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McDonald JS, McDonald RJ. Risk of Acute Kidney Injury Following IV Iodinated Contrast Media Exposure: 2023 Update, From the AJR Special Series on Contrast Media. AJR Am J Roentgenol 2024; 223:e2330037. [PMID: 37791729 DOI: 10.2214/ajr.23.30037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Iodinated contrast material (ICM) has revolutionized the field of diagnostic radiology through improvements in diagnostic performance and the expansion of clinical indications for radiographic and CT examinations. Historically, nephrotoxicity was a feared complication of ICM use, thought to be associated with a significant risk of morbidity and mortality. Such fears often precluded the use of ICM in imaging evaluations, commonly at the expense of diagnostic performance and timely diagnosis. Over the past 20 years, the nephrotoxic risk of ICM has become a topic of debate, as more recent evidence from higher-quality studies now suggests that many cases of what was considered contrast-induced acute kidney injury (CI-AKI) likely were cases of mistaken causal attribution; most of these cases represented either acute kidney injury (AKI) caused by any of myriad other known factors that can adversely affect renal function and were coincidentally present at the time of contrast media exposure (termed "contrast-associated AKI" [CA-AKI]) or a manifestation of the normal variation in renal function that increases with worsening renal function. This Special Series Review discusses the current state of knowledge regarding CI-AKI and CA-AKI, including the incidence, risk factors, outcomes, and prophylactic strategies in the identification and management of these clinical conditions.
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Affiliation(s)
- Jennifer S McDonald
- Department of Radiology, College of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Robert J McDonald
- Department of Radiology, College of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905
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Chaudhari H, Mahendrakar S, Baskin SE, Reddi AS. Contrast-Induced Acute Kidney Injury: Evidence in Support of Its Existence and a Review of Its Pathogenesis and Management. Int J Nephrol Renovasc Dis 2022; 15:253-266. [PMID: 36311164 PMCID: PMC9604418 DOI: 10.2147/ijnrd.s371700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022] Open
Abstract
The role of contrast-induced nephropathy (CIN) remains controversial. Many experts contend that CIN does not exist or is extremely rare. The diagnosis was previously made too frequently and inappropriately in the presence of coexisting and confounding comorbidities and risk factors making it difficult to singularly isolate the etiologic role of intravenous contrast media in acute kidney injury (AKI). It is probable that many patients were denied important diagnostic information from radiocontrast studies for fear of CIN. Recently, a new terminology for CIN was introduced, and the term CIN was replaced by two interrelated new terms: one is contrast-associated acute kidney injury (CA-AKI), and the second one is contrast-induced acute kidney injury (CI-AKI). CA-AKI occurs in association with risk factors or comorbidities, therefore, it is a correlative diagnosis. On the other hand, CI-AKI is a subtype of CA-AKI that results directly from iodinated contrast media. In this review, we present evidence from various studies that argue against CI-AKI and also those that suggest its existence but with much lower frequency. We will also provide the current status of the pathophysiology and management of CA-AKI/CI-AKI.
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Affiliation(s)
- Harshad Chaudhari
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA,Correspondence: Harshad Chaudhari, Email
| | - Smita Mahendrakar
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Stuart E Baskin
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Alluru S Reddi
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
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Oh SW, Park SY, Yong HS, Choi YH, Cha MJ, Kim TB, Lee JH, Kim SH, Lee JH, Hur GY, Hwang JY, Kim S, Kim HS, Ryu JY, Choi M, Choi CH. Korean Clinical Practice Guidelines for Adverse Reactions to Intravenous Iodinate and MRI-Gadolinium Contrast Agents: Revised Clinical Consensus and Recommendations (3rd Edition, 2022). JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:254-264. [PMID: 36237922 PMCID: PMC9514440 DOI: 10.3348/jksr.2022.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/19/2022] [Indexed: 12/01/2022]
Abstract
대한영상의학회 진료지침위원회는 기존의 2016년 진료지침을 개정하여 ‘주사용 요오드화 조영제 및 MRI용 가돌리늄 조영제 유해 반응에 대한 한국 임상진료지침: 개정된 임상적 합의 및 권고안(2022년 제3판)’을 제작하였다. 대한영상의학회와 대한천식알레르기학회, 대한신장학회에세 추천 및 승인된 전문가 위원들이 함께 참여하였고, 전문가 합의 또는 체계적 문헌 고찰을 기반으로, 조영제를 사용 시 감염관리를 위한 자동주입기 및 연결선에 대한 기술과 요요드화 조영제에 대한 급성 유해반응 및 신장 유해반응에 대한 내용들을 수정 및 추가하였다. 이에 개정된 내용을 소개하고자 한다.
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Affiliation(s)
- Se Won Oh
- Department of Radiology, The Catholic University of Korea, Eunpyeong St. Mary’s Hospital, Seoul, Korea
| | - So Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hwan Seok Yong
- Department of Radiology, Cardiothoracic Division, Korea University Guro Hospital, Seoul, Korea
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Min Jae Cha
- Department of Radiology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jae Yeon Hwang
- Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Yangsan, Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Sang Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Ji Young Ryu
- Division of Nephrology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Miyoung Choi
- Division of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chi-Hoon Choi
- Department of Radiology, Chungbuk National University Hospital, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
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Oral hydration as a safe prophylactic measure to prevent post-contrast acute kidney injury in oncologic patients with chronic kidney disease (IIIb) referred for contrast-enhanced computed tomography: subanalysis of the oncological group of the NICIR study. Support Care Cancer 2021; 30:1879-1887. [PMID: 34613475 DOI: 10.1007/s00520-021-06561-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND T he objective of this study is to evaluate oral hydration compared to intravenous (i.v.) hydration in the prevention of post-contrast acute kidney injury (PC-AKI) in the oncologic subgroup of patients with stage IIIb chronic kidney disease (CKD) included in the NICIR study referred for elective contrast-enhanced computed tomography (CE-CT). MATERIAL AND METHODS We performed a retrospective subanalysis of the oncological subgroup (174/228 patients, 74%) from a continuous prospective database of patients included in the recently published non-inferiority NICIR study. Patients received prophylaxis against PC-AKI with either oral hydration (500 mL of water 2 h before and 2000 mL during the 24 h after CE-CT) or i.v. hydration (sodium bicarbonate (166 mmol/L) 3 mL/kg/h starting 1 h before and 1 mL/kg/h during the first hour after CE-CT). The primary outcome was to compare the proportion of PC-AKI in the first 48 to 72 h after CE-CT in the two hydration groups. Secondary outcomes were to compare persistent PC-AKI, the need for haemodialysis, and the occurrence of adverse events related to prophylaxis in each group. RESULTS Of 174 patients included in the subanalysis, 82 received oral hydration and 92 received i.v. hydration. There were no significant differences in clinical characteristics or risk factors between the two study arms. Overall the PC-AKI rate was 4.6% (8/174 patients), being 3.7% in the oral hydration arm (3/82 patients) and 5.4% (5/92 patients) in the i.v. hydration arm. The persistent PC-AKI rate was 1.2% (1/82 patients) in the oral hydration arm and 3.3% (3/92 patients) in the i.v. hydration arm. No patient required dialysis during the first month after CE-CT or had adverse effects related to the hydration regime. CONCLUSION In oncological patients with stage IIIb CKD referred for elective CE-CT, the rate of PC-AKI in those receiving oral hydration did not significantly differ from that of patients receiving i.v. hydration.
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Kim SY, Beer M, Tshering Vogel DW. Imaging in head and neck cancers: Update for non-radiologist. Oral Oncol 2021; 120:105434. [PMID: 34218063 DOI: 10.1016/j.oraloncology.2021.105434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 12/24/2022]
Abstract
Head and neck cancer (HNC) is the fifth most frequent cancer worldwide and associated with significant morbidity. Along with clinical examination and endoscopic evaluation, imaging plays an important role in pre- and posttherapeutic evaluation of patients with HNC. Cross-sectional Imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography / computed tomography (PET/CT) are routinely used in the assessment of these patients. This review provides an overview of the various cross-sectional imaging modalities used in the evaluation of HNC and will give a short summary of the latest imaging technologies regarding head and neck cancer diagnosis.
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Affiliation(s)
- Soung Yung Kim
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany.
