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Journal of Biochemistry and Molecular Biology Research Journal of Biochemistry and Molecular Biology Research Online Submissions: http://www.ghrnet.org/index./jbmbr/ J. of Biochemistry and Molecular Biology Res 2015 March 1(1): 1-13 doi:10.6051/j.issn.2313-7177.2015.01.3 ISSN 2313-7177 (print) EDITORIAL Cytotoxic Effects of Contrast Media on Renal Tubular Cells. Pathogenesis of Contrast-induced Acute Kidney Injury and Prevention Michele Andreucci, Teresa Faga, Ashour Michael Michele Andreucci, Teresa Faga, Ashour Michael, Nephrology Key words: Contrast induced nephropathy; Nephrotoxicity; Cell Unit, Department of “Health Sciences”, Campus “Salvatore Venuta”, death, Kinase; Cell signalling “Magna Graecia” University, Viale Europa, loc. Germaneto, I-88100 Catanzaro, Italy Andreucci M, Faga T, Michael A. Cytotoxic Effects of Contrast Correspondence to: Michele Andreucci, MD, PhD, Associate Media on Renal Tubular Cells. Pathogenesis of Contrast-induced Professor of Nephrology, Magna Graecia” University, I-88100 Cat- Acute Kidney Injury and Prevention. Journal of Biochemistry and anzaro, Italy Molecular Biology Research 2015; 1(1): 1-13 Available from: URL: Email: [email protected] http://www.ghrnet.org/index.php/jbmbr/article/view/1012 Telephone: +39-339-6814750 Received: January 8, 2015 Revised: January 30, 2015 Accepted: February 4, 2015 INTRODUCTION Published online: March 30, 2015 The continued growth in radiographic procedures for either diagnostic or therapeutic purposes (coronary angiography and ABSTRACT percutaneous coronary interventions) is leading to an increasing number of cases of contrast-induced Acute Kidney Injury (CI-AKI) [1-3] The continued growth in radiographic procedures for diagnostic or secondary to Iodinated RadioContrast Agents (IRCA) . This is in therapeutic purposes is leading to an increasing number of cases part due to the type of patients undergoing these procedures, usually of contrast-induced Acute Kidney Injury (CI-AKI) secondary to being of advanced age, with one or more comorbid conditions, such Iodinated RadioContrast Agents (IRCA). In this review, following as advanced vascular disease, severe long-standing hypertension, [4-7] a brief description of IRCA and CI-AKI, the pathogenesis of CI- diabetes and some renal function impairment . AKI is discussed in detail, particularly focusing on the direct toxic effects by IRCA on endothelial cells, red blood cells and mainly on THE IODINATED RADIOCONTRAST AGENTS renal tubular epithelial cells. In vitro studies of the effects of different IRCA on various signalling pathways known to play a role in cellular (IRCA) survival, growth and proliferation are reported, demonstrating that In the last few decades, attempts have been made by many IRCA cause several and significant changes in a variety of cell investigators to reduce the nephrotoxicity of IRCA making them signalling molecules that play important roles in cellular homeostasis. more soluble, while at the same time allowing more opacity by Factors favouring toxic effects by IRCA on renal tubular epithelial increasing the content of iodine atoms per molecule. Thus, IRCA cells and protection of tubular cells against IRCA toxicity (by have undergone a series of chemical modifications. Firstly, hydrogen e.g. asialoerythropoietin, human serum albumin–Thioredoxin, atoms on the benzene ring have been substituted in order to reduce extracellular volume expansion) are discussed. Measures to protein binding: acetrizoates and diatrizoates were obtained in this prevent IRCA nephrotoxicity by antioxidants and recent studies way. These compounds are ionic and are known as high-osmolar demonstrating reversal of IRCA toxicity on human renal proximal contrast media. The next step was to replace the carboxyl groups tubular cells by white grape juice extract conclude the review. with non-polar groups giving non-ionic soluble molecules with lower osmolality (low-osmolar contrast media); these were further © 2015 ACT. All rights reserved. improved by the addition of more hydroxyl groups for increased 1 © 2015 ACT. All rights reserved. Andreucci M et al . Cytotoxic effects of contrast media hydrophilicity, followed by a more even distribution of the hydroxyl small changes of GFR when GFR is high. It has been thought that groups on the molecule. Finally, the dimerization of two molecules estimates of small changes of renal function based on a rise in serum via side chains on the benzene ring resulted in the non-ionic and cystatin C to be more accurate than those based on a rise in SCr when iso-osmolar group of contrast media with increased iodine atoms the GFR is near to the normal range. Thus, the behaviour of SCr has per molecule[8,9]. Thus, these chemical modifications have resulted been compared to that of cystatin C, although