British Journal of Radiology 75 (2002),874-878 © 2002 The British Institute of Radiology
Renal cortical retention of contrast medium on delayed CT and nephropathy following transcatheter arterial chemoembolisation in patients with high serum creatinine level
H Yamazaki, MD1,3,
H Oi, MD2,
M Matshushita, MD4,
T Inoue, MD3,
H Nakamura, MD2 and
T Inoue, MD3
1 Department of Radiology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Departments of 2 Radiology and 3 Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871 and 4 Department of Radiology, NTT West Osaka Hospital, 2-6-40 Karasugatsuji, Tennoji-ku, Osaka 543-8922, Japan
Correspondence: H Yamazaki, Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Abstract
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The aim of this study was to investigate the prevalence of renal cortical retention (RCR) of contrast media seen on delayed CT, and nephropathy following transarterial chemoembolisation (TACE) in high-risk patients. The findings of 18 patients with abnormally high serum creatinine levels who underwent TACE were reviewed. Nephropathy was defined as an increase in serum creatinine level of more than 44 µmol l-1, or more than 25%, on day 1, 3, 7 or 14. RCR was defined as mild (CT value >50) or severe (CT value >100). RCR was seen in 16 cases (89%) and in seven cases (39%) of post-TACE nephropathy. Patients without severe RCR did not develop nephropathy post-TACE, whereas 50% of those with such retention did (p=0.19). Delayed CT appears to have the potential as an early detector of nephropathy post-TACE in high-risk patients.
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Introduction
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Contrast media that are widely used in radiological procedures can induce mild reduction in renal function in 5–20% of cases [1–3]. Contrast associated nephropathy requiring dialysis is rare. Transarterial chemoembolisation (TACE) may also induce nephropathy and, previously, we reported that 1% of patients with hepatocellular carcinoma may develop acute renal failure following TACE [4]. Renal cortical retention (RCR), of contrast medium was suggested as a sign of renal deficiency following the use of contrast medium [5–6]. However, RCR may also be observed without any signs of nephropathy [7–8]. In this study we have investigated the prevalence of RCR and nephropathy in 18 patients with abnormal serum creatinine concentration who underwent TACE, and evaluated the reliability of this sign in predicting nephropathy after this procedure.
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Materials and methods
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At the NTT West Osaka Hospital, between 1989 and 1996, we performed abdominal CT after TACE for 18 patients with high serum creatinine levels (13 men, 3 women) who had undergone TACE, 16–21 h (median 19 h) after the procedure (Table 1
). Two patients underwent TACE for pelvic tumour (bladder cancer and prostate cancer), one patient for a secondary liver tumour from carcinoma of the pancreas, the other 15 patients for primary hepatocellular carcinoma. Patient age range was 40–77 years (median 62 years). The injected volume of contrast medium per body weight ranged from 2.6 ml kg-1 to 6.8 ml kg-1 (mean±standard deviation 4.7±1.2 ml kg-1). Diatrizoate (76%, Urografin; Schering, Berlin, Germany) was administered in two cases, iopamidol (Iopamiron 370; Bracco, Milan, Italy) in four, iohexol (Omnipaque 350; Winthrop-Breon, New York, NY) in seven and ioxaglate (Hexabrix 320; Guerbet, Aulnay-sous-Bois, France) in five. Details of TACE have been described elsewhere [9]. In brief, a catheter was selectively introduced into the targeted arterial branch using the Seldinger technique. Doxorubicin-in-oil emulsion was used as a chemoembolic material, which was prepared by dissolving doxorubicin hydrochloride in 50% diluted diatrizoate sodium meglumine (Urografin) and emulsifying that solution in a 2:3 volume ratio of iodized oil (Lipiodol; Guerbet). A gelatine sponge particle 1–3 mm in diameter was added to reduce blood flow in the target segment. The mean dosages of iodized oil and doxorubicin were 13 ml (3–30 ml) and 37 mg (10–60 mg), respectively, and three patients received epi-adriamycine (10–30 mg) with lipiodol instead of adriamycin. Cisplatinum was administered to six patients (50–200 mg, median 102 mg). The mean weight of the gelatine sponge particle was 0.04 g (range 0.01–0.16 g). Cases of congestive heart failure, severe hypertension and/or diabetes mellitus not controlled by medication were excluded. Informed written consent was obtained from all patients. RCR was recognized when CT images showed a high density area in the renal cortex as described elsewhere [8]. Whenever possible, CT images of RCR following TACE were compared with those before angiography and evaluated by at least two radiologists. The following classification was used: normal appearance; mild RCR indicated by high density in the renal cortex (CT value >50); and severe RCR indicated by severe opacification (CT value >100). CT was performed with a slice thickness of 10 mm at 120 kV (210 mA) by using a CT/T 8800 (General Electric, Milwaukee, WI) and a Somatom plus (Siemens AG, Erlangen, Germany). Delayed time from TACE to CT was 16–21 h (median 19 h). Serum creatinine level for renal function was obtained from venous blood samples in the morning of the day of the procedure and 1, 3, 7 and 14 days afterwards. Nephropathy post-TACE was defined as an increase in serum creatinine level of more than 44 µmol l-1 or more than 25% on day 1, 3, 7 or 14 after the procedure.
