Résumé
Un nombre croissant d’examens d’imagerie avec injection d’un produit de contraste iodé (PCI) est réalisé en réanimation. La toxicité rénale du PCI, en s’ajoutant aux multiples agressions rénales subies par le patient de réanimation, est susceptible d’influencer le pronostic. L’incidence en réanimation de la néphropathie induite par les PCI (NIPC) est difficile à déterminer en raison des multiples définitions utilisées. En appliquant la définition de l’Acute Kidney Injury Network (AKIN), celle-ci peut être estimée à 10–20 % des patients recevant un PCI en réanimation. En dehors de la gravité générale mesurée par le score Sequential Organ Failure Assessment (SOFA), peu de facteurs de risque, à même d’identifier une sous-population de réanimation particulièrement exposée, ont été mis en évidence. L’effet propre d’un PCI sur la fonction rénale du patient soumis à de multiples facteurs d’agression rénale est difficile à établir à partir des rares études comparant des patients exposés ou non à un PCI dans le contexte de l’urgence et de la réanimation. Néanmoins, la néphrotoxicité du PCI, même minime, est susceptible d’influencer le devenir des patients de réanimation, compte tenu du pronostic sombre de l’insuffisance rénale aiguë dans cette population. Cela justifie des stratégies de prévention reposant sur une évaluation de la balance bénéfice/risque de l’administration du PCI, la correction d’une hypovolémie éventuelle et l’administration de certains traitements médicamenteux qui seront discutées à la lumière des recommandations internationales récentes.
Abstract
A growing number of imaging procedures requiring intravenous administration of iodinated contrast media are performed in the intensive care unit (ICU). Renal toxicity of contrast media added to the multiple renal injuries suffered by the critically ill patients may influence the outcome. The incidence of contrast-induced nephropathy (CIN) in the ICU is difficult to determine because of so many definitions used. Applying the definition of the Acute Kidney Injury Network, about 10–20% of ICU patients receiving iodinated contrast media will develop CIN. In addition to patient’s severity assessed by the Sequential Organ Failure Assessment score, few other ICU-specific risk factors have been identified. The independent effect of contrast media on the kidney function of patients with multiple factors of renal injury is difficult to evaluate and, in the context of emergency imaging, the scarce comparative studies of patients who are either undergoing or not undergoing iodinated contrast-media infusion did not report any difference in the incidence of acute kidney insufficiency. Nevertheless, the independent effect of contrast media, even if minimal, is likely to influence critically ill patients’ outcome, given the poor prognosis of acute kidney insufficiency in this population. Thus, strategies based on the risk/benefit ratio assessment and including hypovolemia correction and preventive drug administration are considered in the light of recent international guidelines.
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Ehrmann, S., Pajot, O. & Lakhal, K. Néphropathie induite par les produits de contraste iodés en réanimation. Réanimation 21, 463–473 (2012). https://doi.org/10.1007/s13546-011-0434-9
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DOI: https://doi.org/10.1007/s13546-011-0434-9
Mots clés
- Tomodensitométrie
- Angiographie
- Insuffisance rénale aiguë
- Réanimation
- Bicarbonate de sodium
- N-acétylcystéine