acute renal failure after angiography - AJR

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Jul 1, 1974 - 546. F. K. Port, R. D. Wagoner and R. E. Fulton. JULY,. 1974 oligunic renal failure. The importance of early recognition and adequate treatment.
JULY,

ACUTE

RENAL By

FAILURE

FREDERICH

AFTER

ANGIOGRAPHY*

K. PORT, M.D., RICHARD RICHARD E. FULTON,

D. WAGONER, M.D.

and

ROCHESTER,

HE potential nephrotoxic effects of the earlier angiographic contrast media such as acetnizoate (Urokon) are well recognized, and acute renal failure was one reported clinical manifestation of this toxicThe

newer

contrast

media,

puncture Innovar.

in doses

generally

considered

in no patient catheterization

least

Mayo

the years undergoing

Clinic

1968

through

developed

acute

at

renal

*

From

the

Foundation,

Division

of Nephrology Rochester,

and

Internal

8

the

failure

Medicine,

of

angiographic

and

Minnesota.

544

and

for

procedure,

Table naphy

for

failure,

low-output

renal

heart

2

atherosclerotic or 2 had aortography arteniography

at

room. are listed angiocardiog-

unilateral

after an angiographic procedure. These 8 patients quite likely do not represent the total number of complications of this nature because our data were obtained by retrospective review of records of patients for whom nephrologic consultation was requested. During this same period, approximately 7,400 patients underwent angiographic studies. Percutaneous arteniognaphy was performed by a modified Seldinger technique’8 via the femoral or, occasionally, the axillary artery. Cardiac catheterization and coronary arteniography were done by the brachial cut-down technique. The contrast media used were sodium and methyiglucamine diatnizoates (Renografin 76 per cent; Renovist) and sodium iothalamate (Vascoray). The routine preparation included an oral laxative on the previous evening, abstinence from oral intake 8 to io hours before angi-

Mayo

recovery

type

the artery titration of monitored fre-

procedure

in the

aortography for tensive disease,

not ex-

1972,

the

at

and findings I. Two patients had

indications,

was bilateral performed.

evaluation

hour

,

The

such

METHOD

During patients

during

quently

the iothalamate and diatnizoate salts, however, have been considered relatively non-nephrotoxic when used in doses up to 5 mg./kg.”3’ This report describes 8 instances of acute oligunic renal failure occurring after angiography. Currently used contrast media were cessive and renal artery

a local anesthetic site, and intravenous Vital signs were

ography,

as

given

M.D.,

MINNESOTA

T

ity)3’’25

1974

for

in

had

hyperwith

suspected

renal masses, and 2 had selective arteniography of the celiac axis (one for arteniovenous fistulas and the other for hepatic vein obstruction). Angiographic renal findings included benign renal cysts in i patient and bilateral renal artery stenosis in 2 others. Acute renal failure was documented, i to 3 days after angiognaphy, by a marked change in serum creatinine concentration or the occurrence ofoligunia, on both. RESULTS

The course of the acute renal failure in our 8 patients is described in terms of serial serum creatinine levels, urinary volumes, and response to diuretics. The severity and duration of renal function impairment, as measured by serial serum creatinine determinations, are shown in Figure I. In all patients, serum creatinine levels increased to more than twice the base-line value, indicating a loss of more than 50 pen cent of renal function and involvement of both kidneys. As early as the first day after angiognaphy, a change in serum creatinine was noted in the 2 patients for whom this information was available. For the remaining patients who did not have serum creatmine determinations until the second or the

Department

of

Diagnostic

Roentgenology,

Mayo

Clinic

and

VOL.

No.

121,

Acute

3

Renal

Failure

after

Case

Age

No.

(yr.)

I

6o

PROCEDURES,

INDICATIONS,

AND

.

Procedure

2

42

3

66

4 5

59 23

Ventriculography

6

8o

Aortography+left

Mitral

.

linding

Mitral insufficiency, artery disease

insufficiency

Budd-Chiari

Hepatic

syndrome

vein

coronary

thrombosis

Hereditary Renovascular

telangiectasia hypertension

Angiomatosis of liver Bilateral renal artery

Congenital

heart

Complete canal

Renal

renal

FINDINGS

.

