intravenous contrast media in patients with kidney disease nejm

Abbreviations: ACR, American College of Radiology; eGFR, estimated glomerular filtration rate; GBCM, gadolinium-based contrast media; KDIGO,Kidney Disease Improving Global Outcomes; NKF, National Kidney Foundation. Extravasation of radiographic contrast material: recognition, prevention, and treatment. Make sure the vein is not obstructed when repositioning the arm. In patients with a history of prior mild reaction (limited hives/itching, limited cutaneous edema, limited itchy/scratchy throat, nasal congestion, or sneezing/conjunctivitis/rhinorrhea), either no premedication prophylaxis or premedication consisting of only an antihistamine prior to the planned imaging study is recommended (protocol below). 2023 Apr 18. doi: 10.1007/s00330-023-09575-3. The use of volume expansion therapy is based upon studies that have shown decreased rates of post-contrast acute kidney injury in patients receiving volume expansion therapy. Epub 2019 Jun 27. Tweedle M., Kanal E., Muller R. Considerations in the selection of a new gadolinium-based contrast agent. The use of cetirizine (Zyrtec) instead of the previously recommended antihistamine diphenhydramine (Benadryl) is preferred in adults due to the side effects associated with diphenhydramine (drowsiness). Online ahead of print. Davenport MS, Khalatbari S, Dillman JR et al. 2014;39:432-7. Similar to the risk in patients receiving a single standard dose (0.1mmol/kg) of group II or group III GBCM, the risk of NSF from multiple, closely spaced, standard doses of group II or group III GBCM in patients with eGFR greater than or equal to 30mL/min per 1.73m2 is likely very small. Specifically, daily dialysis or multiple per-day dialysis sessions are not considered necessary. McDonald R.J., McDonald J.S., Dai D. Comparison of Gadolinium Concentrations within Multiple Rat Organs after Intravenous Administration of Linear versus Macrocyclic Gadolinium Chelates. Rogosnitzky M., Branch S. Gadolinium-based contrast agent toxicity: a review of known and proposed mechanisms. 2009;192(3):711-718. 2023 Feb;49(2):205-215. doi: 10.1007/s00134-022-06966-w. Epub 2023 Jan 30. Contrast-enhanced MRI may be performed immediately before or after contrast-enhanced CT (and vice versa) without additional safety concerns. Br J Surg 1991; 78: 500-1. A subsequent subanalysis of these data stratified by CKD stage found the upper bound of the 95% confidence interval of risk to be 0.2% (one case for every 500 exposed patients) for stage 5D CKD (eGFR<15mL/min per 1.73m2 undergoing maintenance dialysis) based on zero cases in 1,849 exposed individuals, and 0.5% (one case for every 200 exposed patients) for stage 5 CKD (eGFR<15mL/min per 1.73m2 not undergoing maintenance dialysis) based on zero cases in 732 exposed individuals.24 For all patients with stage 5 or 5D CKD, the upper bound of the 95% confidence interval of risk was 0.1% (one case for every 1000 exposed patients) based on zero cases in 2,581 exposed individuals.24 Thus, while the risk of NSF following exposure to group II GBCM is low, that risk estimate is based on data from only 2,581 individuals with CKD stages 5 (n= 732) or 5D (n= 1,849).24, Group III: Few, if any, unconfounded cases of NSF have been associated with group III GBCM administration, but data remain limited about NSF risk due to few published administrations in high-risk patients. Other relationships: disclosed no relevant relationships. Breakthrough reactions occur in at least 2% of patients with a history of prior allergic-type reaction who receive premedication prophylaxis. 2023 Apr 19;12(8):2965. doi: 10.3390/jcm12082965. The incidence of contrast-induced nephropathy (CIN) ranges from 2% in patients with normal baseline renal function to as high as 20% to 30% in patients with a baseline creatinine >2 mg/dL. 2021 Jan;298(1):28-35. doi: 10.1148/radiol.2020202903. Repeated dialysis sessions are not recommended. Bruce RJ, Djamali A, Shinki K et al. The UCSF Department of Radiology routinely screens patients undergoing CT examinations to identify those individuals with chronic kidney disease and thus at potential risk of acute kidney injury and recommends volume expansion therapy to mitigate the risk in this subgroup. The risk of administering modern intravenous iodinated contrast media in patients with reduced kidney function has been overstated, according to new consensus statements from the American College