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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 21-24

The incidence of contrast-induced nephropathy after computed tomography angiography in orthopedic trauma patients


1 Department of Orthopaedic Surgery, Mount Sinai St. Luke's, Mount Sinai West, New York, NY, USA
2 Department of Orthopedic Surgery, Miami Institute for Joint Reconstruction, Miami, FL, USA

Date of Web Publication29-May-2017

Correspondence Address:
Jeremy D Podolnick
Department of Orthopaedic Surgery, Mount Sinai West Hospital, 1000, 10th Avenue, New York, NY 10019
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_15_16

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  Abstract 


Objectives: The aim of this study is to determine the incidence of contrast-induced nephropathy (CIN) after computed tomography angiography (CTA) in orthopedic trauma patients. Design: Retrospective chart review. Setting: Mount Sinai St. Luke's-Roosevelt patient data. Patients and Methods: Patients who presented to our Level I emergency department after a trauma who were diagnosed with a high energy or penetrating injury to an extremity or pelvis and who underwent CTA as a part of their initial work-up from July 2004 to June 2014. Intervention: The incidence of CIN was assessed. Main Outcome Measurements: The main outcome measure was the development of CIN after CTA. CIN was defined as an increase in baseline creatinine of 25% or greater or an increase in baseline creatinine of 0.5 mg/dL within 48–72 h of contrast exposure. Results: A total of 51 patients were included in this study. Of these patients, 27 had a repeat creatinine level available for review. The incidence of CIN was found to be 3.7% in this specific population of patients. The creatinine level of the 1 patient who developed CIN normalized by hospital day 2. None of the patients included in this study developed symptoms of or were readmitted for kidney injury. Conclusions: This review supports the use of CTA as a relatively safe diagnostic tool in orthopedic trauma patients.

Keywords: Computed tomography angiography, contrast-induced nephropathy, orthopedic trauma, vascular injury


How to cite this article:
Podolnick JD, Howard DR, Forsh D, Pino A. The incidence of contrast-induced nephropathy after computed tomography angiography in orthopedic trauma patients. J Orthop Traumatol Rehabil 2017;9:21-4

How to cite this URL:
Podolnick JD, Howard DR, Forsh D, Pino A. The incidence of contrast-induced nephropathy after computed tomography angiography in orthopedic trauma patients. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2017 Oct 16];9:21-4. Available from: http://www.jotr.in/text.asp?2017/9/1/21/207163




  Introduction Top


Orthopedic patients who present after a high energy or penetrating injury to the extremities or pelvis should be immediately assessed for a vascular injury during the primary and secondary trauma survey. If a vascular injury is suspected based on clinical examination or noninvasive testing, computed tomography angiography (CTA) has been shown to be an excellent diagnostic imaging examination with high sensitivity and specificity.[1]

Despite the benefits of CTA, it does pose some risk to the patient. One of the most discussed risks is that of contrast-induced nephropathy (CIN). CIN has been defined as the acute deterioration of renal function after intravenous (IV) administration of radiocontrast media in the absence of other causes.[2] The incidence of CIN has been found to range from 2% to 30%. Tepel et al. identified patients at a higher risk as those with chronic renal dysfunction, diabetes mellitus (DM), congestive heart failure, and advanced age. The development of CIN has been associated with increased patient morbidity, length of stay, and overall treatment cost.[2]

Most studies focusing on CIN in trauma patients have found that CTA is not an independent risk factor for the development of kidney dysfunction. However, there have been no studies that focus on the subgroup of orthopedic trauma patients. This study aims to define the incidence of CIN in orthopedic trauma patients, given their unique injuries compared with general trauma patients. Orthopedic trauma injuries such as long bone fractures and penetrating injuries to the extremities lead to large inflammatory reactions and may contribute to extensive fluid shifts due to hemorrhage. As such, fluid management is important in these patients and adequate resuscitation is necessary to maintain organ perfusion. Given these challenges in orthopedic trauma patients, they are at risk for acute kidney injury (AKI) and may differ in their susceptibility to CIN after CTA compared with general trauma patients.


