ESUR CMSC guideline (version 10) for post-contrast acute kidney injury (PC-AKI)
Definitions
- Post-contrast acute kidney injury (PC-AKI) is defined as an increase in serum creatinine ≥ 0.3mg/dl (or ≥ 26.5 μmol/l), or ≥ 1.5 times baseline, within 48–72 h of intravascular administration of a contrast medium.
- Intra-arterial injection with first pass renal exposure indicates that contrast medium reaches the renal arteries in a relatively undiluted form, e.g. injection into the left heart, thoracic and suprarenal abdominal aorta or the renal arteries.
- Intra-arterial injection with second pass renal exposure indicates that contrast medium reaches the renal arteries after dilution either in the pulmonary or peripheral circulation e.g. injection into the right heart, pulmonary artery, carotid, subclavian, coronary, mesenteric or infra-renal arteries.
Measurement of renal function
- Estimated glomerular filtration rate (eGFR), calculated from the serum creatinine, is recommended to estimate renal function before administration of contrast medium.
- In adults ≥ 18 years, the CKD-EPI formula to estimate GFR is recommended.
eGFR (ml/min/1.73 m2) =
Female sCr ≤ 62 μmol/l: 144 × (sCr/62)−0.329 × 0.993Age
Female sCr > 62 μmol/l: 144 × (sCr/62)−1.209 × 0.993Age
Male sCr ≤ 80 μmol/l: 141 × (sCr/80)−0.411 × 0.993Age
Male sCr > 80 μmol/l: 141 × (sCr/80)−1.209 × 0.993Age
(sCr in μmol/l; age in years)
All equations × 1.159 if African American race
- In children, the revised Schwartz formula to estimate GFR is recommended,
eGFR (ml/min/1.73 m2) = 36.5 × Length/sCr (sCr in μmol/l; length in cm)
Note: Neither serum nor plasma creatinine is an ideal indicator of renal function and may miss decreased renal
function.
Renal adverse reactions to iodine-based contrast media
RISK FACTORS FOR PC-AKI
- Patient-related
- eGFR less than 45 ml/min/1.73 m2 before intra-arterial contrast medium administration with first pass renal exposure or in ICU patients
- eGFR less than 30 ml/min/1.73 m2 before intravenous contrast medium or intra-arterial contrast medium administration with second pass renal exposure
- Known or suspected acute renal failure
- Procedure-related
- Intra-arterial contrast medium administration with first pass renal exposure
- Large doses of contrast medium given intra-arterially with first pass renal exposure
- High osmolality contrast media
- Multiple contrast medium injections within 48-72h
Time of referral
ELECTIVE EXAMINATION
MEASUREMENT OF RENAL FUNCTION
- Measure eGFR before administering intravascular iodine-based contrast medium either
(a) In all patients or
(b) In patients who have a history of
- Renal disease (eGFR < 60 ml/min/1.73 m2)
- Kidney surgery
- Proteinuria
- Hypertension
- Hyperuricemia
- Diabetes mellitus
- Timing of eGFR measurement
- Within 7 days before contrast medium administration in patients with an acute disease, an acute deterioration of a chronic disease or who are hospital inpatients
- Within 3 months before contrast medium administration in all other patients
EMERGENCY EXAMINATION
Identify at-risk patients (see above), if possible:
- Determine eGFR if the procedure can be deferred until the result is available without harm to the patient.
- If eGFR cannot be obtained, follow the protocols for patients with eGFR less than 45 ml/min/1.73 m2 for intraarterial administration with first pass renal exposure and eGFR less than 30 ml/min/1.73 m2 for intravenous and intra-arterial administration with second pass renal exposure as closely as clinical circumstances permit.
Before the examination
ELECTIVE EXAMINATION
At-risk patients (see above)
- Consider an alternative imaging method not using iodine-based contrast media
- Intravenous saline and bicarbonate have similar efficacy for preventive hydration
- For intravenous contrast media administration and intra-arterial contrast media administration with second pass renal exposure hydrate the patient either with intravenous sodium bicarbonate 1.4% (or 154 mmol/l in dextrose 5% water): 3 ml/kg/h for 1 h before contrast medium or with intravenous saline 0.9%, 1 ml/kg/h for 3–4 h before and 4–6 h after contrast medium
- For intra-arterial contrast media administration with first renal exposure hydrate the patient either with intravenous sodium bicarbonate 1.4% (or 154mmol/l in dextrose 5% water): 3ml/kg/h for 1 h before and 1 ml/kg/h for 4–6 h after contrast medium or with intravenous saline 0.9%, 1 ml/kg/h for 3–4 h before and 4–6 h after contrast medium
- The clinician responsible for patient care should individualize preventive hydration in patients with severe congestive heart failure (NYHA grade 3–4) or patients with end-stage renal failure (eGFR < 15ml/min/1.73 m2)
- Oral hydration is not recommended as the sole method of preventive hydration
EMERGENCY EXAMINATION
At-risk patients (see above)
- Consider an alternative imaging method not using iodine-based contrast media
- Use preventive hydration before contrast medium administration (see ‘Elective Examination’ for protocols)
Time of examination
All patients
- Use low or iso-osmolar contrast media
- Use the lowest dose of contrast medium consistent with a diagnostic result
- For intra-arterial contrast medium administration with first pass renal exposure keep either the ratio CM dose (in gram I)/absolute eGFR (in ml/min) < 1.1 or the ratio CM volume (in ml)/eGFR (in ml/min/1.73 m2) < 3.0 (assuming a contrast medium concentration of 350 mg iodine/ ml)
After the examination
At-risk patients
- Continue preventive hydration if appropriate (see protocols above)
- Determine eGFR 48 h after administration of contrast medium
- If at 48 h there is a diagnosis of PC-AKI, monitor the patient clinically for at least 30 days and determine eGFR at regular intervals
Note: No pharmacological prophylaxis (with statins, renal vasodilators, receptor antagonists of endogenous vasoactive mediators or cytoprotective drugs) has been shown to offer consistent protection against PC-AKI.
Patients with diabetes mellitus taking metformin
- Patients with eGFR > 30 ml/min/1.73 m2 and no evidence of AKI receiving either intravenous or intra-arterial iodine-based contrast medium with second pass renal exposure: Continue taking metformin normally.
- Patients
(a) with eGFR < 30 ml/min/1.73 m2 receiving either intravenous or intra-arterial contrast medium with second pass renal exposure or
(b) receiving intra-arterial contrast medium with first pass renal exposure or
(c) with AKI:
Stop taking metformin from the time of contrast medium administration. Measure eGFR within 48 h and restart
metformin if renal function has not changed significantly.
Dialysis and contrast medium administration
- All iodine-based contrast media can be removed by haemodialysis or peritoneal dialysis.
- There is no evidence that haemodialysis protects patients with normal or impaired renal function from PC-AKI.
- In all patients, avoid osmotic and fluid overload.
PATIENTS ON DIALYSIS
Patients on haemodialysis
- Co-ordinating the time of the iodine-based contrast medium injection with the haemodialysis session is unnecessary
- Extra haemodialysis session to remove iodine-based contrast medium is unnecessary
Patients on continuous ambulatory peritoneal dialysis
- Haemodialysis to remove iodine-based contrast medium is unnecessary
Dr. Jan Schillebeeckx
4/5/2019
Bron: 2018 Recommendations for updated ESUR Contrast Medium Safety Committee guidelines
- Post-contrast acute kidney injury – Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors
- Post-contrast acute kidney injury. Part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients