Imaging Pearls ❯ Contrast ❯ Contrast Induced Nephropathy: CIN
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- “Intravenous iodinated contrast media are commonly used with CT to evaluate disease and to determine treatment response. The risk of acute kidney injury (AKI) developing in patients with reduced kidney function following exposure to intravenous iodinated contrast media has been overstated. This is due primarily to historic lack of control groups sufficient to separate contrast-induced AKI (CI-AKI; ie, AKI caused by contrast media administration) from contrast-associated AKI (CA-AKI; ie, AKI coincident to contrast media administration). Although the true risk of CI-AKI remains uncertain for patients with severe kidney disease, prophylaxis with intravenous normal saline is indicated for patients who have AKI or an estimated glomerular filtration rate less than 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis. In individual high-risk circumstances, prophylaxis may be considered in patients with an estimated glomerular filtration rate of 30–44 mL/min/1.73 m2 at the discretion of the ordering clinician.”
Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation
Davenport MS et al.
Radiology 2020 (in press) - “The risk of acute kidney injury (AKI) developing in patients with reduced kidney function following exposure to intravenous iodinated contrast media has been overstated. This is due primarily to historic lack of control groups sufficient to separate contrast-induced AKI (CI-AKI; ie, AKI caused by contrast media administration) from contrast-associated AKI (CA-AKI; ie, AKI coincident to contrast media administration).”
Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation
Davenport MS et al.
Radiology 2020 (in press) - “Patients with AKI or eGFR less than 30 mL/min/1.73 m2 (including nonanuric patients undergoing maintenance dialysis [see below]) should prompt consideration by the referring professional and radiologist to discuss the risks and benefits of contrast media administration acute kidney injury (AKI) or an estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis.”
Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation
Davenport MS et al.
Radiology 2020 (in press) - “The putative risk of administering modern intravenous iodinated contrast media in patients with reduced kidney function has been overstated. 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. 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 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis.”
Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation
Davenport MS et al.
Radiology 2020 (in press) - “The presence of a solitary kidney should not independently influence decision making regarding the risk of CI-AKI. Ad hoc lowering of contrast media dose below a known diagnostic threshold should be avoided due to the risk of lowering diagnostic accuracy.”
Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation
Davenport MS et al.
Radiology 2020 (in press)
- The 2015 ACR Manual on Contrast Media (please note that all further references to this document refer to the 2015 publication, version 10.1) advocates screening of renal function in all hospitalized patients as well as outpatients for certain risk factors such as diabetes mellitus, hypertension requiring medical therapy, age >60, and a history of renal disease (such as dialysis, single kidney, renal cancer, renal surgery, or kidney transplant)."
Imaging patients with renal impairment
Mahan Mathur, Jeffrey C. Weinreb
Abdom Radiol (2016) in press - "This definition has been modified by the Acute Kidney Injury Network (AKIN), with AKI occurring if one of the following criteria are met within 48 h of a nephrotoxic event:
* Absolute serum creatinine increase ≥0.3 mg/dl
* Percentage increase in serum creatinine ≥50% (≥1.5 times above baseline
* Urine output £0.5 mL/kg/h for at least 6 h ."
Imaging patients with renal impairment
Mahan Mathur, Jeffrey C. Weinreb
Abdom Radiol (2016) in press
- Purpose: To determine whether patients with a solitary kidney are at higher risk for contrast material–induced acute kidney injury (AKI) than matched control patients with bilateral kidneys.