1ndcation

Ventriculography+coronary arteriography Visceral arteriography Visceral arteriography Aortography

545

I

TABLE ANGIOGRAPHIC

Angiognaphy

disease

mass

Renal

stenosis

atrioventricular cysts,

benign

arteriography 7

49

8

of multiple

Aortography

Occlusion

Aortography+left

arteries Renal mass

renal

Renal artery stenosis, occlusion of multiple arteries Adrenal tumor

arteriography

third day, an average daily increase of more than I mg./dl. was observed. This increase is similar to that seen in acute renal failure from other causes.

The any

duration

output

of

ofoligunia, less

than

defined 20

ml./hn.

as uninon

500

ml./da., is depicted in Figure 2. Low urine volumes were first noted within 12 hours after angiography in 4 patients and before 24 hours in 2 other patients. In the remaining 2 patients, no adequate measurements of urine volume were made until 31 and 3

hours,

respectively,

procedure.

patients was

likely,

shortly not

after

either

in

level

hours

or

The

of diuretics

serum

creatinine

the

oligunia

within

24

of the renal

the

poor

failure

response

and

to

a further

is

large

increase

in

to 4 days after at5 patients. However, of renal function usually comwithin I week; this is earlier than

tempts

at

recovery menced

expected 1

change

nature

by

doses

0

volumes during

angiography.

severe

indicated

urine case

all

but

the 8 patients had in serum creatin-

of

documented

after

in

procedure

every

7

Thus,

a significant

me

angiographic began

the because

measured

hours.

24

the oligunia

documented

not

were

first

after

Most

for

diunesis

for

2

in

most

patients

with

acute

. S

‘2 Serum

creotlifine mg/dI

Pt

0





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6

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...T)

8

#{163}

02

Days

t

4

I

I

1

2

Angiography

I

I

3

4

Days

Anqiography

Fic.

i.

Serum creatinine values and after angiography.

before

FIG.

2.

Duration

identify

of

curves

oliguria.

in Figure

Symbols i.

5

F. K. Port,

546 oligunic renal early recognition

of this

complication

I, in which kalemia

second during dialysis

fluid

of such

dialysis

The importance adequate treatment

is exemplified

severe were

toneal

ure,

failure. and

R. D. Wagoner

overload

hyper-

that

as early

pen-

as the

day. One death occurred (Case 2) the recovery phase, despite hemoperformed for severe hepatic fail-

and

was

probably

unrelated

severe

R. E. Fulton heart

JULY,

disease

and

in

1974

a newborn

infant.’5”7

by Case and

magnitude

was required

of

and

to renal

failure. In the 7 other patients, gross recovery of renal function to base-line levels occurred before hospital dismissal. The longest recovery time was approximately i6 days.

The literature unexplainable angiography.24’35’37

few reports of failure after

Renovascular

hyperten-

sion was described in 2 patients and diabetes mellitus in a third. In a fourth case, the patient had aortic insufficiency and later developed severe proteinunia; renal biopsy findings in this patient were thought to be compatible with hypersensitivityinduced glomerulonephnitis.4 PATHOPHYS1OLOGIC

There renal

DISCUSSION

contains acute renal

the

are many failure

time

MECHANISMS

possible

after

causes

for acute

angiography.

correlation

Because

between

angiography, renal status prior to angiography, and allergic reactions. Effect of contrast medium dosage and type. The type and amount of contrast medium used in our patients are shown in Table ii.

have

The

occurred

under

specific

An overdose of contrast current multiple myeloma likely cause for several renal damage after

adults.5’24’31’

Two

ally

induced

renal

have

been

documented,

circumstances.

medium or a condisorder was the reported cases of angiography in

cases

of angiographic-

failure

failure

also

in a patient

with

AND

AMOUNT

trast

medium,

established

of

for

dosages

cardiovascular

and

effects

the frequencies

the

concentrations patients

pen cent. In the was the highest,

were

were 70 whose total

the amount

was

MEDIUM

USED

Administered

Type (70-80%)

ml./kg.

I, g./kg.

