nach oben

Erschienen in:

01.12.2018 | Review

Contrast medium induced acute kidney injury: a narrative review

verfasst von: Valentina Pistolesi, Giuseppe Regolisti, Santo Morabito, Ilaria Gandolfini, Silvia Corrado, Giovanni Piotti, Enrico Fiaccadori

Erschienen in: Journal of Nephrology | Ausgabe 6/2018

Einloggen, um Zugang zu erhalten

Abstract

Background and aims

Contrast-induced acute kidney injury (CI-AKI) is the third leading cause of hospital-acquired acute kidney injury. It is more commonly observed following intra-arterial administration of iodinated contrast media (CM) for cardiac procedures in patients with pre-existing chronic kidney disease (CKD), and is associated with increased short- and long-term morbidity and mortality. This review investigates the key current evidence on CI-AKI definition, epidemiology and pathogenesis, as a basis for recommending preventive measures that can be implemented in clinical practice.

Methods

An extensive literature search was performed to identify the relevant studies describing the epidemiology, pathogenesis, outcome and prevention of CI-AKI.

Results and conclusion

Pre-existing CKD, intra-arterial administration and CM volume are the most important risk factors for CI-AKI. Since risk factors for CI-AKI are well defined, and the timing of renal insult is known, patients should be carefully stratified before the administration of CM, in order to reduce the negative impact of modifiable risk factors on renal function. The intravenous administration of moderate amounts of isotonic saline solution or bicarbonate solution still represents the principal intervention with documented and acceptable effectiveness for CI-AKI prevention. More data are needed on aggressive volume expansion strategies along with diuretics, targeting forced diuresis with high urinary output. The role of antioxidant agents remains controversial, and only moderate evidence exists in favour of N-acetylcysteine. Statins could contribute to reducing the incidence of CI-AKI, although their mechanism of action is not fully ascertained. No robust data demonstrate a reduction of CI-AKI incidence by peri-procedural hemodialysis/hemofiltration; renal replacement therapies may carry instead unnecessary risks. Remote ischemic preconditioning might represent a simple, non-invasive and cost effective preventive measure for CI-AKI prevention, but few data are currently available about its clinical application in patients at high risk of CI-AKI.

Rihal CS, Textor SC, Grill DE, Berger PB, Ting HH, Best PJ, Singh M, Bell MR, Barsness GW, Mathew V, Garratt KN, Holmes DR Jr (2002) Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 105:2259–2264PubMed

James MT, Ghali WA, Tonelli M, Faris P, Knudtson ML, Pannu N, Klarenbach SW, Manns BJ, Hemmelgarn BR (2010) Acute kidney injury following coronary angiography is associated with a long-term decline in kidney function. Kidney Int 78:803–809PubMed

Barrett BJ, Parfrey PS (1994) Prevention of nephrotoxicity induced by radiocontrast agents. N Engl J Med 331:1449–1450PubMed

Stacul F, van der Molen AJ, Reimer P, Webb JA, Thomsen HS, Morcos SK, Almén T, Aspelin P, Bellin MF, Clement O, Heinz-Peer G, Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR) (2011) Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 21:2527–2541PubMed

Vanommeslaeghe F, De Mulder E, Van de Bruaene C, Van de Bruaene L, Lameire N, Van Biesen W (2015) Selecting a strategy for prevention of contrast-induced nephropathy in clinical practice: an evaluation of different clinical practice guidelines using the AGREE tool. Nephrol Dial Transplant 30:1300–1306PubMed

James MT, Ghali WA, Knudtson ML, Ravani P, Tonelli M, Faris P, Pannu N, Manns BJ, Klarenbach SW, Hemmelgarn BR, Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators (2011) Associations between acute kidney injury and cardiovascular and renal outcomes after coronary angiography. Circulation 123:409–416PubMed

Maioli M, Toso A, Leoncini M, Gallopin M, Musilli N, Bellandi F (2012) Persistent renal damage after contrast-induced acute kidney injury: incidence, evolution, risk factors, and prognosis. Circulation 125:3099–3107PubMed

Subramaniam RM, Suarez-Cuervo C, Wilson RF, Turban S, Zhang A, Sherrod C, Aboagye J, Eng J, Choi MJ, Hutfless S, Bass EB (2016) Effectiveness of prevention strategies for contrast-induced nephropathy: a systematic review and meta-analysis. Ann Intern Med 164:406–416PubMed

Nash K, Hafeez A, Hou S (2002) Hospital-acquired renal insufficiency. Am J Kidney Dis 39:930–936PubMed

10.

McCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, Tumlin J, CIN Consensus Working Panel (2006) Risk prediction of contrast-induced nephropathy. Am J Cardiol 98:27K-36KPubMed

11.

Liss P, Persson PB, Hansell P, Lagerqvist B (2006) Renal failure in 57 925 patients undergoing coronary procedures using iso-osmolar or low-osmolar contrast media. Kidney Int 70:1811–1817PubMed

12.

McCullough PA, Wolyn R, Rocher LL, Levin RN, O’Neill WW (1997) Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 103:368–375PubMed

13.

Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group (2012) KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl S2:1–138

14.

ACR Committee on Drugs (2017) Manual on contrast media, version 10.3. http://www.acr.org/Quality-Safety/Resources/Contrast-Manual. Accessed 31 May 2017 ISBN:978-1-55903-0120

15.

van der Molen AJ, Reimer P, Dekkers IA, Bongartz G, Bellin MF, Bertolotto M, Clement O, Heinz-Peer G, Stacul F, Webb JAW, Thomsen HS (2018) Post-contrast acute kidney injury—Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors: recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol. https://doi.org/10.1007/s00330-017-5246-5 CrossRefPubMedPubMedCentral

16.

