C adolinium-based contrast agents have a record of causing minimal toxicity in their standarduse in MR imaging [1,2]. Several reports have shown no evidence that gadolinium-based contrast agentsworsen renal function even in patientswith preexistingrenal insufficiency [3,4]. For this reason,theseagentshave been suggestedas alternatives for use in angiogra phy in patients with conditions, such as renal insufficiency, for which iodine-based con trast agents are contraindicated [5,6]. We re port a case of acute worsening of renal insufficiencyafter angiographywith a gado linium-based contrast agent.
Case ReportA 61-year-old woman was admitted to the vascular surgery service 2 weeks after a fifth toe amputation that was not healing. She had insulin-dependent diabetes with diabetic nephropathy and a baseline serum creatinine level of approximately 3.5â€"4 mg/dl. On ad mission, her blood urea nitrogen level was 61 mg/dl and her serum creatinine level was 4.6 mg/dl. Her medicationson admission were fu rosemide, 80 mg orally once per day; omepra zole (Prilosec; Astra/Merck, Wayne, PA), 20 mg orally once per day; ampicillin sodium/ sulbactam sodium(Unasyn;Pfizer,New York, NY), 1.5 g IV every 8 Kr; epoetin alfa (Epo gen; Amgen, Thousand Oaks, CA), 5000 U subcutaneouslythreetimes per week; iron sul fate, 325 mg orally three times per day; and insulin (Humulin; Eli Lilly, Indianapolis, IN), 30 units of neutral protamine Hagedorn each morning. Two days after the patient's admis sion the furosemide dosage was increasedto 80 mg orally twice per day, the Unasyn dos agewas decreasedto 1.5g every 12hr. and 10 mg of cisapride (Propulsid; Janssen,Titus ville, NJ) orally four times per day was added. Losartan potassium (Cozaar; Merck, West Point, PA), which the patient had been taking before admission, was resumed.Two days after admissionthe patient under went lower extremity arteriography to evalu ate whether lower extremity bypass surgery was needed.In view of her renal insufficiency, with the attendantrisk of nephrotoxicity from an iodine-basedcontrast agent, a gadolinium based contrast agent, gadoteridol (Prohance; Bracco Diagnostics, Princeton, NJ), was cho senfor arteriography.On the day of the proce dune blood urea nitrogen and creatinine levels were 63 and 4.7 mg/dl, respectively.The contralateral common femoral artery was cannulated,and the ipsilateral external il iac artery was selected using a Glidewire and Glidecatheter (Medi-tech, Natick, MA). With the catheter positioned within the external il iac artery,digital subtraction imaging was per formed from the inguinal ligament to just below the knee. The catheter was then ad vanced to the distal superficial femoral artery for digital subtraction angiography of the dis Uti vessels of the leg and foot. The total con trast dose was 80 ml of a 0.5-mmoL/ml concentration, or 0.44 mmol per kilogram of body weight. Vital signs were monitored throughout theprocedure, with bloodpressure measured at 5-mm intervals. No episodes of hypotension were noted, and the lowest re corded blood ...
