Hydrierung zur Prävention der Kontrastmittel-induzierten Nephropathie: Ein Update

Zusammenfassung

Die Kontrastmittel-induzierte Nephropathie (CIN) ist eine der häufigsten Ursachen für ein in der Klinik erworbenes akutes Nierenversagen. Da klinische Studien zum präventiven Nutzen verschiedenster Pharmaka überwiegend enttäuschende Ergebnisse zeigten, bleibt die Hydrierung weiterhin die wichtigste Maßnahme zur Prävention der CIN. Einige aktuelle prospektive, randomisierte Studien haben neue Evidenz zur Wirksamkeit der Hydrierung erbracht und wichtige Hinweise zur Optimierung der Hydrierungsprotokolle geliefert. So konnte gezeigt werden, dass eine Bolushydrierung ausschließlich während der Kontrastmitteluntersuchung zur Prävention der CIN nicht ausreicht. Des Weiteren hat sich die Überlegenheit einer isotonen, 0,9 %igen Kochsalzlösung gegenüber der häufig verwendeten halbisotonen, 0,45 %igen Kochsalzlösung erwiesen. Ein Protokoll für ambulante Patienten mit einer Kombination aus oraler Hydrierung vor der Untersuchung und forcierter intravenöser Hydrierung während und nach der Untersuchung scheint ähnlich effektiv zu sein wie die übliche intravenöse Hydrierung über 24 h. Ein ebenfalls gerade für ambulante Patienten interessantes Hydrierungsprotokoll könnte die Infusion von Natriumbikarbonat beinhalten. In einer aktuellen Studie war die Infusion einer Natriumbikarbonatlösung als Bolus über 1 h vor der Untersuchung, gefolgt von einer Infusion über 6 h nach der KM-Applikation, deutlich wirksamer zur Prophylaxe der CIN als die Infusion von Kochsalzlösung. Insgesamt fehlen jedoch weiterhin größere Multicenterstudien, die verschiedene Hydrierungsprotokolle miteinander vergleichen und ihren Einfluss auf klinisch relevante Endpunkte wie Mortalität oder Dialysepflichtigkeit untersuchen.

Abstract

Contrast medium-induced nephropathy (CIN) continues to be one of the most common causes of hospital-acquired acute renal failure. Since most of the clinical studies on the prophylactic use of different drugs to prevent CIN produced disappointing results, hydration remains the mainstay of prophylaxis. A number of recent prospective randomized trials provided further evidence of the effectiveness of hydration and relevant information regarding the optimization of hydration protocols. It was shown that a bolus hydration solely during examination is not sufficient to prevent CIN. In addition, isotonic 0.9 % saline was superior to the commonly used halfisotonic 0.45 % saline in another trial. An outpatient hydration protocol including oral hydration before the examination followed by forced intravenous hydration over 6 hrs. beginning 30 to 60 min. prior to examination seems to be comparable to the usual hydration over 24 hrs. Another hydration protocol, which could also be very attractive especially for outpatients, included the infusion of sodium bicarbonate. In a recent trial, hydration with sodium bicarbonate, given as a bolus for 1 hr. prior to examination followed by an infusion for 6 hrs. after examination, was more effective than hydration with sodium chloride for the prophylaxis of CIN. However, there is still a lack of large-scale, multi-center trials comparing different hydration protocols and investigating their influence on clinically relevant endpoints such as mortality or the need for dialysis.

Key words

Biological effects - safety - contrast agents

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