Centola M, Lucreziotti S, Salerno-Uriarte D, Sponzilli C, Ferrante G, Acquaviva R, Castini D, Spina M, Lombardi F, Cozzolino M, Carugo S (2016) A comparison between two different definitions of contrast-induced acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Int J Cardiol 210:4–9PubMed

17.

Shacham Y, Rofe M, Leshem-Rubinow E, Gal-Oz A, Arbel Y, Keren G, Roth A, Ben-Assa E, Halkin A, Finkelstein A, Banai S, Steinvil A (2014) Usefulness of urine output criteria for early detection of acute kidney injury after transcatheter aortic valve implantation. Cardiorenal Med 4:155–160PubMedPubMedCentral

18.

Newhouse JH, Kho D, Rao QA, Starren J (2008) Frequency of serum creatinine changes in the absence of iodinated contrast material: implications for studies of contrast nephrotoxicity. Am J Roentgenol 191:376–382

19.

Bruce RJ, Djamali A, Shinki K, Michel SJ, Fine JP, Pozniak MA (2009) Background fluctuation of kidney function versus contrast-induced nephrotoxicity. Am J Roentgenol 192:711–718

20.

McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, Williamson EE, Kallmes DF (2013) Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology 267:106–118

21.

Davenport MS, Khalatbari S, Dillman JR, Cohan RH, Caoili EM, Ellis JH (2013) Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology 267:94–105PubMedPubMedCentral

22.

Wichmann JL, Katzberg RW, Litwin SE, Zwerner PL, De Cecco CN, Vogl TJ, Costello P, Schoepf UJ (2015) Contrast-induced nephropathy. Circulation 132:1931–1936PubMed

23.

McDonald RJ, McDonald JS, Carter RE, Hartman RP, Katzberg RW, Kallmes DF, Williamson EE (2014) Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality. Radiology 273:714–725PubMed

24.

McDonald JS, McDonald RJ, Carter RE, Katzberg RW, Kallmes DF, Williamson EE (2014) Risk of intravenous contrast material-mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate. Radiology 271:65–73PubMed

25.

Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE, Klein EY (2017) Risk of acute kidney injury after intravenous contrast media administration. Ann Emerg Med 69:577–586PubMed

26.

Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR (2018) Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med 71:44–53PubMed

27.

McDonald JS, McDonald RJ, Williamson EE, Kallmes DF, Kashani K (2017) Post-contrast acute kidney injury in intensive care unit patients: a propensity score-adjusted study. Intensive Care Med 43:774–784PubMed

28.

Wilhelm-Leen E, Montez-Rath ME, Chertow G (2017) Estimating the risk of radiocontrast-associated nephropathy. J Am Soc Nephrol 28:653–659PubMed

29.

Weisbord SD, du Cheryon D (2018) Contrast-associated acute kidney injury is a myth: no. Intensive Care Med 44:107–109PubMed

30.

Kashani K, Levin A, Schetz M (2018) Contrast-associated acute kidney injury is a myth: we are not sure. Intensive Care Med 44:110–114PubMed

31.

Ehrmann S, Aronson D, Hinson JS (2018) Contrast-associated acute kidney injury is a myth: yes. Intensive Care Med 44:104–106PubMed

32.

Nikolsky E, Aymong ED, Dangas G, Mehran R (2003) Radiocontrast nephropathy: identifying the high-risk patient and the implications of exacerbating renal function. Rev Cardiovasc Med 4(Suppl 1):S7–S14PubMed

33.

Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G (2004) A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 44:1393–1399

34.

Manske CL, Sprafka JM, Strony JT, Wang Y (1990) Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. Am J Med 89:615–620PubMed

35.

McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, Kallmes DF (2013) Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology 267:119–128PubMed

36.

Mehran R, Nikolsky E (2006) Contrast-induced nephropathy: definition, epidemiology, and patients at risk. Kidney Int Suppl 100:S11-15

37.

Rudnick MR, Goldfarb S, Tumlin J (2008) Contrast-induced nephropathy: is the picture any clearer? Clin J Am Soc Nephrol 3:261–262PubMed

38.

Morabito S, Pistolesi V, Benedetti G, Di Roma A, Colantonio R, Mancone M, Sardella G, Cibelli L, Ambrosino M, Polistena F, Pierucci A (2012) Incidence of contrast-induced acute kidney injury associated with diagnostic or interventional coronary angiography. J Nephrol 25:1098–1107PubMed

39.

Marenzi G, De Metrio M, Rubino M, Lauri G, Cavallero A, Assanelli E, Grazi M, Moltrasio M, Marana I, Campodonico J, Discacciati A, Veglia F, Bartorelli AL (2010) Acute hyperglycemia and contrast-induced nephropathy in primary percutaneous coronary intervention. Am Heart J 160:1170–1177PubMed

40.

Nikolsky E, Mehran R, Lasic Z, Mintz GS, Lansky AJ, Na Y, Pocock S, Negoita M, Moussa I, Stone GW, Moses JW, Leon MB, Dangas G (2005) Low hematocrit predicts contrast-induced nephropathy after percutaneous coronary interventions. Kidney Int 67:706–713PubMed

41.

Xu J, Zhang M, Ni Y, Shi J, Gao R, Wang F, Dong Z, Zhu L, Liu Y, Xu H (2016) Impact of low hemoglobin on the development of contrast-induced nephropathy: a retrospective cohort study. Exp Ther Med 12:603–610PubMedPubMedCentral

42.

