Contrast medium nephropathy N14.2

Contrast-induced nephropathy (CIN) is a renal complication that can occur after the administration of iodine-containing contrast media (Cousin 2024). An increase in serum creatinine of > 0.5 mg/dl or an increase in creatinine of more than 25 % of the initial value occurs within 3 days of contrast medium administration (Herold 2025).

Contrast media nephropathy is the third most common cause of acute renal failure in hospital, accounting for around 10% of cases (Jörres 2010).

The incidence of CIN in the general population is approx. 1% and - if renal insufficiency is present - 15%. The risk of kidney failure requiring dialysis is around 0.5% (Herold 2025).

The estimated incidence of patients with severe renal failure is between 3-18% after administration of gadodiamide and between 0.1-1% after administration of gadopentetate dimeglumine (ESUR guidelines 2018).

CIN is thought to be multifactorial. It includes:

- Renal vasoconstriction and resulting tissue hypoxia

- Possibly a direct toxicity of iodine derivatives. This leads to inflammation and necrosis of the tubules (Cousin 2024).

In > than 70% of those affected, pre-existing creatinine levels can be restored after approx. 10 days. The remaining 30% may suffer permanent kidney damage (Herold 2025).

• To date, there is no medical prophylaxis that can prevent kidney damage associated with contrast media (ESUR guidelines 2018).
• Hypovolemia before contrast medium administration should be avoided at all costs
• Overall, caution should be exercised with regard to the indication for contrast medium administration in high-risk patients.
• Renal insufficiency in stage CKD G 2 with an eGFR > 60 ml/min/1.73m2: There is no clinically relevant nephrotoxicity in this stage, prophylactic measures are therefore not necessary.
• Renal insufficiency in stage CKD G 3a with an eGFR of 60 to 45 ml/min/1.73m2: No prophylactic measures are required for intravenous administration of X-ray contrast media. In the case of additional risk factors, adequate hydration is necessary before and especially after the examination. This can be done with 0.9 % saline solution of at least 1,000 ml before and up to 12 h after administration of the contrast medium.
• Renal insufficiency in stage CKD G 3b with an eGFR of 45 to 30 ml/min/1.73m2: Hydration measures are necessary for both i.a. and i.v. administration. The intake of RAAS inhibitors must be paused 48 h before administration of the contrast medium.
• Renal insufficiency in stage CKD 4 with an eGFR < 30 ml/min/1.73m2: Alternative imaging methods should be used from this stage onwards (Herold 2025).

General information

• Patient-related risk factors for CIN are:
  • Known or suspected acute kidney failure (ESUR guidelines 2018)
  • Pre-existing renal insufficiency, especially with concomitant diabetes mellitus and multiple myeloma (Herold 2025)
  • Congestive heart failure
  • Dehydration
  • Hypotension
  • Diabetes mellitus (Cousin 2024)
  • anemia
  • Use of NSAIDs

• Risk factors for CIN caused by the examination are:
  • High osmolar contrast media 1,200 mosmol/l (the least toxic is isoosmolar iodixanol with 300 mosmol/l)
  • Repeated administration of contrast medium (Herold 2025)

• Prevention of CIN:

- When measuring renal function, the eGFR should be determined to assess renal function, as neither serum creatinine nor plasma creatinine is a reliable indicator of renal function (ESUR guidelines 2018).

- In high-risk patients, a cautious indication of X-ray contrast media is recommended (Herold 2025)

- Sufficient intravenous fluids should be administered before and after contrast administration

- Application of the smallest possible amount of contrast medium

- Administration of metformin and non-steroidal anti-inflammatory drugs at the time of contrast agent administration is contraindicated (Cousin 2024). The intake of metformin should only be resumed after the administration of the contrast agent if there has been no significant change in renal function within 48 hours (ESUR guidelines 2018).

- The least toxic are isoosmolar (300 mosmol/l) iodixanol (Herold 2025).

1. Cousin F, Moise M, Ilbert C, Meunier P, Jouret F (2024) Prevention of contrast-induced nephropathy. Rev Med Liege. 79 (5-6) 418-423
2. ESUR guidelines (2018) ESUR guidelines for contrast media (European Society of Urogenital Radiology) Version 10.0
3. Herold G et al (2025) Internal medicine. Herold Publishing House 1026-1027
4. Jörres A (2010) Acute renal failure in intensive care patients: practice and therapy. Deutscher Ärzteverlag GmbH Cologne 23