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Dechen W Tshering Vogel
- University Institute for Diagnostic, Interventional and Paediatric Radiology, Inselspital University Hospital Bern, University of Bern, Freiburgstrasse 10, Bern 3010, Switzerland
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Sebastià C, Páez-Carpio A, Guillen E, Paño B, Garcia-Cinca D, Poch E, Oleaga L, Nicolau C. Oral hydration compared to intravenous hydration in the prevention of post-contrast acute kidney injury in patients with chronic kidney disease stage IIIb: A phase III non-inferiority study (NICIR study). Eur J Radiol 2021; 136:109509. [PMID: 33516141 DOI: 10.1016/j.ejrad.2020.109509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/03/2020] [Accepted: 12/28/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the non-inferiority of oral hydration compared to intravenous (i.v.) hydration in the prevention of post-contrast acute kidney injury (PC-AKI) in patients with stage IIIb chronic kidney disease (CKD) referred for an elective contrast-enhanced computed tomography (CE-CT). MATERIAL AND METHODS This is a prospective, randomized, phase 3, parallel-group, open-label, non-inferiority trial. Patients were randomly assigned 1:1 to receive prophylaxis against PC-AKI either with oral hydration: 500 mL of water two hours before and 2000 mL during the 24 h after performing CE-CT or i.v. hydration: sodium bicarbonate (166 mmol/L) 3 mL/kg/h starting one hour before and sodium bicarbonate (166 mmol/L) 1 mL/kg/h during the first hour after CE-CT. 100 mL of non-ionic iodinated contrast was administered in all cases. The primary outcome was the proportion of PC-AKI in the first 48-72 h after CE-CT. Secondary outcomes were persistent PC-AKI, the need for hemodialysis, and the occurrence of adverse events related to prophylaxis. RESULTS Of 264 patients randomized between January 2018 and January 2019, 114 received oral hydration, and 114 received i.v. hydration and were evaluable. No significant differences were found (p > 0.05) between arms in clinical characteristics or risk factors. PC-AKI rate was 4.4 % (95 %CI: 1.4-9.9 %) in the oral hydration arm and 5.3 % (95 %CI: 2.0-11.1%) in the i.v. hydration arm. The persistent PC-AKI rate was 1.8 % (95 %CI: 0.2-6.2 %) in both arms. No patient required dialysis during the first month after CE-CT or had adverse effects related to the hydration regime. CONCLUSION In those with stage IIIb CKD referred for an elective CE-CT, we provide evidence of non-inferiority of oral hydration compared to i.v. hydration in the prevention of PC-AKI.
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Affiliation(s)
- Carmen Sebastià
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain.
| | | | - Elena Guillen
- Department of Nephrology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Blanca Paño
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Esteban Poch
- Department of Nephrology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laura Oleaga
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain; Universitat de Barcelona, Campus Clínic, Barcelona, Spain
| | - Carlos Nicolau
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain; Universitat de Barcelona, Campus Clínic, Barcelona, Spain
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Brito C, Falcão L, Raimundo M, Fernandes S, Fernandes A, Silva S, Vilela P, Almeida ED. Contrast-induced acute kidney injury in acute ischaemic stroke patients. Neuroradiol J 2020:1971400920977206. [PMID: 33283660 DOI: 10.1177/1971400920977206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The potential nephrotoxicity of intravenous iodinated contrast media is a major concern for acute ischaemic stroke imaging evaluation. This study aimed to assess the incidence of acute kidney injury after intravenous iodinated contrast media exposure in acute ischaemic stroke patients. METHODS We conducted a retrospective cohort analysis between January 2012 and July 2018 to select adult patients admitted to the emergency department with acute ischaemic stroke. The exposed patients received a uniform intravenous dose of low osmolar non-ionic iodinated contrast media, as part of the imaging protocol for acute ischaemic stroke. The unexposed patients underwent a non-enhanced cranial computed tomography scan. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes criteria, limited to the first 72 hours. RESULTS A total of 161 and 105 patients were included in the exposed and unexposed groups, respectively. The median age was 72.8 years (interquartile range 20), 53% were men and 97% were white. Demographic and baseline characteristics were similar between the groups. The incidence of acute kidney injury between exposed (n = 10, 6.2%) and unexposed (n = 1, 1%) groups (P = 0.073) was similar and contrast exposure was not a significant predictor of acute kidney injury. CONCLUSION Intravenous iodinated contrast media exposure during acute ischaemic stroke imaging protocols is not an independent predictor of acute kidney injury in patients with normal or near-normal renal function. Studies with larger sample sizes would help to clarify if patients with both cardiovascular risk factors and impaired renal function could benefit from prophylactic measures.
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Affiliation(s)
- Catarina Brito
- Neuroradiology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
- University College London, UK
- *These authors contributed equally to the study and final manuscript
| | - Luís Falcão
- Nephrology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
- *These authors contributed equally to the study and final manuscript
| | - Mário Raimundo
- Nephrology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Sara Fernandes
- Nephrology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
| | | | - Sónia Silva
- Nephrology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Pedro Vilela
- Neuroradiology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
- Institutional Council of the European Society of Neuroradiology
- Portuguese Neuroradiology Society, Portugal
- Spanish Neuroradiology Society, Spain
| | - Edgar de Almeida
- Nephrology Department, Hospital Beatriz Ângelo, Lisbon, Portugal
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Sebastià C, Nicolau C, Martín de Francisco Á, Poch E, Oleaga L. Prophylaxis against postcontrast acute kidney injury (PC-AKI): Updates in the ESUR guidelines 10.0 and critical review. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sebastià C, Nicolau C, Martín de Francisco Á, Poch E, Oleaga L. Profilaxis de la lesión renal aguda poscontraste (LRA-PC). Actualización según la guía clínica ESUR 10.0 y revisión crítica. RADIOLOGIA 2020; 62:292-297. [DOI: 10.1016/j.rx.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 11/12/2019] [Accepted: 12/11/2019] [Indexed: 12/09/2022]
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Hur KY, Kim MK, Ko SH, Han M, Lee DW, Kwon HS. Metformin treatment for patients with diabetes and chronic kidney disease: A Korean Diabetes Association and Korean Society of Nephrology consensus statement. Kidney Res Clin Pract 2020; 39:32-39. [PMID: 32138474 PMCID: PMC7105629 DOI: 10.23876/j.krcp.20.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 01/21/2023] Open
Abstract
The safety of metformin use for patients with type 2 diabetes mellitus (T2DM) and advanced kidney disease is controversial, and more recent guidelines have suggested that metformin be used cautiously in this group until more definitive evidence concerning its safety is available. The Korean Diabetes Association and the Korean Society of Nephrology have agreed on consensus statements concerning metformin use for patients with T2DM and renal dysfunction, particularly when these patients undergo imaging studies using iodinated contrast media (ICM). Metformin can be used safely when the estimated glomerular filtration rate (eGFR) is ≥ 45 mL/min/1.73 m2. If the eGFR is between 30 and 44 mL/min/1.73 m2, metformin treatment should not be started. If metformin is already in use, a daily dose of ≤ 1,000 mg is recommended. Metformin is contraindicated when the eGFR is < 30 mL/min/1.73 m2. Renal function should be evaluated prior to any ICM-related procedures. During procedures involving intravenous administration of ICM, metformin should be discontinued starting the day of the procedures and up to 48 hours post-procedures if the eGFR is < 60 mL/min/1.73 m2.
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Affiliation(s)
- Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mee Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Miyeun Han
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Dong Won Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyuk-Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Hur KY, Kim MK, Ko SH, Han M, Lee DW, Kwon HS. Metformin Treatment for Patients with Diabetes and Chronic Kidney Disease: A Korean Diabetes Association and Korean Society of Nephrology Consensus Statement. Diabetes Metab J 2020; 44:3-10. [PMID: 32097995 PMCID: PMC7043977 DOI: 10.4093/dmj.2020.0004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/23/2020] [Indexed: 02/02/2023] Open
Abstract
The safety of metformin use for patients with type 2 diabetes mellitus (T2DM) and advanced kidney disease is controversial, and more recent guidelines have suggested that metformin be used cautiously in this group until more definitive evidence concerning its safety is available. The Korean Diabetes Association and the Korean Society of Nephrology have agreed on consensus statements concerning metformin use for patients with T2DM and renal dysfunction, particularly when these patients undergo imaging studies using iodinated contrast media (ICM). Metformin can be used safely when the estimated glomerular filtration rate (eGFR) is ≥45 mL/min/1.73 m². If the eGFR is between 30 and 44 mL/min/1.73 m², metformin treatment should not be started. If metformin is already in use, a daily dose of ≤1,000 mg is recommended. Metformin is contraindicated when the eGFR is <30 mL/min/1.73 m². Renal function should be evaluated prior to any ICM-related procedures. During procedures involving intravenous administration of ICM, metformin should be discontinued starting the day of the procedures and up to 48 hours post-procedures if the eGFR is <60 mL/min/1.73 m².
