Contrast-induced nephropathy: Difference between revisions
 
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===Healthy Patients===
===Healthy Patients===
*CIN not likely to occur in patients with a Cr<1.5 or a GFR >60ml/min<ref>Davenport MS. et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013 Apr;267(1):94-105</ref><ref>Sinert R, Brandler E, et al. Acad Emerg Med2012;19(11):1261</ref>
*Not likely to occur in patients with a Cr<1.5 or a GFR >60ml/min<ref>Davenport MS. et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013 Apr;267(1):94-105</ref><ref>Sinert R, Brandler E, et al. Acad Emerg Med2012;19(11):1261</ref>


===Impaired Renal Function===
===Impaired Renal Function===
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*Isotonic hydration with [[normal saline]] 1-1.5L (15ml/kg) prior to the contrast load in patients with impaired renal function may lessen the chances of developing CIN <ref>Mueller C. et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162(3):329</ref><ref>Bertrand Dussol. et al. A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients. Nephrol. Dial. Transplant. 2006. 21 (8): 2120-2126</ref><ref name="traub">Traub SJ, et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med 2013;62(5):511-20 [http://www.annemergmed.com/article/S0196-0644(13)00350-8/pdf PDF]</ref>
*Isotonic hydration with [[normal saline]] 1-1.5L (15ml/kg) prior to the contrast load in patients with impaired renal function may lessen the chances of developing CIN <ref>Mueller C. et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162(3):329</ref><ref>Bertrand Dussol. et al. A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients. Nephrol. Dial. Transplant. 2006. 21 (8): 2120-2126</ref><ref name="traub">Traub SJ, et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med 2013;62(5):511-20 [http://www.annemergmed.com/article/S0196-0644(13)00350-8/pdf PDF]</ref>
*If suspect the development or confirm the diagnosis continue adequate hydration to maintain urine output of 0.7cc-1cc/kg
*If suspect the development or confirm the diagnosis continue adequate hydration to maintain urine output of 0.7cc-1cc/kg
*Early research suggests a potential benefit for forced [[furosemide]] diuresis (300ml/h) while continuing intravenous hydration fluids (0.5mg/kg) but should be performed in consult with radiologist and nephrologist<ref>Marenzi G. et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial. JACC Cardiovasc Interv. 2012 Jan;5(1):90-7</ref>
*Early research suggests a potential benefit for forced [[furosemide]] diuresis (300ml/h) while continuing [[IVF|intravenous hydration fluids]] (0.5mg/kg) but should be performed in consult with radiologist and nephrologist<ref>Marenzi G. et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial. JACC Cardiovasc Interv. 2012 Jan;5(1):90-7</ref>


===[[N-acetylcysteine]]===
===[[N-acetylcysteine]]===
*'''Is not useful for preventing CIN'''<ref>ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011 Sep 13;124(11):1250-9 [http://circ.ahajournals.org/content/124/11/1250.full.pdf PDF]</ref><ref name="traub"></ref>
*'''Is not useful for preventing CIN'''<ref>ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011 Sep 13;124(11):1250-9 [http://circ.ahajournals.org/content/124/11/1250.full.pdf PDF]</ref><ref name="traub"></ref>
===Other Measures===
===Other Measures===
*Low osmolar contrast agents
*Low osmolar contrast agents
*[[Bicarbonate]] infusion
*[[Bicarbonate]] infusion
*[[Hypertonic saline]]
*[[Hypertonic saline]]
==Disposition==
==Prevention<ref>Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology. 2000 Aug;216(2):481-4.</ref><ref>ACR Manual on Contrast Media – Version 10, 2015. [http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/2015_Contrast_Media.pdf PDF] Accessed 08/10/15</ref>==
* ED patients do NOT require creatinine measurement prior to IV contrast if the study is immediately necessary to prevent life-threatening decompensation or delay in emergent treatment (e.g., trauma patients, dissection r/o)
* [https://lacounty-my.sharepoint.com/personal/jshim_dhs_lacounty_gov/_layouts/15/onedrive.aspx?FolderCTID=0x01200042EAB0B5A27C63468CDB5666D0718199&id=%2Fpersonal%2Fjshim%5Fdhs%5Flacounty%5Fgov%2FDocuments%2FMicrosoft%20Teams%20Chat%20Files%2FUse%20of%20IV%2 DHS IV Contrast Expected Practices 10-2022]
** '''Ok to give IV contrast if GFR>30'''
** '''No need for GFR screening if age <60 with no pertinent history''' (AKI, CKD, HD with urine output, renal transplant, Metformin use)
** If the GFR<30, ER physician should state in the CT order “Clinical History” or document in the chart that IV contrast is necessary and authorized.
*** Alternately, the '''CT tech may call the physician to confirm IV contrast is necessary and authorized, and CT tech should document this communication in the chart.'''
** Screening for MRI contrast is unnecessary unless using  Eovist for liver mets study (all ED Emergent studies should use Dotarem or Gadavist)


