Olof Hellberg

Renal Effects of CO2 and Iodinated Contrast Media in Patients Undergoing Renovascular Intervention: A Prospective, Randomized Study

PURPOSE CO2 gas has been proposed for use instead of iodinated contrast media in angiographic examinations in patients at risk of developing renal failure from contrast media. The influence of intraarterial injection of CO2 with small added amounts of ioxaglate (200 mgI/mL) or ioxaglate alone on renal function in patients with suspected renal artery stenosis was studied in a prospective, randomized study. MATERIALS AND METHODS One hundred twenty-three patients underwent renovascular intervention (n = 83) and/or renal angiography (n = 40) for suspected renal artery stenosis. Patients with a serum creatinine concentration less than 200 micromol/L (n = 82) were randomized prospectively to receive CO2 with small added amounts of ioxaglate (n = 37) or only ioxaglate (n = 45). Patients with serum creatinine levels greater than 200 micromol/L (n = 41) were not randomized and initially received CO2. Serum creatinine concentrations were measured within 1 day before and 1 day, 2 days, and 2-3 weeks after the procedure. RESULTS The amount of injected CO2 did not relate to an increase in serum creatinine level. In the randomized groups, and also when the whole patient sample was considered, the amount of injected iodine was significantly correlated (P = .011) with an increase in serum creatinine level and a decrease in estimated creatinine clearance after 2 days. Among the randomized patients, one in the CO2 group and three in the ioxaglate group had a more than 25% increase in serum creatinine level within the first 2 days after the intervention. CONCLUSION The risk of impairment of renal function is lower after injection of CO2 with small amounts of added ioxaglate compared with injection of a larger amount of ioxaglate alone. The larger the amount of administered iodinated contrast medium, the greater the risk of development of renal failure.

Red-cell trapping in the rat renal microcirculation induced by low-osmolar contrast media and mannitol

RATIONALE AND OBJECTIVES.In acute renal failure after ischemia, intravascular obstruction by trapped red blood cells in the microvasculature of the renal outer medulla is a consistent finding. The influence of intravenously injected contrast media (CM) on such obstruction was investigated. METHODS.Anesthetized rats were subjected to 45 minutes of unilateral renal ischemia. Red-cell trapping in ischemically injured kidneys and in the contralateral uninjured kidneys was estimated from the intrarenal distribution of 51Cr-labelled erythrocytes after injection of ioxaglate or iopamidol in a dose of 1,600 mg I/kg body weight. As an osmolar control substance, mannitol (950 mOsm/kg) was given to a third group and isotonic Ringers solution was administered to a fourth group. RESULTS.In the uninjured kidneys, treatment with ioxaglate or mannitol resulted in no red-cell trapping, while the iopamidol-treated group showed red-cell trapping in the inner stripe of the outer medulla in a dose-dependent manner. In the ischemically injured kidneys, both CM and mannitol enhanced the red-cell trapping in the inner stripe of the renal medulla. CONCLUSION.The results indicate that intravenously administered ioxaglate and iopamidol enhance the microvascular obstructions evoked by ischemic injury and that iopamidol may induce local impairment in renal medullary microcirculation in a normal kidney.

Ischemia-induced renal expression of hyaluronan and CD44 in diabetic rats

Background/Aims: Unilateral renal ischemia during 30 min causes severe, non-reversible renal damage in diabetic (DM) rats, but not in nondiabetic rats. Hyaluronan (HA) is a glycosaminglycan involved in various forms of renal injury. We examined the role of HA and CD44, a major receptor for HA, in the development of postischemic renal injury in DM rats. Methods: The left renal artery of streptozotocin diabetic Wistar rats was clamped for 30 min. The HA content in the kidneys was measured. A biotinylated HA-binding probe was used to localize HA. Inflammatory cells and other cells expressing CD44 were identified by immunohistochemistry. Results: In ischemic DM kidneys the renal HA-content started to increase already after 24 h and significantly so after 1–8 weeks after ischemia/reperfusion (I/R). The relative water content of the kidneys increased in parallel. HA started to appear in the cortex of ischemic DM kidneys 1 week after I/R. In contrast, the non-DM ischemic kidneys showed no increase of HA and water content after 1–8 weeks after I/R. The tubular cells in the cortex and outer medulla demonstrated increased staining for CD44. In the same compartments the increased numbers of infiltrating inflammatory cells also expressed CD44. Conclusion: HA-accumulation in the renal cortex might contribute to the renal damage seen after transient ischemia in DM rats by promoting inflammation through interaction between HA and CD44 expressing inflammatory cells. Furthermore, HA accumulation may contribute to an interstitial renal edema.

Oxygen radicals in postischaemic damages in the kidney.

