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Intravenous Contrast Related Acute Renal Failure

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Intravenous Contrast Related Acute Renal Failure, IV Contrast Related Acute Renal Failure, Renal Failure due to Radiocontrast Material, Contrast-Induced Nephropathy, Radiocontrast Nephropathy, Post Contrast Acute Kidney Injury, PC-AKI

  • See Also
  1. Intravenous Contrast
  2. Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
  3. Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)
  4. Prevention of Kidney Disease Progression
  5. Chronic Kidney Disease
  6. Acute Kidney Injury
  • Risk Factors
  1. See Acute Renal Failure Risk
  2. See Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
  • Definition
  1. Postcontrast Acute Kidney Injury (Contrast-Induced Nephropathy)
    1. Onset within 48-72 hours of Intravenous Contrast exposure of at least one of the following criteria
    2. Serum Creatinine increased 0.3 mg/dl (some studies use 0.5 mg/dl) over baseline OR
    3. Relative increase of Serum Creatinine >50% (some studies use >25%) over baseline OR
    4. Urine Output decreased to 0.5 ml/kg/h for 6 hours
  • Precautions
  1. Degree to which radiocontrast causes nephropathy is controversial
  2. Most recent studies find no significant impact on Acute Kidney Injury with radiocontrast if GFR>30 ml/min
    1. However, Serum Creatinine may transiently increase in 2-3% of patients
    2. Aulicky (2010) J Neurol Neurosurg Psychiatry 81(7):783-7 [PubMed]
    3. McDonald (2013) Radiology 267(1): 106-18 [PubMed]
    4. Ng (2010) AJR Am J Roentgenol 195(2): 414-22 [PubMed]
    5. Davenport (2013) Radiology 268(3): 719-28 [PubMed]
    6. McDonald (2014) Radiology 273(3): 714-25 [PubMed]
    7. Hinson (2017) Ann Emerg Med 69(5): 577-86 [PubMed]
  3. American College of Radiology (ACR) Recommendations
    1. ACR recommends no baseline Creatinine before scan if age <60, no renal disease, Hypertension, diabetes
    2. GFR >30 ml/min is sufficient to undergo radiocontrast scan
  4. References
    1. Morgenstern in Herbert (2019) EM:Rap 19(10): 4-6
    2. Spangler and Werner (2021) EM:Rap 21(8): 12-3
  • Prevention (Indicated for Acute Renal Failure Risk)
  1. Avoid concurrent Nephrotoxic Drugs
    1. See Nephrotoxic Drugs
    2. Avoid NSAIDs
  2. Use low osmolality (non-ionic) or iso-osmolal Contrast Material
  3. Allow 2-5 days between IV contrast procedures
  4. Exercise caution with IV Contrast in Diabetes Mellitus with eGFR <60 ml/min (CKD 3a)
  5. Hydrate before and after procedure (most important measure)
    1. Adjust for Congestive Heart Failure
    2. Oral Option: (non-caffeinated fluid)
      1. Take at least 500 ml before contrast
      2. Take 2500 ml over the 24 hours post-contrast
    3. IV Option: Intravenous Normal Saline
      1. Infuse 100 ml/hour saline for 4 hours pre-contrast
      2. Infuse 100 ml/hour for the 24 hours post-contrast
    4. IV Option: Intravenous Isotonic Bicarbonate
      1. Prepare 3 ampules of Sodium Bicarbonate (50 meq/ampule) in 850 cc D5W
      2. Give 3 ml/kg IV one hour before procedure and 1 ml/kg/hour for 6 hours post-procedure
      3. Reference
        1. Stuart (2007) Park Nicollet Primary Care Conference, Minneapolis, MN
  6. Adjust IV contrast dose
    1. Contrast Dose: (5 cc/kg)/(Serum Creatinine)
    2. Maximum total dose: 300 cc
  7. Acetylcysteine (Mucomyst) for 3 days (questionable efficacy)
    1. Not typically used in U.S. (hydration is used instead)
    2. Indications
      1. Safe and low cost prevention (consider in all at risk patients)
      2. Chronic Kidney Disease
      3. Acute Renal Failure Risk Factors
      4. Diabetes Mellitus
    3. Protocol
      1. Used in combination with hydration protocol above
      2. Start day before contrast exposure
    4. High dose protocol (replaces the older, ineffective 600 mg dose)
      1. Mucomyst 1200 mg orall twice daily
      2. Give on the day before and the day of contrast administration
    5. Efficacy
      1. Initial studies showed risk of nephropathy reduced by 56%
      2. Recent data suggests that standard dose ineffective; higher dose may be effective
      3. References
        1. Williams (2008) Mayo Selected Topics in Internal Medicine, Lecture
        2. Trivedi (2009) Am J Med 122(9): 874 [PubMed]
    6. References
      1. Birck (2003) Lancet 362:598-603 [PubMed]
      2. Isenbarger (2003) Am J Cardiol 92:1454-8 [PubMed]
  8. Other agents to consider
    1. Calcium Channel Blocker for 24 hours before procedure
  9. Agents with no benefit
    1. Avoid Furosemide (Lasix)
    2. Avoid Mannitol
  • Monitoring
  1. Recheck the Serum Creatinine in patients with Acute Renal Failure Risk within the first 3 days following contrast exposure
  • References
  1. Mende (2001) CME Medicine Lecture, San Diego
  2. Maddox (2002) Am Fam Physician 66(7):1229-34 [PubMed]
  3. Quader (1998) Ann Vasc Surg 12:612-20 [PubMed]