For example, in the case of patients with kidney disease, doctors need to use radioactive dyes to determine how well the kidneys are functioning. CI-AKI risk should be determined primarily by using CKD stage and AKI. Mayo Clinic does not endorse companies or products. These statements enable providers to make judgments in specific circumstances. Neither term implies a causal relationship between contrast medium administration and an AKI event. Kidney function measurement in infants and children is optimally evaluated by the Bedside Schwartz equation rather than by eGFR equations developed and validated in adults.59, 60, 61 In general, the aforementioned recommendations should not be altered for infants and children, but there are minimal data assessing risk of CI-AKI in this population.62 Recommendations for this population are largely based on extrapolated adult data.15 The risk of CI-AKI from intravenous contrast media in infants and children is a pressing research need. and transmitted securely. Consensus Statements from the American College of Radiology and the National Kidney Foundation. Although endovascular stent-graft repair tends to show better outcomes than . Too C.W., Ng W.Y., Tan C.C., Mahmood M.I., Tay K.H. In a review of biopsy-proven cases of NSF reported in 98 articles, 27 (8%) of 325 patients had no clear exposure to these agents,62 and in the review of 639 biopsy-proven cases discussed above, 14 (2%) did not.50 This suggests that gadolinium-based contrast agents are a major trigger for NSF, but they may not be the only one. This is due in part to shifting perceptions regarding the true risks of modern contrast media,1, 2, 3, 4, 5, 6 improvements inscientific methodology used to study these adverse events,7, 8, 9, 10, 11, 12, 13 incomplete penetrance of new knowledge intoscientific practice,14 latent bias related to historical precedent,1,2 uncertainty regarding the interpretation of recently conducted well-controlled observational studies,4, 5, 6 and differences in recommendations across radiology and medical subspecialties.15, 16, 17, 18, In this document, joint statements are made by a multidisciplinary group of radiologists (MD, RM, JW, JD, CW) and nephrologists (MP, JY, RR, DF). Inaugural consensus statements were developed and endorsed by the American College of Radiology (ACR) and the National Kidney Foundation to improve and standardize the care of patients with kidney disease who have indication (s) to receive ACR-designated group II or group III intravenous gadolinium-based contrast media (GBCM). Davenport M.S., Khalatbari S., Dillman J.R., Cohan R.H., Caoili E.M., Ellis J.H. The impact of renin-angiotensin-aldosterone system blockade on contrast-induced nephropathy: a meta-analysis of 12 studies with 4,493 patients. It is important to recognize that in clinical practice, a multitude of factors are used to determine whether intravenous contrast media should be administered (eg, probability and necessity of an accurate diagnosis, alternative methods of diagnosis, risks of misdiagnosis, expectations about kidney functional recovery, allergic-like reaction risk). Try to: Pay attention to labels when taking over-the-counter (OTC) pain medications. Does renin-angiotensin aldosterone system blockade exacerbate contrast-induced nephropathy in patients with chronic kidney disease? KDIGO: Contrast media dose reduction recommended. On the basis of their NSF risk (and specifically on the numbers of unconfounded single-agent cases of NSF recorded for each agent), the 9 available gadolinium-based contrast agents are grouped into 3 groups (Table 3)41: Group Iagents associated with the greatest number of NSF cases. Help families facing kidney I have IgA nephrology. This is recommended in high-risk patients unless they are clinically volume-overloaded. RAASi may be restarted if CA-AKI does not occur or following the return of kidney function to baseline. They reviewed available literature, and found that reported rates of contrast induced nephropathy ranged from 8 to 50 percent variability they found unacceptable when seeking evidence for best practice. United States Food and Drug Administration FDA revises warnings regarding use of diabetes medicine metformin in certain patients with reduced kidney function. The introduction of contrast enhancement ultrasound (CEUS) in daily clinical practice has significantly reduced the use of contrast enhancement computed tomography (CECT) and contrast enhancement magnetic resonance (CEMR), especially in patients with renal disease. Statins have been postulated to reduce the risk of CI-AKI because of their pleiotropic anti-inflammatory and antioxidant effects, which help stabilize plaque. CI-AKI usually presents within 24 to 48 hours of exposure to iodinated contrast media, with elevation in creatinine and, rarely, oliguria. You can also ask to talk to the radiologist, radiology technician and