Acute kidney injury from contrast-enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies

Abstract

Patients with cancer are subjected to several imaging examinations which frequently require the administration of contrast medium (CM). However, it has been estimated that acute kidney injury (AKI) due to the injection of iodinated CM accounts for 11% of all cases of AKI, and it is reported in up to 2% of all computed tomography (CT) examinations. Remarkably, the risks of developing AKI are increased in the elderly, in patients with chronic kidney disease or diabetes, and with dehydration or administration of nephrotoxic chemotherapeutics. Given the common occurrence of post-contrast acute kidney injury (PC-AKI) in clinical practice, primary care physicians and all specialists involved in managing patients with cancer should be aware of the strategies to reduce the risk of this event. In 2018, a panel of five experts from the specialties of radiology, oncology and nephrology were speakers at the annual meeting of the Italian Society of Medical Radiology (Società Italiana di Radiologia Medica e Interventistica), with the aim of commenting on existing evidence and providing their experience on the incidence and management of PC-AKI in patients with cancer. The discussion represented the basis for this white paper, which is intended to be a practical guide organised by statements describing methods to reduce renal injury risks related to CM-enhanced CT examinations in patients with cancer.

Tri̇i̇yodoani̇li̇n’i̇n Sentezlenmesi̇, Nanosüspansi̇yonlarinin Hazirlanmasi, i̇n Vi̇tro Karakteri̇zasyonu Ve Radyokontrast Özelli̇kleri̇ni̇n İncelenmesi̇

“…Mevcut kontrast ajanların akut böbrek hasarı oluşturma riski fazla olduğu için [22,23] görüntülemede tercih edilmemekle birlikte daha yüksek maliyetli ve uzun süren tetkiklere yönelinmektedir [24]. Özellikle suda çözünen bileşiklerin vücut içerisinde oluşturdukları osmotik basınç ve çözünen moleküllerin hücrelerde ve/veya organlarda bırakacağı hasar oldukça risk taşımaktadır [25].…”

Risk of acute kidney injury in cancer patients after iodinated contrast medium administration and prophylactic strategies: Summary from the most recent guidelines

“…It is thus clear that avoiding, whenever possible, close administrations of CM and chemotherapy can protect renal function. 2 Since PC-AKI is often multifactorial, considering all the possible causes, recognizing patients at risk, removing the modifiable risk factors, and using prophylactic measures could contribute to reduce its incidence (Figure 1).…”

“…The enhancement of the organ tissues comes from the concentration of iodine in vascular and extracellular volumes and it is influenced by body weight; therefore, the dose of CM should be adjusted to lean body weight of each patient in order administer the lowest effective dose to obtain diagnostic images and protect renal function. 2…”

“…Despite these figures, over the last 10-15 years the scientific community has discussed, and is still debating, about the real impact of AKI due to CM injection and its clinical relevance; indeed, CM nephrotoxicity has been probably overrated, but, in fragile patients, risks and benefits of using CM should nevertheless be weighted. 2 It is thus important to assess the actual risk of CM-induced nephrotoxicity, with the aim of preventing unnecessary avoidance of contrast-enhanced imaging potentially leading to missed diagnosis, preserving as much as possible further kidney injury in patients often exposed to many nephrotoxic agents and/or with pre-existing CKD, and in order to adopt prevention strategies whenever needed.…”

KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancer

“…saline and/or oral hydration, depending on the GFR level, is often used, although the results of prospective studies and meta-analyses are somewhat conflicting. 58 For example, in the AMACING randomized controlled trial of non-cancer patients with CKD G3a-G3b, no prophylaxis was noninferior and cost-saving compared with i.v. hydration in preventing post-contrast AKI.…”