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Dr Sudhir Kale Profile• “Head of the Department and Lead Consultant
Radiology”- Aster CMI hospital Bangalore.• Postgraduation from Barnard institute of Radiology- Madras Medical college• 14 yrs experience in cross sectional imaging.• Certified and Trained in MR guided HIFU surgeries• Strengths: Whole body CT / MRI imaging.• About 55 platform presentations in CME, state and
national conferences. • He is well-versed with advanced applications
including Coronary imaging, Neuro imaging, Gastro Imaging, Liver segmentation and sports injuries.
• Author of MR HIFU chapter in book on Text book and Atlas of fibroids, already in press probable release June 2016.
• He has been associated in Research Projects in Neuro Radiology (Multiple Sclerosis, Peripheral Vascular Disease, Fibroids and Cartilage Mapping).
• Life member IRIA, ICRI and IACI. • Has reported cross sectional imaging for NCA
(national cricket academy) and KSCA. Many Indian, international and IPL players.
Contrast Media and Prevention of Contrast Induced Nephropathy
Dr Sudhir KaleChief RadiologistAster CMI hospital Bangalore
Objectives
Patient selection strategies
Contrast Media in Renal Impaired patients
Prevention of contrast induced nephropathy (CIN).
CT - Contrast Agents• Compounds used to improve the visibility of
internal bodily structures in an image.
• Types:– Radiographic agents based on iodine
• Ionic or non-ionic agents
• High osmolar (HOCM) and low osmolar, iso-osmolar (LOCM)
CT - Contrast Agents
IONIC NON-IONIC
1. IOHEXOL2. IOPAMIDOL3. IOPROMIDE4. IOVERSOL
IODIXANOL (VISIPAQUE)
X
Commonly used iodinated contrast agents
NameName TypeType Iodine Iodine ContentContent
OsmolalityOsmolality
IonicIonic
DiatrizoateDiatrizoate(Hypaque 50)(Hypaque 50)
Ionic Ionic MonomerMonomer
300300 15501550High High
OsmolarOsmolarMetrizoateMetrizoate(Isopaque Coronar (Isopaque Coronar 370) 370)
IonicIonic 370370 21002100
Ioxaglate (Hexabrix)Ioxaglate (Hexabrix) IonicIonic 320320 580580
Low Low OsmolarOsmolarNon-Non-
IonicIonic
Iopamidol (Isovue Iopamidol (Isovue 370)370)
Non-ionic Non-ionic monomermonomer
370370 796796
Iohexol Iohexol (Omnipaque 350)(Omnipaque 350)
Non-ionicNon-ionic 350350 884884
Iodixanol Iodixanol (Visipaque 320)(Visipaque 320)
Non-ionic Non-ionic dimerdimer
320320 290290 Iso Iso OsmolarOsmolar
PATIENT FOR CONTRAST STUDY
RADIOLOGY DEPARTMENT
?
Patient selection and Preparation strategiesClinical history: {ARC information }1.Allergy / Asthma: H/o prior allergic-like reactions to contrast media is associated with an upto 5 fold increased likelihood of experiencing subsequent reaction. 2.Renal insufficiency: Contrast induced nephrotoxicity and Nephrogenic systemic fibrosis.3.Cardiac Status: Significant cardiac disease increases risk for contrast reactions. Angina or congestive heart failure symptoms , Aortic stenosis, Primary pulmonary hypertension or severe cardiomyopathy
Patient selection and Preparation strategies4. Miscellaneous:
Para-protienemias particularly multiple myeloma predispose patients to irreversible renal failure – High osm contrast media) – tubular protein precipitation.
Pheochromocytoma: Hypertensive crisis, more chances in direct intra-arterial injections in renal or adrenal arteries.
Sickle cell disease
Patient Care Forum
If any risk factor, then:
RADIOLOGIST + REFERRING Doctor
Risk Vs BenefitAlternative Imaging
Serum Creatinine Adult Male (>18 yrs) : 0.7 to 1.4 mg/dl. Adult Female (>18 yrs) : 0.6 to 1.2 mg/dl. Pediatric age group 1 to 15 yrs: 0.3 to 0.7 mg/dl. Neonate: 0.2 to 0.5 mg/dl
eGFR Calculation is preferred in the present guidelinesEstimated GFR
MDRD Calculator for eGFR
Cockcroft Gault eGFR Calculator
eGFR calculation by MDRD
Renal Toxicity
Risk Factors – 5 - 10 fold increase with pre-existing renal
insufficiency (increased creatinine) – Dehydration – CHF – Age > 70 – Taking nephrotoxic drugs (nonsteroidal
inflammatory agents, gentomycin etc.)
Reddinger W. Contrast Media. http://www.e-radiography net/contrast_media/CT_contrast_media pdf. Accessed January 7, 2014.
Properties of Contrast Media
CM: Osmolality and Viscosity• Low osmolality contrast media are hyperosmolar to
blood• Iodixanol is the only contrast media not hyperosmolar
to blood
Jo SH, Youn TJ, Koo BK, et al. Renal Toxicity Evaluation and Comparison Between Visipaque (Iodixanol) and Hexabrix (Ioxaglate) in Patients With Renal Insufficiency Undergoing Coronary Angiography: The RECOVER Study: A Randomized Controlled Trial. Journal of the American College of Cardiology. 2006;48(5):924-930.
