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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 79-82

Nephrotoxicity of iodixanol versus iohexol inpatients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures


Department of General Medicine, Sher-I-Kashmir Institute of Syeed Basit Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Riyaz Ahmad Bhat
House No. 2, Madina Bagh Chanapora, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.153608

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  Abstract 

Background: The choice of radiographic contrast media for use in patients at increased risk of contrast-induced nephropathy is of ongoing interest. Materials and Methods: The current study is a prospective, randomized in which comparison of nonionic, isoosmolal agent, iodixanol, versus the nonionic, low-osmolal agent, iohexol, on the renal effects was carried out. A total of 526 subjects with impaired baseline renal functionand diabetes mellitus underwent diagnostic and/or therapeutic coronary angiographic procedures. The coprimary end points were the peak increase in serum creatinine and the incidence of contrast-induced nephropathy, that is, ≥0.5 mg/dl in serum creatinine from baseline within 72 h of receiving contrast media. Results: Of the 129 patients, 97 received iodixanol and 97 received iohexol randomly. The median peak increase in serum creatinine in the iodixanol arm was 0.10 mg/dl; whereas in the Iohexol arm, the median peak increase was 0.09 mg/dl (P = 0.13). The overall contrast-induced nephropathy incidence was 10.5% in the iodixanol arm and 9.8% in the iohexol arm (P = 0.7). The volume of contrast media, volume of saline administered, frequency of coronary interventional procedures, and severity of baseline kidney disease and of diabetes mellitus were similar between treatments. Conclusions: In the present study, the overall rate of contrast-induced nephropathy in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures was 10.5%. There was no significant difference between iodixanol and iohexol in either peak increase in serum creatinine or risk of contrast-induced nephropathy.

Keywords: Contrast-induced nephrotoxicity, coronary angiography, iodixanol


How to cite this article:
Bhat RA, Khan I, Noor R. Nephrotoxicity of iodixanol versus iohexol inpatients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures. Int J Health Allied Sci 2015;4:79-82

How to cite this URL:
Bhat RA, Khan I, Noor R. Nephrotoxicity of iodixanol versus iohexol inpatients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures. Int J Health Allied Sci [serial online] 2015 [cited 2020 Oct 1];4:79-82. Available from: http://www.ijhas.in/text.asp?2015/4/2/79/153608


  Introduction Top


Contrast-induced nephrotoxicity (CIN) is defined as acute deterioration in renal function within 72 h in patients receiving radiographic contrast media. Risk factors identified for CIN represent a constellation of clinical and procedure specific variables. Identification of high risk patients and mitigation of the risk of CIN is important for short- and long-term effects on renal recovery. The general agreement exists about the benefit of low-osmolal contrast media for CIN prevention in subjects at risk; differences between iso- and low-osmolal contrast media with respect to CIN continue to motivate research. The current study is a prospective, randomized study comparing the renal effects of the isoosmolal agent, iodixanol (Visipaque, GE Healthcare, Princeton, NJ) with the low-osmolal agent, iohexol (Isovue, Bracco Diagnostics, Inc., Princeton, NJ), in subjectsundergoing coronary angiography with or without percutaneous coronary intervention.


  Materials and methods Top


The study was conducted in the Department of Cardiology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar India, over a period of 2 years from December 2010 to November 2012. This study was cleared by ethical committee. It was a prospective, randomized study in which a total of 194 patientswhounderwent percutaneous coronary angiographic diagnostic and therapeuticinterventions were assessed for change in serum creatinine levels from baseline creatinine after 24, 48, and 72 h of exposure to contrast media. Each patient was randomly assigned to receive one of the two contrast media. The volume used varied and was not standardized. All patients were well hydrated before angiography.

Inclusion criteria

A, Nonazotemic; B, age older than 18 years; and C, diabetes mellitus that was being treated with insulin or oral antidiabetic drugs.

Exclusion criteria

A, Pregnancy; B, lactation; C, intravascular administration of an iodinated contrast medium within the previous 7 days; D, treatment with nonsteroidal anti-inflammatory drugs within the previous 48 h; E, intake of nephrotoxic drugs within the previous 7 days; F, history of serious reaction to iodinated contrast media; and G, newly discovered complicated diabetes.

Patients were divided into two groups: A, Those who received iohexol which include 94 patients and B, those who received iodixanol which include 94 patients.

Statistical analysis

The data was processed in Statistical Package for Social Sciences (SPSS, IBM)-16 using repeated measurement analysis within and between factors. Independent t-test was used to see significant difference of means. P - value (< 0.05) was considered as significant.


