Other Strategies

Several other nonpharmacologic strategies have been suggested as approaches for minimizing renal dysfunction after cardiac catheterization and PCI. However, many of these strategies require intense resources, and their use is limited to the highest-risk patients.

The use of forced diuresis with a combination of intravenous hydration, furosemide, dopamine, and mannitol may be valuable, but only if implemented after the measurement of right- and left-sided filling pressures with adjustments made according to baseline pressures.66 In this setting, with a careful protocol to ensure adequate hydration, one clinical trial suggested that the use of forced diuresis led to higher urine flow rates. However, only modest clinical benefits were noted in regard to serum creatinine levels and the incidence of contrast-related nephropathy.

Another approach that has been suggested is the routine use of hemodialysis or hemofiltration after or during contrast agent exposure. Although contrast agents can be effectively removed from blood by hemodialysis, several studies have suggested that use of hemodialysis is not associated with better clinical outcomes.43 One explanation for the lack of efficacy is that hemodialysis may result in hemodynamic or inflammatory changes that are nephrotoxic and offset the benefit of removal of contrast agents. To better address this issue, Marenzi and colleagues recently studied the use of hemofiltration in 114 patients with severe CKD undergoing PCI.67 Hemo-filtration has the advantage of avoiding hypovole-mia, and it can provide high-volume hydration without concerns of intravascular congestion. In this group, the use of hemofiltration starting at least 4 to 6 hours before PCI was associated with improved clinical outcomes, including lower rates of renal replacement therapy, in-hospital mortality, and 1-year mortality. The intensive resources required for this intervention limit its use to tertiary-care centers and the highest-risk patients.

Finally, another recently proposed mechanism for contrast agent removal after cardiac catheterization is coronary sinus cannulation followed by contrast agent removal with an extracorporeal absorbing column.68 The feasibility of this system was demonstrated in a swine model and awaits human use.

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