—Dr Tannenbaum raises two interesting questions. First, was this patient's renal failure a consequence of obstructive jaundice, unrelated to the administration of angiographic contrast, and second, would mannitol be suitable prophylaxis against renal failure in this clinical setting. Renal failure has been described following uncomplicated biliary obstruction,1 although the authors gave no details of the patient's degree of hydration or the severity of azotemia. Renal failure does not commonly occur with biliary obstruction alone, but develops after major surgery,2-5 possibly as a result of endotoxemia resulting from handling the bowel.6,7 Although obstructive jaundice was clearly a risk factor for renal failure in the patient under discussion, it seems unlikely to be the sole cause, particularly as renal failure resolved despite persisting severe hyperbilirubinemia. The temporal relationship of cholangiography and azotemia suggests contrast nephropathy.
As Tannenbaum points out, Dawson demonstrated the efficacy of mannitol prophylaxis in jaundiced rats