nurse. The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest. The type of gadolinium used in older contrast agents isn't safe for people with moderate or advanced chronic kidney disease. Contrast induced nephropathy (CIN) is a rare kidney disorder that affects only about 2 percent of patients receiving contrast dyes, according to the National Kidney Foundation. A recent systematic review and meta-analysis evaluated the pooled risks of NSF in patients with stage 4 or 5 chronic kidney disease receiving a group II gadolinium-based contrast agent.52 The authors analyzed 16 studies with 4,931 patients who received group II agents. Acute kidney injury (AKI) may develop after administration of iodinated contrast material. Heterogeneous . Your support helps families facing kidney disease at every step of their journey. Mehta R.L., Kellum J.A., Shah S.V. Nevertheless, CI-AKI remains real. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. In many cases a scan without contrast material is adequate for diagnosis. Contrast agents for both CT and MRI are an extremely safe group of drugs and adverse side effects rarely develop. NSF is a rare but serious disease affecting skin and other organs that has been found in some patients with advanced CKD after exposure to gadolinium-containing contrast dyes that are used in magnetic resonance imaging (MRI). The Royal College of Radiologists . This is primarily because of the conflation of contrast-associated acute kidney injury (CA-AKI) with contrast-induced acute kidney injury (CI-AKI) in uncontrolled studies. Weisbord S.D., du Cheryon D. Contrast-associated acute kidneyinjury is a myth: No. At UCSF we use a questionnaire to identify patients who need lab testing before scanning to ensure that its safe to inject the contrast material. Data on risk of CI-AKI in pediatric patients is extrapolated from data in adult patients. CIN is a rare disorder and occurs when kidney problems are caused by the use of certain contrast dyes. Prolonged vasoconstriction, which appears to be mediated through alterations in endothelin, nitric oxide, adenosine, and prostaglandin levels, eventually leads to medullary ischemia. An official website of the United States government. If your labs are all normal your doctor may just want to watch you every 6 -12 months. All cases of acute kidney injury were then adjudicated by 2 nephrologists through chart review to ascertain the cause. The risk of CI-AKI appears to be highest in patients with the lowest kidney function, but the overall risk is lower than initially thought. Pannu N., Wiebe N., Tonelli M., Alberta Kidney Disease Network Prophylaxis strategies for contrast-induced nephropathy. The risks of prophylaxis (eg, heart failure, other hypervolemic conditions) should be considered before initiation.34,35 Prophylaxis is not indicated for the general population of patients with stable eGFR greater than or equal to 30mL/min/1.73m2,35 for patients undergoing chronic dialysis, or for patients at risk for heart failure.34,35 This eGFR threshold should not be adjusted solely based on concomitant diabetes mellitus.7, 8, 9, 10, 11,13,15,36 In a 1:1 propensity-matched observational study of 1112 patients with stable eGFR of 3044mL/min/1.73m2, diabetes mellitus did not independently increase risk of CI-AKI in patients undergoing contrast-enhanced CT (P=.22).31. In 2012, the Kidney Disease Improving Global Outcomes Working Group suggested the term CI-AKI and defined it as a 50% increase in creatinine from baseline within 7 days of exposure or a 0.3 mg/dL increase within 48 hours.5 CI-AKI is now the accepted terminology to describe kidney injury precipitated by iodinated contrast media. Advertising revenue supports our not-for-profit mission. Mayo Clinic health care delivery researchers in Florida sought to determine what the best available option was for patients. Sept. 12, 2022. If contrast material will be helpful then we follow a process to make sure that it is safe to inject it. The contrast agents used for MRI scans often contain a chemical element called gadolinium (gad-oh-LIN-e-um).. Ad hoc lowering of contrast media dose below a known diagnostic threshold should be avoided due to the risk of lowering diagnostic accuracy. Abbreviations: ACR,albumin creatinine ratio; AER,albumin excretion rate; Cr,creatinine; GFR,glomerularfiltration rate. Those who question the diagnosis of CI-AKI point to studies reporting similar rates of acute kidney injury in patients undergoing contrast-enhanced CT compared with those undergoing an unenhanced study. Although the true risk of CI-AKI remains unknown, prophylaxis with intravenous normal saline is indicated for patients without contraindication (eg, heart failure) who have acute kidney injury (AKI) or an estimated glomerular filtration rate (eGFR) less than 30mL/min/1.73m2 who are not undergoing maintenance dialysis. Blood pressure: Can it be higher in one arm? 1Department of Radiology, Michigan Medicine, Ann Arbor, MI, 