Brown JR, DeVries JT, Piper WD, Robb JF, Hearne MJ, Ver Lee PM, Kellet MA, Watkins MW, Ryan TJ, Silver MT, Ross CS, MacKenzie TA, O’Connor GT, Malenka DJ, Northern New England Cardiovascular Disease Study Group (2008) Serious renal dysfunction after percutaneous coronary interventions can be predicted. Am Heart J 155:260–266

43.

Marenzi G, Lauri G, Assanelli E, Campodonico J, De Metrio M, Marana I, Grazi M, Veglia F, Bartorelli AL (2004) Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 44:1780–1785PubMed

44.

Bainey KR, Rahim S, Etherington K, Rokoss ML, Natarajan MK, Velianou JL, Brons S, Mehta SR, CAPTAIN Investigators (2015) Effects of withdrawing vs. continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial. Am Heart J 170:110–116PubMed

45.

van der Molen AJ, Reimer P, Dekkers IA, Bongartz G, Bellin MF, Bertolotto M, Clement O, Heinz-Peer G, Stacul F, Webb JAW, Thomsen HS (2018) Post-contrast acute kidney injury. Part 2: Risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients: recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol. https://doi.org/10.1007/s00330-017-5247-4 CrossRefPubMedPubMedCentral

46.

Owen RJ, Hiremath S, Myers A, Fraser-Hill M, Barrett BJ (2014) Canadian Association of Radiologists consensus guidelines for the prevention of contrast-induced nephropathy: update 2012. Can Assoc Radiol J 65:96–105PubMed

47.

Abu Jawdeh BG, Leonard AC, Sharma Y, Katipally S, Shields AR, Alloway RR, Woodle ES, Thakar CV (2017) Contrast-induced nephropathy in renal transplant recipients: a single center experience. Front Med (Lausanne) 4:64

48.

Cheungpasitporn W, Thongprayoon C, Mao MA, Mao SA, D’Costa MR, Kittanamongkolchai W, Kashani KB (2017) Contrast-induced acute kidney injury in kidney transplant recipients: a systematic review and meta-analysis. World J Transplant 7:81–87PubMedPubMedCentral

49.

Pahade JK, LeBedis CA, Raptopoulos VD, Avigan DE, Yam CS, Kruskal JB, Pedrosa I (2011) Incidence of contrast-induced nephropathy in patients with multiple myeloma undergoing contrast-enhanced CT. Am J Roentgenol 196:1094–1101

50.

Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, Moltrasio M, Grazi M, Rubino M, Veglia F, Fabbiocchi F, Bartorelli AL (2009) Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality. Ann Intern Med 150:170–177PubMed

51.

Solomon R (2008) Contrast-induced acute kidney injury: is there a risk after intravenous contrast? Clin J Am Soc Nephrol 3:1242–1243PubMedPubMedCentral

52.

Karlsberg RP, Dohad SY, Sheng R, Iodixanol Peripheral Computed Tomographic Angiography Study Investigator Panel (2011) Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium. J Vasc Interv Radiol 22:1159–1165PubMed

53.

Dong M, Jiao Z, Liu T, Guo F, Li G (2012) Effect of administration route on the renal safety of contrast agents: a meta-analysis of randomized controlled trials. J Nephrol 25:290–301PubMed

54.

Nyman U, Almén T, Jacobsson B, Aspelin P (2012) Are intravenous injections of contrast media really less nephrotoxic than intra-arterial injections? Eur Radiol 22:1366–1371PubMed

55.

Solomon R, Dauerman HL (2010) Contrast-induced acute kidney injury. Circulation 122:2451–2455PubMed

56.

Kooiman J, Seth M, Dixon S, Wohns D, LaLonde T, Rao SV, Gurm HS (2014) Risk of acute kidney injury after percutaneous coronary interventions using radial versus femoral vascular access: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Circ Cardiovasc Interv 7:190–198PubMed

57.

Shacham Y, Steinvil A, Arbel Y (2016) Acute kidney injury among ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention: a multifactorial entity. J Nephrol 29:169–174PubMed

58.

Kane GC, Doyle BJ, Lerman A, Barsness GW, Best PJ, Rihal CS (2008) Ultra-low contrast volumes reduce rates of contrast-induced nephropathy in patients with chronic kidney disease undergoing coronary angiography. J Am Coll Cardiol 51:89–90PubMed

59.

Cigarroa RG, Lange RA, Williams RH, Hillis LD (1989) Dosing of contrast material to prevent contrast nephropathy in patients with renal disease. Am J Med 86:649–652PubMed

60.

Freeman RV, O’Donnell M, Share D, Meengs WL, Kline-Rogers E, Clark VL, DeFranco AC, Eagle KA, McGinnity JG, Patel K, Maxwell-Eward A, Bondie D, Moscucci M, Blue Cross-Blue Shield of Michigan Cardiovascular Consortium (BMC2) (2002) Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose. Am J Cardiol 90:1068–1073PubMed

61.

Laskey WK, Jenkins C, Selzer F, Marroquin OC, Wilensky RL, Glaser R, Cohen HA, Holmes DR Jr, NHLBI Dynamic Registry Investigators (2007) Volume-to-creatinine clearance ratio: a pharmacokinetically based risk factor for prediction of early creatinine increase after percutaneous coronary intervention. J Am Coll Cardiol 50:584–590PubMed

62.

Barrett BJ, Carlisle EJ (1993) Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Radiology 188:171–178PubMed

63.

Lameire N, Kellum JA, KDIGO AKI Guideline Work Group (2013) Contrast-induced acute kidney injury and renal support for acute kidney injury: a KDIGO summary (Part 2). Crit Care 17:205PubMedPubMedCentral

64.

