Néphropathie induite par les produits de contraste iodés après cathétérisme cardiaque : Une étude prospective de 180 patients
Mots-clés :
Coronarographie ; Produit de contraste iodé ; Néphropathie induite par un produit de contraste ; Insuffisance rénale ; Incidence ; Facteurs de risque.Résumé
Prérequis : La néphropathie induite par les produits de contraste iodés (NCI) est responsable d’une importante morbi-mortalité. Son incidence ainsi que ses facteurs prédictifs sont peu documentés chez les patients tunisiens.But : Déterminer l’incidence de la NCI et d’identifier ses facteurs de risques ainsi que ses répercussions pronostiques et thérapeutiques dans une cohorte de patients tunisiens.
Méthodes : Cette étude prospective mono-centrique a inclus 180 patients consécutifs candidats à une exploration coronarographique urgente ou non. La durée de suivi a été de 3 mois pour tous les patients.
Résultats : L’incidence de la NCI, définie par une ascension de la créatininémie, 48 heures après l’examen, de 5 mg/l (44μmol/l) et/ou une augmentation de 25% par rapport à la valeur de base, a été de 17,2%. L’étude multi variée en régression logistique a démontré que le diabète sucré (Odds Ratio (OR)=2.26 ; intervalle de confiance à 95% (IC95%) : 1.29-3.98, p=0.005), une clairance de la créatinine < 80ml/mn (OR=2.87 ; IC95% : 1.59-5.19, p<0.001), une fraction d’éjection du ventricule gauche (FEVG) < 45% (OR=2.03 ; IC95% :1.22-3.39, p=0.007) et une quantité de produit de contraste iodé (PCI) > 90ml (1.72 ; IC95% : 0.99-2.99, p=0.05) étaient prédictifs de survenue d’une NCI. L’hypotension artérielle en per-procédure a été le facteur de risque indépendant de NCI le plus puissant de notre étude (OR=3.99 ; IC95% : 1.65-9.66, p=0.002). Après un mois de suivi, un retour à la fonction rénale de base a été obtenu chez 27 (86.7%) patients. A la fin de la période de suivi (3 mois), 3 patients (10%) ont gardé une dysfonction rénale résiduelle.
Conclusion : Plus d’un examen coronarographique sur 6 s’est compliqué de NCI dans notre population. Cette pathologie affecte le pronostic cardiovasculaire des patients même si la normalisation de la fonction rénale est habituellement obtenue dans le mois suivant l’exploration. Acôté de l’identification des facteurs prédictifs de NCI dans le but de mettre en oeuvre les mesures préventives adéquates chez les patients à risque, nous insistons sur l’importance d’assurer un bon état hémodynamique en per-procédure.
Téléchargements
Références
Thomsen HS, Morcos SK. Contrast media and the kidney: European Society of Urogenital Radiology (ESUR) guidelines. Br J Radiol 2003; 76: 513-18.
Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents. N Engl J Med 1994; 331: 1416 -20.
Solomon RJ, Natarjan MK, Doucet S, et al. Cardiac Angiography in Renally Impaired Patients (CARE) study: Arandomized double-blind trial of contrast-induced nephropathy in patients with chronic kidney disease. Circulation 2007; 115: 3189 - 96.
McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neil WW. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997; 103: 368 -75.
Iakovou I, Dangas G, Mehran R, et al. Impact of gender on the incidence and outcome of contrast-induced nephropathy after percutaneous coronary intervention. J Invasive Cardiol 2003; 15: 18 -2.
McCullough PA, Adam A, Becker CR, et al. Risk prediction of contrast-induced nephropathy. Am J Cardiol 2006; 98 (suppl): 27K-36K.
Budano C, Levis M, D'Amico M,et al. Impact of contrast-induced acute kidney injury definition on clinical outcomes. Am Heart J. 2011;161:963-71.
Harjai KJ, Raizada A, Shenoy C, et al. Acomparison of contemporary definitions of contrast nephropathy in patients undergoing percutaneous coronary intervention and a proposal for a novel nephropathy grading system. Am J Cardiol. 2008;101:812-9
Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 2003; 348: 491- 499.
Carraro M, Mancini W, Artero M, et al. Dose effect of nitrendipine on urinary enzymes and microproteins following non-ionic radiocontrast administration. Nephrol Dial Transplant 1996; 11: 444 - 48.
Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 2002; 105: 2259 - 64.
Solomon R. Contrast-medium-induced acute renal failure. Kidney Int 1998; 53: 230-42.
Gleeson TG, Bulugahapitiya S. Contrast-induced nephropathy. Am J Roentgenol 2004; 183: 1673-89.
Bartholomew BA, Harjai KJ, Dukkipati S, et al. Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Am J Cardiol 2004; 93: 1515-19.
Goldenberg I, Matetzky S. Nephropathy induced by contrast media: pathogenesis, risk factors and preventive strategies. CMAJ 2005; 172: 1461-71.
Dangas G, Iakovou I, Nikolsky E, et al. Contrast-Induced Nephropathy After Percutaneous Coronary Interventions in Relation to Chronic Kidney Disease and Hemodynamic Variables. Am J Cardiol 2005; 95: 13-19.
Mehran R, Aymong ED, Nikolsky E, et al. A Simple Risk Score for Prediction of Contrast Induced Nephropathy after Percutaneous Coronary Intervention. J Am Coll Cardiol 2004; 44: 1393-9.