of Radiology (ACR) and the National Kidney Foundation (NKF), jointly published in the journals Radiologyand Kidney Medicine. Gadolinium-induced nephrogenic systemic fibrosis: the rise and fall of an iatrogenic disease. The .gov means its official. ACR Manual on Contrast Media Version 10.3, 2017:35-46. However, unlike the ACR and theCanadian Association of Radiology, the European Society of Urogenital Radiology advises caution when administering group II GBCM to patients with eGFR less than 30mL/min per 1.73m2.30. The https:// ensures that you are connecting to the Oak Brook, IL 60523-2251 USA, Copyright 2023 Radiological Society of North America | Terms of Use | Privacy Policy | Cookie Policy|Feedback, To help offer the best experience possible, RSNA uses cookies on its site. The most rigorously studied and accepted risk factor for the development of contrast-induced nephropathy is pre-existing severe renal insufficiency. The risk estimate of NSF for group II GBCM in patients with stage 5 or 5D chronic kidney disease is based on data from 2,581 individuals. What you need to know about: imaging in patients with renal failure Activities not related to the present article: is a consultant for GE Healthcare; has grants/grants pending with Bayer and GE Healthcare. Jiang H, Li Y, Wu X, Yu H, Zhang X, Ge W, Yan S. Front Pharmacol. Manual on contrast media. Association of Intravenous Radiocontrast With Kidney Function This trial showed that in average risk patients premedication prophylaxis did decrease the overall rate of allergic-type reaction (4.7% vs. 1.7%) and of mild reactions (1.9% vs 0.2%) but did not show statistically significant reductions in moderate or severe reactions. Prince M.R., Zhang H.L., Roditi G.H., Leiner T., Kucharczyk W. Risk factors for NSF: a literature review. Review of the evidence showed that risk for contrast-induced AKI is negligible in people with eGFRs 30 mL/minute. The affected extremity should be elevated above the heart and cold compresses applied topically. We have simplified this recommendation to only include methylprednisolone for two reasons: 1) To simplify the recommended premedication protocol by only including one medication, and 2) the relevant randomized control trial utilizing prednisone did so with dosing at 13, 7, and 1 hours prior to contrast administration (not 12 and 2 hours as per prior and current UCSF protocols). and transmitted securely. However, some GBCM exhibit more pronounced protein binding and/or partial hepatobiliary excretion. Intravenous CT Contrast Media and Acute Kidney Injury: A Multicenter Werner A, Freesmeyer M, Khnel C, Drescher R, Greiser J. Diagnostics (Basel). nausea/vomiting, hypertension, vasovagal reactions, arrhythmia). Most major and minor reactions will occur in patients without any known risk factors. No unconfounded cases of NSF have been reported for gadoxetate disodium. Halved contrast medium dose in lower limb dual-energy computed tomography angiography-a randomized controlled trial. Dr. Rachel M. Erdil (Medicine): A 58-year-old woman was evaluated in the infectious disease clinic of this hospital because of fatigue, abdominal bloating, and eosinophilia. 2019 Aug;70(3):226-232. doi: 10.1016/j.carj.2019.04.001. However other routes may need to be used and each is considered separately. Online ahead of print. ACR: Use of prophylaxis is not specifically addressed. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Other relationships: disclosed no relevant relationships. FDA Drug Safety Communication New warnings for using gadolinium-based contrast agents in patients with kidney dysfunction. Federal government websites often end in .gov or .mil. 2020 Jan 22;2(1):85-93. doi: 10.1016/j.xkme.2020.01.001. Prior allergic-type reaction to intravascular iodinated contrast is the greatest risk factor for subsequent reaction, with up to 35% of patients experiencing recurrent reactions in the absence of premedication prophylaxis. Activities not related to the present article: has grants/grants pending with Bracco Diagnostics and Guerbet. The optimal IV volume expansion protocol is unknown and ideally should be tailored to the patients volume status and medical conditions, which may necessitate discussion between the referring physician and the radiology team. Surez Carantoa C, Escobar Cervantes C, Fabregate M, Lpez Rodrguez M, Bara Ledesma N, Soto Prez-Olivares J, Ruiz Ortega RA, Lpez Castellanos G, Olavarra Delgado A, Blzquez Snchez J, Gmez Del Olmo V, Moralejo Martn M, Pumares lvarez MB, Snchez Gallego MC, Llcer P, Liao F, Manzano L. J Clin Med. Although the true risk of CI-AKI remains uncertain for patients with severe kidney disease, prophylaxis with intravenous normal saline is indicated for patients who have AKI or an estimated glomerular filtration rate less than 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis. Quant Imaging Med Surg. Marckmann P., Skov L., Rossen K. