Pathogenesis, clinical features, and diagnosis of contrast-induced nephropathy
- Michael R Rudnick, MD
Michael R Rudnick, MD
- Associate Professor of Medicine
- University of Pennsylvania School of Medicine
Contrast nephropathy is a generally reversible form of acute kidney injury (AKI) that occurs soon after the administration of radiocontrast media [1-11]. Important issues that remain unresolved include its pathogenesis and relative efficacies of various prophylactic strategies.
A review of the pathogenesis, clinical characteristics, and diagnosis of iodinated radiocontrast media-induced nephropathy is presented here. Preventive strategies for reducing the risk of contrast nephrotoxicity and a discussion of acute tubular necrosis (ATN), the most common cause of AKI developing in hospitalized patients, are presented separately. (See "Prevention of contrast-induced nephropathy" and "Etiology and diagnosis of prerenal disease and acute tubular necrosis in acute kidney injury (acute renal failure)".)
Overview — The best data related to the pathogenesis of contrast nephropathy come from animal models. Studies show evidence of acute tubular necrosis (ATN), but the mechanism by which ATN occurs is not well understood [12-14]. The two major theories are that ATN is caused by renal vasoconstriction resulting in medullary hypoxia, possibly mediated by alterations in nitric oxide, endothelin, and/or adenosine, and that ATN is a direct result of the cytotoxic effects of the contrast agents [12-20].
However, unlike other types of ATN, contrast nephropathy is usually characterized by relatively rapid recovery of renal function. If ATN contributes to contrast nephropathy, it is not clear why recovery occurs relatively quickly (ie, within a few days) compared with a longer duration (ie, one to three weeks), as with ATN due to other causes. There are at least two possibilities to explain the short duration of ATN:
●The degree of tubular necrosis is much less severe than seen in other settings.
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- Renal vasoconstriction
- Tubular injury
- Chronic kidney disease
- Diabetic nephropathy with renal insufficiency
- Dose and type of contrast agent
- Specific radiologic procedure
- Multiple myeloma
- CLINICAL FEATURES
- Creatinine increase
- Other laboratory manifestations
- Radiographic manifestations
- Differential diagnosis
- PROGNOSIS AND MANAGEMENT
- SUMMARY AND RECOMMENDATIONS