Minimizing The Risk Of Renal Dysfunction

D5W, 5% dextrose in water; NS, normal saline; NSAIDs, nonsteroidal anti-inflammatory drugs.

normal saline infusions at a rate of 1 mL/kg/hour for 6 to 12 hours before the procedure and continuing after the procedure.53 Data from a large trial suggested that the substitution of isotonic saline for 0.45% normal saline may modestly reduce the incidence of contrast-related nephropathy, particularly among patients with diabetes mellitus and those receiving large doses of contrast agents.54 In a small clinical trial of 36 patients with serum creatinine levels at baseline equal to or greater than 1.4 mg/dL, it was demonstrated that 1 L orally followed by 6 hours of intravenous hydration starting at the time of contrast agent exposure was equivalent to prepro-cedural intravenous hydration.55 This approach may be more realistic for outpatients who come in the day of their procedure.

From a practical standpoint, a quick assessment of the adequacy of hydration is possible before contrast injection by assessing the left ventricular end-diastolic pressure with a pigtail or multipurpose catheter even if a pulmonary capillary wedge pressure is unavailable. If the patient appears to be dehydrated based on hemodynamic parameters, then fluid boluses may be given intermittently before contrast agent exposure.

Recently, there has been great interest in the use of sodium bicarbonate infusions to hydrate patients with CKD during the periprocedural period. Sodium bicarbonate may relieve oxidative stress, which is a possible mechanism of action by which contrast-related nephropathy occurs. In a recently published clinical trial, 119 patients with serum creatinine levels equal to or greater than 1.1 mg/dL who were undergoing diagnostic catheterization were randomly assigned to receive either sodium bicarbonate or sodium chloride boluses and infusions before and after their procedure.56 Although those who received sodium bicarbonate were significantly less likely to develop contrast-related nephropathy, some have raised methodologic concerns about this study, particularly because of its early unscheduled termination. However, the major benefit of this approach is that it requires no new procedures, but simply replaces one infusion with another.

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