CT with IV contrast in low renal function - Revision history

Mikael Häggström: /* Other risk factors */ Linked

2019-07-25T08:40:36Z

Other risk factors: Linked

Mikael Häggström: /* Other risk factors */ Grammar

2019-07-04T11:26:43Z

Other risk factors: Grammar

Mikael Häggström: /* Actions */ + Split bolus

2019-07-04T11:25:31Z

Actions: + Split bolus

Mikael Häggström: +Swedish

2019-04-08T06:05:49Z

+Swedish

Mikael Häggström: wording

2019-02-15T10:39:38Z

wording

Mikael Häggström: /* Treating risk factors */ +Factors

2019-02-15T10:37:29Z

Treating risk factors: +Factors

Mikael Häggström: /* Actions */ Updated

2019-02-15T10:34:49Z

Actions: Updated

Mikael Häggström: /* Actions */ Adjust radiation

2019-01-22T09:48:14Z

Actions: Adjust radiation

Mikael Häggström: Spacing

2019-01-15T16:36:09Z

Spacing

Mikael Häggström: /* How much contrast is needed */ Specified

2018-11-15T15:01:44Z

How much contrast is needed: Specified

@@ Line 44: / Line 44: @@
 Metformin use potentially causes lactic acidosis if contrast-induced nephropathy occurs, and European guidelines (ESUR) recommends stopping metformin at least 48 hours before a CT with IV contrast if GFR is between 30 and 44 ml/min/1.73 m<sup>2</sup>, unless emergent, and resume metformin 48 hours after the CT if renal function has not deteriorated. If lower, no contrast should be given unless absolutely necessary.<ref>{{cite web|url=http://www.esur.org/guidelines/|website=ESUR|accessdate=2018-11-09|title=Iodine-based contrast media}}</ref> In such cases, Swedish guidelines only include withholding metformin ''after'' the CT, and not before.<ref>{{cite web|url=file:///C:/Users/mikha19/Downloads/Nationella_rek_metformin_kontrastmedel_v61_2018-05-07.pdf|title=Nationella rekommendationer: Svensk uroradiologisk förenings kontrastmedelsgrupp: METFORMIN. Version 6.1|date=2018-05-07}}</ref>
-Other relative or absolute contraindications to IV contrast, regardless of GFR, are [[CT_with_IV_contrast#Allergy|contrast allergy]] and untreated hyperthyroidism.
+Other relative or absolute contraindications to IV contrast, regardless of GFR, are contrast allergy ''(see [[CT with IV contrast#Allergy]])'' and untreated hyperthyroidism ''(see [[Iodinated contrast and hyperthyroidism]])''.
 ==How much contrast can be given?==

@@ Line 42: / Line 42: @@
 *Individuals who have undergone kidney transplantation
-Metformin use potentially causes lactic acidosis if contrast-induced nephropathy occurs, and European guidelines (ESUR) recommends to stop metformin at least 48 hours before a CT with IV contrast if GFR is between 30 and 44 ml/min/1.73 m<sup>2</sup>, unless emergent, and resume metformin 48 hours after the CT if renal function has not deteriorated. If lower, no contrast should be given unless absolutely necessary.<ref>{{cite web|url=http://www.esur.org/guidelines/|website=ESUR|accessdate=2018-11-09|title=Iodine-based contrast media}}</ref> In such cases, Swedish guidelines only include withholding metformin ''after'' the CT, and not before.<ref>{{cite web|url=file:///C:/Users/mikha19/Downloads/Nationella_rek_metformin_kontrastmedel_v61_2018-05-07.pdf|title=Nationella rekommendationer: Svensk uroradiologisk förenings kontrastmedelsgrupp: METFORMIN. Version 6.1|date=2018-05-07}}</ref>
+Metformin use potentially causes lactic acidosis if contrast-induced nephropathy occurs, and European guidelines (ESUR) recommends stopping metformin at least 48 hours before a CT with IV contrast if GFR is between 30 and 44 ml/min/1.73 m<sup>2</sup>, unless emergent, and resume metformin 48 hours after the CT if renal function has not deteriorated. If lower, no contrast should be given unless absolutely necessary.<ref>{{cite web|url=http://www.esur.org/guidelines/|website=ESUR|accessdate=2018-11-09|title=Iodine-based contrast media}}</ref> In such cases, Swedish guidelines only include withholding metformin ''after'' the CT, and not before.<ref>{{cite web|url=file:///C:/Users/mikha19/Downloads/Nationella_rek_metformin_kontrastmedel_v61_2018-05-07.pdf|title=Nationella rekommendationer: Svensk uroradiologisk förenings kontrastmedelsgrupp: METFORMIN. Version 6.1|date=2018-05-07}}</ref>
 Other relative or absolute contraindications to IV contrast, regardless of GFR, are [[CT_with_IV_contrast#Allergy|contrast allergy]] and untreated hyperthyroidism.

