PCI complications: renal failure

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

Incidence

• 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 (1-4).
• 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 (1, 2, 4, 5).
• 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

Etiology

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 (1, 6), and the risk for cholesterol embolization syndrome relates to catheter manipulation in an ascending or descending atherosclerotic aorta that releases cholesterol crystals (7).
  • 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 (5).

Risk Factors

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

Toxicities Associated with Radiocontrast Agents

• 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

References

1. ref1 PMID 16489569
2. ref2 PMID 15957128
3. ref3 PMID 12943868
4. ref4 PMID 15864241
5. ref5 PMID 12010907
6. ref6 PMID 15619387
7. ref7 PMID 12875753