Conclusion: Our study did not demonstrate any significant differences in the rate of AKI, dialysis, or death attributable to contrast-enhanced CT in patients with a solitary kidney versus bilateral kidneys. Is the Presence of a solitary Kidney an independent risk Factor for acute Kidney injury after contrast-enhanced CT? McDonald JS et al. Radiology 2016; 278:74–81 - “After propensity score matching, the rate of acute kidney injury (AKI) after contrast material– enhanced CT was similar between patients with solitary versus bilateral kidneys (AKI definition increase in serum creatinine [SCr] level 0.5 mg/dL odds ratio = 1.11 [95% confidence interval {CI}: 0.65, 1.86], P = .70; AKI definition increase in SCr level 0.3 mg/dL or 50% over baseline odds ratio = 0.96 [95% CI: 0.41, 2.07], P = .99).” Is the Presence of a solitary Kidney an independent risk Factor for acute Kidney injury after contrast-enhanced CT? McDonald JS et al. Radiology 2016; 278:74–81
- “The rate of emergent dialysis was rare and also not significantly different between patients with solitary versus bilateral kidneys (0.8% [two of 247 patients] vs 0.4% [three of 691 patients], respectively; odds ratio = 1.87 [95% CI: 0.16, 16.4]; P = .61).” Is the Presence of a solitary Kidney an independent risk Factor for acute Kidney injury after contrast-enhanced CT? McDonald JS et al. Radiology 2016; 278:74–81
- “Each of these studies shows with excellent power that the per-patient risk of contrast-induced AKI after IV LOCM or IV IOCM administration is either rare or non-existent for patients with a stable estimated glomerular filtration rate (GFR) of 45 mL/ min/1.73 m2 or greater (i.e., normal kidney function or stage I–IIIA chronic kidney disease).”
Contrast Media Controversies in 2015: Imaging Patients With Renal Impairment or Risk of Contrast Reaction Davenport MS et al. AJR 2015;204: 1174-1181 - “Because there remains scientific uncertainty about the true incidence and significance of contrast-induced AKI, the American College of Radiology (ACR) suggests that we proceed as if it is a real phenomenon, albeit one that occurs in a limited and infrequently encountered patient population. Prospective trials investigating the role of contrast material in the development of postcontrast AKI are still needed.”
Contrast Media Controversies in 2015: Imaging Patients With Renal Impairment or Risk of Contrast Reaction Davenport MS et al. AJR 2015;204: 1174-1181 - “Estimated GFR is superior to serum creatinine as a measure of stable renal function because it accounts for patient age, patient race, and patient sex all factors known to influence a patient’s renal function. Although estimated GFR is not perfect because it is based on serum creatinine and therefore is subject to similar limitations, it is widely used because of its relative ease of acquisition, low cost, repeatability,and prognostic power.”
Contrast Media Controversies in 2015: Imaging Patients With Renal Impairment or Risk of Contrast Reaction Davenport MS et al. AJR 2015;204: 1174-1181 - “To summarize, for prophylaxis against contrast-enhanced AKI, volume expansion with isotonic IV fluid remains the standard method to reduce postcontrast AKI risk, although no single protocol can claim superiority or uniform acceptance. Use of the lowest effective dose of iodinated contrast material is reasonable, but there is no conclusive evidence supporting a dose-toxicity relationship for contrast-induced AKI within the range of clinically used doses.”
Contrast Media Controversies in 2015: Imaging Patients With Renal Impairment or Risk of Contrast Reaction Davenport MS et al. AJR 2015;204: 1174-1181 - “The real and apparent safety margin of modern contrast agents continues to widen. Contrast-induced AKI is rarer than previously thought, but there remains controversy about its incidence for patients with an estimated GFR of less than 45 mL/min/1.73 m2. If contrast-induced AKI exists after IV contrast administration, patients with an estimated GFR of less than 30 mL/min/1.73 m2 are at highest risk.”
Contrast Media Controversies in 2015: Imaging Patients With Renal Impairment or Risk of Contrast Reaction Davenport MS et al. AJR 2015;204: 1174-1181
- “Anuric patients with end-stage renal disease are no longer at risk for CIN and may receive intravascular iodinated contrast material without risk of additional renal injury.”
ACR Manual on Contrast Media
Version 9 (2013) - “The MDRD formula is known to underestimate eGFR in patients with normal and near normal renal function . Herts et al showed that when patients’ eGFR was calculated by the MDRD formula, a significantly higher percentage of patients had an eGFR of <60 mL/min than had a serum creatinine of >1.4 mg/dL. These patients might have been denied contrast medium administration had eGFR been used to determine suitability for injection (15.3% vs. 6.2%).”
ACR Manual on Contrast Media
Version 9 (2013)
- “Intravenous contrast material administration was not associated with excess risk of AKI acute kidney injury , dialysis, or death, even among patients with comorbidities reported to predispose them to nephrotoxicity.”
Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality.
McDonald RJ et al.
