Contrast media and the kidney: European Society of Urogenital Radiology (ESUR) Guidelines

Abstract

The Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has looked at the effects of contrast media on the kidney including prevention of contrast medium induced nephropathy. This has resulted in four reports dealing with 1) contrast medium induced nephrotoxicity, 2) haemodialysis and contrast media, 3) use of gadolinium contrast media instead of iodinated contrast media and 4) contrast media injection in diabetic patients receiving metformin. The review presents an overview of these four reports and offers the current understanding of the interaction between contrast agents and the kidney.

Good MRI images: to Gad or not to Gad?

“…Again, a glance at the literature reveals that colleagues have been studying Gad-contrastinduced nephrotoxicity (CIN) since the early 1990s. CIN is now defined by the European Society of Urogenital Radiology (ESUR) [12] as an increase in serum creatinine of more than 25%, or more than 0.5 mg/dl, occurring within 3 days after the intravascular administration of the contrast medium in the absence of an alternative etiology. Interestingly, the controversial results are mostly due to the differing definitions of nephrotoxicity, patient's collectives, renal diseases, contrast agents, and contrast-agent concentrations that have been employed and published.…”

“…Unfortunately, due to sparse data on the renal lesions associated with this condition, very little is known about the mechanism of Gad nephrotoxicity. The nephrotoxic effects of iodinated contrast agents, which have been studied more intensely, are multifactorial, including a vasoconstrictive effect leading to hypoxic or ischemic tubular cell injury and a direct tubulotoxicity mediated by the generation of reactive oxygen species [12]. As Gad-based and iodinated contrast agents share the same pharmacodynamics [12,15] and their nephrotoxic effects are often clinically similar, they may cause renal damage through the same mechanisms.…”

“…Gadodiamide, for example, leaves two to four times more Gad in the bone than other contrast agents in patients with normal renal function [10,12]. Because of the longer half-life of Gad-based contrast media in patients with ESRD, it could be speculated that Gad liberation might be causing systemic effects.…”

“…At the same time, we must protect them from an unjustified risk caused by the possibility of adverse Gad-associated events. Raised serum creatinine levels (particularly secondary to diabetic nephropathy), dehydration, congestive heart failure, an age of over 70 years, and concurrent administration of nephrotoxic drugs (nonsteroidal anti-inflammatory drugs) are all considered potential risk factors by the guidelines [12]. Consequently, patients undergoing a diagnostic MRI scan with potential Gad exposure should be well hydrated, low-or iso-osmolar contrast media should be used, and nephrotoxic drugs should have been stopped for at least 24 h. Alternatively, other imaging techniques that do not require the administration of Gad should be taken into consideration.…”

“…All in all, the less Gad, the better! In patients on continuous ambulatory PD (CAPD) and severely reduced renal function, one should avoid Gad doses exceeding 0.3 mmol/ kg bw [12].…”