Pre-en posthydration in chronic kidney disease

W. Wieling
Department of Internal Medicine, Academic Medical Center, University of Amsterdam, (The Netherlands)

Introduction

In coronary angiography and PCI, contrast fluids are used. The most common type of contrast fluid used is fluid containing iodine. Iodine can cause contrast induced nephropathy, an acute deterioration in kidney function(> 25% or > 44 micromol/l elevation of creatinine) 2 to 5 days after intravascular fluid administration[1].

Prevention

For prevention of contrast nefropathy, in the Netherlands the guideline issued by the CBO is used[2]. It advised for patients with eGFR < 45 ml/min to hydrate periprocedural. In patients with eGFR < 60 ml/min in combination with risk factors for nephropathy are also advised to hydrate. Risk factors are mentioned in table 1.

Hydration schemes

Hydration in people with normal cardiac function is done by prehydration with 0.9% NaCl 3-4 ml/kg/hr in 4 hours and posthydration with the same scheme (table 2). In patients with cardiac dysfunction the hydration is spread out over 12 hours (in stead of 4 hours) or the fast scheme with sodium bicarbonate (NaHCO3) can be used.

Table 1: risk factors for contrast nephropathy
Diabetes mellitus
Peripheral arterial disease
Decompensatio cordis
Age > 75 years
Anemia
Symptomatic hypotension
High volume contrast fluid
Dehydration
Medication: diuretics, NSAID’s

Table 2: indications for pre- and posthydration
eGFR < 45 ml / min	+ diabetes mellitus
eGFR < 60 ml / min	+ 2 risk factors (table 1)
eGFR < 60 ml/min	+ M. Kahler or M. Waldenstrom with excretion of light chains urine
eGFR any	+ earlier contrast nephropathy

Table 3: schemes for pre- posthydration
Normal	0.9% NaCl 0.9% 3-4 ml/kg/hr 4 hours pre- and postprocedural
Slow	0.9% NaCl 0.9% 3-4 ml/kg/hr 4 hours pre- and postprocedural
Fast	1.4% NaHCO3 3 ml/kg/hr 1 hour preprocedural and 6 hours postprocedural

References

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1. Kooiman pmid=23515034
2. Jodiumhoudende http://www.diliguide.nl/document/3527/jodiumhoudende-contrastmiddelen-voorzorgsmaatregelen-bij.html

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