Radiology. 2014 Dec;273(3):714-25 - “Within this cohort, the risks of AKI acute kidney injury ( OR odds ratio , 0.94; 95% confidence interval [ CI confidence interval ]: 0.83, 1.07; P = .38), emergent dialysis ( OR odds ratio , 0.96; 95% CI confidence interval : 0.54, 1.60; P = .89), and 30-day mortality (hazard ratio [ HR hazard ratio ], 0.97; 95% CI confidence interval : 0.87, 1.06; P = .45) were not significantly different between the contrast group and the noncontrast group. Although patients who developed AKI acute kidney injury had higher rates of dialysis and mortality, contrast material exposure was not an independent risk factor for either outcome for dialysis ( OR odds ratio , 0.89; 95% CI confidence interval : 0.40, 2.01; P = .78) or for mortality ( HR hazard ratio , 1.03; 95% CI confidence interval : 0.82, 1.32; P = .63), even among patients with compromised renal function or predisposing comorbidities.”
Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality.
McDonald RJ et al.
Radiology. 2014 Dec;273(3):714-25 - “ Although patients who developed AKI acute kidney injury had higher rates of dialysis and mortality, contrast material exposure was not an independent risk factor for either outcome for dialysis ( OR odds ratio , 0.89; 95% CI confidence interval : 0.40, 2.01; P = .78) or for mortality ( HR hazard ratio , 1.03; 95% CI confidence interval : 0.82, 1.32; P = .63), even among patients with compromised renal function or predisposing comorbidities.”
Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality.
McDonald RJ et al.
Radiology. 2014 Dec;273(3):714-25
- “ 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.”
The Challenges in Assessing Contrast-Induced Nephropathy: Where Are We Now-
Davenport MS et al.
AJR 2014;202:784-789 - “ In conclusion it is an exciting time for the study of CIN. Although most recent investigations agree that CIN is an overdiagnosed illness confounded by countless alternative nephrotoxic events and physiologic variation, there are data indicating that for at least patients with severe renal insufficiency, IV LOCM and IOCM are potential nephrotoxins that merit continued scrutiny.”
The Challenges in Assessing Contrast-Induced Nephropathy: Where Are We Now-
Davenport MS et al.
AJR 2014;202:784-789
- “ Intravenous low osmolality iodinated contrast material is a risk factor for post CT AKI (contrast induced nephrotoxicity), but is not a risk factor in patients with SCr levels less than 1.5 mg/dL. This information can be used to make decisions regarding administration of intravenous low-osmolality iodinated contrast material to at-risk patients.”
Contrast Material-induced Nephrotoxicity and Intravenous Low-Osmolality Iodinated Contrast Material
Davenport MS et al.
Radiology 2013; 267:94-105 - “ Intravenously administered low-osmolality iodinated contrast material is independent risk factor for post CT acute renal injury (AKI). Risk increases with increases in pre-CT SCr.”
Contrast Material-induced Nephrotoxicity and Intravenous Low-Osmolality Iodinated Contrast Material
Davenport MS et al.
Radiology 2013; 267:94-105 - “ However, there are many other factors that contribute to the development of post-CT AKI, and not all cases of post-CT AKI are due to CIN. These factors likely account for the equivalence in post-CT AKI rates after unenhanced and contrast enhanced CT shown in recent reports.”
Contrast Material-induced Nephrotoxicity and Intravenous Low-Osmolality Iodinated Contrast Material
Davenport MS et al.
Radiology 2013; 267:94-105 - “ After propensity score adjustment for difference in presumed risk factors of contrast material induced nephropathy (CIN) recipients of unenhanced CT scans are at equivalent risk of serum creatinine defined acute kidney injury (AKI) compared with recipients of contrast enhanced CT scans.”
Intravenous Contrast Material-induced Nephropathy: Causal or Coincident Phenomenon
McDonald RJ et al
Radiology 2013; 267:106-118 - “ Counterfactual analysis of a large subset of patients who underwent both a contrast enhanced and unenhanced CT scan demonstrates an equivalent likelihood of AKI after either scan.”
Intravenous Contrast Material-induced Nephropathy: Causal or Coincident Phenomenon
McDonald RJ et al
Radiology 2013; 267:106-118 - “ Published nonrandomized controlled studies show a similar relative risk (RR) of acute kidney injury (AKI), mortality, and dialysis in patients who received intravenous contrast medium as compared with control groups of patients who underwent an imaging examination without contrast medium or otherwise did not receive contrast medium.”
