Renal Function and Interventional Oncology: Don`t Sacrifice the War to Win the Battle

It is common for many of our interventional oncology patients to have comorbid conditions that predispose them to compromised renal function. Combined with perioperative treatment and management, these patients can be at high risk for temporary or permanent renal insufficiency.  Typical risk factors for contrast induced nephropathy (CIN) includediabetic nephropathy, volume of contrast media administered,and intravascular volume depletion. For those patients with pre-existing poor renal function, contrast-associated nephropathy can occur in 30% to 50%of patients. Many interventional oncology procedures require a significant volume of contrast. Patients with hepatocellular carcinoma are often volume depleted. This can be exacerbated by post embolization syndrome in which patients decrease their intake because of nausea and vomiting. Moreover, those patients with post procedure hepatic failure also have a propensity for acute renal failure. Although rare, nontarget embolization of the renal arteries can place patients at higher risk for renal failure. Finally both preoperative and procedural drugs can exacerbate renal failure. One prospective paper reports the risk incidence of post TACE acute renal failure in HCC to be 8.6%.

It does not accomplish much for the overall patient if the tumor is treated but they are now subjected to a different chronic debilitating disease. Considering the predisposing factors the most successful means of reducing CIN is to limit contrast volume. This can easily be accomplished by using carbon dioxide digital subtraction angiography (CO₂ DSA). Carbon dioxide can perform all of the initial road mapping, anatomical detail, and catheter placement imaging. The size of these vessels is ideal for CO₂ imaging. Its low viscosity will also demonstrate tumor vessels on many occasions. If portal vein patency is a question the microcatheter can be wedged in the distal arterty and CO₂ injected. When necessary, dilute or low volume iodinated contrast can be administered as a supplement. Using CO₂ DSA and hydration can significantly reduce the volume of contrast and avoid potential renal insult.  Additionally, patients who may have been precluded from treatment because of elevated creatinine now can have the procedure without jeopardizing the overall health of the patient. Do no harm!