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  • Dr Sudhir Kale ProfileHead of the Department and Lead Consultant Radiology- Aster CMI hospital Bangalore.Postgraduation from Barnard institute of

    Radiology- Madras Medical college14 yrs experience in cross sectional imaging.Certified and Trained in MR guided HIFU surgeriesStrengths: 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 NephropathyDr Sudhir KaleChief RadiologistAster CMI hospital Bangalore

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  • Objectives

    Patient selection strategies

    Contrast Media in Renal Impaired patients

    Prevention of contrast induced nephropathy (CIN).

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  • CT - Contrast AgentsCompounds 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

    IONICNON-IONICIOHEXOLIOPAMIDOLIOPROMIDEIOVERSOL

    IODIXANOL (VISIPAQUE)X

  • Commonly used iodinated contrast agents

    NameTypeIodine ContentOsmolality

    IonicDiatrizoate(Hypaque 50)Ionic Monomer3001550High OsmolarMetrizoate(Isopaque Coronar 370) Ionic3702100Ioxaglate (Hexabrix)Ionic320580

    Low Osmolar

    Non-IonicIopamidol (Isovue 370)Non-ionic monomer370796Iohexol (Omnipaque 350)Non-ionic350884Iodixanol (Visipaque 320)Non-ionic dimer320290Iso Osmolar

  • PATIENT FOR CONTRAST STUDY

    RADIOLOGY DEPARTMENT

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  • Patient selection and Preparation strategiesClinical history: {ARC information }Allergy / Asthma: H/o prior allergic-like reactions to contrast media is associated with an upto 5 fold increased likelihood of experiencing subsequent reaction. Renal insufficiency: Contrast induced nephrotoxicity and Nephrogenic systemic fibrosis.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 strategiesMiscellaneous: 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 CreatinineAdult 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

    The osmolality of a solution is the measurement of the number of molecules and particles in a solution per kilogram of water. Osmolality can be described as a measurement of the number of molecules that can crowd out or displace water molecules in a kilogram of water. The radiographic significance of the osmolality value of contrast media is that it is higher than the osmolality valueof blood plasma. Any solution that has an osmolality value greater than blood plasma is said to be a hyperosmolar solution. Therefore, ionic and non-ionic contrast media are hyperosmolar solutions when compared to blood plasma.The following are examples of approximate average osmolality values of blood plasma, cerebrospinal fluid, non-ionic contrast media, and ionic contrast media.

    Contrast media is primarily divided into two categories, high osmolar contrast media (HOCM) and low osmolar contrast media (LOCM)

    References:Reddinger W. Contrast Media. http://www.e-radiography.net/contrast_media/CT_contrast_media pdf. Accessed January 7, 2014.*

  • CM: Osmolality and ViscosityLow osmolality contrast media are hyperosmolar to bloodIodixanol is the only contrast media not hyperosmolarto 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 NephropathyHigher association between CIN and osmolality than between CIN and viscosity, ionicity and chemotoxicity

    Low contrasting contrast media is hyperosmolar to bloodIodixanol is only contrast not hyperosmolar to bloodHigher association between CIN and osmolality than between CIN and viscosity, ionicity and chemotoxicity

    References: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.*

  • Currently VISPAQUE (IODIXANOL) is the contrast media with least incidence of CINJo 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

    Low contrasting contrast media is hyperosmolar to bloodIodixanol is only contrast not hyperosmolar to bloodHigher association between CIN and osmolality than between CIN and viscosity, ionicity and chemotoxicity

    References: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.*

  • Correlation Between CIN Incidenceand OsmolalityDavidson C, Stacul F, McCullough PA, et al. Contrast medium use. Am J Cardiol. 2006;98(6A):42K-58K.VISIPAQUE (IODIXANOL)IOHEXOLIONIC CM

    As seen in the studies, there is a correlation between CIN incidence and osmolality. This was significant with a p value of 0.046.

    Reference:Davidson C, Stacul F, McCullough PA, et al. Contrast medium use. Am J Cardiol. 2006;98(6A):42K-58K.*

  • 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

    Nguyen et al compared the effects of Visipaque and the LOCM iopromide in 117 patients with impaired kidney function undergoing CT examination in aprospective, single-centre, randomised, double-blind study. SCr levels after CM administration were significantly lower in the Visipaque than inthe LOCM group, as was the incidence of CIN in this high-risk patient group undergoing contrast-enhanced CT.

    References: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.*

  • Incidence of CIN Lower in IodixanolThan LOCM IoversolThe 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 pronouncedHernandez 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

    Visipaque and the LOCM ioversol were also compared in a double-blind, prospective trial in 337 patients with stable Chronic Kidney Disease undergoing coronary angiography (the VALOR trial)The primary end-points were the mean peak percentage change in SCr and the incidence of CIN (SCr rise >44.2 mol/l [0.5 mg/dL]) within 72 hours post-contrast. This percentage was significantly lower in the Visipaque group: 12.9% versus 22.4%, p=0.01. The CIN rate was not significantly different, but again was lower in the Visipaque group: 21.9% versus 26.4%; p=0.57.

    Reference: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;