View source for Contrast-induced nephropathy

''This page only applies to contrast agents usually used for CT scans. MRIs with contrast use gadolinium, which can cause [[nephrogenic systemic fibrosis]] in patients with renal dysfunction.''
==Background==
*Often defined as [[AKI|creatinine rise]] of more than 0.5mg/dL or ≥25% above baseline<ref>Goldfarb, S. et al. Contrast-Induced Acute Kidney Injury: Specialty-Specific Protocols for Interventional Radiology, Diagnostic Computed Tomography Radiology, and Interventional Cardiology. Mayo Clin Proc. Feb 2009; 84(2): 170–179 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664588/ Text]</ref>
*Vasoconstriction leading to ischemia in the deeper portion of the outer medulla
*Toxic to kidney tubular cells, inducing vacuolization, change in mitochondrial function, and apoptosis
*Less likely to occur with low and iso-osmolar contrast agents

===Healthy Patients===
*Not likely to occur in patients with a Cr<1.5 or a GFR >60ml/min<ref>Davenport MS. et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013 Apr;267(1):94-105</ref><ref>Sinert R, Brandler E, et al. Acad Emerg Med2012;19(11):1261</ref>

===Impaired Renal Function===
*Administration should follow your local hospital protocols
*Less likely to occur in iso-osmolar contrast agents (iodixanol/Visipaque) and contrary to traditional teaching, maybe not even an occurrence in patients with creatinine greater than 2.0mg/dL. <ref>McDonald RJ, McDonald JS, et al. Radiology. 2013;267(1):106</ref>
===Risk Factors===
*Renal disease
*Recent contrast study within 72 hrs
*[[Hypotension]]
*[[Dehydration]]
*[[DM]]
*[[Multiple myeloma]]
*Age > 70
*[[Hypertension]]
*[[Uremia|Hyperuricemia]]
*[[Diuretics]]

==Clinical Features==
*Decreased urine output
*0.5mg/dl absolute or >25% relative increase in serum creatinine 48-72hrs after contrast exposure

==Differential Diagnosis==
*Poor renal perfusion
*Nephrotoxic medications

{{Contrast complications DDX}}

==Evaluation==
*Same as for [[Acute_kidney_injury#Work-up|AKI]]

==Management==
''Hallmark of management is prevention in at-risk patients.''

===Hydration===
*Isotonic hydration with [[normal saline]] 1-1.5L (15ml/kg) prior to the contrast load in patients with impaired renal function may lessen the chances of developing CIN <ref>Mueller C. et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162(3):329</ref><ref>Bertrand Dussol. et al. A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients. Nephrol. Dial. Transplant. 2006. 21 (8): 2120-2126</ref><ref name="traub">Traub SJ, et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med 2013;62(5):511-20 [http://www.annemergmed.com/article/S0196-0644(13)00350-8/pdf PDF]</ref>
*If suspect the development or confirm the diagnosis continue adequate hydration to maintain urine output of 0.7cc-1cc/kg
*Early research suggests a potential benefit for forced [[furosemide]] diuresis (300ml/h) while continuing [[IVF|intravenous hydration fluids]] (0.5mg/kg) but should be performed in consult with radiologist and nephrologist<ref>Marenzi G. et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (Induced Diuresis With Matched Hydration Compared to Standard Hydration for Contrast Induced Nephropathy Prevention) trial. JACC Cardiovasc Interv. 2012 Jan;5(1):90-7</ref>

===[[N-acetylcysteine]]===
*'''Is not useful for preventing CIN'''<ref>ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011 Sep 13;124(11):1250-9 [http://circ.ahajournals.org/content/124/11/1250.full.pdf PDF]</ref><ref name="traub"></ref>

===Other Measures===
*Low osmolar contrast agents
*[[Bicarbonate]] infusion
*[[Hypertonic saline]]

==Disposition==

==Prevention<ref>Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology. 2000 Aug;216(2):481-4.</ref><ref>ACR Manual on Contrast Media – Version 10, 2015. [http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/2015_Contrast_Media.pdf PDF] Accessed 08/10/15</ref>==
* ED patients do NOT require creatinine measurement prior to IV contrast if the study is immediately necessary to prevent life-threatening decompensation or delay in emergent treatment (e.g., trauma patients, dissection r/o)
* [https://lacounty-my.sharepoint.com/personal/jshim_dhs_lacounty_gov/_layouts/15/onedrive.aspx?FolderCTID=0x01200042EAB0B5A27C63468CDB5666D0718199&id=%2Fpersonal%2Fjshim%5Fdhs%5Flacounty%5Fgov%2FDocuments%2FMicrosoft%20Teams%20Chat%20Files%2FUse%20of%20IV%2 DHS IV Contrast Expected Practices 10-2022]
** '''Ok to give IV contrast if GFR>30'''
** '''No need for GFR screening if age <60 with no pertinent history''' (AKI, CKD, HD with urine output, renal transplant, Metformin use)
** If the GFR<30, ER physician should state in the CT order “Clinical History” or document in the chart that IV contrast is necessary and authorized. 
*** Alternately, the '''CT tech may call the physician to confirm IV contrast is necessary and authorized, and CT tech should document this communication in the chart.'''
** Screening for MRI contrast is unnecessary unless using  Eovist for liver mets study (all ED Emergent studies should use Dotarem or Gadavist)

==See Also==
*[[MRI contraindications]]
*[[CT contrast media extravasation‎]]
*[[Contrast induced allergic reaction]]

==References==
<references/>

[[Category:Renal]]
[[Category:Radiology]]