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Affiliation(s)
- Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mee Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Miyeun Han
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Won Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.
| | - Hyuk Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Contrast-Induced Acute Kidney Injury Among Patients With Chronic Kidney Disease Undergoing Imaging Studies: A Meta-Analysis. AJR Am J Roentgenol 2019; 213:728-735. [DOI: 10.2214/ajr.19.21309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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13
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Mamoulakis C, Tsarouhas K, Fragkiadoulaki I, Heretis I, Wilks MF, Spandidos DA, Tsitsimpikou C, Tsatsakis A. Contrast-induced nephropathy: Basic concepts, pathophysiological implications and prevention strategies. Pharmacol Ther 2017. [PMID: 28642116 DOI: 10.1016/j.pharmthera.2017.06.009] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Contrast-induced nephropathy (CIN) is reversible acute renal failure observed following administration of iodinated contrast media (CM) during angiographic or other medical procedures such as urography. There are various mechanisms through which CM develop their nephrotoxic effects, including oxidative stress and apoptosis. CIN is a real-life, albeit not very rare, entity. Exact pathophysiology remains obscure and no standard diagnostic criteria apply. The Acute Kidney Injury Network criteria was recently employed but its incidence/clinical significance warrants further clarification based on recent methodological advancements, because most published studies to date were contaminated by bias. The current study is a comprehensive review conducted to provide an overview of the basic concepts of CIN and summarize recent knowledge on its pathophysiology and the evidence supporting potential prevention strategies. CIN is expected to increase morbidity, hospital stay and mortality, while all patients scheduled to receive CM should undergo risk assessment for CIN and high-risk patients may be considered candidates for prevention strategies. The value of using compounds with antioxidant properties other than sodium bicarbonate, remains controversial, warranting further clinical investigation.
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Affiliation(s)
- Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece.
| | | | - Irini Fragkiadoulaki
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, Heraklion 71003, Greece
| | - Ioannis Heretis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Martin F Wilks
- Swiss Centre for Applied Human Toxicology, University of Basel, CH-4055 Basel, Switzerland
| | - Demetrios A Spandidos
- Department of Virology, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Christina Tsitsimpikou
- Department of Hazardous Substances, Mixtures and Articles, General Chemical State Laboratory of Greece, Ampelokipi, Athens, Greece
| | - Aristides Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, Heraklion 71003, Greece
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Abstract
The German Society of Internal Medicine ("Deutsche Gesellschaft für Innere Medizin", DGIM) founded the Choosing wisely initiative in order to address diagnostic and therapeutic procedures that are frequently inappropriately applied, whether this be in terms of over-, under-, or misuse of health services. The German Society of Nephrology ("Deutsche Gesellschaft für Nephrologie," DGfN) strongly supports the initiative and has contributed five positive and five negative recommendations. These ten recommendations are discussed in the current publication. The positive recommendations reflect the importance of early recognition of renal disease via simple blood and urine tests, the use of radiocontrast media in cases of impaired renal function, as well as the problems associated with low vaccination rates. Three of the negative recommendations are focused on hydration and diuretics. The remaining two negative recommendations concern angioplasty in cases of renal artery stenosis and the unconsidered use of nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- J Galle
- Klinik für Nephrologie und Dialyseverfahren, Klinikum Lüdenscheid, Paulmannshöher Str. 14, 58515, Lüdenscheid, Deutschland.
| | - J Floege
- Klinik für Nieren- und Hochdruckkrankheiten, rheumatologische und immunologische Erkrankungen (Medizinische Klinik II), Universitätsklinikum Aachen, AöR, Aachen, Deutschland
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15
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Do C. Intravenous Contrast: Friend or Foe? A Review on Contrast-Induced Nephropathy. Adv Chronic Kidney Dis 2017; 24:147-149. [PMID: 28501076 DOI: 10.1053/j.ackd.2017.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intravenous iodinated contrast is used in many contrasted imaging studies ranging from computed tomography to angiography. The risks of contrast-induced nephropathy (CIN) and its incidence have not been clearly defined. Most iodinated contrast media used today are hypertonic compared with serum osmolality and pose biological risks. However, the risk of CIN in the general population may be overestimated. Confounding risk factors may contribute to acute kidney injury other than attributable risk of contrast exposure. In high-risk populations such as in those with CKD, CIN risk may be higher and thus caution should be exerted with contrast exposure. The volumes of contrast should be minimized as much as possible and hemodynamic status should be optimized before contrast administration.
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16
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Prevention of post procedural acute kidney injury in the catheterization laboratory in a real-world population. Int J Cardiol 2017; 226:42-47. [DOI: 10.1016/j.ijcard.2016.10.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/04/2016] [Accepted: 10/09/2016] [Indexed: 02/02/2023]
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17
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Clinical Significance of Persistent Global and Focal Computed Tomography Nephrograms After Cardiac Catheterization and Their Relationships to Urinary Biomarkers of Kidney Damage and Procedural Factors. Invest Radiol 2016; 51:797-803. [DOI: 10.1097/rli.0000000000000268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Navin P, Murray AM, Nandikumar K, Waldron R, Tuohy B, Casey M. Shaped-bolus protocol reduces contrast medium volume in abdominal CT while maintaining image quality. Clin Radiol 2016; 72:265.e1-265.e5. [PMID: 27884388 DOI: 10.1016/j.crad.2016.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/10/2016] [Accepted: 10/18/2016] [Indexed: 01/29/2023]
Abstract
AIM To prospectively assess whether bolus shaping to exponentially decrease the contrast medium injection rate leads to alteration in image validity or renal function. MATERIALS AND METHODS In this prospective study, patients alternatively received 100 ml contrast medium versus 75 ml via bolus shaping. Image quality was assessed via measurement of attenuation values in the aorta, liver, and spleen and also blinded subjective assessment of image sharpness, low contrast detectability, image noise, and overall quality. Renal function was assessed by change in creatinine levels up to 72 hours post-contrast medium administration. RESULTS Of 190 abdominal computed tomography (CT) studies performed in the 3-month period, 98 received the 75 ml dose. There was no significant difference in renal function or objective image quality with a significant improvement in image sharpness in the 100 ml group. CONCLUSIONS By using bolus-shaping software, it is possible to maintain objective image quality while reducing the contrast medium load to the patient. This has significant implications regarding clinical practice in decreasing cost and risks associated with iodinated contrast media.
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Affiliation(s)
- P Navin
- Department of Radiology, Mayo General Hospital, Castlebar, County Mayo, Ireland.
| | - A M Murray
- Department of Radiology, Mayo General Hospital, Castlebar, County Mayo, Ireland
| | - K Nandikumar
- Department of Radiology, Mayo General Hospital, Castlebar, County Mayo, Ireland
| | - R Waldron
- Department of General Surgery, Mayo General Hospital, Castlebar, County Mayo, Ireland
| | - B Tuohy
- Department of Physics, Saolta University Healthcare Group, Galway, Ireland
| | - M Casey
- Department of Radiology, Mayo General Hospital, Castlebar, County Mayo, Ireland
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19
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Cernigliaro JG, Haley WE, Adolphson DP, Jepperson MA, Crook JE, Thomas CS, Parker AS. Contrast-induced nephropathy in outpatients with preexisting renal impairment: a comparison between intravenous iohexol and iodixanol. Clin Imaging 2016; 40:902-6. [DOI: 10.1016/j.clinimag.2016.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/14/2016] [Accepted: 04/21/2016] [Indexed: 02/06/2023]
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20
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Heller M, Krieger P, Finefrock D, Nguyen T, Akhtar S. Contrast CT Scans in the Emergency Department Do Not Increase Risk of Adverse Renal Outcomes. West J Emerg Med 2016; 17:404-8. [PMID: 27429690 PMCID: PMC4944796 DOI: 10.5811/westjem.2016.4.28994] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/25/2016] [Accepted: 04/08/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Michael Heller
- Icahn School of Medicine, Department of Emergency Medicine, New York, New York; Mount Sinai Beth Israel Medical Center, Department of Emergency Medicine, New York, New York
| | - Paul Krieger
- Icahn School of Medicine, Department of Emergency Medicine, New York, New York; Mount Sinai Beth Israel Medical Center, Department of Emergency Medicine, New York, New York
| | - Douglas Finefrock
- Hackensack University Medical Center, Department of Emergency Medicine, Hackensack, New Jersey
| | - Thomas Nguyen
- Mount Sinai Beth Israel Medical Center, Department of Emergency Medicine, New York, New York
| | - Saadia Akhtar
- Icahn School of Medicine, Department of Emergency Medicine, New York, New York; Mount Sinai Beth Israel Medical Center, Department of Emergency Medicine, New York, New York
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21
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Khatami MR, Sabbagh MRP, Nikravan N, Khazaeipour Z, Boroumand MA, Sadeghian S, Davoudi B. The role of neutrophil-gelatinase-associated lipocalin in early diagnosis of contrast nephropathy. Indian J Nephrol 2015; 25:292-6. [PMID: 26628795 PMCID: PMC4588325 DOI: 10.4103/0971-4065.147370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Neutrophil-gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury. The aim of this study was to define a cut-off for NGAL in the early diagnosis of contrast-induced nephropathy (CIN) in patients with normal kidney function. We enrolled 121 patients with normal serum creatinine who underwent coronary angiography. NGAL was measured in urine before the procedure and 12 and 24 h afterward. CIN was defined as a 0.3 mg/dl increase in serum creatinine within 48 h after the procedure. Seven of 121 patients had CIN (5.8%). The NGAL levels in the 12- and 24-h urine samples of these patients were 30 (5–45) and 20 (15–40) ng/ml, respectively, whereas those in patients without CIN were 15 (5–45) and 15 (10–51) ng/ml, respectively (P = 0.8). In patients with CIN, the sensitivity and specificity of NGAL with a cut-off of 22.5 ng/ml were 71.4% and 57.9% in 12-h urine samples, with the negative predictive values (NPV) and positive predictive values (PPV) of 97.1% and 9.4%, respectively. In conclusion, we suggest that urine NGAL with cut-off point of 22.5 ng/ml has acceptable sensitivity and specificity for early diagnosis of CIN in patients with normal serum creatinine, but regarding NPV and PPV the best performance of this value is to rule out the CIN in patients at risk who received contrast media.