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. Ann Emerg Med. 23 An analysis of data from. NSF is a potentially debilitating and sometimes fatal systemic fibrotic condition that occurs almost exclusively in patients with AKI or severe CKD (estimated glomerular filtration rate [eGFR]<30mL/min per 1.73m2). Studies utilizing unmatched control groups published in the last two decades have found no correlation between intravascular contrast administration and subsequent abnormal kidney function. Virtually all life-threatening reactions occur immediately or within 20 minutes after contrast injection. Radiology. Therefore, there is no defined threshold of contrast administration above which additional intravenous iodinated contrast should be withheld. For several reasons, it is preferable for referring physicians to prescribe the premedication regimen, although other arrangements may be possible depending on individual circumstances. Patients with extravasation should be assessed and reassured by a radiologist, and referred to the Emergency Department if there is skin blistering, altered tissue perfusion, increasing pain, or change in sensation distal to the site of extravasation. Use of Intravenous Gadolinium-based Contrast Media in Patients - PubMed Finally, it is important to note that at least 2% of patients with a history of prior allergic-type reaction will still experience a recurrent reaction (breakthrough reaction) despite receiving premedication prophylaxis. These criteria define specific changes in serum creatinine or urine output within 48 hours of a nephrotoxic event necessary to make the diagnosis of acute kidney injury. The supervising physician must be physically present in the facility or office suite and available in order to provide immediate medical intervention to prevent or mitigate injury to the patient in the event of an adverse contrast reaction. Bonner BP, Yurista SR, Coll-Font J, Chen S, Eder RA, Foster AN, Nguyen KD, Caravan P, Gale EM, Nguyen C. J Am Heart Assoc. First, the patients electronic medical record is searched to determine whether a serum creatinine and an estimated glomerular filtration rate (eGFR) acquired within the past 6 weeks are available for outpatients and within the last 7 days for inpatients. Girardi M., Kay J., Elston D.M., Leboit P.E., Abu-Alfa A., Cowper S.E. In fact, in one retrospective study, patients with a history of prior mild allergic-type contrast reaction had lower rates of breakthrough reactions when they had received an antihistamine alone as opposed to either a corticosteroid alone or a corticosteroid and antihistamine (2). This article is a simultaneous joint publication in Radiology and Kidney Medicine. American College of Radiology; Reston, Va: 2018. Either version may be used in citing this article. Are gadolinium-based contrast media nephrotoxic? These recommendations also apply to patients receiving nephrotoxic medications, chemotherapy, or contrast-enhanced CT. Jeffrey C. Weinreb, MD, Roger A. Rodby, MD, Jerry Yee, MD, Carolyn L. Wang, MD, Derek Fine, MD, Robert J. McDonald, MD, PhD, Mark A. Perazella, MD, Jonathan R. Dillman, MD, MS, and Matthew S. Davenport, MD. The evidence for and against corticosteroid prophylaxis in at-risk patients. An electronic order for an imaging study is placed by a referring physician in the electronic medical record. The risk of acute kidney injury (AKI) developing in patients with reduced kidney function following exposure to intravenous iodinated contrast media has been overstated. 2020 Nov 10;3(1):142-150. doi: 10.1016/j.xkme.2020.10.001. A short peripheral IV catheter in the antecubital or forearm area is the preferred route for intravenous contrast administration. 