NDT Advance Access originally published online on January 28, 2008
Nephrology Dialysis Transplantation 2008 23(5):1473-1475; doi:10.1093/ndt/gfn019
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Does prophylactic haemodialysis protect kidney function after angiography?
Medizinische Klinik Nephrologie, Charité Campus Benjamin Franklin, Berlin, Germany
Correspondence and offprint requests to: Martin Tepel, Charité Campus Benjamin Franklin, Med. Klinik Nephrologie, Hindenburgdamm 30, 12200 Berlin, Germany. Fax: +49-30-8445-4235; Email: Martin.Tepel{at}charite.de
Keywords: haemodialysis; nephropathy; radiocontrast
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What was known about prophylactic haemodialysis after radiocontrast administration? |
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 Top What was known about... What do novel studies...Practical recommendations...References |
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On the one hand, it is well known that radiocontrast media can effectively be reduced by haemodialysis [1]. On the other hand, several prospective randomized studies clearly demonstrated that prophylactic haemodialysis after the administration of radiocontrast media did not prevent contrast-induced nephropathy and did not improve outcome of patients with chronic kidney disease. Lehnert et al. performed a study in 30 patients with chronic renal failure receiving radiocontrast. Mean baseline serum creatinine concentration was 2.4 mg/dL (212 µmol/L). Patients were randomly assigned to receive either a haemodialysis procedure for 3 h, started as soon as possible after the administration of radiocontrast or a conservative treatment. Contrast-induced nephropathy was not significantly different between the two groups [2]. Vogt et al. performed a randomized trial to test whether radiocontrast nephropathy can be avoided by prophylactic haemodialysis immediately after the administration of radiocontrast in patients with baseline serum creatinine concentrations >2.3 mg/dL (>200 µmol/L). In the haemodialysis group serum creatinine decreased at Day 1, peaked at Day 4 and returned to baseline at Day 6, whereas in the control group no significant changes of serum creatinine concentrations could be observed. Eight patients in the haemodialysis group and three patients in the control group required additional haemodialysis treatments. Therefore, Vogt et al. concluded that the strategy of performing haemodialysis immediately after the administration of low-osmolality radiocontrast media did not diminish the rate of complications, and prophylactic haemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful [3]. In a prospective, randomized, controlled trial Frank et al. tested the effect of a 4-h online haemodialysis during radiocontrast application in patients with advanced chronic renal failure. Mean baseline creatinine clearance was 18 mL/min. In that study no difference between creatinine clearance at 1 and 8 weeks after angiography between the haemodialysis group (n = 7) and the control group (n = 10) could be observed. Furthermore, two patients developed end-stage renal disease and requested permanent dialysis during follow-up in each group [4]. Finally, Reinecke et al. reported that haemodialysis after the administration of radiocontrast neither prevented contrast-induced nephropathy nor did it provide any evidence for an outcome benefit. In their large study, mean baseline glomerular filtration rates were 49 mL/min/1.73 m2 in the haemodialysis group (n = 138) and 47 mL/min/1.73 m2 (n = 140) in the control group [5]. From all these studies it had been concluded that prophylactic haemodialysis after radiocontrast administration does not make sense.
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What do novel studies add to our knowledge on prophylactic haemodialysis or haemofiltration? |
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TopWhat was known about...What do novel studies...Practical recommendations...References |
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Lee et al. recently presented a prospective, randomized trial indicating that prophylactic haemodialysis might be useful in patients with severely impaired renal function [6]. Within 3 years they included 82 patients with a mean baseline creatinine clearance of 13 mL/min/1.73 m2 that were routinely scheduled for coronary angiography or coronary intervention. Patients were treated with normal saline at 1 mL/kg/h for 6 h before and 12 h after radiocontrast administration and randomized to receive haemodialysis for 4 h as soon as possible after angiography or control treatment. Four days after angiography, serum creatinine concentrations were lower in the haemodialysis group compared to the control group. Out of 42 patients, 1 patient (2%) in the haemodialysis group but 14 (35%) out of 40 patients in the control group required temporary haemodialysis after coronary angiography. Temporary haemodialysis was started 1–13 days after the angiography because of oliguria for >48 h or serum potassium >6 mmol/L. Furthermore, none of the 42 patients in the haemodialysis group, but 5 (13%) out of 40 patients in the control group, required maintenance haemodialysis after discharge from the hospital (P < 0.05).
The results of that trial are quite remarkable. First, the interpretation of serum creatinine concentrations obtained 4 days after angiography seems difficult, in particular when 35% of patients in the control group required temporary haemodialysis as well, which might have been started as early as 1 day after the angiography. However, it should be noted that Lee et al. compared serum creatinine levels between the haemodialysis group and the control group 4 days after radiocontrast administration because creatinine levels are necessarily lowered after haemodialysis. Vogt et al. previously showed that in the haemodialysis group serum creatinine decreased after 24 h and peaked after 4 days [3]. Hence, under these study conditions measurements of serum creatinine 4 days after radiocontrast administration appear reasonable. In the study by Vogt et al. these data were from patients who did not require subsequent haemodialysis. It is unclear whether the data on serum creatinine concentrations at Day 4 reported by Lee et al. were solely derived from patients who did not require subsequent haemodialysis. Anyway, in patients with advanced chronic kidney disease parameters including the requirement of temporary haemodialysis after radiocontrast administration or the requirement of maintenance haemodialysis after discharge are probably more important outcome measures.
