CORRESPONDENCE: LETTER TO THE EDITOR
Prophylactic Use of Hemodialysis to Prevent Radiocontrast-Induced NephropathyThe Discussion Is Open Again!
Dominik E. Uehlinger, MD*
* Universität Bern, Klinik und Poliklinik für Nephrologie und Hypertonie, Freiburgstrasse 15, 3010 Bern-Inselspital, Switzerland (Email: uehlinger{at}mph.unibe.ch).
Lee et al. (1) present very interesting results on the prophylactic use of hemodialysis to prevent radiocontrast-induced nephropathy. Unfortunately, the quality of their discussion falls behind the quality of the data presented. The authors somehow fail to mention that several randomized controlled studies have previously failed to show an improvement of renal outcome by prophylactic hemodialysis after radiocontrast media application and that a recent meta-analysis of the controlled studies has revealed no advantage of prophylactic hemodialysis with respect to outcome (2). The failure to mention the previous controlled studies hindered the authors to emphasize the differences between their study and the ones previously done.
In contrast to previous studies including our own (2,3), the authors were very careful to avoid intravascular volume depletion during the prophylactic dialysis procedure. Not only was there no ultrafiltration provided during dialysis, but saline was administered at the beginning of the dialysis procedure to counteract expected volume shifts out of the vascular space into the intracellular space during dialysis. Although patients might have profited from the careful volume control during the prophylactic dialysis session, it is conceivable that the poor outcome of patients without dialysis might have resulted from the lack of a comparable volume management. According to protocol, patients were dialyzed when they remained oliguric despite 1,000 mg of furosemide. In a setting where dialysis is possible at any time, the approach to oliguria might be the application of volume rather than furosemide!
No study has so far been done in patients with such an advanced degree of renal failure (i.e., with a mean creatinine clearance of about 13 ± 4 ml/min), and the observed poor outcome of the patients in the control group might well be related to the advanced renal failure before the procedure. However, polymorbid patients with a glomerular filtration rate slightly above 10 ml/min might profit from the initiation of a chronic renal replacement therapy even without the administration or radiocontrast media.
Given all the information available today, the study by Lee et al. (1) does not provide enough evidence to prophylactically dialyze all patients with advanced renal failure; nevertheless, it certainly reopens the discussion about this subject!
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1. Lee PT, Chou KJ, Liu CP, et al. Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial. J Am Coll Cardiol 2007;50:1015-1020.[Abstract/Free Full Text]2. Cruz DN, Perazella MA, Bellomo R, et al. Extracorporeal blood purification therapies for prevention of radiocontrast-induced nephropathy: a systematic review Am J Kidney Dis 2006;48:361-371.[CrossRef][Medline] 3. Vogt B, Ferrari P, Schonholzer C, et al. Prophylactic hemodialysis after media in patients with renal insufficiency is potentially harmful Am J Med 2001;111:692-698.[CrossRef][Web of Science][Medline]
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