Nefropatía Inducida por

Contraste 2015
Dr. Cristhian Mauricio Bueno Lara
Especialista en medicina interna – Universidad Autónoma de Bucaramanga
Fellow en Nefrología – Universidad del Valle
 Medios de contraste

• Antes de 1980
• Alta osmolaridad (2000 mOsm/L)

• 1980
• baja osmolaridad (600 - 900
mOsm/L)

contrast-induced nephropathy: how it develops, how to prevent it. Cleveland clinic journal of
medicine. volume 73, number 1. January 2006
 Medios de contraste

• En la actualidad
• Iso-osmolar (300 mOsm/L)

contrast-induced nephropathy: how it develops, how to prevent it. Cleveland clinic journal of
medicine. volume 73, number 1. January 2006
Medios de contraste

2003

Iso-osmolar Vs Baja osmolaridad

3% 26% Vs
Valor P = 0.002
 Nefropatía Inducida de Contraste
Definición

Incremento en la creatinina sérica ≥ 0.5 mg/dL

o un aumento del 25% en relación al valor de
base 48 horas posterior al contraste.

KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements (2012) 2,
4
Nefropatía Inducida de Contraste
Definición

2010
 Nefropatía Inducida de Contraste
Epidemiología

• El riesgo de NIC en ausencia de enfermedad renal es 1 a 2%.

• Con enfermedad renal preexistente puede aumentar hasta el 25%

KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements (2012) 2,
4
 Nefropatía Inducida de Contraste
Epidemiología

Lesión renal aguda 3% - 7%

Lesión renal aguda

Nefropatía por contraste

Nefropatía por contraste
Terapia de reemplazo renal
33% Muerte
Hemof
7.1% - 35.7%

KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements (2012) 2,
4
Nefropatía Inducida de Contraste
Fisiopatología

Contrast Medium–induced Nephrotoxicity: Which Pathway?. Radiology 2005; 235:752–755

 Nefropatía Inducida de Contraste
Fisiopatología

Efecto hemodinámico

• Respuesta hemodinámica “bifásica”

• Hipótesis de la isquemia.
• Modelos animales = Isquemia al detener el flujo sanguíneo renal por 120
minutos.

Contrast Medium–induced Nephrotoxicity: Which Pathway?. Radiology 2005; 235:752–755

 Nefropatía Inducida de Contraste
Fisiopatología
Alteraciones bioquímica y
Toxicidad directa

• Vacuolización celular, inflamación intersticial, necrosis celular y

enzimuria.

Contrast Medium–induced Nephrotoxicity: Which Pathway?. Radiology 2005; 235:752–755

 Nefropatía Inducida de Contraste
Factores de riesgo

Disfunción renal
preexistente

• Factor de riesgo mas importante.

• 60 % de los pacientes que realizan nefropatía inducida por contraste

tienen compromiso renal previo.

Probabilidad de NIC = Creatinina sérica (mg/dL) x 10

contrast-induced nephropathy: how it develops, how to prevent it. Cleveland clinic journal of
medicine. volume 73, number 1. January 2006
 Nefropatía Inducida de Contraste
Factores de riesgo

2010 Diabetes Mellitus

6358
Pacientes
Nefropatía Inducida de Contraste
Factores de riesgo

Volumen del contraste

1989

Peso: 70 Kg
Creatinina: 2 mg/dL
Volumen permitido: 175 ml
Nefropatía Inducida de Contraste
Valoración pre-test

2004
Nefropatía Inducida de Contraste
Valoración pre-test

2004

Riesgo de nefropatia inducida Riesgo de requerimiento de

por contraste hemodialisis
Nefropatía Inducida de Contraste
Valoración pre-test

Escala de riesgo de Mehran

Nefropatía Inducida de Contraste
Valoración pre-test

2014
Nefropatía Inducida de Contraste
Valoración pre-test

2014

67% 76%
Sensibilidad Especificidad
 Nefropatía Inducida de Contraste
Valoración pre-test

2015

Edad≥ 75 años: 1 punto Riesgo bajo 0 puntos: 0%

Función ventricular < 40%: 1
punto Riesgo moderado 1 punto: 5.10%

Creatinina sérica > 1.5 mg/dL: 2

puntos Riesgo alto ≥ 2 puntos: 19.4%
Nefropatía Inducida de Contraste
Valoración pre-test

2015
 Nefropatía Inducida de Contraste
Prevención

Trang H. Au, PharmD, Anne Bruckner, PharmD, Syed M. Mohiuddin, MD, and Daniel E. Hilleman,
PharmD. The Prevention of Contrast-Induced Nephropathy. Annals of Pharmacotherapy 2014, Vol.
48(10) 1332–1342
Nefropatía Inducida de Contraste
Prevención