2Department of Urology, Michigan Medicine, Ann Arbor, MI, 3Michigan Radiology Quality Collaborative, Ann Arbor, MI, 4American College of Radiology, Reston, VA, 5National Kidney Foundation, New York, NY, 6Section of Nephrology, Yale University School of Medicine, New Haven, CT, 8Department of Nephrology, Henry Ford Health System, Detroit, MI, 9Department of Radiology, Cincinnati Childrens Hospital Medical Center at University of Cincinnati College of Medicine, Cincinnati, OH, 10Department of Nephrology, Johns Hopkins Medicine, Baltimore, MD, 11Department of Radiology, Mayo Clinic, Rochester, MN, 12Department of Nephrology, Rush University Medical Center, Chicago, IL, 13Department of Radiology, University of Washington, Seattle, WA, 7Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT. Intravenous iodinated contrast media are commonly used with CT to evaluate disease and to determine treatment response. Asking about avoiding certain contrast dyes because of the risk of developing NSF or CIN. Studies need to target this high-risk cohort to better delineate the risks and better establish the utility, or futility, of the currently practiced prophylactic measures. The acetylcysteine story mirrors that of bicarbonate: a multitude of small studies followed by a series of meta-analyses yielding conflicting results. information submitted for this request. Risk factors include: pre-existing renal insufficiency, dehydration, diabetes mellitus . Iodine-based contrast media, multiple myeloma and monoclonal gammopathies: literature review and ESUR Contrast Media Safety Committee guidelines. The terms CA-AKI or PC-AKI are recommended for use in clinical practice due to the large proportion of AKI events correlated with but not necessarily caused by contrast media administration. Symptoms and signs of NSF can include burning and itching of the skin, red or dark patches on the skin, joint stiffness, or muscle weakness. It depends on the type of magnetic resonance imaging (MRI) scan you have. Agency for Healthcare Research and Quality (US); Rockville, Md: 2015. With the highly stable class II gadolinium-based contrast agents, the risk of nephrogenic systemic fibrosis appears to be extremely low and as such safe even for patients with advanced, predialysis kidney disease. Screening based on eGFR should be used to identify patients at potential risk of CI-AKI.15,16 Screening based on eGFR is preferred over serum creatininebased screening.17,23,24,41 Ideally, serum creatinine measurements should undergo calibration traceable to isotope dilution mass spectroscopy.42 Following accurate calibration, eGFR should be calculated with a validated isotope dilution mass spectroscopytraceable equation (eg, chronic kidney disease epidemiology collaboration, Modification of Diet in Renal Disease).42. This content does not have an Arabic version. Mayo Clinic on Incontinence - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press. The type of fluid used for volume expansion has also been a topic of debate, with bicarbonate-based hydration protocols proposed. Schwartz G.J., Work D.F. A kidney-failure-risk equation (eight variables) is available on the website https://www.qxmd.com . The following article was written by Ronald Zagoria, MD, FACR, Professor and Chief of Abdominal Imaging in the UCSF Department of Radiology and Biomedical Imaging. Discomfort or throbbing in the lower . Patient evaluation before gadolinium contrast administration for magnetic resonance imaging. Schnenberger E., Martus P., Bosserdt M. Kidney injury after intravenous versus intra-arterial contrast agent in patients suspected of having coronary artery disease: a randomized trial. Report No. When prophylaxis is indicated, isotonic volume expansion with normal saline is the preferred method.15,26,32,33 The ideal timing, volume, and rate of volume expansion is uncertain. March 23, 20197:15 AM ET By Clayton Dalton Enlarge this image Contrast agent, a drug that enhances CT scans, is sometimes skipped because of concerns about side effects. The pathophysiologic basis for CI-AKI is still not completely understood, but direct and indirect mechanisms have been suggested.10, Iodinated contrast media are directly toxic to the tubular epithelial cells, leading to loss of polarity (loss of channel restriction to either luminal or basolateral membranes) and eventual apoptosis and necrosis. This material does not constitute medical advice. Bethesda, MD 20894, Web Policies Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging, Description of 12 cases of nephrogenic fibrosing dermopathy and review of the literature, Dialysis-associated systemic fibrosis (nephrogenic fibrosing dermopathy): study of inflammatory cells and transforming growth factor B1 expression in affected skin, Induction of the expression of profibrotic cytokines and growth factors in normal human peripheral blood monocytes by gadolinium contrast agents, Gadolinium deposition