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 ===Adjust radiation===
 Use low voltage protocols where appropriate. Also, in the elderly, consider increasing radiation dosage.
 ==Example==

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 *Individuals who have undergone kidney transplantation
-Metformin use potentially causes lactic acidosis if contrast-induced nephropathy occurs, and according to European guidelines it should be stopped at least 48 hours before a CT with IV contrast if GFR is between 30 and 44 ml/min/1.73 m<sup>2</sup>. If lower, no contrast should be given unless absolutely necessary.<ref>{{cite web|url=http://www.esur.org/guidelines/|website=ESUR|accessdate=2018-11-09}}</ref>
+Metformin use potentially causes lactic acidosis if contrast-induced nephropathy occurs, and European guidelines (ESUR) recommends to stop metformin at least 48 hours before a CT with IV contrast if GFR is between 30 and 44 ml/min/1.73 m<sup>2</sup>, unless emergent, and resume metformin 48 hours after the CT if renal function has not deteriorated. If lower, no contrast should be given unless absolutely necessary.<ref>{{cite web|url=http://www.esur.org/guidelines/|website=ESUR|accessdate=2018-11-09|title=Iodine-based contrast media}}</ref> In such cases, Swedish guidelines only include withholding metformin ''after'' the CT, and not before.<ref>{{cite web|url=file:///C:/Users/mikha19/Downloads/Nationella_rek_metformin_kontrastmedel_v61_2018-05-07.pdf|title=Nationella rekommendationer: Svensk uroradiologisk förenings kontrastmedelsgrupp: METFORMIN. Version 6.1|date=2018-05-07}}</ref>
 Other relative or absolute contraindications to IV contrast, regardless of GFR, are [[CT_with_IV_contrast#Allergy|contrast allergy]] and untreated hyperthyroidism.

@@ Line 105: / Line 105: @@
 Risk factors can sometimes be treated or at least mitigated, especially if having suddenly appeared, such as a decreased renal function when it was previously normal. In such cases a common easily treated cause is dehydration.
-'''Hydration''' should be done in patients with suspected dehydration (such as recent vomiting, diarrhea and/or diuretic use), and is done by drinking or by intravenous volume expander, either before or after contract administration. Hydration should be avoided otherwise.<ref group="notes">Hydration of non-dehydrated individuals seems to only increase complication rates, including electrolyte imbalances and cardiac arrhythmias:<br>{{cite journal|last1=Nijssen|first1=Estelle C|last2=Rennenberg|first2=Roger J|last3=Nelemans|first3=Patty J|last4=Essers|first4=Brigitte A|last5=Janssen|first5=Marga M|last6=Vermeeren|first6=Marja A|last7=Ommen|first7=Vincent van|last8=Wildberger|first8=Joachim E|title=Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial|journal=The Lancet|volume=389|issue=10076|year=2017|pages=1312–1322|issn=01406736|doi=10.1016/S0140-6736(17)30057-0}}</ref>
+'''Hydration''' should be done in patients with suspected dehydration (such as recent vomiting, diarrhea and/or diuretic use), and is done by drinking or by intravenous volume expander, either before or after contract administration. Hydration should be avoided otherwise.<ref group="notes">Hydration of people with low renal function, without separating dehydrated from non-dehydrated individuals, seems to only increase complication rates, including electrolyte imbalances and cardiac arrhythmias:<br>{{cite journal|last1=Nijssen|first1=Estelle C|last2=Rennenberg|first2=Roger J|last3=Nelemans|first3=Patty J|last4=Essers|first4=Brigitte A|last5=Janssen|first5=Marga M|last6=Vermeeren|first6=Marja A|last7=Ommen|first7=Vincent van|last8=Wildberger|first8=Joachim E|title=Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial|journal=The Lancet|volume=389|issue=10076|year=2017|pages=1312–1322|issn=01406736|doi=10.1016/S0140-6736(17)30057-0}}</ref>
 ===Adjust radiation===

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 |}
-==Actions==
+==Underweight or overweight?==
 At moderate weight deviations, corrections can be made by adjusting contrast dose proportionally to patient weight. Still, the needed dose is actually proportional to the ''lean body weight'' of the patient. For both men and women weighing more than about 85 kg,<ref group="notes">At above this weight, calculated contrast amount with the Boer formula deviates more than 10% from both the weight-unadjusted amount, as well as the amount taken proportionally to the weight, for both men and women.</ref> contrast dose is optimally calculated by the Boer formula, using height and weight of the patient.<ref name="CarusoDe Santis2018">{{cite journal|last1=Caruso|first1=Damiano|last2=De Santis|first2=Domenico|last3=Rivosecchi|first3=Flaminia|last4=Zerunian|first4=Marta|last5=Panvini|first5=Nicola|last6=Montesano|first6=Marta|last7=Biondi|first7=Tommaso|last8=Bellini|first8=Davide|last9=Rengo|first9=Marco|last10=Laghi|first10=Andrea|title=Lean Body Weight-Tailored Iodinated Contrast Injection in Obese Patient: Boer versus James Formula|journal=BioMed Research International|volume=2018|year=2018|pages=1–6|issn=2314-6133|doi=10.1155/2018/8521893}}</ref> Taking this formula, the needed volume of IV contrast from the unadjusted volume given in the table above becomes:
 [[File:Diagram - weight.png|thumb|Boer formula for volume of contrast in a normal height patient if having received 60 ml if weight was normal.<ref group="notes">176 cm male and 162 cm female</ref>]]
@@ Line 100: / Line 99: @@
 Still, it is generally enough to make a rough estimation of the needed contrast, since there are for example inherent standard deviations in the usage of creatinine or cystatin C in calculating GFR.
 ===Treating risk factors===
 Risk factors can sometimes be treated or at least mitigated, especially if having suddenly appeared, such as a decreased renal function when it was previously normal. In such cases a common easily treated cause is dehydration.
-'''Hydration''' by drinking or intravenous volume expander, either before or after contract administration, decreases the risk of contrast-induced nephropathy.<ref name="YangHiremath2013">{{cite journal|last1=Yang|first1=Xiaoming|last2=Hiremath|first2=Swapnil|last3=Akbari|first3=Ayub|last4=Shabana|first4=Wael|last5=Fergusson|first5=Dean A.|last6=Knoll|first6=Greg A.|title=Prevention of Contrast-Induced Acute Kidney Injury: Is Simple Oral Hydration Similar To Intravenous? A Systematic Review of the Evidence|journal=PLoS ONE|volume=8|issue=3|year=2013|pages=e60009|issn=1932-6203|doi=10.1371/journal.pone.0060009}}</ref>
+'''Hydration''' should be done in patients with suspected dehydration, and is done by drinking or by intravenous volume expander, either before or after contract administration. It should be avoided otherwise.<ref group="notes">Hydration of non-dehydrated individuals seems to only increase complication rates, including electrolyte imbalances and cardiac arrhythmias:<br>{{cite journal|last1=Nijssen|first1=Estelle C|last2=Rennenberg|first2=Roger J|last3=Nelemans|first3=Patty J|last4=Essers|first4=Brigitte A|last5=Janssen|first5=Marga M|last6=Vermeeren|first6=Marja A|last7=Ommen|first7=Vincent van|last8=Wildberger|first8=Joachim E|title=Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial|journal=The Lancet|volume=389|issue=10076|year=2017|pages=1312–1322|issn=01406736|doi=10.1016/S0140-6736(17)30057-0}}</ref>
 ===Adjust radiation===

