Anemia and the risk of contrast-induced nephropathy in patients with renal insufficiency undergoing contrast-enhanced MDCT

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Abstract

Purpose

The purpose of this study was to assess the effect of anemia on the incidence of contrast-induced nephropathy (CIN) in patients with renal impairment undergoing MDCT.

Materials and methods

Institutional review board approval was waived for this retrospective review of 843 patients with stable renal insufficiency (eGFR between 15 and 60 mL/min) who had undergone contrast-enhanced MDCT. Baseline hematocrit and hemoglobin values were measured. Serum creatinine (SCr) was assessed at the baseline and at 48–72 h after contrast administration.

Results

The overall incidence of CIN in the patient population with renal insufficiency was 6.9%. CIN developed in 7.8% (54 of 695) of anemic patients, and in 2.8% (4 of 148) of non-anemic patients (P = .027). After adjustment for confounders, low hemoglobin and low hematocrit values remained independent predictors of CIN (odds ratio 4.6, 95% CI 1.0–20.5, P = .046).

Conclusions

Anemia is associated with a higher incidence of CIN in patients with renal insufficiency. Anemia is a potentially modifiable risk factor for CIN, and has an unfavorable impact on prognosis in patients with renal insufficiency undergoing contrast-enhanced MDCT.

Introduction

Contrast-induced nephropathy (CIN) is defined as an acute form of kidney injury caused by exposure to intravascular iodinated contrast medium (CM), and usually defined as an increase in the mean serum creatinine (SCr) level of ≥.5 mg/dL (44.2 μmol/L), or ≥25% from the baseline value within 48–72 h after administration of contrast medium in the absence of other etiologies. Although CIN is mostly mild and reversible, it can occasionally lead to the need for renal replacement therapy and increase long-term mortality [1], [2], [3].

Several mechanisms of CIN have been implicated, including ischemic injury, direct cytotoxicity to renal structures, oxidative stress, apoptosis, and a decline in renal blood flow [4], [5]. Pre-existing renal insufficiency, diabetes mellitus, older age, and a higher volume of CM are well known risk factors for the development of CIN [6], [7], [8].

Anemia is a relatively frequent condition in the general population, and is often under-diagnosed and untreated. The underlying causes of anemia may include conditions such as iron, folate or B12 deficiency, malnutrition, cancer-induced blood loss, bone marrow suppression, or cytokine induction due to chronic disease [9]. Anemia is also a frequent feature of reduced kidney function, and may be related to the presence of chronic kidney disease (CKD), which is also an increasing public health problem worldwide, associated with poor outcomes. Anemia might be one of the factors responsible for worsening of renal ischemia and affect the ability of the nephrons to recover quickly from that anoxic event. The combination of anemia and CKD may be harmful in individuals who already have a reduced oxygen supply and increased oxygen demand [10], [11]. However, the significance of anemia in the development of CIN has not been reported.

In the present study, we investigated the effect of anemia on the incidence and outcomes of CIN in patients with renal insufficiency undergoing contrast-enhanced MDCT examinations.

Section snippets

Patient population

This study was HIPAA compliant, and in view of its retrospective design, institutional review board approval was waived. From the institutional database, records were obtained for all contrast-enhanced MDCT examinations performed between January and December 2009. A retrospective analysis based of the records of 10,659 patients who had undergone contrast-enhanced MDCT during this period was then conducted. The inclusion criteria were patient age ≥18 years, measurement of SCr within 7 days

Results

Of the 5536 patients, 1843 had a baseline eGFR of <60 mL/min, and only 843 of 1843 patients had SCr available within 48–72 h after administration of CM. The mean patient age was 65 ± 11 years. The overall population mean baseline SCr was .85 ± .19 mg/dL, and the corresponding mean eGFR was 48.9 ± 6.5 mL/min. Baseline clinical characteristics of the patients are presented in Table 1. In the cohort overall, the incidence of CIN in patients with stable renal insufficiency after contrast-enhanced MDCT

Discussion

Following the introduction of MDCT technology, the number of patients undergoing contrast-enhanced MDCT studies has grown steadily over the last decade. Effective prevention of CIN in patients at risk would be of significant benefit to public health, as it could potentially reduce the in-hospital mortality rate, the period of hospitalization, and the subsequent use of chronic hemodialysis.

The incidence of CIN in the present study was 6.9%. Since 1000 patients had not measured had not measured

Conclusions

In our present cohort, the overall incidence of CIN in patients with renal insufficiency after contrast-enhanced MDCT examination was 6.9%. Anemic patients showed a significantly higher incidence of CIN than non-anemic patients. Anemia is a potentially modifiable risk factor for CIN, and has an unfavorable impact on prognosis in patients with renal insufficiency undergoing contrast-enhanced MDCT. A prospectively designed trial to clarify the value of anemia correction in such patients is

Conflict of interest

The authors have no conflicts of interest to declare. The authors alone were responsible for the content and writing of the paper.

References (30)

  • S.A. Nguyen et al.

    Iso-osmolality versus low-osmolality iodinated contrast medium at intravenous contrast-enhanced CT: effect on kidney function

    Radiology

    (2008)
  • C. Haller et al.

    Cytotoxicity of radiocontrast agents on polarized renal epithelial cell monolayers

    Cardiovascular Research

    (1997)
  • P. Liss

    Effects of contrast media on renal microcirculation and oxygen tension. An experimental study in the rat

    Acta Radiologica. Supplementum

    (1997)
  • P.S. Parfrey et al.

    Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study

    New England Journal of Medicine

    (1989)
  • S.G. Albert et al.

    Analysis of radiocontrast-induced nephropathy by dual-labeled radionuclide clearance

    Investigative Radiology

    (1994)

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