Contrast-induced nephropathy
Citation, DOI & article data
- Contrast nephropathy
- Contrast-induced acute kidney injury (CI-AKI)
- Contrast mediated nephrotoxicity
- Post contrast acute kidney injury (PC-AKI)
Contrast-induced nephropathy (CIN) describes an association between intravenous or intra-arterial contrast administration and renal impairment, but increasingly the evidence shows that contrast is not the cause of the renal impairment and that confounding factors such as sepsis are likely to be responsible.
A number of case-controlled studies and meta-analyzes 8-11 have been published, with most identifying no difference in the incidence of renal impairment between patients receiving and not receiving intravenous contrast, in patients with baseline normal renal function. One of the major confounding factors of propensity-matched case-controlled studies is that even though baseline renal function may have been similar in the two groups, physicians may have chosen to not prescribe contrast to sicker patients, so the two cohorts may have in fact not been truly matched. There are no randomized controlled trials as yet.
On this page:
Definition
A number of different definitions are used in the literature, most relying on measurement of serum creatinine concentrations. A baseline creatinine level should be obtained before the procedure. Estimated glomerular filtration rate (eGFR) has been used for the assessment of renal function before intravenous contrast injection. This is calculated from the patient's age, race, sex and serum creatinine level. Online calculators are also available to assist in easily calculating eGFR.
Post-contrast peak effect on creatinine occurs between 48 and 72 hours:
- relative: 50% rise over baseline
- absolute: increase of greater than 27 μmol/L
Contrast-induced acute kidney injury (CI-AKI) has also been described in which injury or damage to the kidney has taken place, but is subclinical in that no measurable reduction in renal filtration is apparent 4.
The American College of Radiology suggests using the term postcontrast acute kidney injury (PC-AKI) rather than CIN as the literature points to an association but not causality 7.
ADVERTISEMENT: Supporters see fewer/no ads
Risk stratification
Risk for most normal individuals with no risk factors is based on baseline renal function, using creatinine (Cr) or creatinine clearance (CrCl) as surrogate markers:
- low: Cr <130 μmol/L or CrCl >60 mL/min
- medium: Cr 130-200 μmol/L or CrCl 30-60 mL/min
- high: Cr >200 μmol/L or CrCl <30 mL/min
For risk stratification using eGFR:
- very low risk: >60 mL/min
- low risk: 45-59 mL/min
- moderate: 30-45 mL/min
- high risk: <30 mL/min
The Royal Australian and New Zealand College of Radiologists recommend that patients in the emergency setting that require contrast media for computed tomographic examinations should have no delay to scan time due to renal function testing 6.
The stance of the American College of Radiology in their Manual on Contrast 7 is that “at the current time, there is very little evidence that IV iodinated contrast material is an independent risk factor for AKI in patients with eGFR ≥30 mL/min/1.73 m2”
High dose contrast
However, if they are going to have an investigation with more than 300 mL of iodinated contrast or two studies less than 72 hours apart, their risk is elevated to the medium group irrespective of their baseline renal function.
Predisposing risk factors
Patients with risk factors are automatically elevated to higher risk groups
-
diabetes mellitus, multiple myeloma, congestive heart failure, cirrhosis, nephrotic syndrome, sepsis
- low: as above
- medium: Cr 110-130 μmol/L or CrCl <90 mL/min
- high: Cr 130-200 μmol/L or CrCl <60 mL/min
-
renal transplant, dehydration or hypotension
- low: not possible
- medium: even if their renal function is normal
- high: Cr 130-200 μmol/L or CrCl 30-60 mL/min
ADVERTISEMENT: Supporters see fewer/no ads
Treatment and prognosis
The most important factor is adequate prehydration and assessment of renal function. Risk stratification helps to determine what the most appropriate preparation is, and protocols will vary from institution to institution:
- low: oral fluids only
-
medium:
- IV 0.9% normal saline for 12 hours before and after the procedure
- at 48 hours: if the creatinine is 25% above baseline, a further check five days post-procedure should be taken
-
high:
- IV 0.9% normal saline for 12 hours before and after the procedure
- N-acetylcysteine (NAC) 600 mg orally bd (three days before the procedure and one day afterwards)
- check creatinine at baseline, 48 hours, five days and ten days
Quiz questions
References
- 1. Gleeson TG, Bulugahapitiya S. Contrast-induced nephropathy. AJR Am J Roentgenol. 2004;183 (6): 1673-89. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Ellis JH, Cohan RH. Reducing the risk of contrast-induced nephropathy: a perspective on the controversies. AJR Am J Roentgenol. 2009;192 (6): 1544-9. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.09.2368 - Pubmed citation
- 3. Richenberg J. How to reduce nephropathy following contrast-enhanced CT: A lesson in policy implementation. Clin Radiol. 2012;67 (12): 1136-45. doi:10.1016/j.crad.2012.05.003 - Pubmed citation
- 4. Ronco C, Stacul F, McCullough PA. Subclinical acute kidney injury (AKI) due to iodine-based contrast media. Eur Radiol. 2013;23 (2): 319-23. Eur Radiol (full text) - doi:10.1007/s00330-012-2607-y - Pubmed citation
- 5. Katzberg RW, Lamba R. Contrast-induced nephropathy after intravenous administration: fact or fiction?. (2009) Radiologic clinics of North America. 47 (5): 789-800, v. doi:10.1016/j.rcl.2009.06.002 - Pubmed
- 6. The Royal Australian and New Zealand College of Radiologists Level 9,. Iodinated Contrast Media Guideline, 2016 Edition. Sydney: The Royal Australian and New Zealand College of Radiologists, 2017. [Link].