Frequency of Acute Kidney Injury Following Intravenous Contrast Medium Administration: A Systematic Review and Meta-Analysis
McDonald JS et al.
Radiology 2013; 267:119-128 - “ Controlled contrast medium-induced nephropathy studies demonstrate a similar incidence of AKI, dialysis, and deaths between the contrast medium group and control group.”
Frequency of Acute Kidney Injury Following Intravenous Contrast Medium Administration: A Systematic Review and Meta-Analysis
McDonald JS et al.
Radiology 2013; 267:119-128 
- “The creatinine level increases in patients who are not receiving con- trast material as often as it does in published series of patients who are receiving contrast material. The role of contrast material in nephropathy may have been overestimated.”
Frequency of Serum Creatinine Changes in the Absence of Iodinated Contrast Material: Implications for Studies of Contrast Nephrotoxicity
Newhouse JH
AJR 2008; 191:378-382 - OBJECTIVE. Most studies of contrast-induced nephropathy lack controls to distinguish it from nephropathy from other causes. We assessed the frequency and magnitude of serum creatinine changes in patients not receiving iodinated contrast material to compare with creatinine changes in publications regarding contrast nephropathy.
MATERIALS AND METHODS. From the electronic medical records of an academic medical center, adults with creatinine determinations on five consecutive days who had not received contrast material during the previous 10 days were identified. The first creatinine level was compared with those on subsequent days. We calculated the frequency with which these levels exceeded thresholds used to identify contrast nephropathy in previous publications.
RESULTS. Among 32,161 patients, more than half showed a change of at least 25% and more than two fifths, a change of at least 0.4 mg/dL. Among patients with baseline creatinine levels of 0.6–1.2 mg/dL, increases of at least 25%, 33%, and 50% occurred in 27%, 19%, and 11% of patients, respectively. Increases of 0.4, 0.6, and 1.0 mg/dL occurred in 13%, 7%, and 3% of patients. Among patients with baseline creatinine levels greater than 2.0 mg/dL, increases of at least 25%, 33%, and 50% occurred in 16%, 12%, and 7%. Increases of 0.4, 0.6, and 1.0 mg/ dL occurred in 33%, 26%, and 18%. These increases were not different from the incidences of contrast nephropathy previously published. - “We conclude that because serum creatinine levels change frequently in the absence of iodinated contrast material, prior studies of the relationship between iodinated contrast material and renal function must be interpreted with caution, and that future experiments should have appropriate controls. We do not claim that IV contrast material never induces nephropathy, but it may do so less frequently and severely than previously thought. If subsequent experimentation proves its safety, it could be used more frequently in patients with renal failure, which could both increase the diagnostic capacity of CT and avoid the cost and risk of gadolinium-enhanced MRI.”
Frequency of Serum Creatinine Changes in the Absence of Iodinated Contrast Material: Implications for Studies of Contrast Nephrotoxicity
Newhouse JH
AJR 2008; 191:378-382 - “The results of that study clearly show that there is some baseline level of nephropathy (or at least, of creatinine change) that occurs in sick patients who do not receive contrast media. To what degree we should discount the perceived risk of nephropathy from the administration of contrast media is not answered by this study because the patients evaluated are not matched against any population who received contrast media. Nevertheless, the bar has been raised for the design of future studies of CIN.”
Contrast-Induced Nephropathy: Contrast Material Not Required-
Baumgarten DA, Ellis JH
AJR 2008; 191:383-386 
- “ The ACR Manual on Contrast Media of the American College of Radiology states that available data are insufficient to permit a specific recommended threshold level, but suggests that a creatinine level of 2.0 mg/dL is a level at which below which contrast medium is safe.”
Quantitating Contrast Medium-induced Nephropathy: Controlling the Controls
Newhouse JH, RoyChoudhury
Radiology 2013; 267:4-8 - “ This study showed that increasing the dose of IV contrast medium can compensate for a reduced radiation dose and visa versa while SNR and CNR are maintained.”
Seesaw Balancing Radiation Dose and IV Contrast Dose: Evaluation of a new Abdinal CT Protocol for Reducing Age Specific Wrist
AJR 2013; 200:383-388
- “ Heart failure, low BMI (body mass index), and repeated contrast material administration were identified as risk factors for CIN under current treatment strategy. The low incidence of CIN supports the use of hydration as a preventive measure in patients at high risk for CIN.”