Cristaloides

2013
 pre-

pre-

pre-
CAG.SCr# 1.5 mg/

hou

afte
pos

pos

pos
Statin = statin-treated group(high-dose);Control = cont
pro

and

glomerular filtration rate;NAC= N-acetylcysteine;NS= 0.9% sodium chlorid

Sim

Sim
eGFR$ 70 ml/min

St a

Ato

Ato

Ato

Ato

Ato
pro

bef
NA

Statin = statin-treated group(high-dose);Control = control group(low-dose

for
fro
rate;NAC= N-acetylcysteine;NS=

20

40
ad
CAG and/or PCI.
SCr# 3 mg/dl

eGFR$ 70 ml/min per 1.73 m2

Nefropatía Inducida de Contraste

CAG.eGFR. 60 ml/min per

1.73 m2

CAG.SCr$ 1.1 mg/dL or

CAG.SCr# 1.5 mg/dl or

Table 1. Characteristics of included studies.

doi:10.1371/journal.pone.0034450.t001
CrCl# 60 mL/min

CAG and/or PCI.

CAG and/or PCI.

CrCl, 60 ml/min
Prevención

SCr# 3 mg/dl
CAG or PCI
Inclusion

1.73 m2
crit eria
121

PCI
70

doi:10.1371/journal.pone.0034450.t001
in Cont rol

Estatinas
filtration
Giuseppe Patti 120

118

152

115

121
60

50

80

70
Pat ient s,n
Hakan Ozhan

St at

118

152

113

Giuseppe Patti 120

50

80

60
glomerular
et al,2010

et al,2010

et al,2011

Efficacy of Short-Term High-Dose Statin in Preventing

Hakan Ozhan
Sadik Acikel
Jo

Anna Toso
et al,2008

et al,2009

et al,2009

et al,2009

et al,2010

et al,2010

et al,2011
Zhou Xia
Aut hor,

Sang-Ho

Contrast-Induced Nephropathy: A Meta-Analysis of Xinwei

year

Seven Randomized Controlled Trials

Tab le 1. Characteristics of included studies. 2012
PLoS AprilLi2012
. | Volume
ONE | www.plosone.org
Yongchuan , Yawei 7 | Fu,
Liu . , Lili Issue 4 | e34450
Changlin 2
Mei*, Bing Dai* April 2012 | Volume 7 | Issue 4 | e34450
M ed ian
Division of Nephrology, Nephrology Institute of PLA, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China cont rast
Aut hor, Inclusion St at in Cont rast Hyd rat ion
year Pat ient s,n crit eria p rot ocol Cont rol t yp e volum e,m l p roced ure
St at in Cont rol St at in Cont rol