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Statistical analysis
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2 test, t-test and Mann Whitney U methods were used. All analyses used the conventional 0.05 significance level.
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Results
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Of the 18 cases studied, nephropathy post-TACE was demonstrated in 7 (39%) and RCR in 16 (89%). Patients' details are provided in Table 1
. 50% of patients with severe RCR developed nephropathy post-TACE, while those with mild RCR or without RCR showed no signs of nephropathy (p=0.19). No predisposing factor was recognized as significant in this series (Table 2). Only one patient with severe, pre-existing renal failure required haemodialysis post-procedure.
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Discussion
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Contrast media can induce acute functional changes in the kidney, characterized by an increase in renal vascular resistance and urine flow together with a reduction in glomerular filtration rate and sodium reabsorption. These acute changes resolve within a few hours, followed 24 h later by a decline in renal function which can last for several days [10]. The pathophysiology of contrast media induced nephropathy is complex, poorly understood, and likely to be multifactorial [10, 11].
Risk factors for contrast media associated nephropathy include diabetic nephropathy, osmolarity, dose of contrast media administered and intravascular volume depletion [10]. The largest risk factor is pre-existing renal impairment, paticularly when the serum creatinine concentration is more than 220 µmol l-1. Contrast media associated nephropathy may occur in 30–50% of patients with pre-existing poor renal function [2]. Several authors have reported on RCR detected by delayed CT [12, 13] and its correlation with renal function. Jakobsen et al [14, 15] found that RCR did not correlate with reduction in normal function and considered this sign irrelevant for contrast nephropathy. On the other hand, Love et al [16] concluded that RCR seen on CT conducted 24 h after contrast media administration is reliable for predicting the development of contrast medium induced nephropathy.
In agreement with Jakobsen et al [14, 15], we also reported that RCR is not unusual after angiography and can be seen in patients with normal renal function [7]. In our study, 47% of patients showed evidence of RCR after angiography, but nephropathy developed in only 3%. We concluded that RCR seems to be largely an incidental phenomenon that does not correlate with clinical renal failure. Furthermore, financial considerations and the risk of unnecessary radiation exposure make the use of delayed CT solely for the purpose of detecting early signs of nephropathy inadvisable.
Few studies have dealt with post-TACE renal dysfunction, despite the fact that TACE plays an important role in the treatment of liver tumours and may exacerbate pre-existing nephropathy Post-TACE nephropathy may develop later than contrast media induced nephropathy, which usually develops within a few days after contrast media administration, partially because liver dysfunction occurs as late as 2 weeks after TACE [8]. Renal failure following hepatic dysfunction is a well recognized complication and may also occur post-operatively, following hepatic resection [18]. In cases of TACE for hepatocellular carcinoma, liver injury can be caused by the TACE and is also enhanced by pre-existing chronic liver disease, e.g. liver cirrhosis. The development of post-embolisation syndrome, which includes fever, abdominal pain, nausea, vomiting, abdominal fullness and appetite loss, can induce volume depletion and thereby lead to the development of nephropathy. Renal infarctions may also be induced by embolic materials [19]. The use of chemotherapeutic agents and contrast materials also tends to increase the risk of renal dysfunction post-TACE.
In the study presented here, over 89% (16 of 18) of patients showed RCR, which is higher than that observed previously. In addition, 39% (7 of 18) of cases in this series showed signs of post-TACE nephropathy, which was much higher than the incidence reported in previous series (6% post-TACE and 3% post-angiography) [7, 8]. This is due to the fact that the majority of our patients had pre-existing renal function impairment, which is one of the most significant prognostic factors for RCR and nephropathy. The type and dose of contrast media, as well as the presence of diabetes mellitus did not influence the incidence of post-TACE nephropathy (Table 2).
None of the patients without severe RCR showed post-TACE nephropathy, whereas 50% of those with severe RCR did (p=0.19). Delayed CT in our patients was performed to detect lipiodol deposition [9], at no additional cost. Thus, if CT is performed, for whatever reason, post-TACE, the observation of severe RCR should raise concerns about the development of post-TACE nephropathy and biochemical assessment of renal function should be considered in such cases. We conclude that severe RCR at delayed CT appears to have potential as an early detector of post-TACE nephropathy.
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Footnotes
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This study was supported by the Grant-in-aid for Cancer Research from the Ministry of Health and Welfare of Japan. 
Received for publication September 5, 2001.
Revision received July 8, 2002.
Accepted for publication August 1, 2002.
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References
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Abstract
Introduction