285

4.6

1.70

210

4.1

1.52

3 4

i8

4.2

1.34

144

3.4

1.26

5

Renovist

230

4.9

1.82

6 7 8

Vascoray

110

1.4

o.6

1.3

0.62

3.4

1.26

Angio-Conray

Renografin-76

simi-

70

310

to

8o

dose

close to

Renografin-76 Renografin-76 Renografin-76 Renografin-76

i

2

pa-

after

II

OF CONTRAST

ml.

renal

our

lar to our total experience for all angiographic studies during this period at the Mayo Clinic. Recorded doses include all test injections and averaged 193 ml. or 3.4

Amount Case

well

onset

tients, certain explanations are possibilities, such as dosage and nephrotoxicity of con-

TABLE TYPE

was

ml./kg.;

children

in

procedure

the

angio-

Currently used angiognaphic contrast media such as the diatnizoate and iothalamate salts have been considered to be safe by many investigators.6”3’ Although acute renal failure has not been reported in animal experiments with these media, sevenal studies have suggested a transient and mild decrease in renal function.27’34’36’38 Few clinical instances of severe impairment of renal function have been reported and most

graphic

and

the

VOL.

121, No.

Acute

3

Renal

Failure

the proposed upper limit of ml./kg. Some workers36 consider this average dose to be too high. The 2 patients who had a relatively small amount of contrast medium had been exposed to contrast agents only I and 3 days previously. Two other patients had had a similar exposure within I week; the others had had no studies with contrast medium for more than I month prior to angiography. Renal function impairment had not been detected after these preceding studies, and all patients had adequate urinary output prior to angiography. The direct mechanism by which contrast medium might cause renal damage is still controversial.’6 Hypertonicity of the medium may cause crenation of enythrocytes with a secondary decrease in renal blood 0 Vasoconstniction and subsequent vasodilatation immediately after exposure to contrast medium and release of histamine, particularly after a repeated study, have also been implicated.2’9’20’2’ In our patients, a relatively high dosage or repeated administration of contrast medium may have been an etiologic factor. However, no patient in this series underwent bilateral selective renal angiography, a procedure that often produces maximal exposure of the kidneys to contrast medium. Usually, aortography utilizing 6o ml. of contrast medium and bilateral selective renal artery injections with 12 to 15 ml. per kidney is used for studies performed because renal

of mass.

contraindication

renovascular

Renal

hypertension

or

a

stenosis

is not

a

artery for

selective

injection

if

occlusion of the renal orifice can be avoided. More than 2,700 such bilateral studies were performed at the Mayo Clinic during the period of review and no renal complications were observed in this group. Cardiovascular effects. A prolonged decrease in blood pressure was not observed in any of our patients despite close monitoring. In only i instance was there a brief, moderate decrease in blood pressure, which responded immediately to a vasopressor agent (Vasoxyl). Decreased peripheral and possibly renal

after

Angiography

perfusion

547

have octhough their blood pressure remained normal. In Case I there was a short episode of atnial fibrillation without associated signs of impaired peripheral perfusion. The congenital heart disease in Case 5 was associated with a chronically low cardiac output. Large arteniovenous fistulas in Case 3 produced a shunt of approximately 5 liters/mm., and curned

this

after

in

may

angiognaphy

several

have

impaired

patients

may

even

perfusion

to other

organs. A suspected pulmonary after venography in Case 2 and

embolus a recurrent gastrointestinal hemorrhage in Case 3 also could have resulted in significantly decreased renal perfusion. However, blood pressures remained stable during these episodes.

Dehydration etiologic factor

has been considered as an in angiographically induced complications.’2 The preparation, with fluid restriction and a laxative, may have induced a mild dehydration in our patients. However, none was prepared for simultaneous renal vein renin determinations-a procedure that often produces marked dehydration. In the same 4 year period, there were no recognized instances of acute renal failure in more than 500 patients who had combined renal vein renin and angiographic study in the salt-depleted and dehydrated state. Some of these salt-depleted patients, however, did receive 500 to I ,000 ml. of saline after the renal venous blood sampling. Dehydration per se apparently did not play a significant role in the development of acute renal failure in our patients. Other causes of decreased renal perfusion cannot be specifically excluded. Renal disease. Renal abnormalities were present prior to arteniography in most of our patients and frequently were related to systemic disorders. Five of the 8 patients had an increased serum creatinine value, which clearly indicated a decreased glomerulan filtration rate, before the angiographic study. The impairment of function was mild to moderate in all cases. Likely conditions responsible for these renal abnormalities included diabetic glomerulopathy, ur-

