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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