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Pathogenesis, clinical features, and diagnosis of contrast-induced nephropathy


Last literature review for version 17.3: September 30, 2009  |  This topic last updated: March 26, 2009

INTRODUCTION

The administration of radiocontrast media can lead to a usually reversible form of acute renal failure that begins soon after the contrast is administered [1-11]. Many important issues remain unresolved including the pathogenesis of the disorder, relative efficacies of various prophylactic strategies, and the relative nephrotoxicity of different iodinated radiocontrast agents.

Types of radiocontrast agents — Iodinated radiocontrast agents are either ionic or nonionic and, at the concentrations required for arteriography or computed tomography, are of variable osmolality [12,13]:

  • First generation agents are ionic monomers (single benzene ring with three iodine atoms) they are highly hyperosmolal (approximately 1400 to 1800 mosmol/kg) compared with the osmolality of plasma.
  • Second generation agents, such as iohexol, are nonionic monomers with a lower osmolality than the first generation radiocontrast media; however, they still have an increased osmolality (500 to 850 mosmol/kg) compared with plasma. Until recently, all available nonionic agents were such "low osmolality" agents. In addition, there is an ionic low osmolar contrast agent (ioxaglate).
  • The newest nonionic contrast agents are dimers (two benzene rings joined together as a single molecule) with an even lower osmolality, with iodixanol (the first such agent) being iso-osmolal (approximately 290 mosmol/kg). Thus, iso-osmolal agents have a lower osmolality than "low osmolal" second generation drugs.

The nephrotoxic properties of these agents appear to vary, with low- and iso-osmolal agents being associated with a relatively lower incidence of renal injury among high-risk patients.

Gadolinium has been considered to carry low or no risk of nephrotoxicity. However, there are some reports of reversible acute renal failure, particularly in patients with significant renal dysfunction. More importantly, the administration of gadolinium to patients with renal dysfunction has been associated with a severe fibrosing disorder called nephrogenic systemic fibrosis (NSF). (See "Prevention of contrast-induced nephropathy", section on 'Contrast-enhanced MRI as an alternative' and "Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced renal failure".)

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References Top
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