  Results Top


Of the 129 patients, 97 received iodixanol and 97 received iohexol randomly. There was no blinding. The two groups appeared to be clinically similar with regard to demographic and other baseline characteristics [Table 1]. The mean serum creatinine (mg/dl) at 72 hrs iodixanol and iohexol group was1.1834 and 1.250, respectively as compared to mean baseline serum creatinine (mg/dl) value of 1.0945 and 1.0433 in two respective groups.
Table 1: Baseline characteristics of two groups

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This difference of rise in mean serum creatinine at 72 h of contrast exposure between iodixanol and iohexol was statistically significant (P - value 0.030) [Table 2]. The overall increase in mean creatinine (mg/dl) over 72 h from baseline in iohexol group was 1.144, while in iodixanol group it was 1.139 (P - value 0.854) [Table 3].
Table 2: Mean serum creatinine comparing iohexol and iodixanol baseline and after exposure to contrast agent

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Table 3: The difference in increase in mean creatinine over 72 h from the baseline between iohexol and iodixanol

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In diabetics, the overall increase in mean creatinine (mg/dl) over 72 h from baseline in iohexol group was 1.200, while in iodixanol group it was 1.079 (P - value 0.125) [Table 4].
Table 4: Mean creatinine comparing iohexol and iodixanol in diabeticsbefore exposure to contrast agent V1 and at 24, 48, and 72 h after contrast exposure

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  Discussion Top


Contrast-induced nephropathy has emerged as an important cause of iatrogenic acute renal impairment due to increasing use of contrast media in both diagnostic and interventional procedures. Contrast-induced nephropathy is the most common cause of in-hospital acute renal failure after hypotension and surgery. [1] CIN is defined as an acute impairment of renal function manifested by an absolute increase in the serum creatinine concentration of at least 0.5 mg/dl (44.2 μmol/l) or by a relative increase of at least 25% from the baseline value. [2],[3],[4],[5],[6]

The consequences of contrast-induced nephropathy are prolonged hospital stay, increased nonrenal morbidity and cardiovascular risk and mortality. [7] Various risk factors like azotemia, diabetes, congestive cardiac failure, advanced age, dehydration, volume, and type of contrast play an important role in the incidence of contrast-induced nephropathy. [3]

Isoosmolar contrast mediums are less nephrotoxic than low-osmolar contrast mediums. The reason is unclear. The difference might be explained by differences in either the osmolality or the chemotoxicity of the contrast mediums or their ionic composition. [8],[9],[10] The osmotic diuresis induced by low-osmolar mediums is generally greater than that induced by isoosmolar mediums. This diuresis may enhance distal sodium delivery, increasing medullary work, and inducing hypoxia or volume depletion, with consequent activation of vasoregulatory hormones.

In our study, we compared the effect of iodixanol with iohexolin patients undergoing coronary angiography (diagnostic or therapeutic). We found that the mean serum creatinine (mg/dl) at 72 h after contrast exposure in iodixanol groupwas 1.1834 compared to mean baseline serum creatinine (mg/dl) value of 1.0945. In comparison, the mean serum creatinine (mg/dl) at 72 h after contrast exposure in iohexol group was 1.2507 compared to mean baseline serum creatinine (mg/dl) value of 1.0433. This difference of rise in mean serum creatinine at 72 h of contrast exposure between iodixanol and iohexol was statistically significant (P = 0.030). This observation suggests that the use of iodixanol is associated with less increase in mean serum creatinine.

The first study to suggest that there was a reduced incidence of nephropathy with iodixanol was published by Chalmers and Jackson, who investigated 124 patients with serum creatinine concentrations of more than 1.7 mg/dl (150 μmol/l), one-third of whom had diabetes (11). In that unblinded study, patients were randomly assigned prospectively to receive either iodixanol or iohexol; the incidence of nephropathy (defined by an increase of 25% or more in the serum creatinine concentration) in the iodixanol group (3.7%) was less than half that in the iohexol group (10.0%). [11]

Various studies have come to the same conclusion. [1],[7],[12],[13],[14],[15],[16]

The overall increase in mean creatinine over 72 h from baseline in iohexol group was 1.144 mg/dl, while in iodixanol group was 1.139 mg/dl (P = 0.854). Furthermore, the overall increasein mean creatinine over 72 h from baseline increase in serum creatinine in iodixanol group was lower than that in iohexol group that was not statistically significant (1.144 versus 1.139, P = 0.854). This observation suggests that following contrast administration there is increase in serum creatinine from the baseline value over a period of 72 h, but increase in serum creatinine on Iodixanol exposure was lower than that on Iohexol exposure.