- 7. American College of Radiology Manual on Contrast Media, version 10.3. https://www.acr.org/Clinical-Resources/Contrast-Manual, accessed 25 April 2018
- 8. Wichmann JL, Katzberg RW, Litwin SE, Zwerner PL, De Cecco CN, Vogl TJ, Costello P, Schoepf UJ. Contrast-Induced Nephropathy. (2015) Circulation. 132 (20): 1931-6. doi:10.1161/CIRCULATIONAHA.115.014672 - Pubmed
- 9. McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, Kallmes DF. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. (2013) Radiology. 267 (1): 119-28. doi:10.1148/radiol.12121460 - Pubmed
- 10. Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. (2018) Annals of emergency medicine. 71 (1): 44-53.e4. doi:10.1016/j.annemergmed.2017.06.041 - Pubmed
- 11. Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: A retrospective propensity-matched analysis. (2019) Journal of critical care. 51: 111-116. doi:10.1016/j.jcrc.2019.02.003 - Pubmed
Related articles: Imaging in practice
- imaging in practice
-
general radiography (adult)
- portable radiography
- chest radiography
- abdominal radiography
-
upper limb radiography
-
shoulder girdle radiography
- scapula series
-
shoulder series
- shoulder (AP view)
- shoulder (internal rotation view)
- shoulder (external rotation view)
- shoulder (superior-inferior axial view)
- shoulder (inferior-superior axial)
- shoulder (West Point view)
- shoulder (Velpeau view)
- shoulder (modified trauma axial view)
- shoulder (supine lateral view)
- shoulder (modified transthoracic supine lateral)
- shoulder (lateral scapula view)
- shoulder (AP glenoid view)
- shoulder (Garth view)
- shoulder (outlet view)
- shoulder (Stryker notch view)
- acromioclavicular joint series
-
clavicle series
- clavicle (AP view)
- clavicle (AP cephalic view)
- clavicle (oblique view)
- sternoclavicular joint series
- arm and forearm radiography
- wrist and hand radiography
- wrist series
- scaphoid series
- hand series
- thumb series
- fingers series
- rheumatology hands series
- bone age (radiograph)
-
shoulder girdle radiography
-
lower limb radiography
- pelvic girdle radiography
- thigh and leg radiography
- ankle and foot radiography
- skull radiography
-
paranasal sinus and facial bone radiography
- facial bones
- mandible
- nasal bone
- zygomatic arches
- paranasal sinuses
- temporal bones
- dental radiography
- orthopantomography
- temporomandibular joints
- temporomandibular joint (AP axial view)
- temporomandibular joint (axiolateral oblique view)
-
spinal radiography
- cervical spine series
-
thoracic spine series
- thoracic spine (AP view)
- thoracic spine (lateral view)
- thoracic spine (oblique view)
- lumbar spine series
- sacrococcygeal radiography
- scoliosis radiography
-
pediatric radiography
- radiographic positioning terminology
- systematic radiographic technical evaluation (mnemonic)
- pediatric immobilization
- foreign body ingestion series (pediatric)
- foreign body inhalation series (pediatric)
- shunt series
- chest radiograph (pediatric)
- abdomen radiograph (pediatric)
- upper limb radiography (pediatric)
-
lower limb radiography (pediatric)
- pelvis radiograph (pediatric)
- femur series (pediatric)
- pediatric femur (AP view)
- pediatric femur (lateral view)
- leg length view
- knee series (pediatric)
- pediatric knee (AP view)
- pediatric knee (lateral view)
- tibia fibula series (pediatric)
- pediatric tibia fibula (AP view)
- pediatric tibia fibula (lateral view)
- pediatric tibia fibula (oblique view)
- ankle series (pediatric)
- foot series (pediatric)
- skull radiography (pediatric)
- spine radiography (pediatric)
-
skeletal survey
-
skeletal survey (non-accidental injury)
- torso
- pediatric chest (AP erect view)
