CT and Contrast-Induced Nephrophathy (CIN)

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1 CT and Contrast-Induced Nephrophathy (CIN) Philipp A Kaufmann, MD Professor and Director of Cardiac Imaging University Hospital Zurich, Switzerland DISCLOSURE: Institutional Research contract with GE

2 CIN controversy CIN is a subgruop of acute kidney injury (AKIN) Almost everything about CIN is subject to debate, including its definition methods for measuring the condition causative agents the mechanism for damage the best means of prevention, and its true effect on mortality rates

3 CIN: definition Common definition: Serum creatinine increase 25% and/or 44 μmol/l = 0.5 mg/dl or more from baseline after contrast material exposure In different trials only parts of the definition were used The time point serum creatinin increase measurement was not standardized

4 CIN background Contrast-induced nephropathy (CIN) was first recognized more than 50 years ago. Bartels E, Brun GC, Gammeltof A, Gjorup LA. Acute anuria following intravenous pyelography in a patient with myelomatosis. Acta Med Scand. 1954;150: Contrast media have changed over time to become increasingly safe and well tolerated, but the indications for use of contrast media have greatly expanded. There are now more than 25,000 CT scanners worldwide.

5 CIN background The number of CT examinations performed annually has increased as improvements in technology have created new indications for CT and CT angiography. In the United States alone, 50 million CT procedures are performed annually, and approximately 50% of CT examinations use contrast. Cardiac catheterization and percutaneous coronary intervention (PCI) increased 390% between 1979 and 2002 (further increase occuring now)

6 CIN impact on outcome From AM et al. Mayo Clin Proc. 2008;83(10):

7 CIN impact on outcome Twofold-to-fivefold increase in mortality while patients are in the hospital, mostly related to an increase in adverse cardiac events. Hospital resource consumption is increased. Hospital lengths of stay increase by 5-10 days. Use of dialysis facilities increases 10% to 15%. Long-term mortality (at 1 year) also increases threefold. If dialysis required: In-hosp mortality up to 35%.

8 CIN is a predictable event Occurring immediately after exposure to contrast media (both iodinated contrast and gadolinium compounds) in vulnerable individuals. Its incidence is 10% to 50% in susceptible individuals receiving cardiac angiography, rising in parallel with the baseline serum creatinine level. The incidence for CT studies is less clear.

9 CIN facts But the minority is a CT coronary angiography! Nash K et al. Am J Kidney Dis. 2002;39:

10 CIN in cath pts (n=1 196)

11 CIN risk factors D. mellitus+renal failure, oral antidiabetics (metformin) Renal disease or solitary kidney disease Aged 70 years or older Sepsis or acute hypotension Cardiovascular disease Organ transplant Nephrotoxic drugs (e.g. nonsteroidal anti-inflammatory drugs, chemotherapy) Human immunodeficiency syndrome or acquired immunodeficiency syndrome

12 CIN: how big is the problem? Risk of CIN lower than 2% in general population. Highest for for patients who have impaired renal function in combination with diabetes. The estimated GFR, using serum creatinine measurements, is thought to be more accurate than serum creatinine level alone for measuring risk for CIN. GFR 60 to 30 ml/min: 10% to 20% risk of CIN GFR <30 ml/min: 40% to 50% risk of CIN

13 From cath to CT: differential impact Intra-arterial CM application may be more toxic. Multiple bolus injection of CM in the cath as opposed to one bolus in CT coronary angiography may have molre adverse impact. Patients undergoing CT coronary angiography are younger, have much less concomitant disease.

14 CIN: Impact of different CM

15 Pugliese F, RAD Magazine 2008

16 Pugliese F, RAD Magazine 2008

17 Differences between 5 PCI studies Aspelin et al. N Engl J Med. 2003; Jo et al. J Am Coll Cardiol. 2006; Solomon RJ et al. Circ. 2007; Nie et al. Catheter Cardiovasc Int. 2008; Wessely R et al. ACC 2008 abstract.

18 CIN- Incidence in 5 PCI studies Aspelin et al. N Engl J Med. 2003; Jo et al. J Am Coll Cardiol. 2006; Solomon RJ et al. Circ. 2007; Nie et al. Catheter Cardiovasc Int. 2008; Wessely R et al. ACC 2008 abstract.

19 CIN in CCTA

20 CIN and coronary CT angiography (CCTA) Most of the CIN risk factors are rare in CCTA, as mainly used for CAD rule out or coron. anomalies in younger patients decreased GFR unlikely nephrotoxic drugs rare iv is less nephrotoxic than ic/ia where bolus reaches kidney almost undiluted CM bolus much smaller than in cath

21 CM bolus in CT much lower than in cath Pazhenkottil et al. In J Card Imag 2010;26:

22 1997

23 Procedure related CIN Cardiac cath CT overall Periph. cath ERCP Pulmon. angio Cholangiography Renal angiography For CT angio only few individual cases have been observed Nash K et al. Am J Kidney Dis. 2002;39:

24 CIN: Strategies of prevention Fischman & Reddan. Acta Radiol 2008

25 Fischman & Reddan. Acta Radiol 2008

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27 If you image, image gently! Non-invasively Low CM Low radiation (1-2m Sv) Be diagnostic! Be evidence-based:

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29 Husmann et al. Eur Heart J 2008;29: msv

30 Kaufmann, Knuuti EHJ 2010

31 A L A R A!

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34 If you image, image gently! Non-invasively Low CM Low radiation (1-2m Sv) Be diagnostic! Be evidence-based: Choose low-dose CT-angiography!