  Patients And Methods Top


The study approval was obtained from the Institutional Review Board. A retrospective review was performed of all CTA scans performed of the upper extremities, lower extremities, and/or pelvis of patients in the emergency department of our Level I Trauma Center from July 2004–June 2014. Of the CTA scans that were performed, we identified those that were ordered for the evaluation of a traumatic injury such as fracture, stab wound, gunshot wound, or blunt trauma, and defined these as orthopedic trauma patients for inclusion in the study. The charts of these patients were reviewed to confirm that they had suffered an orthopedic injury.

Demographic and clinical information were collected on all patients identified in this review. Demographic information included age, gender, and ethnicity. Ethnicity was recorded as African-American or other, given that African-American patients have been shown to have higher rates of AKI and kidney function decline.[3] Clinical information collected included a prior diagnosis of hypertension (HTN), chronic kidney disease, prior dialysis treatment, DM, mechanism of injury, fracture diagnosis, and vascular injury detected by CTA. Laboratory information collected included creatinine for 72 h and hemoglobin for 72 h when available. Additional information collected included blood pressure on presentation, heart rate on presentation, number of CTAs within 72 h, and medications administered in the first 72 h, which were cross-referenced with lists of potentially nephrotoxic medications.[4],[5]

Laboratory and physical examination abnormalities were reviewed. Abnormal laboratory findings included creatinine >1.3 mg/dL, hemoglobin <12 g/dL, heart rate <60 or >100 beats per min, and systolic blood pressure <100 mmHg. The estimated glomerular filtration rate (eGFR) was calculated based on the modification of diet in renal disease study equation. An abnormal eGFR was defined as <60 mL/min/1.73 m 2.

Patients who developed CIN were identified from among those who had repeat creatinine values, and the incidence of CIN was calculated. CIN was defined as an increase in baseline creatinine of 25% or greater or an increase in baseline creatinine of 0.5 mg/dL within 48–72 h of contrast exposure.[6]

Inclusion criteria were all patients who underwent a CTA for the evaluation of possible vascular injury after traumatic injury to an extremity or pelvis. Exclusion criteria included patients with a previous diagnosis of chronic renal failure. No protected health information was collected or reported.


  Results Top


A chart review identified 52 patients who had a CTA of an extremity or pelvis to evaluate vascular anatomy after a traumatic orthopedic injury. One of these patients had a prior diagnosis of chronic kidney disease on hemodialysis and was excluded from the study. Clinical notes were unavailable for seven patients due to a change in electronic medical records systems; although, the laboratory values and radiology reports were available for these patients and analyzed for the study. The average age of the patients was 35.8 ± 17.5 (range 17–88) years with three being 65-year-old or greater. Forty-five patients were male and six were female. Twenty-four patients were diagnosed with a fracture or dislocation. The average Injury Severity Score (ISS) of the patients was 7.9 ± 4.9 (range 2–22). Twenty-seven patients had a repeat creatinine available for comparison collected within 24 h of the CTA, and these patients had an average ISS of 10.1 ± 5.3 (range 4–22).

Of the 51 patients in this cohort, 27 (52.9%) had a repeat basic metabolic panel collected within 24 h of the CTA, 15 (29.4%) had a repeat basic metabolic panel collected within 48 h of the CTA, and 12 (23.5%) had a repeat basic metabolic panel collected within 72 h of the CTA. Three of the six patients with a creatinine >1.3 mg/dL on presentation had a repeat basic metabolic panel within 24 h, and all had a return to normal levels. The mechanisms of injury in these six patients were gunshot wound (n = 5) and motorcycle accident (n = 1).

Thirty-seven of the 51 patients were admitted to the hospital for further evaluation. All but one patient with an abnormal creatinine on presentation were admitted to the hospital. Twenty-seven of the 37 admitted patients had repeat creatinine levels recorded. None of the admitted patients developed symptoms of kidney disease. Of the remaining patients who were discharged after treatment in the emergency department, none returned to the hospital system with the signs or symptoms of kidney disease.

The most common mechanism of injury was a gunshot wound (n = 25). Other mechanisms identified were stab wounds (n = 8), pedestrians struck by a vehicle (n = 5), fall from standing (n = 3), motor vehicle accidents (n = 3), fall from height (n = 2), and other (n = 5). CTA detected five patients with vascular injury and one additional patient with a possible vascular injury.

