabe J. PREPARED: Preparation for Angiography in Renal Dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction.  Chest. 1998;  114 1570-1574
• 78 VanZee B E, Hoy W E, Talley T E, Jaenike J R. Renal injury associated with intravenous pyelography in nondiabetic and diabetic patients.  Ann Intern Med. 1978;  89 51-54
• 79 Wambach G, Winkert T. Nierenfunktionsstörungen nach Röntgenkontrastmittelgabe: Prophylaxe durch das atriale natriuretische Peptid?.  Nieren- und Hochdruckkrankheiten. 1990;  19 312-317
• 80 Wang A, Holcslaw T, Bashore T M, Freed M I, Miller D, Rudnick M R, Szerlip H, Thames M D, Davidson C J, Shusterman N, Schwab S J. Exacerbation of radiocontrast nephrotoxicity by endothelin receptor antagonism.  Kidney Int. 2000;  57 1675-1680
• 81 Weinstein J M, Heyman S, Brezis M. Potential deleterious effect of furosemide in radiocontrast nephropathy.  Nephron. 1992;  62 413-415
• 82 Weisberg L S, Kurnik P B, Kurnik B R. Dopamine and renal blood flow in radiocontrast-induced nephropathy in humans.  Ren Fail. 1993;  15 61-68
• 83 Weisberg L S, Kurnik P B, Kurnik B R. Risk of radiocontrast nephropathy in patients with and without diabetes mellitus.  Kidney Int. 1994;  45 259-265
• 84 Weissleder R. Can gadolinium be safely given in renal failure?.  Am J Roentgenol. 1996;  167 278-279
• 85 Workman R J, Shaff M I, Jackson R V, Diggs J, Frazer M G, Briscoe C. Relationship of renal hemodynamic and functional changes following intravascular contrast to the renin-angiotensin system and renal prostacyclin in the dog.  Invest Radiol. 1983;  18 160-166
• 86 Younathan C M, Kaude J V, Cook M D, Shaw G S, Peterson J C. Dialysis is not indicated immediately after administration of nonionic contrast agents in patients with end-stage renal disease treated by maintenance dialysis.  Am J Roentgenol. 1994;  163 969-971
• 87 Zwaan M, Kloess W, Kagel C, Kummer K D, Matthies Z S, Schutz R M, Weiss H D, Zwaan W. Carbon dioxide as an alternative contrast medium in peripheral angiography.  Fortschr Röntgenstr. 1996;  164 445-448