Seeliger E, Lenhard DC, Persson PB (2014) Contrast media viscosity versus osmolality in kidney injury: lessons from animal studies. Biomed Res Int 2014:358136PubMedPubMedCentral

65.

Michael A, Faga T, Pisani A, Riccio E, Bramanti P, Sabbatini M, Navarra M, Andreucci M (2014) Molecular mechanisms of renal cellular nephrotoxicity due to radiocontrast media. Biomed Res Int 2014:249810PubMedPubMedCentral

66.

Solomon R (1998) Radiocontrast-induced nephropathy. Semin Nephrol 18:551–557PubMed

67.

Persson PB, Hansell P, Liss P (2005) Pathophysiology of contrast medium-induced nephropathy. Kidney Int 68:14–22PubMed

68.

Heyman SN, Rosen S, Rosenberger C (2008) Renal parenchymal hypoxia, hypoxia adaptation, and the pathogenesis of radiocontrast nephropathy. Clin J Am Soc Nephrol 3:288–296PubMed

69.

Myers SI, Wang L, Liu F, Bartula LL (2006) Iodinated contrast induced renal vasoconstriction is due in part to the downregulation of renal cortical and medullary nitric oxide synthesis. J Vasc Surg 44:383–391PubMed

70.

Sendeski MM (2011) Pathophysiology of renal tissue damage by iodinated contrast media. Clin Exp Pharmacol Physiol 38:292–299PubMed

71.

Fiaccadori E, Maggiore U, Rotelli C, Giacosa R, Lombardi M, Sagripanti S, Buratti S, Ardissino D, Cabassi A (2004) Plasma and urinary free 3-nitrotyrosine following cardiac angiography procedures with non-ionic radiocontrast media. Nephrol Dial Transplant 19:865–869PubMed

72.

Agmon Y, Peleg H, Greenfeld Z, Rosen S, Brezis M (1994) Nitric oxide and prostanoids protect the renal outer medulla from radiocontrast toxicity in the rat. J Clin Invest 94:1069–1075PubMedPubMedCentral

73.

Brezis M, Rosen S (1995) Hypoxia of the renal medulla: its implications for disease. N Engl J Med 332:647–655PubMed

74.

Fishbane S (2008) N-Acetylcysteine in the prevention of contrast-induced nephropathy. Clin J Am Soc Nephrol 3:281–287PubMed

75.

Ronda N, Potì F, Palmisano A, Gatti R, Orlandini G, Maggiore U, Cabassi A, Regolisti G, Fiaccadori E (2013) Effects of the radiocontrast agent iodixanol on endothelial cell morphology and function. Vascul Pharmacol 58:39–47PubMed

76.

Liu ZZ, Schmerbach K, Lu Y, Perlewitz A, Nikitina T, Cantow K, Seeliger E, Persson PB, Patzak A, Liu R, Sendeski MM (2014) Iodinated contrast media cause direct tubular cell damage, leading to oxidative stress, low nitric oxide, and impairment of tubuloglomerular feedback. Am J Physiol Renal Physiol 306:F864–F872PubMedPubMedCentral

77.

Haller C, Schick CS, Zorn M, Kübler W (1997) Cytotoxicity of radiocontrast agents on polarized renal epithelial cell monolayers. Cardiovasc Res 33:655–665PubMed

78.

Lei R, Zhao F, Tang CY, Luo M, Yang SK, Cheng W, Li XW, Duan SB (2018) Mitophagy plays a protective role in iodinated contrast-induced acute renal tubular epithelial cells injury. Cell Physiol Biochem 46:975–985PubMed

79.

Abe M, Morimoto T, Nakagawa Y, Furukawa Y, Ono K, Kato T, Kadota K, Ando K, Ishii M, Masunaga N, Akao M, Kimura T (2017) Impact of transient or persistent contrast-induced nephropathy on long-term mortality after elective percutaneous coronary intervention. Am J Cardiol 120:2146–2153PubMed

80.

Margolis G, Gal-Oz A, Letourneau-Shesaf S, Khoury S, Keren G, Shacham Y (2017) Acute kidney injury based on the KDIGO criteria among ST elevation myocardial infarction patients treated by primary percutaneous intervention. J Nephrol. https://doi.org/10.1007/s40620-017-0461-3 CrossRefPubMed

81.

Narula A, Mehran R, Weisz G, Dangas GD, Yu J, Généreux P, Nikolsky E, Brener SJ, Witzenbichler B, Guagliumi G, Clark AE, Fahy M, Xu K, Brodie BR, Stone GW (2014) Contrast-induced acute kidney injury after primary percutaneous coronary intervention: results from the HORIZONS-AMI substudy. Eur Heart J 35:1533–1540PubMed

82.

Weisbord SD, Chen H, Stone RA, Kip KE, Fine MJ, Saul MI, Palevsky PM (2006) Associations of increases in serum creatinine with mortality and length of hospital stay after coronary angiography. J Am Soc Nephrol 17:2871–2877PubMed

83.

Vuurmans T, Byrne J, Fretz E, Janssen C, Hilton JD, Klinke WP, Djurdjev O, Levin A (2010) Chronic kidney injury in patients after cardiac catheterisation or percutaneous coronary intervention: a comparison of radial and femoral approaches (from the British Columbia Cardiac and Renal Registries). Heart 96:1538–1542PubMed

84.

Drey N, Roderick P, Mullee M, Rogerson M (2003) A population-based study of the incidence and outcomes of diagnosed chronic kidney disease. Am J Kidney Dis 42:677–684PubMed

85.