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Affiliation(s)
- M R Khatami
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M R P Sabbagh
- Imam Khomeini Hospital, Tehran University of Medical Sciences, Internal Medicine Ward, Imam Khomeini Hospital, Keshavarz Blvd, Tehran, Iran
| | - N Nikravan
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Z Khazaeipour
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - M A Boroumand
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave., Tehran, Iran
| | - S Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave., Tehran, Iran
| | - B Davoudi
- Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave., Tehran, Iran
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22
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Sailer AM, Nelemans PJ, van Berlo C, Yazar O, de Haan MW, Fleischmann D, Schurink GWH. Endovascular treatment of complex aortic aneurysms: prevalence of acute kidney injury and effect on long-term renal function. Eur Radiol 2015; 26:1613-9. [PMID: 26431707 PMCID: PMC4863901 DOI: 10.1007/s00330-015-3993-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 12/04/2022]
Abstract
Objectives To analyse predictors for short- and long-term renal function changes after fenestrated and branched endovascular aortic repair (EVAR). Methods A total of 157 patients underwent fenestrated and branched EVAR. Procedural intra-arterial iodinated contrast volume was documented. Serum creatinine and estimated glomerular filtration rate (eGFR) at baseline, during 48 h following EVAR, at discharge and latest moment of follow-up were recorded. Development of post-EVAR acute kidney injury (AKI; according to AKIN criteria), and potential risk factors for renal failure were recorded. Multivariate regression analyses were used to identify independent risk factors for AKI and eGFR decrease during follow-up. Results Forty-three patients (28 %) developed post-EVAR AKI. Long procedure time and occlusion of accessory renal arteries were independent risk factors for development of AKI. (odds ratio (OR) 1.005 per minute, 95 % CI 1.001–1.01; p = 0.025 and OR 3.02, 95 % CI 1.19–8.16; p = 0.029). Post-EVAR AKI was associated with a significantly increased risk for eGFR decrease at discharge and latest follow-up (hazard ratio (HR) 3.47, 95 % CI 1.63–7.36, p = 0.001 and HR 3.01, 95 % CI 1.56–5.80; p = 0.001). Iodinated contrast volume was not an independent risk factor for AKI or eGFR decrease during follow-up. Conclusion Development of post-EVAR AKI is an independent risk factor for long-term renal function decrease. Key Points • Longer procedure time is associated with an increased risk for AKI. • Renal perfusion defects on angiography are associated with increased risk for AKI. • Post-EVAR AKI is associated with higher probability for long-term eGFR decrease. • Iodinated contrast volume is not an independent risk factor for AKI. • Iodinated contrast volume is not an independent risk factor for long-term eGFR decrease.
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Affiliation(s)
- Anna M Sailer
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Department of Radiology, Stanford University Hospitals and Clinics, Stanford, CA, USA.
| | - Patricia J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maatsricht, The Netherlands
| | - Camille van Berlo
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ozan Yazar
- Department of Vascular Surgery, Cliniques del Europe, Brussels, Belgium
| | - Michiel W de Haan
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dominik Fleischmann
- Department of Radiology, Stanford University Hospitals and Clinics, Stanford, CA, USA
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Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction. AJR Am J Roentgenol 2015; 204:1174-81. [PMID: 25730301 DOI: 10.2214/ajr.14.14259] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The incidence and significance of complications related to intravascular contrast material administration have become increasingly controversial. This review will highlight current thinking regarding the imaging of patients with renal impairment and those at risk for an allergiclike contrast reaction. CONCLUSION The risk of contrast-induced acute kidney injury remains uncertain for patients with an estimated glomerular filtration rate (GFR) less than 45 mL/min/1.73 m(2), but if there is a risk, it is greatest in those with estimated GFR less than 30 mL/min/1.73 m(2). In this population, low-risk gadolinium-based contrast agents appear to have a large safety margin. Corticosteroid prophylaxis remains the standard of care in the United States for patients identified to be at high risk of a contrast reaction, but it has an incomplete mitigating effect on contrast reaction rates and the number needed to treat is large.
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24
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Abstract
OBJECTIVE The objective of our study was to exposit the shifting perspectives on contrast-induced nephropathy (CIN) for IV low-osmolar iodinated contrast media. CONCLUSION The historically inflated risk of CIN reflects logistic and intellectual pitfalls that continue to confound the study of this disease. Recent advances have clarified that the incidence of CIN is much lower than previously thought, but there are lingering questions. We suggest that CIN is likely real but is rare and offer directions for future study.
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25
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Davenport MS, Khalatbari S, Cohan RH, Ellis JH. Contrast medium-induced nephrotoxicity risk assessment in adult inpatients: a comparison of serum creatinine level- and estimated glomerular filtration rate-based screening methods. Radiology 2013; 269:92-100. [PMID: 23579047 PMCID: PMC3781354 DOI: 10.1148/radiol.13122462] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To compare serum creatinine (SCr) level- and estimated glomerular filtration rate (eGFR)-based screening methods for identifying adult inpatients at risk for contrast medium-induced nephrotoxicity (CIN). MATERIALS AND METHODS Institutional review board approval was obtained; informed consent was waived for this HIPAA-compliant retrospective study. Computed tomographic examinations performed during 10 years in adult inpatients with stable renal function were identified (n = 28 390). The proportion of inpatients meeting various eGFR (≥60, <60, <45, <30, 30-44, 45-59 mL/min/1.73 m(2)) and SCr (<1.5, ≥1.5, ≥1.6, ≥1.7, ≥1.8, ≥1.9, ≥2.0 mg/dL) thresholds were contrasted with each other and with published guidelines (≥2.0 mg/dL [SCr] and <45 mL/min/1.73 m(2) [eGFR]) using McNemar and binomial tests. RESULTS Most inpatients were considered low risk for CIN with commonly used thresholds: 92.6% (26 285 of 28 390) had SCr <1.5 mg/dL; 91.3% (25 922 of 28 390) had eGFR of ≥45 mL/min/1.73 m(2). Using SCr threshold of ≥1.5 mg/dL, identified inpatients had the following eGFRs: 19.6% (413 of 2105), 45-59 mL/min/1.73 m(2); 51.1% (1075 of 2105), 30-44 mL/min/1.73 m(2); 28.6% (603 of 2105), <30 mL/min/1.73 m(2); and 0.7% (14 of 2105), ≥60 mL/min/1.73 m(2) . Using SCr threshold of ≥2.0 mg/dL, identified inpatients had the following eGFRs: 100% (658 of 658), <45 mL/min/1.73 m(2); 74.6% (491 of 658), <30 mL/min/1.73 m(2). Threshold of SCr ≥2.0 mg/dL could not be used to identify eGFR <30 mL/min/1.73 m(2) in 0.4% (112 of 28 390) and <45 mL/min/1.73 m(2) in 6.4% (1810 of 28 390) of all inpatients. Using eGFR <45 mL/min/1.73 m(2) instead of SCr of ≥1.5 mg/dL would result in a significant but small increase in identified inpatients (8.7% [2468 of 28 390; 95% confidence interval: 8.4%, 9.0%] vs 7.4% [2105 of 28 390; 95% confidence interval: 7.1%, 7.7%]; P < .0001). CONCLUSION Screening using eGFR <45 mL/min/1.73 m(2) instead of common SCr thresholds would significantly increase the number of inpatients identified to be at risk for CIN but would reduce misidentification of a large number of inpatients at low risk according to eGFR criteria.