The incidence of contrast medium-induced nephropathy was 2.06% in the iodixanol group and 5.15% in the iohexol group. Further more, the percentage of diabetic patients who had increase in serum creatinine greater than 25% from the baseline value was 0% in iodixanol group and (5%) in iohexol group. In a study conducted by Peter Aspelin et al., comparing iodixanol with iohexolin contrast-induced nephropathy in diabetics, mean age in iodixanol group was 71.1 ± 6.0 years and that in iohexol group was70.6 ± 8.6 years. Total number of patients in iodixanol group was 64 with 41 being male and 23 female, while in iohexol group total number of patients was 65 with 35 male and 30 female. Mean baseline serum creatinine concentration (mg/dl) iniodixanol group was 1.49 ± 0.53 and in iohexol group was 1.60 ± 0.52. Mean volume of contrast medium (ml) used in iodixanol group was163 ± 88 and in iohexol group was162 ± 82. [17]


  Conclusions Top


There was a statistically significant yet small difference in the nephrotoxicity between the iodixanol and iohexol group in patients undergoing coronary angiography.

 
  References Top

1.
Narang R, Sakahre M, Bahl VK. Contrast-induced nephropathy. Indian Heart J 2004;56:13-20.  Back to cited text no. 1
    
2.
Barrett BJ, Parfrey PS, Vavasour HM, McDonald J, Kent G, Hefferton D, et al. Contrast nephropathy in patient′s with impaired renal function: High versus low osmolar media. Kidney Int 1992;41:1274-9.  Back to cited text no. 2
    
3.
Rudnick MR, Goldfarb S, Wexler L, Ludbrook PA, Murphy MJ, Halpern EF, et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: A randomized trial: The Iohexol Cooperative Study. Kidney Int 1995;47:254-61.  Back to cited text no. 3
    
4.
Taliercio CP, Vlietstra RE, Ilstrup DM, Burnett JC, Menke KK, Stensrud SL, et al. A randomized comparison of the nephrotoxicity of iopamidol and diatrizoate in high risk patients undergoing cardiac angiography. J Am Coll Cardiol 1991;17:384-90.  Back to cited text no. 4
    
5.
Manske CL, Sprafka JM, Strony JT, Wang Y. Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. Am J Med 1990;89:615-20.  Back to cited text no. 5
    
6.
Wang A, Holcslaw T, Bashore TM, Freed MI, Miller D, Rudnick MR, et al. Exacerbation of radiocontrast nephrotoxicity by endothelin receptor antagonism. Kidney Int 2000;57:1675-80.  Back to cited text no. 6
    
7.
Levy EM, Viscoli CM, Horwitz RI. The effects of acute renal failure on mortality. A cohort analysis. JAMA 1996;275:89-94.  Back to cited text no. 7
    
8.
Berg KJ. Nephrotoxicity related to contrast media. Scand J Urol Nephrol 2000;34:317-22.  Back to cited text no. 8
    
9.
Morcos SK. Contrast media-induced nephrotoxicity - questions and answers. Br J Radiol 1998;71:357-65.  Back to cited text no. 9
    
10.
Katzberg RW. Urography into the 21 st century: New contrast media, renal handling, imaging characteristics, and nephrotoxicity. Radiology 1997;204:297-312.  Back to cited text no. 10
    
11.
Chalmers N, Jackson RW. Comparison of iodixanol and iohexol in renal impairment. Br J Radiol 1999;72:701-3.  Back to cited text no. 11
    
12.
Reed MC, Moscucci M, Smith DE, Share D, LaLonde T, Mahmood SA, et al. The relative renal safety of iodixanol and low-osmolar contrast media in patients undergoing percutaneous coronary intervention. Insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). J Invasive Cardiol 2010;22:467-72.  Back to cited text no. 12
    
13.
From AM, Al Badarin FJ, McDonald FS, Bartholmai BJ, Cha SS, Rihal CS. Iodixanol versus low-osmolar contrast media for prevention of contrast induced nephropathy: Meta-analysis of randomized, controlled trials. Circ Cardiovasc Interv 2010;3:351-8.  Back to cited text no. 13
    
14.
McCullough PA, Bertrand ME, Brinker JA, Stacul F. A meta-analysis of the renal safety of isosmolar iodixanol compared with low-osmolar contrast media. J Am Coll Cardiol 2006;48:692-9.  Back to cited text no. 14
    
15.
From AM, Bartholmai BJ, Williams AW, McDonald FS. Iodixanol compared to iohexol for contrast procedures: A case-matched retrospective cohort study. Acta Radiol 2008;49:409-14.  Back to cited text no. 15
    
16.
Waybill MM, Waybill PN. Contrast media-induced nephrotoxicity: Identification of patients at risk and algorithms for prevention. J Vasc Interv Radiol 2001;12:3-9.  Back to cited text no. 16
    
17.
Aspelin P, Aubry P, Fransson S.G. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 2003; 348: 491-499.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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