The incidence of CIN, calculated from the 27 patients who had repeat creatinine values, was 3.7% (n = 1). One additional patient met the criteria of CIN but had a prior diagnosis of chronic kidney disease on hemodialysis and was excluded from the study. The one patient who met the criteria for CIN was a 50-year-old, non-African-American male, who sustained a gunshot wound to his leg causing a tibial plateau fracture and a vascular injury. His initial creatinine was 1.1 mg/dL, which then increased to 1.4 mg/dL on hospital day 1. This subsequently normalized and was 0.9 mg/dL on hospital day 2. On presentation, his eGFR was 75.31 mL/min/1.73 m 2 and hemoglobin was 15.7 g/dL.

Of the 47 patients in whom documented medications received were available in the medical records, 37 received at least one medication that is considered potentially nephrotoxic, and 28 received two or more medications that are considered potentially nephrotoxic. Therefore, no connection could be made between potentially nephrotoxic medications and the incidence of CIN in these patients.


  Discussion Top


In the orthopedic trauma patient with a suspected or possible arterial injury, immediate and accurate diagnosis is paramount. CTA is a rapid diagnostic tool to identify vascular injury. CTA has been shown to be an excellent screening tool. A recent meta-analysis quoted the sensitivity and specificity of CTA at detecting vascular injury at 96.2% (95% confidence interval [CI]: 93.5%–97.8%) and 99.2% (95% CI: 96.8%–99.8%), respectively.[1],[7] However, the administration of IV contrast during CTA has been associated with adverse reactions, chiefly contrast-induced nephropathy.

CIN is defined as “the acute deterioration of renal function after parenteral administration of radiocontrast media in the absence of other causes.”[2] Quantitative values used to make the diagnosis of CIN are an increase in serum creatinine concentration >0.5 mg/dL or 25% increase in creatinine above baseline within 48 h of contrast administration.[2] Although the exact mechanism of pathology is not fully identified, it has been hypothesized that increased vasoconstriction and decreased vasodilation in the kidney leads to ischemic changes. In addition, contrast media may have a direct toxic effect on renal tubular cells.[2]

Although the increase in serum creatinine is transient in most cases, it may lead to increased morbidity and mortality in some patients.[6] In 2009, a review of 294 patients who were enrolled in a prospective, randomized, double-blind comparison of CIN prevention strategies was performed. This review found that the patients who developed CIN had a statistically higher rate of major adverse events after more than 1 year of follow up, including death, stroke myocardial infarction, and end-stage renal disease that required dialysis, as compared to the group that did not develop CIN.[8]

The risk of CIN or AKI after contrast administration specifically in trauma patients has been quoted between 1.9% and 29.8%.[9],[10],[11],[12],[13],[14],[15] Most literature has found that IV contrast administration is not an independent risk factor for the development of CIN or AKI.[10],[14],[15]

Kim et al.[15] performed a retrospective review of all patients admitted to a Level I trauma center Intensive Care Unit for >48 h, excluding those with chronic renal dysfunction. There were 571 patients who met the inclusion criteria and of those, 170 (29.8%) developed AKI. Age ≥65 and ISS ≥25 were independent risk factors for the development of CIN. In this cohort, exposure to IV contrast was not an independent risk factor for the development of CIN. Colling et al. performed a retrospective review of all blunt trauma patients admitted over a 1-year period. They found the incidence of CIN was 4% and 1% of these patients had continued kidney dysfunction on discharge. DM and ISS >16 were risk factors found to be significantly associated with CIN. A review by Hipp et al.[13] of 235 trauma patients who had a computed tomography with contrast and a repeat creatinine within 48 h found the incidence of CIN to be 5.1%. Risk factors for the development of CIN were elevated baseline creatinine and increased age.

After reviewing the literature, no studies were found that focused on the relationship between CIN and CTA in orthopedic trauma patients. However, there are data focusing on the kidney profile of orthopedic patients. Paul et al.[16] conducted a prospective study of 55 patients with orthopedic arm and/or leg trauma; although, they did not specifically focus on the relationship between contrast administration and kidney dysfunction. Of the 55 patients, five developed acute renal failure; three of these patients recovered and two died. They found a correlation between acute renal failure and lower extremity injuries, mangled extremity severity score >7, increased age, presentation in shock, and increased myoglobin.