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Affiliation(s)
- Matthew S Davenport
- Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48103
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26
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Moos SI, van Vemde DNH, Stoker J, Bipat S. Contrast induced nephropathy in patients undergoing intravenous (IV) contrast enhanced computed tomography (CECT) and the relationship with risk factors: a meta-analysis. Eur J Radiol 2013; 82:e387-99. [PMID: 23711425 DOI: 10.1016/j.ejrad.2013.04.029] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/04/2013] [Accepted: 04/24/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE To summarize the incidence of contrast-induced nephropathy (CIN) and associations between CIN incidence and risk factors in patients undergoing intravenous contrast-enhanced computed tomography (CECT) with low- or iso-osmolar iodinated contrast medium. METHODS This review is performed in accordance with the preferred reporting items in systematic reviews and meta-analysis (PRISMA) guidelines. We searched the MEDLINE, EMBASE and Cochrane databases from 2002 till November 2012. Two reviewers included papers and extracted data. The pooled data were analysed by either fixed or random-effects approach depending on heterogeneity defined as the I(2) index. RESULTS 42 articles with 18,790 patients (mean age 61.5 years (range: 38-83 years)) were included. The mean baseline eGFR was 59.8 mL/min and ranged from 4 to 256 mL/min. Of all patients 45.0% had an estimated glomerular filtration rate (eGFR)<60 mL/min, 55.2% had hypertension; 20.2% had diabetes mellitus (DM) and 6.5% had congestive heart failure (CHF). The overall pooled CIN incidence, defined as a SCr increase of ≥ 25% or ≥ 0.5mg/dL, was 4.96% (95%CI: 3.79-6.47). Data analysis showed associations between CIN and the presence of renal insufficiency, DM, malignancy, age>65 years and use of non-steroidal anti-inflammatory drugs (NSAID's) with odds ratios of 1.73 (95%CI: 1.06-2.82), 1.87 (95%CI: 1.55-2.26), 1.79 (95%CI: 1.03-3.11), 1.95 (95%CI: 1.02-3.70) and 2.32 (95%CI: 1.04-5.19), respectively while hypertension, anaemia and CFH were not associated (p=0.13, p=0.38, p=0.40). CONCLUSION The mean incidence of CIN after intravenous iodinated CECT was low and associated with renal insufficiency, diabetes, presence of malignancy, old age and NSAID's use.
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Affiliation(s)
- Shira I Moos
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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27
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Glomerular filtration rate in evaluation of the effect of iodinated contrast media on renal function. AJR Am J Roentgenol 2013; 200:822-6. [PMID: 23521455 DOI: 10.2214/ajr.12.8871] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to use measured glomerular filtration rate (GFR), the reference standard of renal function, to assess the deleterious effect of iodinated contrast media on renal function. Such an effect has been traditionally defined as a greater than 0.5-mg/dL increase in serum creatinine concentration or a 25% or greater increase 24-72 hours after the injection of iodinated contrast medium. SUBJECTS AND METHODS This pilot investigation was focused on the consequences of clinically indicated IV injection of iodinated contrast media; intraarterial injection was excluded. One hundred thirteen patients with normal serum creatinine concentrations were enrolled in an approved protocol. At random, as chosen by one of the investigators, patients underwent imaging with one of three monomeric agents (iopamidol 300, iopromide 300, iohexol 300) and one dimeric agent (iodixanol 320). Measured GFR was determined immediately before CT and approximately 3 and 72 hours after the contrast injection for the CT examination. Iodinated contrast medium, a glomerular filtrate with no tubular excretion or reabsorption, was the GFR marker. Measured GFR was determined by x-ray fluorescence analysis with nonisotopic iodinated contrast media. RESULTS Monomeric and dimeric contrast agents in diagnostic CT volumes (based on bodyweight and imaging protocol) did not induce a significant change in measured GFR (95% confidence by Wilcoxon test), suggesting that use of the evaluated contrast media will not lead to more than a 12% variation. CONCLUSION The three monomeric agents studied and the one dimeric agent were equivalent in terms of lack of a significant effect on measured GFR when administered to patients with a normal GFR.
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Davenport MS, Khalatbari S, Cohan RH, Dillman JR, Myles JD, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate. Radiology 2013; 268:719-28. [PMID: 23579046 DOI: 10.1148/radiol.13122276] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine the effect of intravenous (IV) low-osmolality iodinated contrast material (LOCM) on the development of post-computed tomography (CT) acute kidney injury (AKI), stratified by pre-CT estimated glomerular filtration rate (eGFR), in patients with stable renal function. MATERIALS AND METHODS Institutional review board approval was obtained and patient consent waived for this HIPAA-compliant, retrospective study. CT examinations performed over a 10-year period on unique adult inpatients with sufficient serum creatinine (SCr) data and stable renal function (difference between baseline and pre-CT SCr within 0.3 mg/dL and 50% of baseline) were identified. A 1:1 propensity score matched cohort analysis with multivariate analysis of effects was performed with post-CT AKI as the primary outcome measure (8826 nonenhanced and 8826 IV contrast agent-enhanced CT studies in 17 652 patients). Propensity matching was performed with respect to likelihood of receiving IV contrast material (19 tested covariates). Post-CT AKI with Acute Kidney Injury Network SCr criteria was the primary endpoint. A stepwise multivariate conditional logistic regression model was performed to identify the effect of IV LOCM on post-CT AKI. RESULTS After 1:1 propensity matching, IV LOCM had a significant effect on the development of post-CT AKI (P = .04). This risk increased with decreases in pre-CT eGFR (≥ 60 mL/min/1.73 m(2): odds ratio, 1.00; 95% confidence interval: 0.86, 1.16; 45-59 mL/min/1.73 m(2): odds ratio, 1.06; 95% confidence interval: 0.82, 1.38; 30-44 mL/min/1.73 m(2): odds ratio, 1.40; 95% confidence interval: 1.00, 1.97; <30 mL/min/1.73 m(2): odds ratio, 2.96; 95% confidence interval: 1.22, 7.17). CONCLUSION IV LOCM is a nephrotoxic risk factor in patients with a stable eGFR less than 30 mL/min/1.73 m(2), with a trend toward significance at 30-44 mL/min/1.73 m(2). IV LOCM does not appear to be a nephrotoxic risk factor in patients with a pre-CT eGFR of 45 mL/min/1.73 m(2) or greater.
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Affiliation(s)
- Matthew S Davenport
- Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor, MI 48103, USA.
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Stratta P, Izzo C, Canavese C, Quaglia M. Letter to the Editor re: Are intravenous injections of contrast media really less nephrotoxic than intra-arterial injections? Eur Radiol 2013; 23:1260-3. [DOI: 10.1007/s00330-012-2720-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/21/2012] [Indexed: 11/28/2022]
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McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, Williamson EE, Kallmes DF. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology 2013; 267:106-18. [PMID: 23360742 DOI: 10.1148/radiol.12121823] [Citation(s) in RCA: 265] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To determine the causal association and effect of intravenous iodinated contrast material exposure on the incidence of acute kidney injury (AKI), also known as contrast material-induced nephropathy (CIN). MATERIALS AND METHODS This retrospective study was approved by an institutional review board and was HIPAA compliant. Informed consent was waived. All contrast material-enhanced (contrast group) and unenhanced (noncontrast group) abdominal, pelvic, and thoracic CT scans from 2000 to 2010 were identified at a single facility. Scan recipients were sorted into low- (<1.5 mg/dL), medium- (1.5-2.0 mg/dL), and high-risk (>2.0 mg/dL) subgroups of presumed risk for CIN by using baseline serum creatinine (SCr) level. The incidence of AKI (SCr ≥ 0.5 mg/dL above baseline) was compared between contrast and noncontrast groups after propensity score adjustment by stratification, 1:1 matching, inverse weighting, and weighting by the odds methods to reduce intergroup selection bias. Counterfactual analysis was used to evaluate the causal relation between contrast material exposure and AKI by evaluating patients who underwent contrast-enhanced and unenhanced CT scans during the study period with the McNemar test. RESULTS A total of 157,140 scans among 53,439 unique patients associated with 1,510,001 SCr values were identified. AKI risk was not significantly different between contrast and noncontrast groups in any risk subgroup after propensity score adjustment by using reported risk factors of CIN (low risk: odds ratio [OR], 0.93; 95% confidence interval [CI]: 0.76, 1.13; P = .47; medium risk: odds ratio, 0.97; 95% CI: 0.81, 1.16; P = .76; high risk: OR, 0.91; 95% CI: 0.66, 1.24; P = .58). Counterfactual analysis revealed no significant difference in AKI incidence between enhanced and unenhanced CT scans in the same patient (McNemar test: χ(2) = 0.63, P = .43) (OR = 0.92; 95% CI: 0.75, 1.13; P = .46). CONCLUSION Following adjustment for presumed risk factors, the incidence of CIN was not significantly different from contrast material-independent AKI. These two phenomena were clinically indistinguishable with established SCr-defined criteria, suggesting that intravenous iodinated contrast media may not be the causative agent in diminished renal function after contrast material administration. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12121823/-/DC1.