Nikolsky E, Mehran R, Turcot D, Aymong ED, Mintz GS, Lasic Z, Lansky AJ, Tsounias E, Moses JW, Stone GW, Leon MB, Dangas GD (2004) Impact of chronic kidney disease on prognosis of patients with diabetes mellitus treated with percutaneous coronary intervention. Am J Cardiol 94:300–305PubMed

86.

Sykes L, Nipah R, Kalra P, Green D (2017) A narrative review of the impact of interventions in acute kidney injury. J Nephrol. https://doi.org/10.1007/s40620-017-0454-2 CrossRefPubMedPubMedCentral

87.

Liu YH, Liu Y, Zhou YL, He PC, Yu DQ, Li LW, Xie NJ, Guo W, Tan N, Chen JY (2016) Comparison of different risk scores for predicting contrast induced nephropathy and outcomes after primary percutaneous coronary intervention in patients with ST elevation myocardial infarction. Am J Cardiol 117:1896–1903PubMed

88.

Silver SA, Shah PM, Chertow GM, Harel S, Wald R, Harel Z (2015) Risk prediction models for contrast induced nephropathy: systematic review. BMJ 351:h4395PubMedPubMedCentral

89.

Maioli M, Toso A, Gallopin M, Leoncini M, Tedeschi D, Micheletti C, Bellandi F (2010) Preprocedural score for risk of contrast-induced nephropathy in elective coronary angiography and intervention. J Cardiovasc Med (Hagerstown) 11:444–449

90.

Fu N, Li X, Yang S, Chen Y, Li Q, Jin D, Cong H (2013) Risk score for the prediction of contrast-induced nephropathy in elderly patients undergoing percutaneous coronary intervention. Angiology 64:188–194PubMed

91.

Gurm HS, Seth M, Kooiman J, Share D (2013) A novel tool for reliable and accurate prediction of renal complications in patients undergoing percutaneous coronary intervention. J Am Coll Cardiol 61:2242–2248PubMed

92.

Victor SM, Gnanaraj A, Deshmukh R, Kandasamy M, Janakiraman E, Pandurangi UM, Latchumanadhas K, Abraham G, Mullasari AS (2014) Risk scoring system to predict contrast induced nephropathy following percutaneous coronary intervention. Indian Heart J 66:517–524PubMedPubMedCentral

93.

Yin WJ, Yi YH, Guan XF, Zhou LY, Wang JL, Li DY, Zuo XC (2017) Preprocedural prediction model for contrast-induced nephropathy patients. J Am Heart Assoc 6

94.

Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ, Nephrotoxicity in High-Risk Patients Study of Iso-Osmolar and Low-Osmolar Non-Ionic Contrast Media Study Investigators (2003) Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 348:491–499PubMed

95.

Rudnick MR, Davidson C, Laskey W, Stafford JL, Sherwin PF, VALOR Trial Investigators (2008) Nephrotoxicity of iodixanol versus ioversol in patients with chronic kidney disease: the Visipaque Angiography/Interventions with Laboratory Outcomes in Renal Insufficiency (VALOR) Trial. Am Heart J 156:776–782PubMed

96.

Solomon RJ, Natarajan MK, Doucet S, Sharma SK, Staniloae CS, Katholi RE, Gelormini JL, Labinaz M, Moreyra AE, Investigators of the CARE Study (2007) Cardiac Angiography in Renally Impaired Patients (CARE) study: a randomized double-blind trial of contrast-induced nephropathy in patients with chronic kidney disease. Circulation 115:3189–3196PubMed

97.

Laskey W, Aspelin P, Davidson C, Rudnick M, Aubry P, Kumar S, Gietzen F, Wiemer M, DXV405 Study Group (2009) Nephrotoxicity of iodixanol versus iopamidol in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures. Am Heart J 158:822–828PubMed

98.

Eng J, Wilson RF, Subramaniam RM, Zhang A, Suarez-Cuervo C, Turban S, Choi MJ, Sherrod C, Hutfless S, Iyoha EE, Bass EB (2016) Comparative effect of contrast media type on the incidence of contrast-induced nephropathy: a systematic review and meta-analysis. Ann Intern Med 164:417–424PubMed

99.

Pandya B, Chalhoub JM, Parikh V, Gaddam S, Spagnola J, El-Sayegh S, Bogin M, Kandov R, Lafferty J, Bangalore S (2017) Contrast media use in patients with chronic kidney disease undergoing coronary angiography: a systematic review and meta-analysis of randomized trials. Int J Cardiol 228:137–144PubMed

100.

Shalansky SJ, Vu T, Pate GE, Levin A, Humphries KH, Webb JG (2005) N-Acetylcysteine for prevention of radiographic contrast material-induced nephropathy: is the intravenous route best? Pharmacotherapy 25:1095–1103PubMed

101.

Zhao SJ, Zhong ZS, Qi GX, Tian W (2016) The efficacy of N-acetylcysteine plus sodium bicarbonate in the prevention of contrast-induced nephropathy after cardiac catheterization and percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Int J Cardiol 221:251–259PubMed

102.

Xu R, Tao A, Bai Y, Deng Y, Chen G (2016) Effectiveness of N-acetylcysteine for the prevention of contrast-induced nephropathy: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 5:9

103.

Wang N, Qian P, Kumar S, Yan TD, Phan K (2016) The effect of N-acetylcysteine on the incidence of contrast-induced kidney injury: a systematic review and trial sequential analysis. Int J Cardiol 209:319–327PubMed

104.

Briguori C, Airoldi F, D’Andrea D, Bonizzoni E, Morici N, Focaccio A, Michev I, Montorfano M, Carlino M, Cosgrave J, Ricciardelli B, Colombo A (2007) Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies. Circulation 115:1211–1217PubMed

105.

ACT Investigators (2011) Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation 124:1250–1259

106.