Sang-Ho Jo Abst ract

118 118 CAG.SCr$ 1.1 mg/dL or Simvastatin,40 mg every 12 Placebo Iodixanol 173 191 Isotonic saline,1 mg/kg/hour for 12 h
et al,2008 CrCl# 60 mL/min hours, 1 day pre-procedure before and 12 h after procedure
and 1 day post-procedure
Background: A few studies focused on statin therapy as specific prophylactic measures of contrast-induced nephropathy
Anna Toso 152 152 CAG and/or PCI. Atorvastatin,80 mg/day 2 days Placebo+NAC, Iodixanol
et al,2009
have been published with conflicting results. In this
CrCl, 60 ml/min
meta-analysis of randomized
pre-procedure and 2 days post-
controlled trials,
1200 mg bid from 1
we aimed to151assess the 164 NS,1 ml/kg/hour for 12 h before and
after the procedure
effectiveness of shor-term high-dose statin treatment for the prevention
procedure+NAC,1200 mg bidof CINday
and clinical
before to 1 outcomes
day and re-evaluate of the
from 1 day before to 1 day post-procedure
potential benefits of statin therapy. post-procedure
Xinwei 113 115 PCI Simvastatin, 80 mg/day from Simvastatin, 20 mg/ Iodixanol for 227 240 NS, 1 ml/kg/hour for 6 to 12 hours
Methods: We searched PubMed, OVID, EMBASE,admission
et al,2009 Web oftoscience and the Cochrane
the day before, day Central Register offorControlled Trials
CKD,iohexol before and 12 hours after procedure
databases for randomized controlled trials comparing
20 mg/day short-term
after procedurehigh-dose
fromstatin
admissiontreatment
to versus low-dose statin
others
the end
treatment or placebo for preventing CIN. Our outcome measures were the risk of CIN within 2–5 days after contrast
Zhou Xia 50 50 CAG or PCI Atorvastatin,80 mg/day before Atorvastatin, 10 mg/ Iopamidol 119 113 1000 mL saline infusion, for 12 hours
administration and need for dialysis.
et al,2009 for 1day,10 mg/day for 6days day for 7 days before and 12 hours after intervention
after procedure
Results:80Seven80randomized
Sadik Acikel controlled
CAG.eGFR. trials
60 ml/min per with Atorvastatin,40
a total of 1,399 patients
mg/day,3 days were identified and analyzed.
Nothing Iohexol The overall
105 results 103 Isotonic saline,1 ml/kg/hour starting 4 h
et al,2010 1.73 m2
based on fixed-effect model showed that the use pre-procedure
of short-term
post-procedure
and 2 days
high-dose statin treatment was associated with a significant before and continuing until 24 h after
procedure
reduction in risk
Hakan Ozhan 60 70
of CINCAG.S
(RR=Cr#
0.51, 95% CI 0.34–0.76,
1.5 mg/dl or
p = 0.001; I2 = 0%). The incidence
Atorvastatin,80 mg 1 day
of acute renal failure requiring
600 mg NAC bid pre- Iopamidol 97
dialysis 93 1000 ml saline infusion during 6 h after
was not significant different
et al,2010 after
eGFR$ 70 theper
ml/min use1.73
of mstatin
2
(RR= 0.33,and
pre-procedure 95% CI 0.05–2.10,
2 days p = 0.24; I2 = 0%). The use of statin was not
procedure procedure
post-procedure+600 mg
associated with a significant decrease in the plasma C-reactive protein level (SMD 2 0.64, 95% CI: 2 1.57 to 0.29, P= 0.18,

Statin Prevents Contra

NAC bid pre-procedure
2
I = 97%).
Giuseppe Patti 120 121 CAG and/or PCI. Atorvastatin,80 mg(12 hs Placebe+40 mg Iobitridol 209 213 For patients CrCl, 60 ml/min,1 ml/hour/
et al,2011 SCr# 3 mg/dl before)+40 mg(2 hs before), atorvastatin for 2days kg for 12 h before and 24 h after
Conclusions: Although this meta-analysis supports the use of statin to reduce the incidence of CIN, it must be considered in 40 mg for 2days after procedure after procedure intervention

the context of variable patient demographics. Only a limited recommendation can be made in favour of the use of statin
Statin = statin-treated group(high-dose);Contro l = control group(low-dose or non-statin);CAG = coronary angiography;PCI = percutaneous coronary intervention;CrCl = creatinine clearance;Scr = serum creatinine;eGFR = estimated
based on current data. Considering the limitations of included studies, a large, well designed trial that incorporates the
glomerular filtration rate;NAC = N-acetylcysteine;NS = 0.9% sodium chloride.
doi:10.1371/jo urnal.pone.0034450.t001
 pre-

pre-

pre-
CAG.SCr# 1.5 mg/

hou

afte
pos

pos

pos
Statin = statin-treated group(high-dose);Control = cont
pro

and

glomerular filtration rate;NAC= N-acetylcysteine;NS= 0.9% sodium chlorid

Sim

Sim
eGFR$ 70 ml/min

St a

Ato

Ato

Ato

Ato

Ato
pro

bef
NA

Statin = statin-treated group(high-dose);Control = control group(low-dose

for
fro
rate;NAC= N-acetylcysteine;NS=

20

40
ad
CAG and/or PCI.
SCr# 3 mg/dl

eGFR$ 70 ml/min per 1.73 m2

Nefropatía Inducida de Contraste

CAG.eGFR. 60 ml/min per

1.73 m2

CAG.SCr$ 1.1 mg/dL or

CAG.SCr# 1.5 mg/dl or

Table 1. Characteristics of included studies.

doi:10.1371/journal.pone.0034450.t001
CrCl# 60 mL/min

CAG and/or PCI.

CAG and/or PCI.

