A protocol for prevention of radiographic contrast nephropathy during percutaneous coronary intervention: Effect of selective dopamine receptor agonist fenoldopam

Abstract

Radiographic contrast nephropathy (RCN), acute worsening of renal function due to contrast agents, can occur in 15%-40% of patients with baseline renal dysfunction undergoing percutaneous coronary intervention (PCI) and is associated with increased morbidity and in-hospital mortality. The purpose of this study was to evaluate whether the selective dopamine-1 (DA-1) receptor agonist fenoldopam would be beneficial in patients with chronic renal insufficiency (CRI) undergoing PCI and also to design a protocol for prevention of RCN. We analyzed 150 consecutive patients with CRI [baseline serum creatinine (BSCr) +/- 1.5% mg] who underwent PCI and received fenoldopam during and after the procedure, in addition to saline hydration. RCN, defined as > 25% increase of BSCr 48-72 hr after PCI, occurred in 4.7% (n = 7) of 150 PCI patients receiving fenoldopam and 3.5% in diabetics (n = 85) vs. 6.1% in nondiabetics (n = 65; P = NS). No patients required dialysis. The observed 4.7% incidence of RCN with fenoldopam was significantly lower than 18.8% incidence in the historical control group (P < 0.001). Our data suggest that fenoldopam is a useful adjunct in the prevention of RCN during PCI, especially in diabetics.

Contrast‐induced nephropathy

“…Observational studies reported rather low rates of CIN in high-risk patients treated with fenoldopam [17,75,76]. In a double-blind, randomized, placebo-controlled pilot trial [77], the combination of fenoldopam and hydration, compared with hydration alone, resulted in an increase in renal plasma flow, a decrease in peak serum creatinine level 72 hr after exposure to contrast media, and a trend toward decreased incidence of CIN (21% and 41%, respectively; P ¼ 0.14).…”

“…In a study by Kini et al [17], patients receiving ACE inhibitors had a significant increase in serum creatinine after the procedure compared with patients without this therapy. Similarly, in study by Cirit [35], patients with renal insufficiency receiving ACE inhibitors had a higher incidence of CIN after contrast administration than patients who did not receive ACE inhibitors (15.6% vs. 5.8%; P ¼ 0.015).…”

“…The reasons for higher risk of developing CIN in the elderly have not been studied specifically and probably are multifactorial, including age-related change in renal function as diminished glomerular filtration rate (GFR), tubular secretion and concentration ability, as well as more difficult vascular access requiring greater amount of contrast, presence of multivessel disease, etc. Importantly, by multivariate analysis, age older than 70 years appeared to be an independent predictor of CIN in some studies [16][17][18].…”

Clinical Pharmacology, Uses, and Adverse Reactions of Iodinated Contrast Agents: A Primer for the Non-radiologist

“…55,72 Recent findings derived from larger investigations have shown that fenoldopam can reduce the incidence of ICAinduced nephropathy, especially if administered directly into the renal arteries. [73][74][75] Direct administration into the renal vasculature has been shown to reduce the risk of systemic hypotension, possibly allowing higher doses of fenoldopam to reach the kidneys while avoiding systemic hypotension. Other agents, such as adenosine receptor antagonists and calcium channel antagonists, show mixed and inconsistent results in reducing the incidence of contrast-induced nephropathy.…”

Clinical and Experimental Evidence for Prevention of Acute Renal Failure Induced by Radiographic Contrast Media

“…A few non-controlled studies with a small number of patients have shown that fenoldopam prevents radiocontrast nephropathy (84,85). Recently, the effect of fenoldopam on the incidence of radiocontrast nephropathy has been investigated in a multi-institutional randomized placebo-controlled trial (CONTRAST study) of 315 patients with creatinine clearance <60 mL / min (86).…”