Epidemiology of Contrast Material-induced Nephropathy in the Era of Hydration
Balemans CEA et al.
Radiology 2012; 263:706-713 - “ Patients at high risk for were hydrated with 1000 ml of isotonic saline before and after contrast material exposure.”
Epidemiology of Contrast Material-induced Nephropathy in the Era of Hydration
Balemans CEA et al.
Radiology 2012; 263:706-713 - “ In patients with stage 3 and 4 chronic kidney disease who received intravenous contrast material and who underwent treatment in accordance with current guidelines, the incidence of contrast material-induced nephropathy (CIN) was low (2.4%), and heart failure (odds ratio 3.0), low body mass index (odds ratio 0.9 per increment), and repeated contrast material administration (odds ratio, 2.8) were risk factors for CIN.”
Epidemiology of Contrast Material-induced Nephropathy in the Era of Hydration
Balemans CEA et al.
Radiology 2012; 263:706-713 - “The standard hydration procedure involved intravenous infusion of isotonic saline (NaCl 0.9%) at a rate of 250 ml/h for 4 hours before and 4 hours after exposure to contrast media.”
Epidemiology of Contrast Material-induced Nephropathy in the Era of Hydration
Balemans CEA et al.
Radiology 2012; 263:706-713 - Risk Factors for CIN
- Impaired renal function
- Diabetes mellitus
- Peripheral vascular disease
- Heart failure
- Age over 75 years
- Administration of large volumes of contrast
- Use of diuretics
- NSAIDS use
- “The utilization of coronary angiography and percutaneous coronary intervention in the routine care for patients with acute coronary syndromes (ACS) has resulted in significant improvement in their prognosis. Consequently, recommendations on the use of these management strategies are reflected in the ACC/AHA guidelines for the management of patients with unstable angina and myocardial infarction.”
Management of Acute Coronary Syndrome in Patients with Chronic Kidney Disease: If We Don’t Risk Anything We Risk Even More
Asim M, Jeffrey RF
Nephron Clin Pract 2011;19(4);c333-6 - “However, among other causes, the 'phobia' of nephrotoxicity of iodinated contrast media (ICM) in chronic kidney disease (CKD) patients and its claimed adverse effect on short-term and long-term survival has led to a worryingly low use of ICM-based diagnostic and therapeutic interventions in patients with CKD. We argue that the fear of iodinated contrast media-induced acute kidney injury (ICI-AKI) is not a valid reason to avoid ICM-based investigations/interventions in CKD patients with ACS; the risks of myocardial infarction and death greatly outweigh the risk of ICI-AKI in most of these patients and hence they should always be considered for myocardial revascularization.”
Management of Acute Coronary Syndrome in Patients with Chronic Kidney Disease: If We Don’t Risk Anything We Risk Even More
Asim M, Jeffrey RF
Nephron Clin Pract 2011;19(4);c333-6 - Purpose: To compare the incidence of contrast medium-induced acute kidney injury (AKI) after intravenous (IV) administration of iodixanol for computed tomographic (CT) angiography versus intraarterial (IA) injection of iodixanol or low osmolar contrast medium (LOCM) for digital subtraction angiography (DSA) within the same population suspected of peripheral arterial occlusive disease (PAOD).
Conclusion: The rates of contrast medium-induced AKI are not statistically different between IV iodixanol for CT angiography and IA iodixanol or another LOCM for DSA in the same population with suspected PAOD.
Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium.
Karlsberg RP et al.
J Vasc Interv Radiol 2011 Aug 22(8):1159-65 - “The rates of contrast medium-induced AKI are not statistically different between IV iodixanol for CT angiography and IA iodixanol or another LOCM for DSA in the same population with suspected PAOD.”
Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium.
Karlsberg RP et al.
J Vasc Interv Radiol 2011 Aug 22(8):1159-65 - Purpose: To compare the incidence of contrast medium-induced acute kidney injury (AKI) after intravenous (IV) administration of iodixanol for computed tomographic (CT) angiography versus intraarterial (IA) injection of iodixanol or low osmolar contrast medium (LOCM) for digital subtraction angiography (DSA) within the same population suspected of peripheral arterial occlusive disease (PAOD).