Weisbord SD, Gallagher M, Jneid H, Garcia S, Cass A, Thwin SS, Conner TA, Chertow GM, Bhatt DL, Shunk K, Parikh CR, McFalls EO, Brophy M, Ferguson R, Wu H, Androsenko M, Myles J, Kaufman J, Palevsky PM, PRESERVE Trial Group (2018) Outcomes after angiography with sodium bicarbonate and acetylcysteine. N Engl J Med 378:603–614PubMed

107.

Rezaei Y, Khademvatani K, Rahimi B, Khoshfetrat M, Arjmand N, Seyyed-Mohammadzad MH (2016) Short-term high-dose vitamin e to prevent contrast medium-induced acute kidney injury in patients with chronic kidney disease undergoing elective coronary angiography: a randomized placebo-controlled trial. J Am Heart Assoc 5(3):e002919PubMedPubMedCentral

108.

Weisbord SD, Palevsky PM (2008) Prevention of contrast-induced nephropathy with volume expansion. Clin J Am Soc Nephrol 3:273–280PubMed

109.

Ellis JH, Cohan RH (2009) Prevention of contrast-induced nephropathy: an overview. Radiol Clin North Am 47:801–811PubMed

110.

Nijssen EC, Rennenberg RJ, Nelemans PJ, Essers BA, Janssen MM, Vermeeren MA, Ommen VV, Wildberger JE (2017) Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet 389:1312–1322PubMed

111.

Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonton CA 3rd, Rittase RA, Norton HJ, Kennedy TP (2004) Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA 291:2328–2334PubMed

112.

Ozcan EE, Guneri S, Akdeniz B, Akyildiz IZ, Senaslan O, Baris N, Aslan O, Badak O (2007) Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial. Am Heart J 154:539–544PubMed

113.

Brar SS, Shen AY, Jorgensen MB, Kotlewski A, Aharonian VJ, Desai N, Ree M, Shah AI, Burchette RJ (2008) Sodium bicarbonate vs. sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial. JAMA 300:1038–1046PubMed

114.

Maioli M, Toso A, Leoncini M, Gallopin M, Tedeschi D, Micheletti C, Bellandi F (2008) Sodium bicarbonate versus saline for the prevention of contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. J Am Coll Cardiol 52:599–604PubMed

115.

Solomon R, Gordon P, Manoukian SV, Abbott JD, Kereiakes DJ, Jeremias A, Kim M, Dauerman HL, BOSS Trial Investigators (2015) Randomized trial of bicarbonate or saline study for the prevention of contrast-induced nephropathy in patients with CKD. Clin J Am Soc Nephrol 10:1519–1524PubMedPubMedCentral

116.

Navaneethan SD, Singh S, Appasamy S, Wing RE, Sehgal AR (2009) Sodium bicarbonate therapy for prevention of contrast-induced nephropathy: a systematic review and meta-analysis. Am J Kidney Dis 53:617–627PubMed

117.

Dong Y, Zhang B, Liang L, Lian Z, Liu J, Liang C, Zhang S (2016) How strong is the evidence for sodium bicarbonate to prevent contrast-induced acute kidney injury after coronary angiography and percutaneous coronary intervention? Medicine (Baltimore) 95:e2715

118.

Brown JR, Pearlman DM, Marshall EJ, Alam SS, MacKenzie TA, Recio-Mayoral A, Gomes VO, Kim B, Jensen LO, Mueller C, Maioli M, Solomon RJ (2016) Meta-analysis of individual patient data of sodium bicarbonate and sodium chloride for all-cause mortality after coronary angiography. Am J Cardiol 118:1473–1479PubMed

119.

Kooiman J, Sijpkens YW, de Vries JP, Brulez HF, Hamming JF, van der Molen AJ, Aarts NJ, Cannegieter SC, Putter H, Swarts R, van den Hout WB, Rabelink TJ, Huisman MV (2014) A randomized comparison of 1-h sodium bicarbonate hydration versus standard peri-procedural saline hydration in patients with chronic kidney disease undergoing intravenous contrast-enhanced computerized tomography. Nephrol Dial Transplant 29:1029–1036PubMed

120.

Ad-hoc Working Group of ERBP, Fliser D, Laville M, Covic A, Fouque D, Vanholder R, Juillard L, Van Biesen W (2012) A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant 27:4263–4272

121.

Solomon R, Werner C, Mann D, D’Elia J, Silva P (1994) Effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents. N Engl J Med 331:1416–1420PubMed

122.

Briguori C, Visconti G, Ricciardelli B, Condorelli G, REMEDIAL II Investigators (2011) Renal insufficiency following contrast media administration trial II (REMEDIAL II): RenalGuard system in high-risk patients for contrast-induced acute kidney injury: rationale and design. EuroIntervention 6:1117–1122PubMed

123.

Solomon R (2014) Forced diuresis with the RenalGuard system: impact on contrast induced acute kidney injury. J Cardiol 63:9–13PubMed

124.

Marenzi G, Ferrari C, Marana I, Assanelli E, De Metrio M, Teruzzi G, Veglia F, Fabbiocchi F, Montorsi P, Bartorelli AL (2012) Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (induced diuresis with matched hydration compared to standard hydration for contrast induced nephropathy prevention) trial. JACC Cardiovasc Interv 5:90–97PubMed

125.

Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, Golia B, Ricciardelli B, Condorelli G, REMEDIAL II Investigators (2011) Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury. Circulation 124:1260–1269PubMed

126.

Briguori C, Visconti G, Donahue M, De Micco F, Focaccio A, Golia B, Signoriello G, Ciardiello C, Donnarumma E, Condorelli G (2016) RenalGuard system in high-risk patients for contrast-induced acute kidney injury. Am Heart J 173:67–76PubMed

127.

