PCI complications: renal failure

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Editors-In-Chief: Alexandra Almonacid M.D., Jeffrey J.Popma M.D.

## Overview

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Acute kidney injury (AKI) occurs in approximately 7% of patients undergoing PCI, of whom 3% develop AKI that requires dialysis. Increased occurrence of AKI among patients undergoing PCI is associated with the presence of STEMI, preexisting baseline renal failure and cardiogenic shock. The occurrence of AKI following PCI is associated with increased in-hospital mortality.[1]

## Renal Failure

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### Causes

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Renal dysfunction following contrast administration during angiography may relate to either contrast induced nephropathy (CIN), cholesterol embolization syndrome, or both.

* Contrast Induced Nephropathy
* The risk of CIN is dependent on the dose of the contrast agents used, hydration status at the time of the procedure, pre-existing renal function of the patient, age, hemodynamic stability, anemia, and diabetes, and the risk for cholesterol embolization syndrome relates to catheter manipulation in an ascending or descending atherosclerotic aorta that releases cholesterol crystals.
* While the risk of hemodialysis is less than 3 percent in cases of uncomplicated CIN, the in-hospital mortality in the setting of hemodialysis exceeds 30 percent.

### Risk Factors

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* Prior renal insufficiency
* Diabetes Mellitus
* Dehydration before the procedure
* Congestive Heart Failure
* Larger volumes of contrast material
* Nephrotoxic drugs
* Recent (<48 hour) contrast exposure.

### Natural History, Complications and Prognosis

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#### Prognosis

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* The morbidity and mortality associated with PCI relates directly to the extent of baseline renal disease.
* Patients with evidence of mild renal dysfunction have a 20 percent higher risk of death a one year following PCI than patients with preserved renal function.
* Mild renal dysfunction following PCI may increase the risk of death up to four fold at one year following PCI compared with patients with preserved renal function.
* Worsening of renal function may occur after contrast agent administration in 13 to 20% of patients.
* 5% patient will have a 1 mg/dl increase of creatinine following angiography.
* <1% chronic dialysis.

### Toxicities Associated with Radiocontrast Agents

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* Allergic (anaphylactoid) reactions
* Grade I: Single episode of emesis, nausea, sneezing, or vertigo
* Grade II: Hives, multiple episodes of emesis, fevers, or chills
* Grade III: Clinical shock, bronchospasm, laryngospasm or edema, loss of consciousness, hypotension, hypertension, cardiac arrhythmia, angioedema, or pulmonary edema
* Cardiovascular toxicity
* Electrophysiologic
* Bradycardia (asystole, heart block)
* Tachycardia (sinus, ventricular)
* Ventricular fibrillation
* Hemodynamic
* Hypotension (cardiac depression, vasodilation)
* Heart failure (cardiac depression, increased intravascular volume)
* Nephrotoxicity
* Discomfort
* Nausea
* Vomiting
* Heat and flushing
* Hyperthyroidism

## 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[2]

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### Contrast-Induced Acute Kidney Injury (DO NOT EDIT)[2]

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Class I

"1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI.[3][4] (Level of Evidence: C)"
"2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.[5][6][7][8] (Level of Evidence: B)"
"3. In patients with chronic kidney disease (CKD) (creatinine clearance ≤60 mL/min), the volume of contrast media should be minimized.[9][10][11] (Level of Evidence: B)"
Class III (No Benefit)

"1. Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced acute kidney injury.[12][13] [14][15][16] (Level of Evidence: A)"

### PCI in Chronic Kidney Disease (DO NOT EDIT)[2]

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Class I

"1. In patients undergoing PCI, the glomerular filtration rate should be estimated and the dosage of renally cleared medications should be adjusted.[17][18][19] (Level of Evidence: B)"