CIN- Contrast Induced Nephropathy
Higher association between CIN and osmolality than between CIN and
viscosity, ionicity and chemotoxicity
Currently VISPAQUE (IODIXANOL) is the contrast media with least incidence of CIN
Jo SH, Youn TJ, Koo BK, et al. Renal Toxicity Evaluation and Comparison Between Visipaque (Iodixanol) and Hexabrix (Ioxaglate) in Patients With Renal Insufficiency Undergoing Coronary Angiography: The RECOVER Study: A Randomized Controlled Trial. Journal of the American College of Cardiology. 2006;48(5):924-930.
CIN- Contrast Induced Nephropathy
Correlation Between CIN Incidenceand Osmolality
Davidson C, Stacul F, McCullough PA, et al. Contrast medium use. Am J Cardiol. 2006;98(6A):42K-58K.
VISIPAQUE (IODIXANOL)
IOHEXOL
IONIC CM
Incidence of CIN Lower in Iodixanol (VISIPAQUE) compared to iopromide
Nguyen SA, Suranyi P, Ravenel JG, et al. Iso-osmolality versus low-osmolality iodinated contrast medium at intravenous contrast-enhanced CT: effect on kidney function. Radiology. 2008;248(1):97-105.
SCr levels after CM administration were significantly lower in the Visipaque than in the LOCM group, as was the incidence of CIN
Incidence of CIN Lower in IodixanolThan LOCM Ioversol
The overall incidence of CIN with Visipaque was less than a third of that seen with the LOCM; in patients undergoing PCI the difference was even more pronounced
Hernandez F, Mora J, Suberviola V et al. Comparison of iodixanol versus ioversol for prevention of contrast induced nephropathy in diabetic patients undergoing coronary angiography or intervention. Eur Heart J 2007; 28 (Suppl 1): 454
Decreased from usage of ionic HOCM to non-ionic LOCM.
Reference Prevalence (%) Relative Risk Conventional/ Non-ionic Conventional Media Non-ionic media
Overall prevalence of reactionsKatayama et al 12.7 3.1 4.1Palmer Low risk 3.8 1.2 3.2 High risk 10.3 1.3 7.9Wolf et al 4.1 0.7 5.9Prevalence of severe reactionsKatayama et al 0.22 0.04 5.5Palmer Low risk 0.09 0.00 Incalculable High risk 0.36 0.03 12.0All 0.09 0.02 4.5Wolf et al 0.04 0.00 Incalculable
Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. AJR Am J Roentgenol. 1991;157(6):1153-1161.
Non-Ionic media has Lower Adverse Reactions
CT contrast protocol in renal impaired patients to prevent CIN:
1. Assess Serum creatinine and eGFR2. If serum creatinine >1.4 or eGFR : 30 to 60
ml/min3. Plan for Visipaque contrast media (LOCM).4. Adequate hydration prior and after the
procedure.5. Sodium bicarbonate infusion (Pre procedure)6. N-acetylcysteine
KDIGO Protocol for prevention of contrast induced nephropathy
1) IV FLUID1). Normal Saline 12 h pre and for 12 hr post contrast administration2). Tab Mucomix 600 mg-1.2gm 12 hrs on day -1,0,+1 day.
For same day examinations:3). Normal Saline or Isotonic NaHCO3 @ 3 mL/kg/hr for 1-3 hr pre and for 6 hr post contrast administration
MRI contrast agents in renal Impaired patients
1. Extracellular fluid agents Gadopentetate(Magnevist) Gadodiamide (Omniscan) Gadoversetamide (OptiMARK) Gadobenate (MultiHance)
2. Blood Pool Agents– Albumin-binding gadolinium complexes - Gadofosvest (Ablavar, formerly
Vasovist)– Polymeric gadolinium complexes – Gadomelitol
• Hepatobiliary (liver) agents– Gadoxetic acid
MRI contrast agents are Gadolinum-Based
Nephrogenic systemic fibrosis• Nephrogenic systemic fibrosis (NSF) is a rare disease
seen in patients with severe renal impairment after administration of gadolinium-based MRI contrast agents.
• Release of free gadolinium ions may then deposit in different tissues and result in inflammation and fibrosis
• Patients with NSF can have systemic involvement of other organs, including the lungs, liver, muscles and heart.
• Can Cause contractures and joint involvement
Risk of NSF with Different Gadolinium containing Contrast Media:
1. High-risk gadolinium-containing contrast agents Optimark, Omniscan, Magnevist.
2. Medium-risk gadolinium-containing contrast agents
Vasovist, Primovist MultiHance.
3. Low-risk gadolinium-containing contrast agents
Dotarem, ProHance Gadovist.
Nephrogenic systemic fibrosis• Avoid if eGFR is <30ml/min
• eGFR <30 ml/min (if clinical situation demands)– take informed consent (risk of NSF <1/10,000 patients
with eGFR <30 ml/min)– maximum dose of 0.1mmol/kg– adequate hydration must be provided.– A low or medium risk agent with higher relaxivity like
Multihance should be used in half dose, and should not be repeated for at least seven days
Key Take-Away Points•ARC Information once you decide on contrast study. •Any risk factor, discuss with Referring Doctor for alternative imaging or assess Risk Vs benefit.•Use creatinine value to get eGFR.•Discuss with referring doctor if eGFR is <60 •Hydration, Sodium bicarbonate and N acetyl cysteine for prevention of CIN.•CT Contrast : Visipaque (Iodixanol) is the choice•MR contrast : Use Multihance. Take informed consent (risk of NSF <1/10,000 patients with eGFR <30 ml/min).
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