2023 Mar 29;11(1):35. doi: 10.1186/s40364-023-00476-7. Contrast flow is manually tested to ensure patency. RJM: Activities related to the present article: disclosed no relevant relationships. Confounded NSF refers to cases in which there was more than one specific GBCM administered prior to development of NSF, or there was no confirmation that only one specific GBCM was administered. One randomized controlled trial showed that premedication decreased the rate of allergic-like reactions in average-risk (with or without prior history of allergic-like reaction) patients exposed to older high-osmolar iodinated contrast (3). Cardiac magnetic resonance in Fabry disease. But it should be noted that these studies are heterogeneous, with many performed in patients undergoing intra-arterial administration of iodinated contrast. Gadobenate dimeglumine (MultiHance; Bracco Diagnostics) is considered group II because the evidence supporting a very low risk of NSF is actually greater for gadobenate than it is for the macrocyclic GBCM.21, 22, 23 The mechanism is unclear, but it may relate to its partial hepatobiliary excretion. Background fluctuation of kidney function versus contrast-induced nephrotoxicity. MSD: Activities related to the present article: disclosed no relevant relationships. Patients also receive the Patient Information Leaflet for CT (Appendix B) at this time. The ideal route, rate, and volume for volume expansion therapy are unknown. Patients undergoing kidney replacement therapy, patients with AKI, and patients with stage 4 or 5 CKD who are exposed to a group I GBCMespecially repeated doses of a higher off-label dose of a group I GBCMare at greatest risk of NSF. ACR: Not specifically addressed KDIGO: Not specifically addressed. Careers. Interestingly, there have been no reported cases of NSF in neonates or infants despite immature kidney function and eGFR measurements commonly less than 30mL/min per 1.73m2. In all cases, it is critical that the responsible radiologist communicates directly with the patient, referring physician, and Emergency Department as appropriate and documents these communications in the report or medical record. Radiology 2007; 243: 80-7. Heinrich M.C., Kuhlmann M.K., Kohlbacher S. Cytotoxicity of iodinated and gadolinium-based contrast agents in renal tubular cells at angiographic concentrations: invitro study. It is therefore not possible to conclude if patients who developed acute kidney injury did so as a result of receiving contrast versus alternative causes of acute kidney injury. Disentangling contrast-induced AKI (causal AKI) from contrast-associated AKI (correlated AKI) is a critical step forward in improving understanding of the true risk to patients., Updated Consensus Provides Multi-Disciplinary Guidance. In CI-AKI, a causal relationship exists between contrast media and kidney injury, whereas in CA-AKI, a direct causal relationship has not been demonstrated. Use of Intravenous Gadolinium-Based Contrast Media in Patients With Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation. McDonald RJ, Lieske JC, et al. After angiography, the mean urine pH value was 6.70.8 in the sodium bicarbonate group and 6.00.8 in the sodium chloride group (P<0.001). Weinreb JC, Rodby RA, Yee J, Wang CL, Fine D, McDonald RJ, Perazella MA, Dillman JR, Davenport MS. Kidney Med. As a library, NLM provides access to scientific literature. In individual high-risk circumstances, prophylaxis may be considered in patients with an estimated glomerular filtration rate of 30-44 mL/min/1.73 m2 at the discretion of the ordering clinician. Risk mitigation strategies include awaiting kidney function recovery prior to GBCM administration and using group II GBCM. Radiological examination of failure of intravenous infusions. Although these statements are based on a combination of the most current scientific evidence and expert consensus opinion, it is important to recognize that in clinical practice, decisions to administer GBCM may not be based on a single consideration (eg, risk of an adverse event specifically related to kidney impairment) but instead are influenced by many factors (eg, probability and necessity of an accurate diagnosis, alternative methods of diagnosis, risks of delayed or misdiagnosis, comorbidities, expectations regarding kidney function recovery, and the risk of an allergic-like reaction). Multiple subsequent studies have since used propensity score adjustment and propensity score matching to correct for selection bias that may have limited prior studies [9-13]. The patient is observed for any indications of contrast reaction throughout the administrative process. Adult Glomerular Filtration Rate (GFR) Calculator(National Kidney Foundation website), Pallav Kolli, Brett Elicker, Fergus Coakley, Kerry Cho, Charlene Fong, Tina Hampton, Roy Gordon, John Mackenzie, and Ron Zagoria (Updated 7/20/18), 2023 The Regents of the University of California | Accessibility | Terms of Use | Privacy Policy, (T32) Biomedical Imaging for Clinician Scientists, Management of Acute Reactions to Contrast Media in Adults, Treatment of Acute Reactions to Contrast Media in Children, Adult Glomerular Filtration Rate (GFR) Calculator. 