F. K. Port, R. D. Wagoner

548

ate nephnopathy, bilateral renal artery stenosis, and obstructive uropathy in Cases I 3, 4, and 6, respectively. Numerous patients with more marked impairment of renal function were subjected to arteniography during the same period without apparent complications. In our experience’4 with high-dose urography in patients with decreased renal function, there has not been a deleterious effect of the contrast medium. Diabetic patients may be an exception, however. The combination of renal and hepatic impairment might increase the toxicity of the contrast medium, because of the limitations in both major pathways of excretion.32 Although hyperbilinubinemia has been suggested8 as a predisposing condition for the

,

development

of

acute

failure

renal

expeni-

mentally, clinical experience7 does not support this. Of our 8 patients, 3 had marked abnormalities in liven function tests; 2 of these patients also had renal insufficiency. Perhaps there is a greater susceptibility to renal complications in patients with hepatic insufficiency who undergo arteniography. Proteinunia may produce acute renal failure

after

angiography

by

precipitation

of casts or proteinaceous material. Urinary Tamm-Horsfall protein3 and the panaproteinunia of multiple myeloma,28 particularly in the dehydrated patient, have been proposed as precipitating factors in the development of acute renal failure. Although present in the majority of our patients, proteinunia was only mild to moderate and was not associated with the nephnotic syndrome. Protein electrophoresis (obtained in 6 patients) did not suggest the presence of an abnormal serum protein and in no case was multiple myeloma suspected on subsequently diagnosed. Diabetes mellitus was present in I patient, who also had probable diabetic nephropathy. We have observed the development of acute renal failure after excretory unography in 6 diabetic patients during the years 1968 through 1972. Pillay et al.29 and Teal et al.37 also suggested an

R. E. Fulton

and

association to

of

contrast

renal

JULY,

failure

medium

in

with diabetic this has

1974

exposure patients, not been

but the mechanism for clarified. According to Martin,22 hyperunicemia can delay the excretion ofcontrast medium. Increased urinary uric acid excretion induced

by

Mudge26

and

these and

agents

is a potential

particularly

has

been

Postlethwaite in

and

noted

by

Kelley3#{176}

hazard to renal function, dehydrated patients. Serum were abnormally high in

uric acid levels 2 of our 4 patients in whom this value was available. Hypersensitivity allergic reactions could cause acute renal failure as a consequence of induced vasculitis. An interstitial nephnitis was implicated in i previously reported case.4 The methylglucamine cation present in most media has been thought to release histamine’6 and thus cause bronchospasm.’ In our patients, no overt allergic phenomena were observed, and histories of allergies were negative except for I patient who reported previous reactions. PREVENTION

This review of potential causes for acute renal failure in our patients suggests that multiple factors, alone or in combination, are responsible for this nephnologic complication. The factors that identify the patient at risk are not clean, but all of our

patients

had

severe

medical

disorders.

The trend toward the use of angiography in more severely ill patients and the use of greater amounts of contrast medium should be tempered with an increased awareness of potential renal complications. More frequent consultation between the clinician and the radiologist, particularly when planning a study in severely ill patients, seems warranted. We suggest that consideration be given to the prophylactic administration of mannitol by intravenous infusion prior to and during the procedure and that fluid restriction be avoided whenever possible. Careful monitoring of urinary output and serum creatinine for at least 24 hours after angiography may allow the

VoL.

Acute

3

No.

121,

Renal

Failure

early recognition oF this complication that appropriate therapeutic attempts increase urine output, when impending oliguria is suspected, can be instituted earlier.

after

so to

7.

8.

oligunic

renal

failure

developed

do

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Section

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9. DEAN,

cell

Street

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Foundation

BOND,

T.

mental

effects

mi/kg

agents:

12.

hemodynamics

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BERDON,

and

BAKER,

uria:

its

in

R. H., Tamm-Horsfall

H.

to

prolonged

children

and

intravenous myeloma.

and

to

urography Radiology,

protein-

renal

16.

of

high

17.

S.,

D.,

HAWKINS,

KAYE, M. Acute renal failure and syndrome after angiocardiography lumine diatrizoate. New England 284,

1971,

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Application

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