Gussenhoven MJ, Ravensbergen J, Van Bockel JH, Feuth JD, Aarts JC. Renal Dysfunction after angiography: a risk factor analysis in patients with peripheral vascular disease. J Cardiovasc Surg 1991; 32: 81-6.
Gruberg L, Mehran R, Dangas G, et al. Acute renal failure requiring hemodialysis after percutaneous coronary intervention: in-hospital and one-year outcomes. Catheter Cardiovasc Interv 2001; 52: 409-16.
Abe M, Kimura T, Morimoto T, Furukawa Y, Kita T. Incidence of and Risk Factors for Contrast-Induced Nephropathy after Cardiac Catheterization in Japanese Patients. Circ J 2009; 73: 1518 - 22.
Kohli HS, Bhaskaran MC, Muthukumar T, et al. Treatment-related acute renal failure in the elderly: a hospital-based prospective study. Nephrol Dial Transplant 2000; 15: 212-7.
Sidhu RB, Brown JR, Robb JF, et al. Interaction of Gender and Age on Post Cardiac Catheterization Contrast-Induced Acute Kidney Injury. Am J Cardiol 2008; 102: 1482-86.
Freeman RV, O'Donnell M, Share D, et al. Nephropathy requiring dialysis after per cutaneous coronary intervention and the critical role of an adjusted contrast dose. Am J Cardiol 2002; 90: 1068-73.
Ciagorra RG, Lange RA, Williams RH, Hillis LD. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease. Am J Med 1989; 86: 649-52.
Warren K, Laskey WK, Jenkins C, et al. Volume-to-creatinine clearance ratio: A pharmacokinetically-based risk factor for prediction of early creatinine increase after percutaneous coronary intervention. JACC 2007; 50: 584-90.
Nyman U, Bjork J, Aspelin P, Marenzi G. Contrast Medium Dose-to- GFR Ratio: A Measure of Systemic Exposure to Predict Contrast- Induced Nephropathy after Percutaneous Coronary Intervention. Acta Radiologica 2008; 49: 658-67.
Gurm HS, Dixon SR, Smith DE, et al. Renal Function-Based Contrast Dosing to Define Safe Limits of Radiographic Contrast Media in Patients Undergoing Percutaneous Coronary Interventions. J Am Coll Cardiol 2011; 58: 907-14.
Rudnick MR, Goldfarb S, Wexler L, et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative Study. Kidney Int 1995; 47: 254-61.
Talierco CP, Vliestra RE, Ilstrup DM, et al. Arandomized comparison of the nephrotoxicity of iopamidol and diatrizoate in high risk patients undergoing cardiac angiography. J Am Coll Cardiol 1991; 17: 384-90.
Schwab SJ, Hlatky MA, Pieper KS, et al. Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic radiographic contrast agent. N Engl J Med 1989; 320: 149-53.
Gupta RK, Kapoor A, Tewari S, Sinha N, Sharma RK. Captopril for prevention of contrast-induced nephropathy in diabetic patients: A randomised study. Indian Heart J 1999; 51: 521-6.
Toprak O, Cirit M, Bayata S, Yesil M, Aslan SL. The effect of preprocedural captopril on contrast-induced nephropathy in patients who underwent coronary angiography. Anadolu Kardiyol Derg 2003;3: 98-103.
Maeder M, Klein M, Fehr T, Rickli H. Contrast nephropathy: Review focusing on prevention. J Am Coll Cardiol 2004; 44: 1763-71.
Marenzi G, Lauri G, Assanelli E, et al. Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2004; 44: 1780 -85.
From AM, Bartholomai BJ, Williams AW, Sha SS, Mc Donald FS. Mortality associated with nephropathy after radiographic contrast exposure. Mayo Clinic Proc 2008; 83: 1095-100.
Gruber GL, Mintz GS, Mehran R, et al. The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000; 36: 1542-48.
Mueller C, Buerckel G, Buettner HJ, et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med 2002; 162: 329-36.
Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrastinduced nephropathy with sodium bicarbonate: a randomized controlled trial. Jama 2004; 291: 2328-34.
Brar SS, Shen AYJ, Jorgensen MB, et al. Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography. JAMA 2008; 300: 1038-46.
Briguori C, Visconti G, Focaccio A, et al. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II)-RenalGuard System in High-Risk Patients for Contrast-Induced Acute Kidney Injury. Circulation 2011; 124: 1260-9.
Trivedi H, Daram S, Szabo A, Bartorelli AL, Marenzi G. High-dose N-acetylcysteine for the Prevention of Contrast-induced Nephropathy. Am J Med 2009; 122:874.e9-15.
The ACT trial investigators. A pragmatic randomized controlled trial to evaluate the efficacy of acetylcysteine for the prevention of contrast-induced nephropathy. Trials 2009; 10:38.
Thiele H, Hildebrand L, Schirdewan C, et al. Impact of High-Dose NAcetylcysteine Versus Placebo on Contrast-Induced Nephropathy and Myocardial Reperfusion Injury in Unselected Patients With STSegment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2010; 55: 2201-9.
Moore RD, Steinberg EP, Powe NR, et al. Nephrotoxicity of highosmolality versus low-osmolality contrast media: randomized clinical trial. Radiology 1992; 182: 649-55.
Morcos SK, Thomsen HS, Webb JA. Contrast-media-induced nephrotoxicity: a consensus report. Contrast Media Safety Committee, European Society of Urogenital Radiology (ESUR). Eur Radiol 1999; 9: 1602-13.
Vogt B, Ferrari P, Schonholzer C, et al. Prophylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful. Am J Med 2001; 111: 692-8.