CrCl, 60 ml/min
Prevención

SCr# 3 mg/dl
CAG or PCI
Inclusion

1.73 m2
crit eria
121

PCI
70

doi:10.1371/journal.pone.0034450.t001
in Cont rol

Estatinas
filtration
Giuseppe Patti 120

118

152

115

121
60

50

80

70
Pat ient s,n
Hakan Ozhan

St at

118

152

113

Giuseppe Patti 120

50

80

60
glomerular
et al,2010

et al,2010

et al,2011

Efficacy of Short-Term High-Dose Statin in Preventing

Hakan Ozhan
Sadik Acikel
Jo

Anna Toso
et al,2008

et al,2009

et al,2009

et al,2009

et al,2010

et al,2010

et al,2011
Zhou Xia
Aut hor,

Sang-Ho

Contrast-Induced Nephropathy: A Meta-Analysis of Xinwei

year

Seven Randomized Controlled Trials 2012

PLoS AprilLi2012
. | Volume
ONE | www.plosone.org
Yongchuan , Yawei 7 | Fu,
Liu . , Lili Issue 4 | e34450
Changlin 2
Mei*, Bing Dai* April 2012 | Volume 7 | Issue 4 | e34450
Statin Prevents Contrast-Induced Nephropathy
Division of Nephrology, Nephrology Institute of PLA, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China

Abst ract
Background: A few studies focused on statin therapy as specific prophylactic measures of contrast-induced nephropathy
have been published with conflicting results. In this meta-analysis of randomized controlled trials, we aimed to assess the
effectiveness of shor-term high-dose statin treatment for the prevention of CIN and clinical outcomes and re-evaluate of the
potential benefits of statin therapy.

Methods: We searched PubMed, OVID, EMBASE, Web of science and the Cochrane Central Register of Controlled Trials
databases for randomized controlled trials comparing short-term high-dose statin treatment versus low-dose statin
treatment or placebo for preventing CIN. Our outcome measures were the risk of CIN within 2–5 days after contrast
administration and need for dialysis.

Results: Seven randomized controlled trials with a total of 1,399 patients were identified and analyzed. The overall results
based on fixed-effect model showed that the use of short-term high-dose statin treatment was associated with a significant
reduction in risk of CIN (RR= 0.51, 95% CI 0.34–0.76, p = 0.001; I2 = 0%). The incidence of acute renal
Figure 2. Forest plot of risk ratios and 95% confidence
failure requiring dialysis
intervals (CI) for the incidence of contrast induced nephropathy among
was not significant different after thepatients
use of statin (RR=to0.33,
assigned 95%
statin CI 0.05–2.10,
therapy versus p = 0.24; I2 = 0%). The use of statin was not
control.
associated with a significant decrease in the plasma C-reactive protein level (SMD 2 0.64, 95% CI: 2 1.57 to 0.29, P= 0.18,
doi:10.1371/journal.pone.0034450.g002
I2 = 97%).
Statistical
Conclusions: Although this meta-analysis analysis
supports the use of statin to reduce the incidence of CIN, it mustResult s
be considered in
Dichotomous data (contrast-induced nephropathy and need for
the context of variable patient demographics. Only a limited recommendation can be made in favour of the use of statin
based on current data. Considering dialysis) were analyzed
the limitations using studies,
of included the risk aratio (RR)
large, measure
well its thatSelected
andtrial
designed studies
incorporates the and characteristics
95% confidence interval (CI). Moreover, heterogeneity across We identified 322 potentially relevant citations from the initial
 Nefropatía Inducida de Contraste
Prevención

Bicarbonato

2004

Protocolo bicarbonato:

154 meq de Bicarbonato + 846 cc de DAD al 5%

3 ml/Kg/hora 1 hora antes del medio de contraste
1 ml/Kg/hora 6 horas después del medio de contraste
Nefropatía Inducida de Contraste
Prevención

Bicarbonato

2004
Nefropatía Inducida de Contraste
Prevención

Bicarbonato

2010
 Nefropatía Inducida de Contraste
Prevención

N acetilcisteina

Acetylcysteine for Prevention of Renal Outcomes in Patients Undergoing

Coronary and Peripheral Vascular Angiography : Main Results From the
Randomized Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT)
ACT Investigators
2011

Circulation 2011, 124:1250-1259: originally published online August 22, 2011

doi: 10.1161/CIRCULATIONAHA.111.038943
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
72514
RR: 1.0
Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
ISSN: 1524-4539
IC 0.81 – 1.25
Nefropatía Inducida de Contraste
Prevención

N acetilcisteina

2013
Nefropatía Inducida de Contraste
Prevención

Terapias sin evidencia o contraindicadas

Manitol Calcio-antagonistas

Furosemida Teofilina

Dopamina Acido ascórbico

Fenoldopam Sulfato de magnesio

Hemodiálisis o
N acetil cisteína
Hemofiltración

Prostaglandinas
 Nefropatía Inducida de Contraste
Pronóstico

Mortalidad

William F. Finn. The clinical and renal consequences of contrast-induced nephropathy. Nephrol Dial
Transplant (2006) 21 [Suppl 1]: i2–i10
Gracias