==See Also==
==See Also==
*[[Creatinine screening prior to IV contrast]]
*[[MRI contraindications]]
*[[MRI contraindications]]
*[[CT contrast media extravasation‎]]
*[[CT contrast media extravasation‎]]
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[[Category:Renal]]
[[Category:Renal]]
[[Category:Radiology]]

Latest revision as of 17:22, 22 March 2023

This page only applies to contrast agents usually used for CT scans. MRIs with contrast use gadolinium, which can cause nephrogenic systemic fibrosis in patients with renal dysfunction.

Background

  • Often defined as creatinine rise of more than 0.5mg/dL or ≥25% above baseline[1]
  • Vasoconstriction leading to ischemia in the deeper portion of the outer medulla
  • Toxic to kidney tubular cells, inducing vacuolization, change in mitochondrial function, and apoptosis
  • Less likely to occur with low and iso-osmolar contrast agents

Healthy Patients

  • Not likely to occur in patients with a Cr<1.5 or a GFR >60ml/min[2][3]

Impaired Renal Function

  • Administration should follow your local hospital protocols
  • Less likely to occur in iso-osmolar contrast agents (iodixanol/Visipaque) and contrary to traditional teaching, maybe not even an occurrence in patients with creatinine greater than 2.0mg/dL. [4]

Risk Factors

Clinical Features

  • Decreased urine output
  • 0.5mg/dl absolute or >25% relative increase in serum creatinine 48-72hrs after contrast exposure

Differential Diagnosis

  • Poor renal perfusion
  • Nephrotoxic medications

Contrast induced complications

Evaluation

  • Same as for AKI

Management

Hallmark of management is prevention in at-risk patients.

Hydration

  • Isotonic hydration with normal saline 1-1.5L (15ml/kg) prior to the contrast load in patients with impaired renal function may lessen the chances of developing CIN [5][6][7]
  • If suspect the development or confirm the diagnosis continue adequate hydration to maintain urine output of 0.7cc-1cc/kg
  • Early research suggests a potential benefit for forced furosemide diuresis (300ml/h) while continuing intravenous hydration fluids (0.5mg/kg) but should be performed in consult with radiologist and nephrologist[8]

N-acetylcysteine

  • Is not useful for preventing CIN[9][7]

Other Measures

Disposition

Prevention[10][11]

  • ED patients do NOT require creatinine measurement prior to IV contrast if the study is immediately necessary to prevent life-threatening decompensation or delay in emergent treatment (e.g., trauma patients, dissection r/o)
  • DHS IV Contrast Expected Practices 10-2022
    • Ok to give IV contrast if GFR>30
    • No need for GFR screening if age <60 with no pertinent history (AKI, CKD, HD with urine output, renal transplant, Metformin use)
    • If the GFR<30, ER physician should state in the CT order “Clinical History” or document in the chart that IV contrast is necessary and authorized.
      • Alternately, the CT tech may call the physician to confirm IV contrast is necessary and authorized, and CT tech should document this communication in the chart.
    • Screening for MRI contrast is unnecessary unless using Eovist for liver mets study (all ED Emergent studies should use Dotarem or Gadavist)

See Also

References

  1. ↑ Goldfarb, S. et al. Contrast-Induced Acute Kidney Injury: Specialty-Specific Protocols for Interventional Radiology, Diagnostic Computed Tomography Radiology, and Interventional Cardiology. Mayo Clin Proc. Feb 2009; 84(2): 170–179 Text
  2. ↑ Davenport MS. et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013 Apr;267(1):94-105
  3. ↑ Sinert R, Brandler E, et al. Acad Emerg Med2012;19(11):1261
  4. ↑ McDonald RJ, McDonald JS, et al. Radiology. 2013;267(1):106
  5. ↑ Mueller C. et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162(3):329
  6. ↑ Bertrand Dussol. et al. A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients. Nephrol. Dial. Transplant. 2006. 21 (8): 2120-2126
  7. ↑ 7.0 7.1 Traub SJ, et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med 2013;62(5):511-20 PDF
  8. ↑ Marenzi G. et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial. JACC Cardiovasc Interv. 2012 Jan;5(1):90-7
  9. ↑ ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011 Sep 13;124(11):1250-9 PDF
  10. ↑ Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology. 2000 Aug;216(2):481-4.
  11. ↑ ACR Manual on Contrast Media – Version 10, 2015. PDF Accessed 08/10/15
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