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Affiliation(s)
- Robert J McDonald
- Clinician Investigator Training Program, Department of Radiology, College of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
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Davenport MS, Khalatbari S, Dillman JR, Cohan RH, Caoili EM, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology 2013; 267:94-105. [PMID: 23360737 DOI: 10.1148/radiol.12121394] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To determine whether intravenous low-osmolality iodinated contrast material is associated with post-computed tomography (CT) acute kidney injury (AKI). MATERIALS AND METHODS Institutional review board approval was obtained and patient consent waived for this HIPAA-compliant retrospective study. CT examinations performed over a 10-year period in adult inpatients with sufficient serum creatinine (SCr) data were identified. A one-to-one propensity-matched matched cohort analysis with multivariate analysis of effects was performed with post-CT AKI as the primary outcome measure (10,121 unenhanced and 10,121 intravenous contrast-enhanced CT examinations in 20,242 patients). Propensity matching was performed with respect to likelihood of patient receiving intravenous contrast material (36 tested covariates). The primary endpoint was post-CT AKI by using Acute Kidney Injury Network SCr criteria; the secondary endpoint was post-CT AKI by using traditional SCr criteria for contrast material-induced nephrotoxicity (CIN; SCr increase ≥0.5 mg/dL [44.20 μmol/L] or ≥25%). Multivariate subgroup threshold analysis was performed (SCr <1.5 [<132.60 μmol/L]; ≥1.5 to ≥2.0 mg/dL [≥132.60 to ≥176.80 μmol/L]) and adjusted for assigned propensity scores. RESULTS Intravenous low-osmolality iodinated contrast material had a significant effect on the development of post-CT AKI for patients with pre-CT SCr levels of 1.6 mg/dL (141.44 μmol/L) or greater (odds ratio, 1.45; 95% confidence interval [CI]: 1.11, 1.89;P = .007). This effect strengthened as pre-CT SCr increased. Patients with stable SCr less than 1.5 mg/dL (132.60 μmol/L) were not at risk for developing CIN (P = .25, power > 95%). Both endpoints demonstrated similar results (eg, SCr ≥1.6 mg/dL [141.44 μmol/L] by using traditional CIN criteria: odds ratio, 1.64; 95% CI: 1.18, 2.28; P = .003). Post-CT AKI was prevalent in both the unenhanced and contrast-enhanced CT subgroups, and it increased with increases in pre-CT SCr. Many risk factors contributed to development of post-CT AKI, regardless of iodinated contrast material. CONCLUSION Intravenous low-osmolality iodinated contrast material is a nephrotoxic risk factor, but not in patients with a stable SCr level less than 1.5 mg/dL. Many factors other than contrast material can affect post-CT AKI rates.
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Affiliation(s)
- Matthew S Davenport
- Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor, MI 48103, USA.
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McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, Kallmes DF. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology 2013; 267:119-28. [PMID: 23319662 DOI: 10.1148/radiol.12121460] [Citation(s) in RCA: 275] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To perform a systematic review and meta-analysis of controlled studies examining the incidence of acute kidney injury (AKI) and other outcomes in patients exposed to intravenous (i.v.) contrast medium compared with patients who underwent an imaging examination without contrast medium or were otherwise unexposed (control group). MATERIALS AND METHODS MEDLINE, EMBASE, Scopus, and the Cochrane Library were searched for all articles published through September 2011 that contained search terms related to nephrotoxicity following intravenous contrast medium administration. Two independent reviewers identified studies in which the incidence of AKI in patients exposed to i.v. contrast medium was directly compared with the incidence of AKI in unexposed patients through analysis of changes in serum creatinine level or estimated glomerular filtration rate 48-72 hours following imaging procedures or admission. Study characteristics and outcomes of AKI, dialysis, and mortality were extracted by using a standardized protocol. Relative risk (RR) was calculated by using random-effects models and was tested in subgroups of different patient comorbidities, contrast medium types, and AKI diagnostic criteria. RR results of less than 1.00 indicated that there was a higher incidence of these outcomes in the group that did not receive contrast medium (non-contrast medium group). RESULTS Of the 1489 studies originally identified, 13 nonrandomized studies (0.9%) representing 25,950 patients met inclusion criteria. In the group that received contrast medium (contrast medium group), risk of AKI (RR = 0.79; 95% confidence interval [CI]: 0.62, 1.02; P = .07), death (RR = 0.95; 95% CI: 0.55, 1.67; P = .87), and dialysis (RR = 0.88; 95% CI: 0.23, 3.43; P = .85) was similar, compared with the risk of AKI in the non-contrast medium group. This pattern was observed regardless of i.v. contrast medium type, diagnostic criteria for AKI, or whether patients had diabetes mellitus or renal insufficiency. CONCLUSION Controlled contrast medium-induced nephropathy studies demonstrate a similar incidence of AKI, dialysis, and death between the contrast medium group and control group. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12121460/-/DC1.
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Affiliation(s)
- Jennifer S McDonald
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
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Rouse RL, Stewart SR, Thompson KL, Zhang J. Kidney Injury Biomarkers in Hypertensive, Diabetic, and Nephropathy Rat Models Treated with Contrast Media. Toxicol Pathol 2012; 41:662-80. [DOI: 10.1177/0192623312464122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contrast-induced nephropathy (CIN) refers to a decline in renal function following exposure to iodinated contrast media (CM). The present study was initiated to explore the role of known human risk factors (spontaneous hypertension, diabetes, protein-losing nephropathy) on CIN development in rodent models and to determine the effect of CM administration on kidney injury biomarkers in the face of preexisting kidney injury. Spontaneously hypertensive rats (hypertension), streptozotocin-treated Sprague Dawley rats (diabetes), and Dahl salt-sensitive rats (protein-losing nephropathy) were given single intravenous injections of the nonionic, low osmolar contrast medium, iohexol. Blood urea nitrogen (BUN), serum creatinine (sCr), and urinary biomarkers; albumin, lipocalin 2 (Lcn-2), osteopontin (Opn), kidney injury molecule 1 (Kim-1), renal papillary antigen 1 (Rpa-1), α-glutathione S-transferase (α-Gst), µ-glutathione S-transferase (µ-Gst), and beta-2 microglobulin (β2m) were measured in disease models and appropriate controls to determine the response of these biomarkers to CM administration. Each disease model produced elevated biomarkers of kidney injury without CM. Preexisting histopathology was exacerbated by CM but little or no significant increases in biomarkers were observed. When 1.5-fold or greater sCr increases from pre-CM were used to define true positives, receiver–operating characteristic curve analysis of biomarker performance showed sCr was the best predictor of CIN across disease models. β2m, Lcn-2, and BUN were the best predictors of histopathology defined kidney injury.
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Affiliation(s)
- Rodney L. Rouse
- Division of Drug Safety Research, Office of Testing and Research, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sharron R. Stewart
- Division of Drug Safety Research, Office of Testing and Research, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Karol L. Thompson
- Division of Drug Safety Research, Office of Testing and Research, Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Richenberg J. How to reduce nephropathy following contrast-enhanced CT: a lesson in policy implementation. Clin Radiol 2012; 67:1136-45. [PMID: 22717146 DOI: 10.1016/j.crad.2012.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 04/23/2012] [Accepted: 05/01/2012] [Indexed: 12/31/2022]
Abstract
In excess of 50 contrast-enhanced computed tomography (CT) examinations are typically undertaken in our tertiary hospital NHS Trust each weekday, approximately 13,000 each year. In the Department of Radiology alone, we inject more than 1300 l of iodinated contrast medium per annum. There is a real need to devise a policy to anticipate contrast medium-induced nephropathy (CIN) and minimize its effects, without disrupting the high-intensity CT service. Having written a comprehensive yet pragmatic policy to reduce the incidence of this iatrogenic condition, it seemed sensible to share it with the wider radiology community and share the experience and lessons learnt in engaging all the stakeholders, ushering in the change with as little fuss as possible. The ramifications on primary and secondary care had to be anticipated, resource implications managed, and staff trained. This review is therefore presented in four sections: framing the problem, assessing its size and nature; a succeeding section on the available guidelines and their uptake; the policy itself to reduce CIN in CT is presented in the third section; and crucially, a description of the policy introduction process in the last section.