- pediatric chest (oblique ribs view)
- pediatric abdomen (AP supine view)
- pediatric spine (whole lateral view)
- upper limb (both sides)
- lower limb (both sides)
- pediatric femur (AP view)
- pediatric knee (lateral view)
- pediatric tibia fibula (AP view)
- pediatric ankle (lateral view)
- pediatric foot (DP view)
- torso
-
skeletal survey (non-accidental injury)
-
CT
- iodinated contrast media
- CT IV contrast media administration
-
CT protocol
- composite
- whole-body CT (protocol)
- CT Chest abdomen-pelvis (protocol)
- CT NCAP (neck, chest, abdomen and pelvis)
- head & neck
- chest
- abdomen and pelvis
- CT abdomen-pelvis (protocol)
- CT abdominal aorta
- CT adrenals (protocol)
- CT cholangiography (protocol)
- CT colonography (protocol)
- CT enteroclysis (protocol)
- CT enterography (protocol)
- CT gastrography (protocol)
- CT kidneys, ureters and bladder (protocol)
- CT urography (protocol)
- CT Renal mass (protocol)
- CT angiography of the splanchnic vessels (protocol)
- CT renal split bolus
- CT pancreas (protocol)
- liver
- composite
- barium studies
-
MRI
- cine imaging
-
brain
- screen protocol
- stereotaxis protocol
- tumor protocol
- stroke protocol
- infection protocol
- trauma protocol
- demyelination protocol
- epilepsy protocol
- neurodegenerative protocol
- trigeminal neuralgia protocol
- posterior fossa protocol
- temporal bone/IAM/CPA protocol
- pineal and tectal plate protocol
- pituitary gland protocol
- CSF flow
- angiographic protocols
- MRA
- circle of Willis (COW)
- carotid-vertebral system
- MRV
- MRA
- head and neck
- orbits protocol
- sinonasal tract protocol
- salivary glands protocol
- oropharynx and oral cavity protocol
- suprahyoid neck protocol
- infrahyoid neck protocol
- chest
- mediastinum
- cardiac
- abdomen and pelvis
- abdomen
- liver and biliary tree
- liver protocol
- MRCP: cholangiopancreatography
- pancreas protocol
- elastography
- anus and rectum
- uterus and ovaries
- urological
- prostate cancer protocol
- bladder cancer protocol
- kidneys protocol
- musculoskeletal
-
ultrasound
- ultrasound signs
-
obstetric ultrasound
- other
- placenta
-
second trimester
- fetal biometry
- fetal morphology assessment
-
soft markers
- nuchal fold thickness
- ventriculomegaly
- absent nasal bone
- echogenic intracardiac focus
- choroid plexus cysts
- echogenic bowel
- aberrant right subclavian artery
- amnioreduction
- echogenic fetal bowel
- umbilical artery Doppler assessment
- chorionic villus sampling (CVS) and amniocentesis
- nuchal translucency
- failed early pregnancy
- subchorionic hematoma
- multiple gestations
- ectopic pregnancy
-
first trimester and early pregnancy
- gestational sac
- yolk sac
- embryo/fetus
- amnion
- chorion
- Beta-hCG levels
- gynecologic ultrasound
- vascular ultrasound
- carotids
- extremities
- mesenteric vessels
- other
- breast ultrasound
-
musculoskeletal ultrasound
- technique/artifacts
- ultrasound of arthropathies
- skin/soft tissue ultrasound
- lipoma
- parasitic infection
- other
- pediatric musculoskeletal ultrasound
- ankle/foot ultrasound
-
knee ultrasound
- Baker cyst (popliteal cyst)
- infrapatellar bursitis
- hip ultrasound
- hand ultrasound
- wrist ultrasound
- elbow ultrasound
- shoulder ultrasound
- liver ultrasound
- hyperechoic liver lesion
- sonographic halo sign
- ultrasound appearances of liver metastases
- periportal hyperechogenicity
- periportal hypoechogenicity
- generalized increase in hepatic echogenicity
- generalized reduced hepatic echogenicity
- coarsened hepatic echotexture
- starry sky appearance (ultrasound)
- normal hepatic vein Doppler
- hepatic arterial resistive index
- gallbladder ultrasound
