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PostPosted: 10 Oct 2016 01:49 
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Prevention of Contrast Induced Acute Kidney Injury (CI-AKI) In Adult Patients

The Renal Association GB,
British Cardiovascular Intervention Society and The Royal College of Radiologists



The use of intravascular iodinated contrast agents has continued to increase over recent years. It is recognised that there are potential risks associated with the intravascular administration of iodinated contrast agents. It is, therefore, essential

We would encourage practitioners, wherever practicable, to adopt the current trend towards reduced doses of intravenous iodinated contrast media due to the benefit of modern dual-head pumps and fast CT scanners. At the time of publishing these guidelines, investigations into the potential of low-kVp, low iodinated contrast dose CT technique, were in progress.

These guidelines address the issues associated with administering iodinated contrast agents to adult patients only. For children and neonates a paediatric radiologist should be consulted.


Rationale

Acute kidney injury following receipt of iodinated contrast (CI-AKI) has previously been referred to as contrast induced nephropathy (CIN) defined as a rise in serum creatinine by 25% or 44μmol/L from the baseline value.

It is uncommon in the general population, with an incidence of 1-2%, and occurs within 72 hours of receiving contrast media, usually recovering over the following five days.

It is important to exclude other causes of AKI as small rises in serum creatinine have been demonstrated to occur in 8-35% of patients admitted to hospital without exposure to contrast media.

Its incidence increases significantly in patients with risk factors and is associated with increased mortality.

Rationale

The risk of CI-AKI is low in patients with normal kidney function, estimated at 1–2% even in patients with diabetes.

However prior exposure to iodinated contrast media has been identified as the third most common aetiogical factor for AKI in hospital after renal hypoperfusion and nephrotoxic medication.

The risk of CI-AKI has been reported to be as high as 25% in patients with a combination of chronic kidney disease (CKD) and diabetes, cardiac failure, older age and exposure to nephrotoxic drugs.

The CI-AKI Consensus Working Panel has recommended that the risk of CI-AKI becomes clinically important with an eGFR <60 ml/min/1.73m.

Acutely ill patients with sepsis and/or hypotension are particularly vulnerable to injury following iodinated contrast exposure. There is a general consensus that the risk of CI-AKI is higher after arterial compared to venous administration of iodinated contrast media although this has not been proven convincingly.

Risk factors for patients developing CI-AKI include

chronic kidney disease (CKD) eGFR <60ml/min/1.73m2

older age (>75 years old)

cardiac failure

nephrotoxic medication

o aminoglycosides o NSAIDs
o Amphotericin B

hypovolaemia

sepsis

volume (dose) of contrast

intra-arterial administration

It should be appreciated that often a number of these risk factors will be present together in a patient, and that there is currently no validated CI-AKI risk assessment available to recommend.

The use of the estimated glomerular filtration rate (eGFR) to quantify kidney function should only be applied to patients with stable kidney function and should not be used in patients with AKI. Patients identified as at high risk
of CI-AKI may be discussed with a renal physician to assess the individual risk/benefit associated with a specific contrast procedure. In some patients the risk of CI-AKI is outweighed by the potential benefit from the contrast study.

[color=#BF00FF] It is recommended that these risks are explained to the patient in the context of the potential benefit of proceeding with the study. Imaging should not be delayed where the benefit of early imaging clearly outweighs the risk of waiting. [/color

This effectively concludes the Chapter on RADIOLOGY IN CARDIO VASCULAR DISEASE.

G Mohan


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PostPosted: 16 Oct 2016 21:04 
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Interesting article. However it does not give you a definite answers to using contrast media when the kidney function is less than optimal. The article also mentions that the risk of CI-AKI becomes clinically important with an eGFR <60 ml/min. However, we all know that GFR physiologically decreases with age, and in adults older than 70 years, values below 60 mL/min/1.73 m2 could be considered as normal.


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