in nephrogenic fibrosing dermopathy, Nephrogenic systemic fibrosis: history and epidemiology, Pharmacovigilance: what to do if you see an adverse reaction and the consequences, FDA warns that gadolinium-based contrast agents (GBCAs) are retained in the body; requires new class warnings, Assessment report for gadolinium-containing contrast agents, ACR Committee on Drugs and Contrast Media, Nephrogenic systemic fibrosis and gadolinium-based contrast media: updated ESUR Contrast Medium Safety Committee guidelines, Safety of gadolinium contrast agent in hemodialysis patients, 10 Years of nephrogenic systemic fibrosis: a comprehensive analysis of nephrogenic systemic fibrosis reports received by a pharmaceutical company from 2006 to 2016, Gadolinium dimeglumine: an alternative contrast agent for digital subtraction angiography, Comparison of Gd DTPA-BMA (Omniscan) versus Gd HP-DO3A (ProHance) retention in human bone tissue by inductively coupled plasma atomic emission spectroscopy, Gadolinium-based contrast agents in kidney disease: comprehensive review and clinical practice guideline issued by the Canadian Association of Radiologists, MRI contrast agents: basic chemistry and safety, A systematic review of 639 patients with biopsy-confirmed nephrogenic systemic fibrosis, Risk of nephrogenic systemic fibrosis in patients with stage 4 or 5 chronic kidney disease receiving a group II gadolinium-based contrast agent: a systematic review and meta-analysis, Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction, Adverse reactions to ionic and nonionic contrast media. Report No. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Intravenous contrast medium-induced nephrotoxicity: is the medical risk really as great as we have come to believe? In outpatients with stage 3chronic kidney disease, the team found that 2 percent of patients receiving iohexol developed contrast-induced nephropathy, compared to 9 percent of those receiving iodixanol. These statements are endorsed by the American College of Radiology, or ACR, and the National Kidney Foundation, or NKF, to improve and standardize the care of patients with impaired kidney function who have indication(s) to receive intravenous iodinated contrast media. Diagnostic tests such as MRIs, CT scans and angiograms are routinely used because they provide important information about many diseases or injuries and can help in diagnosis and treatment. Post-contrast acute kidney injury. Enter multiple addresses on separate lines or separate them with commas. 15(16)-EHC022-EF. The guidelines set by the FDA and the radiology societies were undoubtedly effective in curbing the disease and eventually eliminating it. Pulse pressure: An indicator of heart health? NSF has not been reported in people with mild kidney damage or normal kidney function. But the dyes themselves may cause damage to the kidneys referred to as contrast-inducednephropathy. Abbreviations: ACR,American College of Radiology; AKI,acute kidney injury; AKIN,Acute Kidney Injury Network; CA-AKI,contrast-associated AKI; CI-AKI,contrast-induced AKI; CKD,chronic kidney disease; eGFR,estimated glomerular filtration rate; KDIGO,Kidney Disease Improving Global Outcomes; NKF,National Kidney Foundation; PC-AKI,postcontrast acute AKI. Refers to Tian, Y. E. et al. Prophylaxis in High-Risk Patients With eGFR< 30 mL/min/1.73 m2: Get the Balance Right. Even when kidney damage occurs, it is almost always temporary and will resolve without treatment. However, in some cases, CIN can lead to more serious kidney problems and possible heart and blood vessel problems. Measurement and estimation ofGFRin children and adolescents. Is the presence of a solitary kidney an independent risk factor for acute kidney injury after contrast-enhanced CT? We know that most patients have normal kidney function and need no precautions, however, not every patient with impaired kidney function will be aware of it. The term postcontrast acute kidney injury (PC-AKI) is synonymous with CA-AKI and appears in radiology guidelines.15 Both terms imply correlative diagnosis. It is intended for informational purposes only. The pooled risk of NSF was 0% (upper bound of 95% CI 0.07%). Solomon et al20 first reported volume expansion with 0.45% saline to be effective in preventing CI-AKI. Resperate: Can it help reduce blood pressure? Clinical studies: MAP, RAR. In some cases, the contrast media can cause kidney failure, especially in patients with underlying kidney problems or dehydration. There, physicians, researchers, data scientists, artificial intelligence engineers and bioethicists are Science Saturday: Pharmacists play key role in clinical research, Mayo Clinic Minute: How awake spinal surgery benefits patients, Science Saturday: Mayo Clinic doctor visits of the future could be powered by omics research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Q and A: COPD treatment with two types of bronchodilators, Mayo Clinic Minute: The many benefits of petroleum jelly. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. This paper aims to compare and contrast kidney disease care strategies between the US and Taiwan, examine their resulting effects on CKD epidemiology, and identify the defining characteristics of a successful CKD care system that can be incorporated into future CKD care practices. The discovery of this rare disease led to the development of newer, safer versions of gadolinium contrast agents. Contrast medium-induced nephrotoxicity risk assessment in adult inpatients: a comparison of serum creatinine level- and estimated glomerular filtration rate-based screening methods. Procedure-related factors include higher-osmolality contrast media, higher volume given, multiple administrations of iodinated contrast media, and intra-arterial administration with first-pass effect.2,6. Despite decades of research on iodinated contrast and kidney injury, many questions are yet to be answered. There is thought to be no clinically relevant difference in risk of CI-AKI between LOCM and IOCM.31, Despite the acronym, LOCM are hyperosmolar (approximately 600mOsm/kg) relative to both IOCM (approximately 290mOsm/kg) and serum (approximately 290mOsm/kg).15 However, the dimeric structure of IOCM renders them more viscous than LOCM.15 Most modern iodinated contrast media are classified as LOCM.15 High-osmolality iodinated contrast media have higher osmolality than do LOCM and IOCM, but high-osmolality iodinated contrast media has been replaced by LOCM and IOCM for intravenous administration in modern clinical practice.15, Prophylaxis is indicated for patients who have AKI or aneGFR less than 30mL/min/1.73m2 and are not undergoingmaintenance dialysis.15,26,32,33 However, the evidence supporting this statement is based on data for the general prevention of CA-AKI rather than CI-AKI specifically. Where feasible, specific commentary about CI-AKI is made. Screening for impaired renal function in outpatients before iodinated contrast injection: Comparing the Choyke questionnaire with a rapid point-of-care-test. LightFieldStudios / Getty Images This article describes the differences between acute kidney failure and chronic kidney disease, including the distinct causes, symptoms, treatments, and outcomes. Dr McDonald: Activities related to the present article: author is scientific advisor for GE Healthcare; institution received research funding from GE Healthcare. Clinicians perceptions of risks and consequently their decisions to give or withhold contrast cannot be ascertained from retrospective analyses. Medical research has resulted in many amazing diagnostic and treatment methods, tools and drugs. As a radiologist at UCSF, I commonly work with patients getting CT and MRI scans. eGFR > 30, but less than 45 indicates that while it is safe to get contrast material, there is a small risk of causing kidney damage. As lifespans lengthen, age-related diseases such as cardiovascular disease and diabetes are becoming more prevalent. Part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients : Recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Accessibility The site is secure. 2023 The Regents of the University of California | Accessibility | Terms of Use | Privacy Policy, (T32) Biomedical Imaging for Clinician Scientists, Using Radium-223 to Treat Metastatic Prostate Cancer, Register Now for the UCSF Abdominal & Pelvic Imaging CME Program in Palm Springs, Join us in Hawaii for the UCSF Body Imaging: Abdominal and Thoracic CME Course, Sina Houshmand, MD Joins UCSF Radiology Faculty, UCSF Radiology's Role in the Multidisciplinary Approach to the Placenta Service (MAPS) at UCSF, Hepatitis B Surveillance and Treatment in the UCSF Department of Radiology and Biomedical Imaging. This can help determine your risk of nephrogenic systemic fibrosis. These contrast dyes have helped in the diagnosis and treatment of many patients with various diseases and injuries, so there is also a risk of not doing these procedures. By contrast, many . The rationale of these new definitions is to eliminate the causality associated with the term CI-AKI. But that might not be the case with older contrast agents. Jo S.H., Lee J.M., Park J., Kim H.S. There are no confirmed clinically relevant differences in risk of CA-AKI between low-osmolality contrast media (LOCM) and iso-osmolarity contrast media (IOCM) for intravenous applications.31 Indirect evidence suggests that the LOCM iohexol may have a higher risk compared with other LOCM, but that potential risk difference has not been confirmed.31 Randomized studies comparing LOCM and IOCM primarily analyzed intra-arterial administrations and have mixed results.31 Based on results of a 2015 systematic review and meta-analysis, any difference in risk of CA-AKI between LOCM and IOCM is not likely to be clinically meaningful.31, No studies have directly compared risk of CI-AKI between LOCM and IOCM.