2 Consequently, many cases of AKI that are coincident . Further study investigating the clinical benefits of GBCM for common indications can improve risk-benefit decision making. Given the confounding factors present in these previous studies, the American College of Radiology has adopted the term post-contrast acute kidney injury (PC-AKI) for any sudden deterioration in renal function that occurs within 48 hours following intravascular administration of iodinated contrast and reserves the term contrast-induced nephropathy (CIN) for PC-AKI that is caused by intravascular administration of iodinated contrast. Signs and symtoms are self-limited without evidence of progression. and transmitted securely. 2014;271(1):65-73. The latest from RSNA journals on COVID-19. Background Although the historical risk of acute kidney injury (AKI) after intravenous administration of contrast media might be overstated, the risk in patients with impaired kidney function remains a concern. Although the true risk of CI-AKI remains uncertain for patients with severe kidney disease, prophylaxis with intravenous normal saline is indicated for patients who have AKI or an estimated glomerular filtration rate less than 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis. Details of kidney function screening including methods and risk factors are provided in a previously published ACR-NKF consensus document on intravenous iodinated contrast media.4. On-label dosing of group II or group III GBCM does not have a clinically important risk of nephrotoxicity. Smorodinsky E., Ansdell D.S., Foster Z.W. In general, the aforementioned recommendations, including those for the group III GBCM gadoxetate disodium, should not be altered for infants and children. Lima FO, Lev MH, Levy RA et al. Recent studies [2-8] suggest that historical concern for CIN after administration of intravenous iodinated contrast was likely overstated. These include the linear ionic GBCM gadobenate dimeglumine (MultiHance; Bracco Diagnostics, Princeton, NJ; 5% hepatobiliary excretion) and all macrocyclic GBCM (gadoterate meglumine [Dotarem; Guerbet, Villepinte, France and Clariscan; GE Healthcare, Oslo, Norway], gadobutrol [Gadavist; Bayer Healthcare, Whippany, NJ], and gadoteridol [ProHance; Bracco Diagnostics]). Many patient-specific factors have been proposed as placing patients at risk for CIN. The site is secure. However, the fact that a patient is on dialysis should NOT be regarded as automatically allowing the administration IV contrast. If multiple urgent group II or group III GBCM doses are indicated, subsequent dose(s) should not be delayed for fear of NSF. These studies are thus limited by selection bias. Elmholdt T.R., Jrgensen B., Ramsing M., Pedersen M., Olesen A.B. Intravenous iodinated contrast media are commonly used with CT to evaluate disease and to determine treatment response. The Bedside Schwartz equation or the creatinine-cystatin C-based CKiD equation should be used to assess eGFR in infants and children. It remains an open question whether this trial failed to show a reduction in moderate or severe reactions because premedication prophylaxis is not effective in this regard or whether the trial was underpowered to capture a difference in these uncommon events. 2023 May 2;84(5):1-9. doi: 10.12968/hmed.2022.0544. Although written documentation of informed consent is not required before administration of group II or group III GBCM, patients with known AKI or known stage 4 or 5 CKD should be informed of the potential risk of NSF associated with GBCM administration, the reason GBCM administration is indicated, and whether there are viable alternative diagnostic strategies. official website and that any information you provide is encrypted Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Higher risk. Current use of any metformin-containing medications. The risk of NSF in pediatric patients appears to be low, but data are limited.
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