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Affiliation(s)
- J Richenberg
- Radiology Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
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Comparative investigation of i.v. iohexol and iopamidol: effect on renal function in low-risk outpatients undergoing CT. AJR Am J Roentgenol 2012; 198:392-7. [PMID: 22268183 DOI: 10.2214/ajr.11.6993] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to compare the effects of i.v. iohexol and iopamidol on renal function in outpatients undergoing CT. SUBJECTS AND METHODS We performed a prospective, double-blind, randomized clinical trial of 389 adults with low risk for contrast-induced nephropathy, comparing i.v. iohexol with iopamidol (300 mg I/mL). Serum creatinine (SCr) concentration was measured at baseline and 2 and 3 days after contrast administration. A noninferiority analysis was planned to compare the mean maximum SCr change from baseline between subject groups. Contrast-induced nephropathy rates (three definitions) for both contrast agents were compared as a secondary end point. RESULTS One hundred ninety and 199 subjects received iohexol and iopamidol, respectively. The mean change in SCr from baseline using the maximum day 2 or 3 measurement was 0.07 ± 0.12 mg/dL (95% CI, 0.05-0.09 mg/dL) for the iohexol group and 0.05 ± 0.12 mg/dL (95% CI, 0.03-0.07 mg/dL) for the iopamidol group. The difference between contrast agents with respect to the mean change in SCr from baseline was -0.02 ± 0.12 mg/dL (95% CI, -0.045 to 0.003 mg/dL; p = 0.08). Contrast-induced nephropathy rates were not statistically different using any definition. CONCLUSION Although our results were unable to show absolute noninferiority of iohexol compared with iopamidol because of a very small difference in increase in mean SCr from baseline (using a noninferiority margin of 0.04 mg/dL), this difference is likely of minimal or no clinical importance in outpatients undergoing CT with low risk for contrast-induced nephropathy.
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Katzberg RW, Monsky WL, Prionas ND, Sidhar V, Southard J, Carlson J, Boone JM, Lin TC, Li CS. Persistent CT nephrograms following cardiac catheterisation and intervention: initial observations. Insights Imaging 2011; 3:49-60. [PMID: 22695998 PMCID: PMC3292644 DOI: 10.1007/s13244-011-0131-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 09/13/2011] [Accepted: 09/23/2011] [Indexed: 11/24/2022] Open
Abstract
Objectives To describe persistent nephrographic patterns detected by unenhanced renal CT at 24 h after cardiac catheterisation and intervention. Methods This prospective study was Health Insurance Portability and Accountability Act-compliant and institutional review board approved. Twenty-nine patients (20 men, nine women; average age 63.27 and range 41–85 years) agreed to undergo unenhanced dual-energy computed tomography (CT) limited to their kidneys at 24 h after cardiac catheterisation. CT attenuation values (Hounsfield units) were made from the cortical and medullary regions and single kidney total parenchymal iodine values (milligrams) were measured. Spearman’s rank correlation coefficient and a two-sided Fisher’s exact test were used in the statistics. Results Focal nephrograms were observed in at least one kidney (range, one to five regions per kidney) in 10/29 (34%) of patients and bilateral global nephrograms in 13/29 (45%) of patients. Focal nephrograms correlated with cardiac catheterisation fluoroscopic time (r = 0.48; P = 0.0087). For global nephrograms, the total iodine content of right and left kidneys correlated with fluoroscopic time (r = 0.79 and 0.76; P < 0.0001, respectively) and the amount of contrast material (CM) used (r = 0.77 and r = 0.74; P < 0.0001, respectively). Conclusion Persistent focal and global nephrograms occur commonly as assessed by non-contrast CT at 24 h post cardiac catheterisation and our observations suggest they could be related to procedural factors. Electronic supplementary material The online version of this article (doi:10.1007/s13244-011-0131-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard W Katzberg
- Department of Radiology, University of California School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA,
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Thomas LE, Goldstein JN, Hakimelahi R, Chang Y, Yoo AJ, Schwamm LH, Gonzalez RG. CT angiography predicts use of tertiary interventional services in acute ischemic stroke patients. Int J Emerg Med 2011; 4:62. [PMID: 21967677 PMCID: PMC3203028 DOI: 10.1186/1865-1380-4-62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 10/03/2011] [Indexed: 11/13/2022] Open
Abstract
Background Patients with acute stroke are often transferred to tertiary care centers for advanced interventional services. We hypothesized that the presence of a proximal cerebral artery occlusion on CT angiography (CTA) is an independent predictor of the use of these services. Methods We performed a historical cohort study of consecutive ischemic stroke patients presenting within 24 h of symptom onset to an academic emergency department who underwent emergent CTA. Use of tertiary care interventions including intra-arterial (IA) thrombolysis, mechanical clot retrieval, and neurosurgery were captured. Results During the study period, 207/290 (71%) of patients with acute ischemic stroke underwent emergent CTA. Of the patients, 74/207 (36%) showed evidence of a proximal cerebral artery occlusion, and 22/207 (11%) underwent an interventional procedure. Those with proximal occlusions were more likely to receive a neurointervention (26% vs. 2%, p < 0.001). They were more likely to undergo IA thrombolysis (9% vs. 0%, p = 0.001) or a mechanical intervention (19% vs. 0%, p < 0.0001), but not more likely to undergo neurosurgery (5% vs. 2%, p = 0.2). After controlling for the initial NIH stroke scale (NIHSS) score, proximal occlusion remained an independent predictor of the use of neurointerventional services (OR 8.5, 95% CI 2.2-33). Evidence of proximal occlusion on CTA predicted use of neurointervention with sensitivity of 82% (95% CI 59-94%), specificity of 71% (95% CI 64%-77%), positive predictive value (PPV) of 25% (95% CI 16%-37%), and negative predictive value (NPV) of 97% (95% CI 92%-99%). Conclusion Proximal cerebral artery occlusion on CTA predicts the need for advanced neurointerventional services.
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Affiliation(s)
- Lisa E Thomas
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Incidence of contrast-induced nephropathy in patients with multiple myeloma undergoing contrast-enhanced CT. AJR Am J Roentgenol 2011; 196:1094-101. [PMID: 21512075 DOI: 10.2214/ajr.10.5152] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The purpose of this article is to evaluate the incidence of contrast-induced nephropathy (CIN) and the effects of associated risk factors in patients with multiple myeloma undergoing contrast-enhanced CT (CECT) with IV administration of nonionic iodinated contrast agent. MATERIALS AND METHODS This retrospective review of medical records identified patients with a diagnosis of myeloma who underwent a CECT examination of the chest, abdomen, or pelvis between January 1, 2005, and December 1, 2008. Analysis for CIN, as defined by an increase in creatinine level after the CECT examination of 25% or more, or of 0.5 mg/dL, compared with the level before the CECT examination, both within 48 hours and within 7 days, was performed. Statistical correlations between the development of CIN and creatinine level before CECT examination, patient location, type and amount of contrast agent, blood urea nitrogen-creatinine ratio, history of diabetes, hypercalcemia, Bence Jones proteinuria, β(2)-microglobulin level, albumin level, International Myeloma Staging System stage, and history of myeloma provided at the time the CT examination was ordered were calculated. RESULTS Forty-six patients who completed 80 unique examinations were included; their average creatinine level before CECT examination was 0.97 mg/dL. There was no significant difference in the average creatinine levels before CT examination between patients without and those with CIN. Four (5%) and 12 (15%) patients developed CIN within 48 hours and 7 days, respectively. Only serum β(2)-microglobulin level showed a statistically significant (p = 0.03) correlation with the development of CIN. CONCLUSION The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with β(2)-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefit of the examination and the expected low risk of developing CIN.
