2023 May;25(5):341-345. . However, 2 studies over the past few years should settle this discussion for good: the Coronary and Peripheral Vascular Angiography (ACT) trial,25 with 2,308 patients undergoing an intravascular angiographic procedure randomized to acetylcysteine vs placebo, and the previously mentioned PRESERVE trial.24 Both trials showed no difference in rates of acute kidney injury between the acetylcysteine and placebo groups. This is especially true for patients who have normal eGFR or mild-to-moderate reductions in eGFR because they are not considered at risk, regardless of the drug(s) prescribed.13,15 However, monitoring eGFR in patients receiving nephrotoxic medications (eg, aminoglycosides) or undergoing chemotherapy is important before, during, and after treatment to identify incident nephrotoxicity (eg, AKI or new eGFR<30mL/min/1.73m2).49, In patients with AKI or eGFRs less than 30mL/min/1.73m2, it may be prudent to withhold nonessential potentially nephrotoxic medications (eg, nonsteroidal anti-inflammatory drugs, diuretics, aminoglycosides, amphotericin, platins, zoledronate, methotrexate) if clinically feasible for 24 to 48 hours before and 48 hours after exposure.17,21,26. Mayo Clinic health care delivery researchers in Florida sought to determine what the best available option was for patients. include protected health information. We also advocate withholding nonsteroidal anti-inflammatory drugs, diuretics, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers in high-risk patients, acknowledging that the data in that regard are insufficient. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Although unproven for intravenous iodinated contrast media, loss of residual kidney function may have adverse quality-of-life and overall survival implications. In that situation, we will inject additional fluid into the patients vein before and after the contrast material injection. These statements are endorsed by the American College of Radiology, or ACR, and the National Kidney Foundation, or NKF, to improve and standardize the care of patients with impaired kidney function who have indication(s) to receive intravenous iodinated contrast media. Radiologist-clinician discussions about risks and benefits of contrast-enhanced imaging can be helpful in patients at high risk for CI-AKI. Renal replacement therapies for prevention of radiocontrast-induced nephropathy: a systematic review. For MRI contrast agents there is no risk of developing the skin disease of concern if the eGFR is >30. If you need to have a CT scan, angiogram or MRI: Ask about your risk for NSF and CIN, based any risk factors you might have: Advanced kidney disease (GFR below 30 mL/min/1.73m2). Measurement and estimation ofGFRin children and adolescents. It is generally accepted that groups I and III should be avoided in patients with advanced chronic kidney disease. About 2 percent of people receiving dyes can develop CIN. CT and MRI Contrast and Kidney Function | UCSF Radiology Department of Nephrology and Hypertension, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, Medical Director, Cleveland Clinic West Dialysis Unit, Department of Nephrology and Hypertension, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, Director, Center for Chronic Kidney Disease, Department of Nephrology and Hypertension, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, Sign In to Email Alerts with your Email Address. McDonald J.S., McDonald R.J., Comin J. 8600 Rockville Pike Iodinated contrast media are commonly used in modern medicine both intravenously with CT studies and arterially during angiographic procedures. If you do not know your GFR, you can ask your doctor or healthcare professional. Schwartz G.J., Work D.F. Nausea and vomiting. Morsa Images/Getty Images. health information, we will treat all of that information as protected health A recent systematic review and meta-analysis evaluated the pooled risks of NSF in patients with stage 4 or 5 chronic kidney disease receiving a group II gadolinium-based contrast agent.52 The authors analyzed 16 studies with 4,931 patients who received group II agents. The Royal College of Radiologists; London, England: 2015. Protect Kidneys From Contrast Dye - Lakewood Ranch Medical Center There is thought to be no clinically relevant difference in risk of CI-AKI between LOCM and IOCM.31, Despite the acronym, LOCM are hyperosmolar (approximately 600mOsm/kg) relative to both IOCM (approximately 290mOsm/kg) and serum (approximately 290mOsm/kg).15 However, the dimeric structure of IOCM renders them more viscous than LOCM.15 Most modern iodinated contrast media are classified as LOCM.15 High-osmolality iodinated contrast media have higher osmolality than do LOCM and IOCM, but high-osmolality iodinated contrast media has been replaced by LOCM and IOCM for intravenous administration in modern clinical practice.15, Prophylaxis is indicated for patients who have AKI or aneGFR less than 30mL/min/1.73m2 and are not undergoingmaintenance dialysis.15,26,32,33 However, the evidence supporting this statement is based on data for the general prevention of CA-AKI rather than CI-AKI specifically. Does renin-angiotensin aldosterone system blockade exacerbate contrast-induced nephropathy in patients with chronic kidney disease? Stanford Type A Acute