Page 1 of 3 Policy # Rad2065 Guidelines: Recommendations for Safe Administration of Iodinated Contrast Administration in Patients with Diminished Renal Function

UMassMemorialMedicalCenter

Department of Radiology

Policies/Procedures and or Clinical Guidelines

Policy #Rad2065 Guidelines: Recommendations for Safe Administration of Iodinated Contrast Administration in Patients with Diminished Renal Function
Developed By:
Byron Chen MD
Matthew Hoimes MD
Steven Baccei, MD Director, Radiology Quality, Patient Safety, and Process Improvement / Effective Date:7/1/2014
Approved by: ______
Max Rosen, MD Radiology Chair
Approved by: ______
Kathryn Green, Sr. Director Radiology
Applicability: / Rescission: Supersedes policy dated:9/2008, 7/2009
Keywords:
  1. Policy:

To standardize departmental practice with regard to iodinated intravenous contrast and preservation of renal function. For the purpose of this policy, renal function will be measured by estimated GFR.

  1. Definitions:

N/A

  1. General Procedure:

RENAL FUNCTION SCREENING:

In the outpatient setting, the following patient population will require renal function screening within 30 days of contrast administration:

  • Age >65 years
  • History of renal disease, including
  • Kidney transplant
  • Single kidney
  • Kidney cancer
  • Kidney surgery
  • History of renal insufficiency
  • History of hypertension requiring medical therapy
  • History of diabetes
  • Metformin (or metformin-containing drug combinations)

For inpatients and ER patients, the same guidelines will apply unless documented in the medical record that medical emergency precludes screening. If labs have already been drawn but are pending, the results should be waited for unless medical emergency is documented.

Labs specific to renal function (eGFR) will be reviewed by the technologist administering the intravenous contrast on the same date, immediately prior to the administration of intravenous contrast to ensure that the most current clinical information is utilized to classify patients with renal insufficiency (see section IV.)

  1. Clinical/Departmental Procedure:

PATIENTS WITH RENAL INSUFFICIENCY

eGFR > 60
(very low risk) / No restrictions
eGFR 45-60
(low risk) / If acute renal failure, consider IV hydration. Otherwise, encourage oral hydration and salt loading as clinically appropriate.
eGFR 30 – 44
(moderate risk) / Consider alternative exams (MRI/Ultrasound). Otherwise IV hydration required (see below) unless documented that medical emergency precludes hydration.Iodixanol (Visipaque) contrast is suggested.
eGFR < 30
(high risk) / No IV contrast unless approved by nephrology or deemed a medical emergency, which must be documented. Iodixanol (Visipaque) contrast is suggested in the event of a documented medical emergency/override authorizing the administration of IV contrast.

*Patients with end-stage renal disease on maintenance hemodialysis (and no expected return of renal function) may receive IV contrast regardless of GFR. Unless an unusually large amount of contrast is administered or there is substantial cardiac dysfunction, there is no need for emergent hemodialysis.

HYDRATION PROTOCOL

For outpatients, isotonic NaCl at 3ml/kg/hr for a minimum of 1 hour prior to contrast administration and 6 hours following contrast.

For inpatients, isotonic NaCl at 1ml/kg/hr for 12 hours prior to contrast administration and 12 hours after contrast administration.

MULTIPLE CONTRAST BOLUSES

Patients should not receive greater than 200mL of iodinated contrast material within a 24 hour period unless medical emergency is documented or nephrology consult has approved administration. Care should be taken to assure that patients did not receive contrast from other departments, for example cardiac catheterization or neuro/vascular IR procedure.

FOLLOW UP TESTING

Renal function testing should be measured greater than 48 hours after administration of IV contrast for those with GFR < 45. To be ordered by referring physician.

  1. Supplemental Materials:

N/A

  1. References:

ACR Manual on Contrast Media v9, 2013. Accessed online:

Trivedi HS et al. A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity. Nephron Clin Pract 2003; 93: C29–C34

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: 329–336

Stacul F,Adam A,Becker CR, et al.Strategies to reduce the risk of contrast- induced nephropathy.Am J Cardiol2006;98:59K–77K.

Younathan CM et al. Dialysis is not indicated immediately after administration of nonionic contrast agents in patients with end-stage renal disease treated by maintenance dialysis. AJR Am J Roentgenol 1994; 163:969-971.