PCI complications: renal failure

# Overview
Acute kidney injury (AKI) occurs in approximately 7% of patients undergoing PCI, of whom 3% develop AKI that requires dialysis. Increased occurrence of AKI among patients undergoing PCI is associated with the presence of STEMI, preexisting baseline renal failure and cardiogenic shock.  The occurrence of AKI following PCI is associated with increased in-hospital mortality.

# Renal Failure

## Causes
Renal dysfunction following contrast administration during angiography may relate to either contrast induced nephropathy (CIN), cholesterol embolization syndrome, or both.
- Contrast Induced Nephropathy
The risk of CIN is dependent on the dose of the contrast agents used, hydration status at the time of the procedure, pre-existing renal function of the patient, age, hemodynamic stability, anemia, and diabetes, and the risk for cholesterol embolization syndrome relates to catheter manipulation in an ascending or descending atherosclerotic aorta that releases cholesterol crystals.
While the risk of hemodialysis is less than 3 percent in cases of uncomplicated CIN, the in-hospital mortality in the setting of hemodialysis exceeds 30 percent.
- The risk of CIN is dependent on the dose of the contrast agents used, hydration status at the time of the procedure, pre-existing renal function of the patient, age, hemodynamic stability, anemia, and diabetes, and the risk for cholesterol embolization syndrome relates to catheter manipulation in an ascending or descending atherosclerotic aorta that releases cholesterol crystals.
- While the risk of hemodialysis is less than 3 percent in cases of uncomplicated CIN, the in-hospital mortality in the setting of hemodialysis exceeds 30 percent.

## Risk Factors
- Prior renal insufficiency
- Diabetes Mellitus
- Dehydration before the procedure
- Congestive Heart Failure
- Larger volumes of contrast material
- Nephrotoxic drugs
- Recent (<48 hour) contrast exposure.

## Natural History, Complications and Prognosis

### Prognosis
- The morbidity and mortality associated with PCI relates directly to the extent of baseline renal disease.
- Patients with evidence of mild renal dysfunction have a 20 percent higher risk of death a one year following PCI than patients with preserved renal function.
- Mild renal dysfunction following PCI may increase the risk of death up to four fold at one year following PCI compared with patients with preserved renal function.
- Worsening of renal function may occur after contrast agent administration in 13 to 20% of patients.
- 5% patient will have a 1 mg/dl increase of creatinine following angiography.
- <1% chronic dialysis.

## Toxicities Associated with Radiocontrast Agents
- Allergic (anaphylactoid) reactions
Grade I: Single episode of emesis, nausea, sneezing, or vertigo
Grade II: Hives, multiple episodes of emesis, fevers, or chills
Grade III: Clinical shock, bronchospasm, laryngospasm or edema, loss of consciousness, hypotension, hypertension, cardiac arrhythmia, angioedema, or pulmonary edema
- Grade I: Single episode of emesis, nausea, sneezing, or vertigo
- Grade II: Hives, multiple episodes of emesis, fevers, or chills
- Grade III: Clinical shock, bronchospasm, laryngospasm or edema, loss of consciousness, hypotension, hypertension, cardiac arrhythmia, angioedema, or pulmonary edema
- Cardiovascular toxicity
Electrophysiologic
Bradycardia (asystole, heart block)
Tachycardia (sinus, ventricular)
Ventricular fibrillation
Hemodynamic
Hypotension (cardiac depression, vasodilation)
Heart failure (cardiac depression, increased intravascular volume)
- Electrophysiologic
Bradycardia (asystole, heart block)
Tachycardia (sinus, ventricular)
Ventricular fibrillation
- Bradycardia (asystole, heart block)
- Tachycardia (sinus, ventricular)
- Ventricular fibrillation
- Hemodynamic
Hypotension (cardiac depression, vasodilation)
Heart failure (cardiac depression, increased intravascular volume)
- Hypotension (cardiac depression, vasodilation)
- Heart failure (cardiac depression, increased intravascular volume)
- Nephrotoxicity
- Discomfort
Nausea
Vomiting
Heat and flushing
- Nausea
- Vomiting
- Heat and flushing
- Hyperthyroidism

# 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)

## Contrast-Induced Acute Kidney Injury (DO NOT EDIT)

## PCI in Chronic Kidney Disease (DO NOT EDIT)