CM Safety

Patients at risk for contrast-induced nephropathy

Prophylactic Measures for Prevention of CIN

• Consider alternative imaging modalities that do not require the administration of iodinated contrast media.
• Stop the administration of nephrotoxic drugs for 24 hours before and after the contrast-enhanced exam.
• Stop the administration of diuretics (especially loop diuretics).
• Hydrate all patients
  • Patients should be properly hydrated before and after contrast administration, especially the at-risk patients.
  • Hydration alone is better than hydration combined with a diuretic.
  • Intravenous (IV) hydration is reportedly more effective than unrestricted oral fluids.
  • Isotonic (0.9% sodium chloride, NaCl) IV hydration is reportedly more effective than half-isotonic (0.45% NaCl) IV hydration.
  • The maximum benefit of isotonic IV hydration is seen in women, diabetics, and patients receiving >250 mL contrast.
  • IV hydration with 0.9% sodium bicarbonate (NaHCO3) is reportedly more effective than IV hydration with 0.9% NaCl. (Solution: D5 NaHCO3 154 mEq/L; load: 3 mL/kg over 1 hour, given 1 hr before contrast; maintenance: 1 mL/kg/hr for 6 hours after procedure; use 110 kg maximum weight for calculations.)
• Limit the dose of contrast to the minimum needed to obtain images of adequate diagnostic quality.
• Do not perform multiple imaging studies with iodinated contrast agents in a short period of time unless absolutely necessary; try to keep an interval =48 hours between contrast exams.
• Use low-osmolar contrast media
  • Nonionic contrast media are less nephrotoxic than ionic, high-osmolar contrast media.
  • Even so, nonionic iodinated contrast agents may further deteriorate the renal function of renally-compromised patients.
• Data in the literature do not fully support the efficacy of any pharmacologic premedication with the exception of hydration, as described above.
  • Fenoldopam has been proven ineffective at preventing CIN.
  • Oral or IV N-acetylcysteine is often recommended, as it is inexpensive and has low risk, but its clinical benefit still needs to be proven. It is also important to note that dialysis rates are not reduced by the use of N-acetylcysteine.
  • Theophylline may be of benefit, but needs more study.