Contrast medium-induced acute kidney injury: comparison of intravenous and intraarterial administration of iodinated contrast medium.
Karlsberg RP et al.
J Vasc Interv Radiol 2011 Aug 22(8):1159-65
- “ The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with β2-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefits of the examination and the expected low risk of developing CIN.”
Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT
Pahade JK et al.
AJR 2011; 196:1094-1101 - “ In patients with myeloma, renal failure is the second most common cause of death after infection. The development of renal failure may affect 20-40% of patients with newly diagnosed myeloma, with 52-69% of patents having normal renal function at diagnosis.”
Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT
Pahade JK et al.
AJR 2011; 196:1094-1101 - Renal Failure in Multiple Myeloma Patients: Etiology
- Toxic effects of excreted monoclonal light chains is primary cause. This can be exacerbated by;
- Hypercalcemia
- Dehydration
- Infection
- Bence Jones proteinuria
- Nephrotoxic drugs
- “ The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with β2-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefits of the examination and the expected low risk of developing CIN.”
Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT
Pahade JK et al.
AJR 2011; 196:1094-1101 - “ In patients with myeloma, renal failure is the second most common cause of death after infection. The development of renal failure may affect 20-40% of patients with newly diagnosed myeloma, with 52-69% of patents having normal renal function at diagnosis.”
Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT
Pahade JK et al.
AJR 2011; 196:1094-1101 - Renal Failure in Multiple Myeloma Patients: Etiology
Toxic effects of excreted monoclonal light chains is primary cause. This can be exacerbated by;
- Hypercalcemia
- Dehydration
- Infection
- Bence Jones proteinuria
- Nephrotoxic drugs "Factors associated with serum creatinine levels after IV contrast material appear to be severity of illness at the time of CT ( as assessed by the non-renal mSOFA score) and sex but not baseline creatinine at the time of CT or its precedent trend."
Effects of IV Contrast Medium on Renal Function in Oncologic Patients Undergoing CT in ICU
Ng CS et al.
AJR 2010; 195:414-422"Administration of IV contrast medium in oncologic ICU patients with relatively normal creatinine is associated with an increase in creatinine but not beyond that of simply undergoing CT or of a matched non-CT group in ICU."
Effects of IV Contrast Medium on Renal Function in Oncologic Patients Undergoing CT in ICU
Ng CS et al.
AJR 2010; 195:414-422"We believe that modern CM pose only a small risk to renal function and that thresholds of creatinine above which CM are withheld for CT should be increased to improve the accuracy of CT examinations"
Intravenous Contrast Medium-induced Nephrotoxicity: Is the Medical Risk Really as Great as We Have Come to Believe
Katzberg RW, Newhouse
JH Radiology 2010; 256;21-28"We believe that the risk of CIN with CE CT is overstated and that a more accurate assessment of the risk of CIN could lead to wider CM use, more accurate diagnoses, and better clinical treatment."
Intravenous Contrast Medium-induced Nephrotoxicity: Is the Medical Risk Really as Great as We Have Come to Believe
Katzberg RW, Newhouse
JH Radiology 2010; 256;21-28"Although admittedly arbitrary, we propose an SCr level of 2 mg/dL, below which the risk of CIN using LOCM appears low enough that no additional precautions (beyond what would be used for a patient with normal renal function) are necessary for an indicated appropriate examination."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"There is no authoritative lower limit of renal function below which special precautions must be taken before iodinated contrast material administration. Renal contraindications to iodinated contrast material use are relative rather than absolute."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Patients with preexisting renal insufficiency appear to be at higher risk and precautionary maneuvers may be warranted in some of these patients; however, iodinated contrast material should not be withheld if a contrast enhanced study is necessary and there is no alternative."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Patients with normal renal function are at exceptionally low risk for CIN. Patients with preexisting renal insufficiency appear to be at higher risk and precautionary maneuvers may be warranted in some of these patients; however, iodinated contrast material should not be withheld if a contrast enhanced study is necessary and there is no alternative."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"We did not find an increased incidence of acute renal injury among patients who received IV iodixanol in comparison with controls who received no contrast agent."
Background Fluctuation of Kidney Function Versus Contrast-Induced Nephtotoxicity
Bruce RJ et al.