An analysis of 893 patients who underwent orthopedic surgery was performed in 2012 to determine the incidence of kidney dysfunction after both elective orthopedic surgery and orthopedic surgery due to trauma.[9] The incidence of kidney dysfunction was found to be 8.9%. The factors that were significantly correlated with the development of kidney disease were perioperative dehydration, history of DM, preexisting kidney dysfunction, perioperative shock, administration of nonsteroid anti-inflammatory drugs, and administration of nephrotoxic antibiotics.

The results of our review were similar to previously published papers. Patients with chronic renal failure were excluded, and only one patient developed CIN. This patient was an elderly male diagnosed with a tibial plateau fracture and a vascular injury, who had a rise in his serum creatinine to >25% above his baseline which subsequently resolved by his second hospital day. All patients with repeat creatinine that presented with an elevated creatinine or abnormally low glomerular filtration rate (GFR) saw a decrease in creatinine levels. Interestingly, no patient with a diagnosis of HTN or DM presented with an abnormal creatinine or GFR.

Our findings may be attributed to several factors. The mean age of the patients in this cohort was 36.6-year-old. Prior studies have found age >65 to be a risk factor for development of CIN.[15] In addition, review of the data we collected shows that most of these patients were relatively healthy. The majority of our patients presented with isolated injuries, reflected by our average ISS of 7.9. Only three patients in our study had an ISS over 16 (an additional four had an ISS equal to 16), the level in the study by Colling et al.[17] that showed increased risk for CIN. None of the patients in our study had an ISS ≥25, which was a risk factor for CIN in the study by Kim et al.[15] In the 41 patients for which the data were available, two had a history of DM, six had a history of HTN, and two had a history of chronic kidney disease. Only four patients presented with an abnormal eGFR (<60 mL/min/1.73 m 2) and only two patients presented with an abnormal hemoglobin level (<10 g/dL). In 31 of these patients, the chart specifically lists IV fluid (IVF) as being administered, in the rest, it is unavailable for review, or it was not listed. However, it is difficult to imagine that in a patient presenting as a trauma, IVF was not started in the field or immediately on arrival to the emergency department. The use of periprocedural IVF to prevent the development of CIN is supported by current recommendations.[2] The combination of a relatively young, healthy population and the administration of IVF are most likely why the rate of CIN was minimal.

We recognize that there are several limitations in this study. Although we collected data over 10 years, there were only 51 patients who met criteria for inclusion, and increasing our sample size would give a more accurate incidence of CIN in the orthopedic trauma patient. In addition, half of the patients identified did not have a repeat creatinine for comparison. No patient without a repeat creatinine presented back to our hospital system after discharge within 72 h, and therefore, we believe that it was unlikely that any of these patients developed renal failure; however, CIN may be asymptomatic and transient. Due to the retrospective nature of the study and due to the limitations of the data review, some clinical notes were inaccessible. Future studies on CIN in orthopedic trauma patients could be conducted prospectively and in multiple centers to increase sample size and variety in ISS of patients undergoing CTA for orthopedic trauma.


  Conclusions Top


This retrospective review identified 51 patients over 10 years of data at a Level I trauma center that sustained trauma to the extremities or pelvis and subsequently underwent CTA as a part of their initial evaluation. We found that one patient met the criteria for the development of CIN, and it resolved rapidly. The incidence of CIN is low in patients who have undergone CTA after sustaining orthopedic trauma but a larger study is necessary to validate these results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: The role of CT angiography. Orthopedics 2008;31:761-7.  Back to cited text no. 1
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Peralta CA, Katz R, DeBoer I, Ix J, Sarnak M, Kramer H, et al. Racial and ethnic differences in kidney function decline among persons without chronic kidney disease. J Am Soc Nephrol 2011;22:1327-34.  Back to cited text no. 3
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Choudhury D, Ahmed Z. Drug-associated renal dysfunction and injury. Nat Clin Pract Nephrol 2006;2:80-91.  Back to cited text no. 4
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McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, et al. Frequency of acute kidney injury following intravenous contrast medium administration: A systematic review and meta-analysis. Radiology 2013;267:119-28.  Back to cited text no. 14
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