← Older revision		Revision as of 09:48, 22 January 2019
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	'''Hydration''' by drinking or intravenous volume expander, either before or after contract administration, decreases the risk of contrast-induced nephropathy.<ref name="YangHiremath2013">{{cite journal\|last1=Yang\|first1=Xiaoming\|last2=Hiremath\|first2=Swapnil\|last3=Akbari\|first3=Ayub\|last4=Shabana\|first4=Wael\|last5=Fergusson\|first5=Dean A.\|last6=Knoll\|first6=Greg A.\|title=Prevention of Contrast-Induced Acute Kidney Injury: Is Simple Oral Hydration Similar To Intravenous? A Systematic Review of the Evidence\|journal=PLoS ONE\|volume=8\|issue=3\|year=2013\|pages=e60009\|issn=1932-6203\|doi=10.1371/journal.pone.0060009}}</ref>		'''Hydration''' by drinking or intravenous volume expander, either before or after contract administration, decreases the risk of contrast-induced nephropathy.<ref name="YangHiremath2013">{{cite journal\|last1=Yang\|first1=Xiaoming\|last2=Hiremath\|first2=Swapnil\|last3=Akbari\|first3=Ayub\|last4=Shabana\|first4=Wael\|last5=Fergusson\|first5=Dean A.\|last6=Knoll\|first6=Greg A.\|title=Prevention of Contrast-Induced Acute Kidney Injury: Is Simple Oral Hydration Similar To Intravenous? A Systematic Review of the Evidence\|journal=PLoS ONE\|volume=8\|issue=3\|year=2013\|pages=e60009\|issn=1932-6203\|doi=10.1371/journal.pone.0060009}}</ref>
		+
		+	===Adjust radiation===
		+	Use low voltage protocols where appropriate. Also, in the elderly, consider increasing radiation dosage.

	==Example==		==Example==

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 |author2=
 }}
 In [[CT with IV contrast]], decreased renal function and several other conditions increase the risk of '''contrast-induced nephropathy''', which is a potentially lethal renal injury to the kidney following intravenous radiocontrast.<ref name="RudnickFeldman2008">{{cite journal|last1=Rudnick|first1=M.|last2=Feldman|first2=H.|title=Contrast-Induced Nephropathy: What Are the True Clinical Consequences?|journal=Clinical Journal of the American Society of Nephrology|volume=3|issue=1|year=2008|pages=263–272|issn=1555-9041|doi=10.2215/CJN.03690907}}</ref>

@@ Line 75: / Line 75: @@
 *{{cite journal|last1=Iezzi|first1=Roberto|last2=Larici|first2=Anna Rita|last3=Franchi|first3=Paola|last4=Marano|first4=Riccardo|last5=Magarelli|first5=Nicola|last6=Posa|first6=Alessandro|last7=Merlino|first7=Biagio|last8=Manfredi|first8=Riccardo|last9=Colosimo|first9=Cesare|title=Tailoring protocols for chest CT applications: when and how?|journal=Diagnostic and Interventional Radiology|volume=23|issue=6|year=2017|pages=420–427|issn=13053825|doi=10.5152/dir.2017.16615}}</ref> || 60 - 80 ml<ref name="IezziLarici2017" group="notes"/> || 55 - 75 ml<ref name="IezziLarici2017" group="notes"/> || Parenchymal changes of the lung can often be evaluated adequately without the use of intravenous contrast.
 |-
-| [[CT pulmonary angiogram]] || 20 ml<ref name="LeroyerMeier2016" group="notes">Using dual energy CTA (such as 90/150SnkVp), according to:
+| [[CT of pulmonary embolism]] || 20 ml<ref name="LeroyerMeier2016" group="notes">Using dual energy CTA (such as 90/150SnkVp), according to:
 *{{cite journal|last1=Leroyer|first1=Christophe|last2=Meier|first2=Andreas|last3=Higashigaito|first3=Kai|last4=Martini|first4=Katharina|last5=Wurnig|first5=Moritz|last6=Seifert|first6=Burkhardt|last7=Keller|first7=Dagmar|last8=Frauenfelder|first8=Thomas|last9=Alkadhi|first9=Hatem|title=Dual Energy CT Pulmonary Angiography with 6g Iodine—A Propensity Score-Matched Study|journal=PLOS ONE|volume=11|issue=12|year=2016|pages=e0167214|issn=1932-6203|doi=10.1371/journal.pone.0167214}}</ref> || 17 ml<ref name="LeroyerMeier2016" group="notes"/> || 15 ml<ref name="LeroyerMeier2016" group="notes"/> || Minimal amount when using specific low-contrast protocol.<ref name="LeroyerMeier2016" group="notes"/>
 |-