Article Figures & Data
Figures
- Figure 1
Our approach to chronic kidney disease patients requiring iodinated contrast media.
- Figure 2
Number of cases of nephrogenic systemic fibrosis associated with gadopentetate dimeglumine in the United States and around with world, by year of disease onset. Vertical dotted line indicates the introduction of the boxed warning by the US Food and Drug Administration in May 2007.
Endrikat J, Dohanish S, Schleyer N, Schwenke S, Agarwal S, Balzer T. 10 Years of nephrogenic systemic fibrosis: a comprehensive analysis of nephrogenic systemic fibrosis reports received by a pharmaceutical company from 2006 to 2016. Invest Radiol 2018; 53(9):541–550. https://journals.lww.com/investigativeradiology/fulltext/2018/09000/10_years_of_nephrogenic_systemic_fibrosis__a.5.aspx
Tables
Contrast-induced nephropathy—Traditional term for worsening kidney function within 48 hours of iodinated contrast media. This term has largely been replaced by contrast-induced acute kidney injury. Contrast-associated acute kidney injury—Any acute kidney injury occurring within 48 hours of iodinated contrast media. The term implies correlative diagnosis and does not suggest a causal relationship between the acute kidney injury and the iodinated contrast media. Postcontrast acute kidney injury—Synonymous with contrast-associated acute kidney injury. This term appears in the radiology literature. Similar to contrast-associated acute kidney injury, it implies correlative diagnosis without suggesting a causal relationship between the acute kidney injury and the iodinated contrast media Contrast-induced acute kidney injury—Replaced contrast-induced nephropathy as the accepted terminology when acute kidney injury is causally linked to iodinated contrast media. It is a subset of contrast-associated acute kidney injury. - TABLE 2
Iodinated contrast media in patients with kidney disease: Key points from the ACR-NKF consensus statement
Consensus statement Authors’ comments The risk of contrast-induced acute kidney injury is substantially less than the risk of contrast-associated acute kidney injury, but the actual risk remains uncertain. However, necessary contrast-enhanced CT without an alternative should not be withheld. We believe this statement should be extrapolated to patients in whom coronary angiographic procedures are deemed necessary. Patients at risk for contrast-induced acute kidney injury include those with recent acute kidney injury or those with eGFR < 30 mL/min/1.73 m2 (including nonanuric dialysis patients). Age, diabetes, hypertension, and proteinuria are absent from the risk classification. We believe patients with an eGFR < 45 mL/min/1.73 m2, particularly those with the above noted risk factors, should also be considered at increased risk. Prophylaxis with intravenous isotonic saline is indicated for patients with eGFR < 30 mL/min/1.73 m2 not undergoing dialysis and in patients with acute kidney injury. We believe that prophylaxis is also warranted in nonanuric patients on hemodialysis or peritoneal dialysis to preserve residual kidney function. Careful attention to volume status is required to avoid hypervolemia. Prophylaxis should be individualized for high-risk patients with eGFR between 30 and 44 mL/min/1.73 m2. We support prophylaxis in this population, particularly in the presence of traditional risk factors (diabetes, hypertension, proteinuria). Prophylaxis is not indicated for patients with stable eGFR ≥ 45 mL/min/1.73 m2. We concur that the risk of contrast-induced acute kidney injury in this population is low. ACR = American College of Radiology; CT = computed tomography; eGFR = estimated glomerular filtration rate; NKF = National Kidney Foundation
Based on information in Davenport et al, reference 28.
- TABLE 4
Key points from the ACR Manual on Contrast Media regarding prevention of nephrogenic systemic fibrosis in patients at risk
Kidney function Recommendation Authors’ comments Chronic kidney disease stage 1 and 2 No increased risk of developing NSF. Any gadolinium-based agent can be given safely. There are no cases reported in this category with any of the gadolinium-based agents. Chronic kidney disease stage 3 The risk of developing NSF is exceedingly rare. No special precautions are necessary. There have been no definite cases reported in patients with stage 3 chronic kidney disease. Chronic kidney disease stage 4 and 5 not on chronic dialysis Group I agents are contraindicated. If a gadolinium-enhanced MRI study is to be done, a group II agent should be used. Given the risk of CI-AKI in this population, we believe that MRI using a group II agent would be preferable to CT with iodinated contrast. End-stage kidney disease on hemodialysis The ACR favors CT rather than MRI if the anticipated diagnostic yield is similar.
Group I agents are contraindicated. Group II agents are preferred and gadolinium-enhanced MRI should be performed as closely before hemodialysis as is possible.We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents.
Our current practice is to perform a single dialysis session rather than 2 consecutive sessions.End-stage kidney disease on peritoneal dialysis The ACR favors CT when possible, but if MRI is desired, then the ACR recommends a group II agent.
The ACR recognizes that peritoneal dialysis may provide less NSF risk reduction than hemodialysis.We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents.
The committee does not comment on the necessity of subjecting these patients to hemodialysis. We believe it is safer to perform a single session of hemodialysis, particularly for peritoneal dialysis patients with no residual kidney function.Acute kidney injury Group I agents should be avoided in patients with known or suspected acute kidney injury. Group II agents are preferred. We favor a stratified approach:
Acute kidney injury on dialysis: As in patients with end-stage kidney disease, we recommend a single session of dialysis following gadolinium exposure.
Nonoliguric acute kidney injury not on dialysis: Similar to advanced chronic kidney disease, if a gadolinium-enhanced MRI study is needed, a group II agent should be used.
Oliguric acute kidney injury not on dialysis: We favor avoiding administration of gadolinium if possible. Otherwise, our practice is to perform a single hemodialysis session.ACR = American College of Radiology; CI-AKI = contrast-induced acute kidney injury; CT = computed tomography; MRI = magnetic resonance imaging; NSF = nephrogenic systemic fibrosis
Based on information in reference 41.
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