Putzu A, Boscolo Berto M, Belletti A, Pasotti E, Cassina T, Moccetti T, Pedrazzini G (2017) Prevention of contrast-induced acute kidney injury by furosemide with matched hydration in patients undergoing interventional procedures: a systematic review and meta-analysis of randomized trials. JACC Cardiovasc Interv 10:355–363PubMed

128.

John S, Schneider MP, Delles C, Jacobi J, Schmieder RE (2005) Lipid-independent effects of statins on endothelial function and bioavailability of nitric oxide in hypercholesterolemic patients. Am Heart J 149:473PubMed

129.

Quintavalle C, Fiore D, De Micco F, Visconti G, Focaccio A, Golia B, Ricciardelli B, Donnarumma E, Bianco A, Zabatta MA, Troncone G, Colombo A, Briguori C, Condorelli G (2012) Impact of a high loading dose of atorvastatin on contrast-induced acute kidney injury. Circulation 126:3008–3016PubMed

130.

Ichiki T, Takeda K, Tokunou T, Iino N, Egashira K, Shimokawa H, Hirano K, Kanaide H, Takeshita A (2001) Downregulation of angiotensin II type 1 receptor by hydrophobic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors in vascular smooth muscle cells. Arterioscler Thromb Vasc Biol 21:1896–1901PubMed

131.

Bonetti PO, Lerman LO, Napoli C, Lerman A (2003) Statin effects beyond lipid lowering—are they clinically relevant? Eur Heart J 24:225–248PubMed

132.

Lee JM, Park J, Jeon KH, Jung JH, Lee SE, Han JK, Kim HL, Yang HM, Park KW, Kang HJ, Koo BK, Jo SH, Kim HS (2014) Efficacy of short-term high-dose statin pretreatment in prevention of contrast-induced acute kidney injury: updated study-level meta-analysis of 13 randomized controlled trials. PLoS One 9:e111397PubMedPubMedCentral

133.

Gandhi S, Mosleh W, Abdel-Qadir H, Farkouh ME (2014) Statins and contrast-induced acute kidney injury with coronary angiography. Am J Med 127:987–1000PubMed

134.

Li H, Wang C, Liu C, Li R, Zou M, Cheng G (2016) Efficacy of short-term statin treatment for the prevention of contrast-induced acute kidney injury in patients undergoing coronary angiography/percutaneous coronary intervention: a meta-analysis of 21 randomized controlled trials. Am J Cardiovasc Drugs 16:201–219PubMed

135.

Leoncini M, Toso A, Maioli M, Tropeano F, Villani S, Bellandi F (2014) Early high-dose rosuvastatin for contrast-induced nephropathy prevention in acute coronary syndrome: results from the PRATO-ACS Study (protective effect of rosuvastatin and antiplatelet therapy on contrast-induced acute kidney injury and myocardial damage in patients with acute coronary syndrome). J Am Coll Cardiol 63:71–79PubMed

136.

Wang N, Qian P, Yan TD, Phan K (2016) Periprocedural effects of statins on the incidence of contrast-induced acute kidney injury: a systematic review and trial sequential analysis. Int J Cardiol 206:143–152PubMed

137.

Deray G (2006) Dialysis and iodinated contrast media. Kidney Int Suppl 100:S25-29

138.

Guastoni C, Bellotti N, Poletti F, Covella P, Gidaro B, Stasi A, Seveso G, D’Urbano M, Mariani M, De Servi S (2014) Continuous venovenous hemofiltration after coronary procedures for the prevention of contrast-induced acute kidney injury in patients with severe chronic renal failure. Am J Cardiol 113:588–592PubMed

139.

Choi MJ, Yoon JW, Han SJ, Choi HH, Song YR, Kim SG, Oh JE, Lee YK, Seo JW, Kim HJ, Noh JW, Koo JR (2014) The prevention of contrast-induced nephropathy by simultaneous hemofiltration during coronary angiographic procedures: a comparison with periprocedural hemofiltration. Int J Cardiol 176:941–945PubMed

140.

Marenzi G, Mazzotta G, Londrino F, Gistri R, Moltrasio M, Cabiati A, Assanelli E, Veglia F, Rombolà G (2015) Post-procedural hemodiafiltration in acute coronary syndrome patients with associated renal and cardiac dysfunction undergoing urgent and emergency coronary angiography. Catheter Cardiovasc Interv 85:345–351PubMed

141.

Cruz DN, Perazella MA, Bellomo R, Corradi V, de Cal M, Kuang D, Ocampo C, Nalesso F, Ronco C (2006) Extracorporeal blood purification therapies for prevention of radiocontrast-induced nephropathy: a systematic review. Am J Kidney Dis 48:361–371PubMed

142.

Cruz DN, Goh CY, Marenzi G, Corradi V, Ronco C, Perazella MA (2012) Renal replacement therapies for prevention of radiocontrast-induced nephropathy: a systematic review. Am J Med 125:66–78.e3PubMed

143.

Lee PT, Chou KJ, Liu CP, Mar GY, Chen CL, Hsu CY, Fang HC, Chung HM (2007) Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial. J Am Coll Cardiol 50:1015–1020PubMed

144.

Gassanov N, Nia AM, Caglayan E, Er F (2014) Remote ischemic preconditioning and renoprotection: from myth to a novel therapeutic option? J Am Soc Nephrol 25:216–224PubMed

145.

Atanda AC, Olafiranye O (2017) Contrast-induced acute kidney injury in interventional cardiology: emerging evidence and unifying mechanisms of protection by remote ischemic conditioning. Cardiovasc Revasc Med 18:549–553PubMedPubMedCentral

146.