AJR 2009;192;711-718- "However, patients who would be excluded from a contrast enhanced CT examination because they have moderate renal disease may safely undergo contrast enhanced CT with iodixanol or one of the other newer low risk agents."
Background Fluctuation of Kidney Function Versus Contrast-Induced Nephtotoxicity
Bruce RJ et al.
AJR 2009;192;711-718 - "These findings suggest that the additional risk of acute kidney injury accompanying administration of contrast medium (CIN) may be overstated and that much of the creatinine elevation in these patients is attributable to background flucutation, underlying disease, or treatment ."
Background Fluctuation of Kidney Function Versus Contrast-Induced Nephtotoxicity
Bruce RJ et al.
AJR 2009;192;711-718 - "We identified a high incidence of acute renal injury among control subjects undergoing unenhanced CT. The incidence of creatinine elevation in this group was statistically similar to that in the isoosmolar contrast medium group for all baseline creatinine values and all stages of chronic renal disease."
Background Fluctuation of Kidney Function Versus Contrast-Induced Nephtotoxicity
Bruce RJ et al.
AJR 2009;192;711-718 "Although admittedly arbitrary, we propose an SCr level of 2 mg/dL, below which the risk of CIN using LOCM appears low enough that no additional precautions (beyond what would be used for a patient with normal renal function) are necessary for an indicated appropriate examination."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"There is no authoritative lower limit of renal function below which special precautions must be taken before iodinated contrast material administration. Renal contraindications to iodinated contrast material use are relative rather than absolute."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Patients with preexisting renal insufficiency appear to be at higher risk and precautionary maneuvers may be warranted in some of these patients; however, iodinated contrast material should not be withheld if a contrast enhanced study is necessary and there is no alternative."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Patients with normal renal function are at exceptionally low risk for CIN. Patients with preexisting renal insufficiency appear to be at higher risk and precautionary maneuvers may be warranted in some of these patients; however, iodinated contrast material should not be withheld if a contrast enhanced study is necessary and there is no alternative."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Patients with normal renal function are at exceptionally low risk for CIN."
Reducing the Risk of Contrast Induced Nephropathy: A Perspective on the Controversies
Ellis JH, Cohan RH
AJR 2009; 192:1544-1549"Literature and survey results suggest a consensus for the use of IV contrast volumes <100 mL, infusion rate of 5 mL/s and a saline chaser. A range of concentrations can be used to attain target coronary artery attenuation values."
IV Contrast Infusion for Coronary Artery CT Angiography: Literature Review and Results of a Nationwide Survey
Johnson PT, Pannu HK, Fishman EK
AJR 2009; 192:130- "From 1999 through 2001, deaths attributable to the International Classifications of Diseases (ICD) code for contrast media occurred at the rate of 1.1-1.2 per million contrast media packages distributed."
Deaths Attributed to X-ray Contrast Media on U.S. Death Certificates
Wysowski DK et al
AJR 2006;186:613-615 - "Contrast material induced nephropathy is not common in patients with normal preexisting renal function; rather, it is more frequent in patients with renal impairment, especially when the impairment is due to diabetic nephropathy."
Risk of Iodinated Contrast Material-induced Nephropathy with Intravenous Contrast
Katzberg WW, Barrett BJ
Radiology 2007; 243:622-628 - Contrast Induced Nephropathy: Risk Factors
- Preexisting renal insufficiency
- Diabetes
- Volume of contrast used
- Use of ionic contrast agents
- dehydration - When renal function is borderline strategies include
- Hydrate pre and post CT study
- Limit contrast volumes
- Use Visipaque-320 over Omnipaque-350 - Contrast Induced Nephropathy: Additional Risk Factors
- Congestive heart failure
- Multiple contrast injections in a short period of time
- Medications that interfere with renal perfusion regulation (i.e. nonsteroidal antiinflammatory drugs- NSAID’s)
- Multiple myeloma - "In MDCT, reducing the amount of contrast medium does not affect aortic enhancement in the early arterial phase but decreases hepatic enhancement at the portal phase. Greater than 1.5 mL/kg reduction in the dose of contrast medium followed by saline flushing may not be advisable for liver CT in low and medium weight patients."
Assessment of the Use of a Saline Chaser to Reduce the Volume of Contrast Medium in Abdominal CT
Orlandini F et al.
AJR 2006; 187:511-515.