Second, the number of patients requiring temporary haemodialysis after the angiography and the number of patients requiring maintenance haemodialysis after discharge is very high, indicating that the trial included patients with advanced chronic kidney disease. There are only very few studies that investigated the effects of radiocontrast media in patients with baseline creatinine clearance <20 mL/min/1.73 m2. The results reported by Lee et al. are in contrast to the results of the small study by Frank et al., who did not observe any difference between the haemodialysis group and the control group [4]. Third, unfortunately the control group did not receive N-acetylcysteine nor bicarbonate, which both had been shown to significantly reduce contrast-induced nephropathy [7,8]. Besides these limitations, this large prospective randomized study by Lee et al. may help to clarify the needs for treatment of those patients with advanced chronic kidney disease (stage 5) and very high risk for contrast-induced nephropathy [6].
Marenzi et al. used a different approach and initiated haemofiltration (fluid replacement rate, 1000 mL/h) and saline hydration in patients with chronic renal failure 4–8 h before the coronary intervention and continued haemofiltration for 18–24 h after the procedure was completed. In that trial baseline creatinine clearance was 26 mL/min. They showed that periprocedural haemofiltration prevented contrast-induced nephropathy and was associated with improved in-hospital and long-term outcomes. They reported very impressive data, i.e. the cumulative 1-year mortality was significantly lower in the haemofiltration group (10% mortality) compared to the control group (30% mortality) [9]. Because of the complexity, cost and risk associated with this procedure, haemofiltration may not be directly applicable to all high-risk patients who are exposed to radiocontrast agents for simpler procedures.
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Practical recommendations including prophylactic haemodialysis |
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TopWhat was known about...What do novel studies...Practical recommendations...References |
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Based on clinical and experimental data, recommendations for prophylaxis and treatment of contrast-induced nephropathy have been published [10–13]. If confirmed by future studies, the novel results on the effects of haemodialysis and haemofiltration on patient outcome should be added to clinical practice considerations to prevent contrast-induced nephropathy in patients with advanced renal failure, i.e. patients with chronic kidney disease stage 5 but not yet on maintenance dialysis. These extended recommendations are listed in Table 1.
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Conflict of interest statement. None declared.
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References |
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TopWhat was known about...What do novel studies...Practical recommendations...References |
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- Baars HG, Schabel J, Weiss M. Contrast medium elimination by hemodialysis. Z Urol Nephrol (1984) 77:473–481.[ISI][Medline]
- Lehnert T, Keller E, Gondolf K, et al. Effect of haemodialysis after contrast medium administration in patients with renal insufficiency. Nephrol Dial Transplant (1998) 13:358–362.[ISI][Medline]
- Vogt B, Ferrari P, Schönholzer C, et al. Prophylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful. Am J Med (2001) 111:692–698.[CrossRef][ISI][Medline]
- Frank H, Werner D, Lorusso V, et al. Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast-induced nephropathy in chronic renal failure. Clin Nephrol (2003) 60:176–182.[ISI][Medline]
- Reinecke H, Fobker M, Wellmann J, et al. A randomized controlled trial comparing hydration therapy to additional hemodialysis or N-acetylcysteine for the prevention of contrast medium-induced nephropathy: the Dialysis-versus-Diuresis (DVD) Trial. Clin Res Cardiol (2007) 96:130–139.[CrossRef][ISI][Medline]
- Lee PT, Chou KJ, Liu CP, et al. Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial. J Am Coll Cardiol (2007) 50:1015–1020.
[Abstract/Free Full Text] - Tepel M, Van Der Giet M, Schwarzfeld C, et al. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med (2000) 343:180–184.
[Abstract/Free Full Text] - Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA (2004) 291:2328–2334.
[Abstract/Free Full Text] - Marenzi G, Marana I, Lauri G, et al. The prevention of radiocontrast-agent-induced nephropathy by hemofiltration. N Engl J Med (2003) 349:1333–1340.
[Abstract/Free Full Text] - Lameire NH. Contrast-induced nephropathy—prevention and risk reduction. Nephrol Dial Transplant (2006) 21:i11–i23.
[Abstract/Free Full Text] - Solomon R, Deray G. Consensus panel for CIN. How to prevent contrast-induced nephropathy and manage risk patients: practical recommendations. Kidney Int Suppl (2006) 100:S51–S53.[Medline]
- Tepel M, Aspelin P, Lameire N. Contrast-induced nephropathy: a clin- ical and evidence-based approach. Circulation (2006) 113:1799–1806.
[Free Full Text] - Thomsen HS. European Society of Urogenital Radiology (ESUR) guidelines on the safe use of iodinated contrast media. Eur J Radiol (2006) 60:307–313.[CrossRef][ISI][Medline]
Accepted in revised form: 9. 1.08
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