Consensus statements: Use of intravenous contrast media in kidney disease patients not as great a risk as previously thought

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Illustration of a kidney

The reputed risk of administering modern intravenous iodinated contrast media in patients with reduced kidney function has been “overstated.”

That is the headline takeaway from consensus statements released by the American College of Radiology and the National Kidney Foundation on the use of intravenous iodinated contrast media in patients with kidney disease.

The research team, led by Matthew S. Davenport, MD, of the departments of radiology and urology at the University of Michigan in Ann Arbor, Michigan, published the statements simultaneously in Radiology and Kidney Medicine.

Davenport et al elaborated on why they believe deployment not to be as much of a risk as is often believed.

“This is primarily because of the conflation of contrast-associated acute kidney injury (CA-AKI) with contrast-induced acute kidney injury (CI-AKI) in uncontrolled studies,” they wrote.

“Although the true risk of CI-AKI remains unknown, prophylaxis with intravenous normal saline is indicated for patients without contraindication (e.g., heart failure) who have acute kidney injury (AKI) or an estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 who are not undergoing maintenance dialysis.

“In individual high-risk circumstances, prophylaxis may be considered in patients with an eGFR of 30–44mL/min/1.73m2 at the discretion of the ordering clinician. The presence of a solitary kidney should not independently influence decision-making regarding the risk of CI-AKI.”

Intravenous iodinated contrast media are commonly used with computerized tomography (CT) to evaluate disease and to determine treatment response.

“Ad hoc lowering of contrast media dose below a known diagnostic threshold should be avoided due to the risk of lowering diagnostic accuracy,” Davenport et al continued. “When feasible, nephrotoxic medications should be withheld by the referring clinician in patients at high risk.

“However, renal replacement therapy should not be initiated or altered solely based on contrast media administration. Prospective controlled data are needed in adult and pediatric populations to clarify the risk of CI-AKI.”

Recent observational studies with sophisticated statistical adjustment led to the suggestion that alleged risks for AKI caused by intravenous iodinated contrast have been overstated, noted Allan S. Brett, MD, the Orlando Benedict Mayer professor of medicine at the University of South Carolina School of Medicine, in review of the statements.

“In any case, this consensus statement concludes sensibly that, if imaging with IV contrast (e.g., computed tomography) likely will yield critical information for patient management (and if alternative imaging modalities would be inadequate), the study should be performed regardless of renal function,” commented the NEJM Journal Watch editor-in-chief.

SOURCE: DOI.ORG/10.1148/RADIOL.2019192094

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