Today’s pearl reviews some of the literature and recommendations regarding the use of iodinated contrast in patients with kidney disease
Will it cause an acute-on-chronic injury? Is it safe?
It’s long been debated what role, if any, iodinated contrast agents play in causing acute kidney injury (AKI). In the largest ED study to date, there was not an increased risk of AKI in patients receiving IV contrast (Hinson 2017). Recently, the American College of Radiology and National Kidney Foundation published an important change of recommendation on the use of IV contrast media in patients with preexisting kidney disease (Davenport 2020). In downgrading their level of caution, they state:
“The risk of AKI developing in patients with reduced kidney function following exposure to IV iodinated contrast media has been overstated.”
The two most important take-aways from the consensus statement are:
- When required for the evaluation of a potentially life-threatening diagnosis, contrast media should never be withheld, regardless of renal function
- For patients with a stable eGFR greater than 30 mL/min per 1.73 m2, there are no data to support withholding contrast media out of concern for precipitating acute kidney injury when contrast media administration is otherwise clinically indicated for any reason
Recommendations for specific subpopulations relevant to ED management include:
- Patients with a solitary kidney should be treated no differently than the general population
- Patients receiving maintenance dialysis should be treated similarly to those who are not receiving renal replacement therapy
- Patients receiving dialysis who receive contrast media do not require an alteration in their routine dialysis schedule, regardless of residual kidney function
Importantly, this consensus statement only applies to those with pre-existing reduced renal function. There is a nice editorial in Annals of EM that discusses the history and data on this topic and helps put the new consensus statement in perspective for ED practice (Hinson 2020).