unfortunately, it has in the availability of newer low-osmolar and iso-osmolar IRCA turned out that the relationship between serum cystatin C and GFR immediately used in clinical practice, and it is acknowledged that was also exponential[22]. Equations based on standardized cystatin C the low-osmolar IRCA and iso-osmolar IRCA are less nephrotoxic (CKD-EPI cystatin C equation) or cystatin C and creatinine (combined than high-osmolar IRCA[10]. Despite this, in vitro cell culture studies CKD-EPI equation) were then proposed by the CKD-EPI consortium have suggested that all of these types of IRCA still have a direct in 2012[23]. The better suitability of these equations (and especially toxic effects on many different types of cells and may cause CI-AKI. the combined CKD-EPI equation) has been shown in different Modern IRCA are based on the triiodinated benzene ring[9]. The most populations[24-26]. It has been recently observed that eGFRcr-cys, common IRCA used in clinical practice are listed in table 1[11,12]. but not eGFRcys, is more accurate than eGFRcr in measuring small changes in renal function[27]. Even the recent KIDGO guidelines [28] CONTRAST-INDUCED ACUTE KIDNEY IN- on CKD recommended using eGFRcr for the initial evaluation and using eGFRcys or eGFRcr-cys for confirmation in the clinical JURY (CI-AKI) settings in which eGFRcr is less accurate. But other Authors[29,30] The most important adverse effect of IRCA is undoubtedly CI- found that estimates of GFR based on cystatin C were not superior AKI, frequently called Contrast-Induced Nephropathy (CIN). It is to those based on SCr in the general population. In other words, an asymptomatic transient impairment of renal function, usually there is no evidence that equations based on cystatin C alone or in non-oliguric, occurring 24-72 hours after exposure to intravascular combination with creatinine provide better GFR estimates in middle- injection of IRCA that cannot be attributed to other causes[13-15]. aged members of the general population than the commonly used The KDIGO Group[16] “proposes that the term Contrast Induced- MDRD and CKD-EPI equations. Acute Kidney Injury (CI-AKI) (rather than CIN) be used for patients Sometimes CI-AKI may cause a severe impairment of renal developing AKI secondary to intravascular radiocontrast media function with oliguria (<400 mL/24 hrs), requiring dialysis. In such [16] exposure”. circumstances, according to the KDIGO Group , it is reasonable The decline of renal function is mirrored by the rise in serum to talk of Acute Renal Failure (ARF). In these cases the mortality Creatinine (SCr) that reaches its peak on the third to fifth day after is high. The clinical feature and the management of ARF caused by [31-37] the injection of IRCA and returns to baseline within 10-14 days[17]. IRCA are the same as that for ARF due to other causes . The extent of the rise in SCr for defining CI-AKI following the CI-AKI is uncommon in patients with normal pre-existing renal intravascular injection of IRCA is an increase in either its absolute function. It occurs more frequently in patients with renal impairment, [38] value (by 0.5 mg/dL or greater) or its relative value (by 25% or particularly if associated with diabetes mellitus . greater on the baseline value). CI-AKI may also be defined as a decrease (to 30-60 mL/min/1.73m2 - renal insufficiency-or less) in PATHOGENESIS OF CONTRAST-INDUCED the estimated glomerular filtration rate (eGFR), i.e. the creatinine clearance calculated by using either the MDRD (Modification of Diet ACUTE KIDNEY INJURY (CI-AKI) in Renal Disease) calculation[18] or the CKD-EPI (Chronic Kidney The pathogenesis of Acute Kidney Injury (AKI) secondary to Disease Epidemiology Collaboration) equation[19], or the very simple Iodinated RadioContrast Agents (IRCA) is not fully understood. Cockcroft-Gault formula[20]. Many factors are involved (Figure 1): Some Authors have suggested that an evaluation of renal function (1) Hemodynamic changes: after intravascular injection, IRCA by serum Cystatin C (or the CKD-EPI cystatin C equation) is better cause immediate and transient vasodilatation followed by prolonged than SCr. Undoubtedly, since the relationship between SCr and GFR vasoconstriction, leading to renal ischemia, especially in the outer is exponential, small SCr differences will greatly impact the GFR renal medulla; the consequence will be a decrease of Renal Blood values at low SCr values (corresponding to high GFR values), but Flow (RBF), thereby leading to a decrease in the GFR[13,39]. the same difference will have minimal impact at high SCr values (2) Renal medullary hypoxia: resulting from (a) the (corresponding to low GFR values)[21]. Therefore, to detect the vasoconstriction of vasa recta[40,41], (b) changes in erythrocyte early impairment
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