Er F, Nia AM, Dopp H, Hellmich M, Dahlem KM, Caglayan E, Kubacki T, Benzing T, Erdmann E, Burst V, Gassanov N (2012) Ischemic preconditioning for prevention of contrast medium-induced nephropathy: randomized pilot RenPro Trial (Renal Protection Trial). Circulation 126:296–303PubMed

147.

Koch C, Chaudru S, Lederlin M, Jaquinandi V, Kaladji A, Mahé G (2016) Remote ischemic preconditioning and contrast-induced nephropathy: a systematic review. Ann Vasc Surg 32:176–187PubMed

148.

Hu J, Liu S, Jia P, Xu X, Song N, Zhang T, Chen R, Ding X (2016) Protection of remote ischemic preconditioning against acute kidney injury: a systematic review and meta-analysis. Crit Care 20:111PubMedPubMedCentral

149.

Zhou CC, Yao WT, Ge YZ, Xu LW, Wu R, Gao XF, Song KW, Jiang XM, Wang M, Huang WJ, Zhu YP, Li LP, Zhou LH, Xu ZL, Zhang SL, Zhu JG, Li WC, Jia RP (2017) Remote ischemic conditioning for the prevention of contrast-induced acute kidney injury in patients undergoing intravascular contrast administration: a meta-analysis and trial sequential analysis of 16 randomized controlled trials. Oncotarget 8:79323–79336PubMedPubMedCentral

150.

Moretti C, Cerrato E, Cavallero E, Lin S, Rossi ML, Picchi A, Sanguineti F, Ugo F, Palazzuoli A, Bertaina M, Presbitero P, Shao-Liang C, Pozzi R, Giammaria M, Limbruno U, Lefèvre T, Gasparetto V, Garbo R, Omedè P, Sheiban I, Escaned J, Biondi-Zoccai G, Gaita F, Perl L, D’Ascenzo F (2018) The EUROpean and Chinese cardiac and renal Remote Ischemic Preconditioning Study (EURO-CRIPS CardioGroup I): a randomized controlled trial. Int J Cardiol 257:1–6PubMed

151.

Mariani J Jr, Guedes C, Soares P, Zalc S, Campos CM, Lopes AC, Spadaro AG, Perin MA, Filho AE, Takimura CK, Ribeiro E, Kalil-Filho R, Edelman ER, Serruys PW, Lemos PA (2014) Intravascular ultrasound guidance to minimize the use of iodine contrast in percutaneous coronary intervention: the MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) randomized controlled trial. JACC Cardiovasc Interv 7:1287–1293PubMedPubMedCentral

152.

Ali ZA, Karimi Galougahi K, Nazif T, Maehara A, Hardy MA, Cohen DJ, Ratner LE, Collins MB, Moses JW, Kirtane AJ, Stone GW, Karmpaliotis D, Leon MB (2016) Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study. Eur Heart J 37:3090–3095PubMed

153.

Ghumman SS, Weinerman J, Khan A, Cheema MS, Garcia M, Levin D, Suri R, Prasad A (2017) Contrast induced-acute kidney injury following peripheral angiography with carbon dioxide versus iodinated contrast media: a meta-analysis and systematic review of current literature. Catheter Cardiovasc Interv 90:437–448PubMed

Titel: Contrast medium induced acute kidney injury: a narrative review
verfasst von: Valentina Pistolesi
Giuseppe Regolisti
Santo Morabito
Ilaria Gandolfini
Silvia Corrado
Giovanni Piotti
Enrico Fiaccadori
Publikationsdatum: 01.12.2018
Verlag: Springer International Publishing
Erschienen in: Journal of Nephrology / Ausgabe 6/2018
Print ISSN: 1121-8428
Elektronische ISSN: 1724-6059
DOI: https://doi.org/10.1007/s40620-018-0498-y

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

^{Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag}

Kostenlos registrieren

Neu im Fachgebiet Innere Medizin

17.04.2024 | DGIM 2024 | Nachrichten

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Contrast medium induced acute kidney injury: a narrative review

Abstract

Background and aims

Methods

Results and conclusion

Leitlinien kompakt für die Innere Medizin

Neu im Fachgebiet Innere Medizin

Denken Sie bei starker Blutung auch an die Hemmkörper-Hämophilie

Adjuvante Brustkrebstherapie: Doppelt hält besser

Delir kann Demenz begünstigen

Vorsicht mit hohen NSAR-Dosen bei ankylosierender Spondylitis!

Update Innere Medizin

Springer Medizin

Abstract

Background and aims

Methods

Results and conclusion

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 6/2018

Epicardial adipose tissue: new parameter for cardiovascular risk assessment in high risk populations

Ultrasound and color Doppler applications in chronic kidney disease

Reflux nephropathy and the risk of preeclampsia and of other adverse pregnancy-related outcomes: a systematic review and meta-analysis of case series and reports in the new millennium

Definition of a new cut-off for the anti-phospholipase A2 receptor (PLA2R) autoantibody immunoassay in patients affected by idiopathic membranous nephropathy

Significance of the nonneoplastic renal parenchymal findings in robotic partial nephrectomy series

Thinking in 3D: a future for dialysis?

Leitlinien kompakt für die Innere Medizin

Neu im Fachgebiet Innere Medizin

Denken Sie bei starker Blutung auch an die Hemmkörper-Hämophilie

Adjuvante Brustkrebstherapie: Doppelt hält besser

Delir kann Demenz begünstigen

Vorsicht mit hohen NSAR-Dosen bei ankylosierender Spondylitis!

Update Innere Medizin