- pancreatic ultrasound
- gastrointestinal ultrasound
- renal ultrasound
- bladder ultrasound
-
testicular and scrotal ultrasound
- other
- epididymis
- paratesticular lesions
- bilateral testicular lesion
-
unilateral testicular lesion
- testicular torsion
- orchitis
- testicular rupture
-
germ cell tumor of the testis
- testicular seminoma
-
non seminomatous germ cell tumors
- mixed germ cell tumor
- yolk sac tumor (endodermal sinus tumor)
- embryonal cell carcinoma
- choriocarcinoma
- testicular teratoma
- testicular epidermoid (teratoma with ectodermal elements only)
- burned out testis tumor
- sex cord / stromal tumors of the testis
- prostate ultrasound
- neck and thyroid ultrasound
- echocardiography
- speckle tracking echocardiography
- fetal echocardiography
- contrast-enhanced echocardiography
- epicardial echocardiography
- three dimensional (3D) echocardiography
- transesophageal echocardiography (TEE)
- transthoracic echocardiography (TTE)
- left ventricular systolic and diastolic function
- structure and morphology
- systolic function
- diastolic function
- right ventricular assessment
- right and left atria
- valvular structure and function
- mitral valve
- aortic valve
- pulmonic valve
- tricuspid valve
- hemodynamics
- pericardium
- cardiomyopathies
- congenital heart disease
- great vessels
- pediatric ultrasound
- ultrasound interventions
- ultrasound-guided biopsy
- ultrasound-guided percutaneous drainage
- ultrasound-guided musculoskeletal interventions
- joint injection
- nerve blocks
- ultrasound-guided intravenous cannulation
- contrast-enhanced ultrasound
- physics and imaging modes
- grey-scale (B-mode)
- motion mode (M-mode)
- color flow Doppler (CFD)
-
spectral Doppler
- pulsed wave Doppler (PWD)
- continuous wave Doppler (CWD)
- superb microvascular imaging (SMI)
- tissue Doppler imaging (TDI)
- nuclear medicine
-
radiation therapy
- external beam radiation therapy (EBRT)
- sealed source radiation therapy (brachytherapy)
- unsealed source radiation therapy
-
interventional
- procedure overview
- neck
- thyroid gland
- breast
- chest
- hepatobiliary
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
-
arthrogram
- upper limb
- lower limb
-
hip
- hip joint injection (technique)
- greater trochanteric bursa injection
- gluteus minimus/medius tendon calcific tendinopathy barbotage
- iliopsoas tendon bursa injection
- lateral cutaneous femoral nerve of the thigh injection
- piriformis injection
- common hamstrings origin injections
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
foot
- calcaneocuboid joint injection
- metatarsophalangeal joint (MTPJ) injection
- naviculocuneiform joint injection
- plantar fascia microtenotomy
- subtalar joint injection
- talonavicular joint injection
- tarsometatarsal joint (TMTJ) injection
-
hip
- spine
- breast imaging
-
mammography
- breast screening
- breast imaging and the technologist
- forbidden (check) areas in mammography
-
mammography views
- craniocaudal view
- mediolateral oblique view
- additional (supplementary) views
- true lateral view
- lateromedial oblique view
- late mediolateral view
- step oblique views
- spot view
- double spot compression view
- magnification view
- exaggerated craniocaudal (axillary) view
- cleavage view
- tangential views
- caudocranial view
- bullseye CC view
- rolled CC view
- elevated craniocaudal projection
- caudal cranial projection
- 20° oblique projection
- inferomedial superolateral oblique projection
- Eklund technique
- normal breast imaging examples
-
mammography
- digital breast tomosynthesis
- breast ultrasound
- breast ductography
- breast MRI
- breast morphology
- breast intervention