## References

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1. ↑ Tsai TT, Patel UD, Chang TI, Kennedy KF, Masoudi FA, Matheny ME; et al. (2014). "Contemporary incidence, predictors, and outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the NCDR Cath-PCI registry". JACC Cardiovasc Interv. 7 (1): 1–9. doi:10.1016/j.jcin.2013.06.016. PMID 24456715.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 2.2 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
3. ↑ Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G (2004). "A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation". Journal of the American College of Cardiology. 44 (7): 1393–9. doi:10.1016/j.jacc.2004.06.068. PMID 15464318. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
4. ↑ Moscucci M, Rogers EK, Montoye C, Smith DE, Share D, O'Donnell M, Maxwell-Eward A, Meengs WL, De Franco AC, Patel K, McNamara R, McGinnity JG, Jani SM, Khanal S, Eagle KA (2006). "Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions". Circulation. 113 (6): 814–22. doi:10.1161/CIRCULATIONAHA.105.541995. PMID 16461821. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
5. ↑ Bader BD, Berger ED, Heede MB, Silberbaur I, Duda S, Risler T, Erley CM (2004). "What is the best hydration regimen to prevent contrast media-induced nephrotoxicity?". Clinical Nephrology. 62 (1): 1–7. PMID 15267006. Unknown parameter `|month=` ignored (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
6. ↑ Mueller C, Buerkle G, Buettner HJ, Petersen J, Perruchoud AP, Eriksson U, Marsch S, Roskamm H (2002). "Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty". Archives of Internal Medicine. 162 (3): 329–36. PMID 11822926. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
7. ↑ Solomon R, Werner C, Mann D, D'Elia J, Silva P (1994). "Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents". The New England Journal of Medicine. 331 (21): 1416–20. doi:10.1056/NEJM199411243312104. PMID 7969280. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
8. ↑ Trivedi HS, Moore H, Nasr S, Aggarwal K, Agrawal A, Goel P, Hewett J (2003). "A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity". Nephron. Clinical Practice. 93 (1): C29–34. PMID 12411756. Unknown parameter `|month=` ignored (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
9. ↑ Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, Moltrasio M, Grazi M, Rubino M, Veglia F, Fabbiocchi F, Bartorelli AL (2009). "Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality". Annals of Internal Medicine. 150 (3): 170–7. PMID 19189906. Unknown parameter `|month=` ignored (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
10. ↑ McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW (1997). "Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality". The American Journal of Medicine. 103 (5): 368–75. PMID 9375704. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
11. ↑ Russo D, Minutolo R, Cianciaruso B, Memoli B, Conte G, De Nicola L (1995). "Early effects of contrast media on renal hemodynamics and tubular function in chronic renal failure". Journal of the American Society of Nephrology : JASN. 6 (5): 1451–8. PMID 8589322. Retrieved 2011-12-06. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
12. ↑ Gonzales DA, Norsworthy KJ, Kern SJ, et al. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med. 2007; 5: 32. Published online November 14, 2007. doi:10.1186/1741-7015-5-32
13. ↑ Ozcan EE, Guneri S, Akdeniz B, et al. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial. Am Heart J. 2007; 154: 539– 44.
14. ↑ Thiele H, Hildebrand L, Schirdewahn C, et al. Impact of high-dose N-acetylcysteine versus placebo on contrast-induced nephropathy and myocardial reperfusion injury in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the LIPSIA-N-ACC (Prospective, Single-Blind, Placebo-Controlled, Randomized Leipzig Immediate PercutaneouS Coronary Intervention Acute Myocardial Infarction N-ACC) Trial. J Am Coll Cardiol. 2010; 55: 2201– 9.
15. ↑ Webb JG, Pate GE, Humphries KH, et al. A randomized controlled trial of intravenous N-acetylcysteine for the prevention of contrast-induced nephropathy after cardiac catheterization: lack of effect. Am Heart J. 2004; 148: 422–9.
16. ↑ ACT Investigators. 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). Circulation. 2011; 124: 1250–9.
17. ↑ Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F (2006). "Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate". Annals of Internal Medicine. 145 (4): 247–54. PMID 16908915. Unknown parameter `|month=` ignored (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
18. ↑ Stevens LA, Nolin TD, Richardson MM, Feldman HI, Lewis JB, Rodby R, Townsend R, Okparavero A, Zhang YL, Schmid CH, Levey AS (2009). "Comparison of drug dosing recommendations based on measured GFR and kidney function estimating equations". American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 54 (1): 33–42. doi:10.1053/j.ajkd.2009.03.008. PMC 2756662. PMID 19446939. Retrieved 2011-12-15. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
19. ↑ Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R (2009). "Impact of a renal drug dosing service on dose adjustment in hospitalized patients with chronic kidney disease". The Annals of Pharmacotherapy. 43 (10): 1598–605. doi:10.1345/aph.1M187. PMID 19776297. Retrieved 2011-12-15. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)

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