SummaryOxygen radicals in postischaemic damages in the kidney: M. Wolgast, A. Bayati, O. Hellberg, Ö. Källskog, K. Nygren and G. Öjteg, Inst. of Physiology and Medical Biophysics, University of Uppsala, Sweden; Ischemic acute renal failure is characterized by a severe depression of the glomerular filtration rate (GFR), isosthenuria and deficient potassium secretion, whereas the total renal blood flow may remain largely intact. As to these symptoms, it would seem established that the depression of GFR results from an ischaemia-induced augmented aging and hence rejection of tubular cells, which thence blocks the tubular lumen. As expected this blockade can be prevented by osmotic diuretics. The isosthenuria and the deficient potassium excretion, on the other hand, results probably from a medullary ischaemia, the latter due to the action by oxygen-derived free radicals in the sense the subsequent damage to the capillary membrane leads to a massive extravasation of plasma and consequent intracapillary trapping of red cells. In line with this idea, superoxide-dismutase (SOD) or Allopurinol may ameliorate these changes. In the recovery phase of postischaemic renal failure, the most prominent feature is the blocking of the ascending loop of Henle with Tamm/Horsfall-protein which, if not washed-out during the first week, leads to a complete degeneration of the nephron. Unfortunately, the process would seem to be unaffected by treatment with e.g. osmotic diuretics and SOD or Allopurinol.

Effects of the contrast medium iopromide on renal hemodynamics and oxygen tension in the diabetic rat kidney.

UNLABELLED We investigated the effects of the contrast medium (CM) iopromide on regional renal blood flow and oxygen tension (pO2) in the streptozotocin (STZ)-induced diabetic Wistar Furth rats. RESULTS In normoglycemic rats, CM injection induced a transient decrease followed by an increase in renal cortical blood flow (CBF), whereas CBF increased directly in the diabetic animals. Renal outer medullary blood flow (OMBF) increased in controls, while it decreased in the diabetic animals following CM injection. In control rats a marked initial decrease in OM pO2 following injection of CM was observed. In animals diabetic for 4 weeks only a slight decrease was seen, whereas in 9-week diabetic animals a persistent increase was recorded. CONCLUSIONS An altered oxygen tension and hemodynamic response to CM was found in diabetic rats. If these disturbances may contribute to the development of renal dysfunction by CM in the diabetic rat kidney remains to be elucidated.

Osmotic diuretics and hemodilution in postischemic renal failure.

In the acute phase of ischemic renal failure, the severe depression of the glomerular filtration rate (GFR) is due to obstruction of the tubules by cells and cell debris rejected from the proximal tubules, a blockade which can be prevented at least partly, by treatment with osmotic diuretics. The isosthenuria, the second typical sign in ischemic acute renal failure, probably derives from the medullary ischemia that results from an intracapillary trapping of red cells. This, in turn, is suggested to be caused by oxygen-derived free radicals, which via increasing the capillary macromolecular permeability result in a massive extravasation of plasma and hence in hemoconcentration. As expected from this hypothesis, scavengers may ameliorate both the trapping and the consequent medullary ischemia. Unfortunately, however, a therapy using both osmotic diuretics and scavengers fails to improve the long-term outcome. Hemodilution would seem more promising, since it will both prevent the medullary ischemia seen in the acute phase and substantially improve the long-term outcome. At a hematocrit of 0.30, rat kidneys exposed to 45-min ischemia will show a GFR 1 month after the insult of more than 50% of the normal GFR as against 15% in untreated animals.

The effects of carbon dioxide versus ioxaglate in the rat kidney.

PURPOSE The renal medulla seems to be particularly vulnerable to vascular injection of iodinated contrast media, particularly in patients with preexisting renal dysfunction. The gas carbon dioxide is frequently used as an alternative to iodinated contrast medium in these patients. In this study, the renal effects of CO(2) are investigated and compared with those of the iodinated contrast medium ioxaglate. MATERIALS AND METHODS Cortical and outer medullary blood flow (measured by laser Doppler flowmetry) and oxygen tension (Po(2); measured by oxygen microelectrodes) were recorded in anesthetized Sprague-Dawley rats given an intraarterial injection of ioxaglate (320 mgI/kg body weight), a volume-matched dose of CO(2), or Ringer solution. RESULTS Injection of CO(2) induced a pronounced and transient decrease in cortical blood flow and Po(2) (approximately -45%), whereas outer medullary blood flow and Po(2) were transiently increased (+21% and +29%, respectively). In contrast, injection of ioxaglate did not influence cortical blood flow and caused outer medullary blood flow to decrease by 17%. Ioxaglate injection also resulted in a decrease in cortical and outer medullary Po(2) (-15% and -33%, respectively). Ringer solution affected none of the recorded parameters. CONCLUSIONS Although injection of CO(2) markedly affected regional renal blood flow and Po(2), there were qualitatively different effects in the cortex and outer medulla compared with those seen after injection of ioxaglate. The pronounced decrease in medullary blood flow and Po(2) observed after injection of ioxaglate was absent in the animals injected with CO(2). This might suggest beneficial effects of the use of CO(2) instead of iodinated contrast media in patients with increased risk of developing renal failure.