Does Safe Dosing of Iodinated Contrast Prevent Contrast-Induced Acute Kidney Injury?

Abstract

Background-Previous work on contrast-induced acute kidney injury (CI-AKI) has identified contrast volume as a risk factor and suggested that there is a maximum allowable contrast dose (MACD) above which the risk of CI-AKI is markedly increased. We hypothesized that there is a relationship between contrast volume and CI-AKI and that there might be reason to track incremental contrast volumes above and below the MACD limit. Methods and Results-Consecutive patients undergoing percutaneous coronary intervention (PCI) were prospectively enrolled from 2000 to 2008 (nϭ10 065). Patients on dialysis before PCI were excluded (nϭ155). MACD was defined as (5 mLϫbody weight [kg])/baseline serum creatinine [mg/dL]) and divided into categories in which 1.0 reflects the MACD limit: ՅMACD ratios (Ͻ0.5, 0.5 to 0.75, and 0.75 to 1.0) and ϾMACD (1.0 to 1.5, 1.5 to 2.0, and Ͼ2.0). CI-AKI was defined as a Ն0.3 (mg/dL) or Ն50% increase in serum creatinine from baseline or new dialysis. Multivariable regression was conducted to evaluate the effect of exceeding the MACD on CI-AKI.

Reducing Acute Kidney Injury Due to Contrast Material: How Nurses Can Improve Patient Safety

“…These key points must be communicated before the start of the procedure and acknowledged with the procedure time out. 26,37,38 As shown in Figure 3, exceeding a safe dose of contrast material significantly increases the risk for CI-AKI.…”

“…Handoff communication includes the patient's history, maximum acceptable dose of contrast material (MACD, calculated as 5 mL contrast medium times body weight in kilograms divided by baseline level of serum creatinine) or the Gurm equation (calculated as 3 times the ratio of contrast volume to calculated creatinine clearance), eGFR, and hydration status. 26,37,38 Most likely the MACD will be surpassed in some instances in patients with especially poor renal function, and the calculated MACD might be too low to complete the intervention. These key points must be communicated before the start of the procedure and acknowledged with the procedure time out.…”

“…11 During this time, the prolonged exposure of the renal tubules to the contrast agent propagates direct cellular injury, inducing tubular apoptosis ( Figure 1). 12 Measures to prevent CI-AKI have been studied, including the use of physiological saline for volume expansion, 13 intravenous versus oral volume expansion, [14][15][16][17][18][19] physiological saline versus sodium bicarbonate intravenous prophylaxis, 20 use of medications such as N-acetylcysteine [21][22][23] and ascorbic acid, 24 withholding nephrotoxic medications before the procedure with contrast material and after the dose of contrast material is administered, 3 type of contrast medium used, 25 use of volumes of contrast material based on initial estimated glomerular filtration rate (eGFR), [26][27][28] and postprocedure hydration. Such studies indicated the following: Use of physiological saline alone protected better against renal insufficiency than did physiological saline with mannitol or furosemide.…”

“…25 Incremental increases in the volume of contrast medium exceeding the safe contrast limit were associated with a higher risk for contrast-induced nephropathy. 26,27 These studies were performed primarily by physicians and researchers; the study by Solomon et al 13 was the only investigation in which one of the authors was a nurse. Contrast-induced nephropathy prevention has been a topic of interest in nursing research, and reviews have published 29,30 ; however, no treatment path has clearly reduced the risk for CI-AKI in all populations of patients.…”

Guidelines on the use of iodinated contrast media in patients with kidney disease 2012: digest version

“…Although the volume of contrast media used in CAG ranges from 50-100 mL in many patients, it is recommended that contrast media used for patients with CKD should be limited to the minimal required volume. In a study of 10,065 patients undergoing PCI, Brown et al [53] reported that the incidence of AKI was significantly higher in patients receiving doses of contrast media above the minimal required volume compared to those receiving doses below it. Nyman et al [52] suggested that the contrast medium dose-to-eGFR ratio (gram-iodine/ eGFR) should be kept under 1.0 (see CQ4-1), and Laskey et al [76] recommended that the ratio of the volume of contrast media to CCr should be limited to \3.7.…”