Aortic Dissection Associated with - ResearchGate For many of these scans, contrast material is injected intravenously to complete the scan. This research is part of a broad spectrum of projects within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The ideal hydration protocol for prevention remains uncertain, and various volume-expansion algorithms have been suggested using fixed or weight-adjusted regimens. Davenport et al13 used a 1:1 propensity matching algorithm and retrospectively reviewed over 17,000 patients who underwent contrast-enhanced CT or unenhanced CT. The articles are identical except for stylistic changes in keeping with each journal's style. . If you need to have an MRI with an older gadolinium contrast agent, your provider may want you to have dialysis once a day for up to three days after the scan. Approximately 25 percent of patients presenting for coronary angiography procedures are at high risk for an issue called Contrast Induced Acute Kidney Injury (AKI)*. MRI: Is gadolinium safe for people with kidney problems? On the basis of their NSF risk (and specifically on the numbers of unconfounded single-agent cases of NSF recorded for each agent), the 9 available gadolinium-based contrast agents are grouped into 3 groups (Table 3)41: Group Iagents associated with the greatest number of NSF cases. Pahade J.K., LeBedis C.A., Raptopoulos V.D. Gupta R.K., Kapoor A., Tewari S., Sinha N., Sharma R.K. Captopril for prevention of contrast-induced nephropathy in diabetic patients: a randomised study. Other relationships: disclosed no relevant relationships. This is primarily because of the conflation of contrast-associated acute kidney injury (CA-AKI) with contrast-induced acute kidney injury (CI-AKI) in uncontrolled studies. Click here for an email preview. Heterogeneous . However, . Additionally, in recent years, there have been data suggesting that gadolinium can deposit in the brain after repeated exposure to gadolinium-based contrast agents, even in patients with healthy kidneys.63 This finding was confirmed histologically64 and has led to the birth of a new term to describe it: gadolinium deposition disease.65 The significance of this brain deposition remains unknown, and to date, no adverse health effects have been uncovered. In 2007, both the FDA39 and the European Medicine Agency40 issued warnings highlighting the risk of NSF associated with the use of gadolinium-based contrast agents. Contrast-Enhanced MRIs in Patients with Kidney Disease - NEJM Journal Watch Study concepts/study design or data acquisition or data analysis/interpretation: all authors. Multiple small trials and subsequent meta-analyses provided highly divergent results until the Prevention of Serious Adverse Events Following Angiography (PRESERVE) trial put this discussion to rest.24 This large 2-by-2 factorial study randomly assigned 5,177 patients undergoing nonemergency angiography to receive isotonic sodium bicarbonate vs isotonic saline as well as oral acetylcysteine vs placebo. Reduced urine output is another criterion to diagnose AKI by using KDIGO criteria, but change in urine output can be more challenging to assess in retrospective studies because it is not always rigorously documented.7,8,10,11,13. A meta-analysis of 12 studies and 4493 patients found no difference in risk of CA-AKI (odds ratio: 1.27; 95% confidence interval: 0.77, 2.11; P=.35) between patients receiving and patients not receiving RAASi.57 However, in stratified analysis, there was an increased risk for CA-AKI (odds ratio: 2.06; 95% confidence interval: 1.62, 2.61; P< .001) for chronic RAASi users who did not withhold the drug. The controversy of contrast-induced nephropathy with intravenous contrast: what Is the risk? Despite decades of research on iodinated contrast and kidney injury, many questions are yet to be answered. 3rd ed. Cheungpasitporn W., Thongprayoon C., Brabec B.A., Edmonds P.J., OCorragain O.A., Erickson S.B. In most cases contrast dyes used in tests, such as CT (computerized tomography) and angiograms, have no reported problems. Group IIagents associated with few, if any, unconfounded cases of NSF. In response to this crisis, the authorities and radiology societies were quick to react. However, the event rate in this trial was lower than in previous trials, and therefore, caution should be used with interpreting the results. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Morris Z.S., Wooding S., Grant J. Newsletter: Mayo Clinic Health Letter Digital Edition, Book: Mayo Clinic Family Health Book, 5th Edition, Angiotensin-converting enzyme (ACE) inhibitors. In a related project, investigators looked at the effectiveness of adding computerized clinical alerts to the electronichealth recordto potentially reducethe number of patients who develop contrast-induced nephropathy. McDonald J.S., McDonald R.J., Carter R.E., Katzberg R.W., Kallmes D.F., Williamson E.E. Even when kidney damage occurs, it is almost always temporary and will resolve without treatment. Patients with poor kidney function are the people at risk for these side effects. Combined with the fact that iodixanol is nearly five times as expensive as iohexol, the value of this shift, for patients, was clear. Post-contrast acute kidney injury. Contrast-Induced Acute Kidney Injury: Review and Practical Update