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Contrast induced nephropathy (CIN) is defined as 25% rise or 0.5 mg/dl of absolute rise in serum creatinine above baseline within 72 hours of contrast exposure. The incidence of CIN varies widely from 3.3% in general population to 19% in patients with renal dysfunction. Currently pre-hydration is the crux of intervention to prevent CIN. Currently, it is underutilized. Our study hypothesizes that induced diuresis with euvolemic fluid resuscitation helps preventing CIN.
Active intervention included insertion of urinary catheter, intravenous cannula, intravenous bolus of 250 ml normal saline (NS) over 30 min and then 0.5 mg per kg of frusemide at the end of fluid bolus,90 min prior to contrast exposure. Urine output was measured hourly and replaced with intravenous NS in next 1 hour for up to 6 hours. In the conventional arm, all patients received 1 ml/kg/hr of NS for 12 hours pre- and post- contrast procedures. Iodixanol was used in all cases and nephrotoxic drugs were withheld whenever possible.
Total of 166 patients were enrolled, half into each group (n=83). Based on estimated glomerular filtration rate (eGFR; ml·min–1· (1.73 m2)–1) patients were grouped – group 1: 45–60, group 2: 30–44 and group 3: 20 to 29. Computer generated block randomization number was used. Age, sex, CIN comorbidities, baseline creatinine/eGFR, and calculated Mehran’s score were well matched in both groups. There was no death nor need for dialysis in any arm. Hospital stay was significantly shorter in the intervention arm. No statistically significant major or minor complications were seen in the interventional arm.
|Characteristics||Active Arm||Conventional Arm||P value|
|Total urine output/24 h in ml||4883 ± 1528 (3800–11700)||2251 ± 810 (1000–5000)||<0.001|
|Total fluid intake/24 h in ml||5254 ± 1572||2917 ± 1167||<0.001|
|Incidence of CIN (%) Group 3 Group 2 Group 1||1/83 (1.2) 1/9 (11%) 0/34 0/40||15/83 (18) 3/8 (37.5%) 5/31(16.1%) 7/44(15.9%)||<0.001 RR: 0.48 (0.38, 0.60) 0.24 <0.02 <0.008|
|Length of hospital stay (days)||2.12 ± 0.76||3.24 ± 1.1||<0.001|
|Pulmonary edema or >2 kg weight gain||0||2+ 5 (8.4%)||<0.001|
|Hypokalemia||4 (4.8%)||3 (3.6%)||0.5|
|Urinary tract infection/Hematuria||3 (3.6)||1 (1.2%)||0.3|
|Need for dialysis||Nil||Nil||N/A|
Induced diuresis with euvolemic fluid resuscitation is very effective in reducing the incidence of CIN. It reduces the length of hospital stay. This intervention is simple and safe and can be conducted in remote places as well, because it does not require any special equipment.
OTHER: Renal Insufficiency and Contrast Nephropathy