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Off-label use of intravascular iodinated organic and MR contrast media. Radiol Med 2010; 116:1-14. [PMID: 20981503 DOI: 10.1007/s11547-010-0601-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 03/11/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED This paper analyses off-label prescribing of the iodinated organic and magnetic resonance (MR) contrast media used in diagnostic imaging and evaluates the liability profiles and medicolegal issues associated with such use. The term off-label generally indicates the use of known drugs for which new scientific evidence suggests use in a manner and in clinical scenarios not explicitly addressed by the drug data sheet and is outside the indications for which the medication was approved. In addition, the term also indicates the use of drugs with a different route of administration and dosage from those indicated in the information leaflet. Intravascular contrast media used in diagnostic imaging are drugs in the complete sense of the term, even though they have unique characteristics which in many ways distinguish them from other pharmacological agents. The off-label use of contrast media in diagnostic imaging is a little-investigated field and most commonly, but not exclusively, applies to gadolinium-based contrast media used in MR angiography as well as cardiac and paediatric applications. In particular, the off-label use of contrast media mostly concerns deviations from the recommended dose. As contrast media are to all effects pharmaceutical agents, their off-label use can be considered admissible within the limitations laid down by the Italian law in force (Article 3 of Law 94/98) and its interpretation, i.e. the following criteria must be present: the lack of a valid diagnostic alternative; written informed consent by the patient; the presence of scientific publications validated at the international level; assumption of responsibility by the radiologist. CONCLUSIONS The use of contrast media in modern image-guided medicine is essential. In cases in which the information contained in the information leaflet is modified and updated in any way whatsoever (indications, dosage, at others), specifically if restrictions are introduced in accordance with the law in force, the pharmaceutical industry must provide formal and timely notification to radiologists. On their part as prescribers and users of contrast media, radiologists must remain up to date regarding any changes in indications, dosage and route of administration. Lastly, we propose that the radiology report includes not only the type but also the dose of contrast medium used.
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The Impact of the Viscosity and Osmolality of Iodine Contrast Agents on Renal Elimination. Invest Radiol 2010; 45:255-61. [DOI: 10.1097/rli.0b013e3181d4a036] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Many unknowns remain concerning how best to reduce a patient's risk of contrast-induced nephropathy (CIN). Many interventions have been proposed, but few have gone unchallenged, and new questions have arisen from analysis of serum creatinine variations in patients who have not been exposed to radiographic iodinated contrast media (RICM). Use of alternate imaging tests that do not use RICM is the most direct way to avoid CIN. Hydration remains the bulwark of intervention when RICM must be administered. The administration of N-acetylcysteine is a popular pharmacologic prophylaxis against CIN but its efficacy is unclear. Hemodialysis has not been effective, but hemofiltration has shown good results in limited series.
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Affiliation(s)
- James H Ellis
- Department of Radiology, University of Michigan Health System, B1-D502 University Hospital, SPC 5030, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109-5030, USA.
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Reducing the Risk of Contrast-Induced Nephropathy: A Perspective on the Controversies. AJR Am J Roentgenol 2009; 192:1544-9. [DOI: 10.2214/ajr.09.2368] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Retention of iodine and expression of biomarkers for renal damage in the kidney after application of iodinated contrast media in rats. Invest Radiol 2009; 44:114-23. [PMID: 19104440 DOI: 10.1097/rli.0b013e318190fbd2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Commercially available iodinated contrast media (CM) show significantly different physico-chemical properties. The relevance of the viscosity of CM may be underestimated as a contributing factor for clinically relevant renal failure as suggested by a large registry data analysis (Swedish registry study). The objective of this preclinical study is to assess differences of a low and high-viscous CM regarding their retention time in the kidney. Furthermore, we investigated the expression of marker genes for renal damage and hypoxia to evaluate a potential renal damage and hypoxia after application of iodinated CM. MATERIAL AND METHODS After application of Iopromide 300 and Iodixanol 320 CM, the iodine concentration over time was determined using computed tomography and x-ray fluorescence analysis in healthy Han Wistar and renally impaired ZSF1 rats. The latter served as a model for age and diabetes-related renal impairment. X-ray attenuation (Hounsfield units) in the renal cortex was analyzed by 2 independent blinded readers. Furthermore, the expression of kidney injury molecule 1 (Kim-1/Havcr1) and heme oxygenase I (HO-1/HMOX1) was measured by quantitative reverse transcription-polymerase chain-reaction. RESULTS Computed tomography and x-ray fluorescence analysis in the kidneys of animals treated with Iodixanol revealed significantly prolonged retention of iodine in the kidney as compared with animals treated with Iopromide. This difference was even more pronounced in renally impaired rats. Twenty-four hours after Iodixanol treatment, significantly increased levels of Kim-1/Havcr1 and HO-1/HMOX1 transcript levels were observed compared with the saline and Iopromide treatment. CONCLUSIONS A prolonged retention of contrast media in the kidney was observed after administration of dimeric CM (Iodixanol 320). One possible explanation for this effect could be the high viscosity of the dimeric CM (Iodixanol 320) and the lack of dilution by osmotic diuresis. This prolonged exposure is possibly associated with higher renal toxicity as indicated by the elevated expression of biomarkers for hypoxia and renal injury.
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Oleinik A, Romero JM, Schwab K, Lev MH, Jhawar N, Delgado Almandoz JE, Smith EE, Greenberg SM, Rosand J, Goldstein JN. CT angiography for intracerebral hemorrhage does not increase risk of acute nephropathy. Stroke 2009; 40:2393-7. [PMID: 19461032 DOI: 10.1161/strokeaha.108.546127] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE CT angiography (CTA) is receiving increased attention in intracerebral hemorrhage (ICH) for its role in ruling out vascular abnormalities and potentially predicting ongoing bleeding. Its use is limited by the concern for contrast induced nephropathy (CIN); however, the magnitude of this risk is not known. METHODS We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with ICH presenting to a single tertiary care hospital from 2002 to 2007. Demographic, clinical, and radiographic data were prospectively collected for all patients. Laboratory data and clinical course over the first 48 hours were retrospectively reviewed. Acute nephropathy was defined as any rise in creatinine of >25% or >0.5 mg/dL, such that the highest creatinine value was above 1.5 mg/dL. RESULTS 539 patients presented during the study period and had at least 2 creatinine measurements. 348 (65%) received a CTA. Acute nephropathy developed in 6% of patients who received a CTA and in 10% of those who did not (P=0.1). Risk of nephropathy was 14% in those receiving no contrast (130 patients), 5% in those receiving 1 contrast study (124 patients), and 6% in those receiving >1 contrast study (244 patients). Neither CTA nor any use of contrast predicted nephropathy in univariate or multivariate analysis. CONCLUSIONS The risk of acute nephropathy after ICH was not increased by use of CTA. Studies of CIN that do not include a control group may overestimate the influence of contrast. Patients with ICH appear to have an 8% risk of developing "Hospital-Acquired Nephropathy."
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Affiliation(s)
- Alexandra Oleinik
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
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Abstract
Contrast media induced nephropathy is a common complication, particularly in high risk patients, such as patients with chronic kidney disease (CKD) and diabetes. The majority of studies show an increased in-hospital mortality and an unfavourable long-term prognosis after manifestation of contrast media induced nephropathy. The course and the potential risk factors of this type of acute renal failure are known. Therefore, an effective prophylaxis should allow to prevent this complication. In low risk patients oral or intravenous volume expansion is probably sufficient combined with the withdrawal of non-steroidal anti-inflammatory drugs. In high risk patients additional prophylactic measures are needed but their efficacy is not clearly defined. Therefore, heterogeneous recommendations exist. Hydration reduces (afferent) renovasoconstriction, the tubuloglomerular feedback, the tubulotoxic effects of contrast media (via dilution) and the oxygen radical formation. The optimal composition, timing and amount of fluid which should be administered to the patients remain unclear. Most studies show that intravenous administration of volume is more effective than oral fluid intake. The majority of studies found a benefit of isotonic sodium bicarbonate in comparison to isotonic saline solutions, even if meta-analyses displayed only a positive trend for sodium bicarbionate due to the heterogeneity of the data. Controversies exist for N-acetylcysteine, vitamin C, fenoldopam, theophylline or statins. Due to low cost and low side effects, N-Acetylcysteine is widely used. Theophyllin (given intravenously 30 minutes before contrast media injection) is renoprotective, particularly in intensive care unit patients. Very important is the reduction of contrast media volume (if possible <30 ml for diagnostic procedures and <100 ml for interventions). Iso-osmolar and low-osmolar contrast media may have a comparable low risk for the induction of contrast media induced nephropathy. This risk is probably higher after intra-arterial as compared to intravenous administration of contrast media. Controversies exist with respect to the reduction of contrast media induced nephropathy and mortality by prophylactic hemodialysis or hemofiltration. A possible benefit of these procedures consists probably for patients with advanced chronic kidney disease (stage 5). With the further increase of investigations using contrast media, with the further increase in vascular interventions, in age and comorbidities of the patients one may suggest that the problem of contrast media induced nephropathy will further increase, despite all prophylactic procedures so far recommended.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Affiliation(s)
- Charles A Herzog
- Charles A. Herzog, Cardiovascular Special Studies Center, United States Renal Data System, Minneapolis, MN 55404, USA.
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Prando A. Imaging. Int Braz J Urol 2008. [DOI: 10.1590/s1677-55382008000500016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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