Safe Use of Contrast Media

Iodinated Contrast Agents (e.g.: Ultravist)

Gadolinium-based Contrast Agents (GBCAs) (e.g.: Gadavist, Dotarem)
• Patient selection strategies
• Premedication
• Treatment of adverse events
• Contrast agent-induced nephropathy (CIN)
• Nephrogenic systemic fibrosis (NSF)
Classification of Contrast Agents
• Iodine-based contrast agents
• Osmolarity (Lower – significant lower rates of acute reactions)
0.2 – 0.7%, severe acute reactions 0.04%, fatal 1 in 170,000
• Ionicity (Non-ionic – less discomfort, fewer adverse reactions)
• Number of benzene rings
• GBCAs
• Ionicity (ionic or non-ionic)
• Chelating ligand (Macrocyclic or linear)
• Pharmacokinetics (Extracellular or organ specific)
• Risk of causing NSF (overall 1 in 10,000 – 40,000, mostly mild and transient)
Patient Selection and Preparation
Risk Factors
• Previous severe reaction to contrast agent: 5-6x
• History of allergies with features of atopy: 3-6x
• Well-controlled asthma: may not be at increased risk
• Reducing volume and osmolality – suggested in patients with
substantial cardiac disease
Shellfish Allergies (Tropomyosins)
• No specific link between shellfish allergy and allergy to contrast
agents
• Tropomyosins unrelated to iodine
Acute Adverse Reactions
• Anaphylactoid (idiosyncratic): unpredictable
• Constitute most clinically important reactions and involve release of
histamine and other biologic mediators
• Chemotoxic-type (physiologic)
• Associated with dose and molecular toxicity of each agent in addition to its
physiologic characteristics
• Distinguishing them is important!
• Allergic: Needs premedications
• Physiologic: do not need premedications
Contrast-Induced Nephropathy (CIN)
• “A sudden deterioration in renal function (ie, acute
kidney injury) following the recent intravascular
administration of contrast media in the absence of
another nephrotoxic event”
• The Acute Kidney Injury Network outlined following criteria
• (a) Sr creatinine increase of ≥ 26.4 μmol/L
• (b) Increase in Sr creatinine ≥ 50%
• (c) urine output reduced to ≤ 0.5 mL/kg/Hr for at least 6 hours
• Risk of CIN is considered low in patients with stable renal function
• Absence of risk factors
• Sr creatinine levels < 159.12 μmol/L at baseline
• Changes in creatinine levels are delayed, should not be used for
treatment decisions
• Patients with end-stage renal disease who are anuric can receive
routine volumes of intravenous contrast material without risk for
further renal damage or the need for urgent dialysis
N-acetylcysteine
• Xu et al (2016) “it is reasonable to administer NAC by the oral route
for patients who are undergoing coronary angiography and who have
renal dysfunction or who are receiving high doses of contrast agent.”
• Standard oral regime: 600mg BD 24H before and on the day of the
procedure, no significant difference with higher dose
• Treatment controversy
• Related to its ability to lower serum creatinine (SCr) rather than to improve
GFR
• The KDIGO guidelines recommend use of NAC in conjunction with
hydration
Nephrogenic Systemic Fibrosis (NSF)
• “A serious, sometimes-fatal disease that occurs in patients receiving
GBCAs who have severe chronic or acute renal failure”
• Skin +/- lungs, pleura, skeletal muscle, heart, pericardium, and
kidneys
• Clinical-pathologic diagnosis: patterned skin plaques; cobblestone,
marked induration, or peau d’orange appearance of the skin; and
joint contractures
• Usually occurs days to months (average time, 2–10 weeks) after
administration of GBCA
Most Important Risk Factor – Degree of Renal
Dysfunction
• Patients undergoing dialysis and those with
• Severe (stage 4; GFR 30–40) or
• End-stage (stage 5, GFR < 30 mL/min per 1.73 m2 ) CKD without
dialysis
• AKI
Conclusions
• Prep patients with history of allergic reaction to contrast media and
atopy
• Allergy to contrast is unrelated to allergy to shellfish
• IV Hydrocortisone 200mg at least 4 hours before scan
• Risk of CIN low in patient with baseline creatinine < 159.12 μmol/L
• No added benefit of IV hydration in patient with high risk of CIN
• NAC therapy remains part of the standard of care
• Avoid GBCAs in patient undergoing dialysis / severe or end-stage renal
failure without dialysis / AKI
Thank you!
• https://pubs.rsna.org/doi/10.1148/rg.2015150033
• https://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(17)30057-0/fulltext
• https://emedicine.medscape.com/article/246751-treatment#d13