Post-contrast acute kidney injury. Part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients

Abstract

ObjectivesThe Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) has updated its 2011 guidelines on the prevention of post-contrast acute kidney injury (PC-AKI). The results of the literature review and the recommendations based on it, which were used to prepare the new guidelines, are presented in two papers.Areas covered in part 2Topics reviewed include stratification of PC-AKI risk, the need to withdraw nephrotoxic medication, PC-AKI prophylaxis with hydration or drugs, the use of metformin in diabetic patients receiving contrast medium and the need to alter dialysis schedules in patients receiving contrast medium.Key points • In CKD, hydration reduces the PC-AKI risk • Intravenous normal saline and intravenous sodium bicarbonate provide equally effective prophylaxis • No drugs have been consistently shown to reduce the risk of PC-AKI • Stop metformin from the time of contrast medium administration if eGFR < 30 ml/min/1.73 m 2 • Dialysis schedules need not change when intravascular contrast medium is given

Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation

“…Typical volume expansion regimens begin 1 hour before and continue 3-12 hours after contrast media administration, with typical doses ranging from fixed (eg, 500 mL before and after) to weight-based volumes (1-3 mL/kg per hour) (15,26). Longer regimens (approximately 12 hours) have been shown to lower the risk of CA-AKI compared with shorter regimens (15,37). However, longer intravenous protocols are generally impractical in the outpatient setting.…”

Impact on clinical practice of updated guidelines on iodinated contrast material: CINART

“…At this time, whereas American and Oceania guidelines still recommend standard intravenous hydration with normal saline 12 h before and 12 h after contrast administration [3,5], the Dutch and European guidelines recommend or include an alternative in the form of intravenous sodium bicarbonate 1 h pre-and an optional 6 h post-contrast [2,9]. The current study has not included the latter protocol in the calculations.…”

“…Recently guidelines have been updated, and standard prophylaxis is no longer routinely recommended for patients like those who participated in the AMACING trial (i.e. with estimated glomerular filtration rate (eGFR) 30-59 ml/min/ 1.73 m 2 combined with risk factors) [2,3,5,[8][9][10]. The changes in the recommendations on standard prophylaxis for elective patients in the Dutch (The Radiological Society of The Netherlands, NVvR) and European (European Society of Urogenital Radiology, ESUR) guidelines are summarised in Table 1.…”

Guideline on the use of iodinated contrast media in patients with kidney disease 2018

“…Patients who inevitably must undergo multiple contrast examinations in a short period of time should receive careful explanation of CIN and appropriate preventive measures, and strict observation of the changes of renal function and general condition over time after the examination is critical. In terms of the perspective of a major academy concerning the risks conferred by the short-term repetition of contrast-enhanced CT, the American College of Radiology claims "There is not enough evidence as a basis for avoiding short-term repetitive contrast CT" [179], while the ESUR states "It poses a risk for CIN to repeat contrast agent administration within 48-72 h" [4,5].…”