Download Contrast Induced Nephropathy Policy

_________________________
2700 Stewart Parkway, Roseburg, OR, 97471
541-677-4418
Contrast Induced Nephropathy Policy
(Nephropathy: Refers to damage or disease of the kidney)
Purpose: To ensure that MMC Imaging department takes every step possible in reducing and
eliminating CIN “Contrast Induced Nephropathy”. The development of acute renal failure is a significant
complication of intravascular contrast media use and is linked with excess morbidity and mortality.
Unless preventative measures are used, increasing use of contrast media, an aging population and an
increase in chronic kidney disease will result in an increased incidence of Contrast Induced Nephropathy.
The major risk factor predicting CIN is preexisting chronic kidney disease, which can be predicted from
glomerular filtration rate (GFR). Serum creatinine (SCr) as an absolute measure is an unreliable measure
of renal function.
Policy: Every patient that is at risk for CIN and will receive IV contrast needs a current GFR value before
contrast administration. The GFR can be determined by using the slide rule system, provided by GE or
the program on your Imaging computer desktop labeled “VisiCalc”. This can be done by the Scheduling
department and/or the technologist; a current body weight, age, sex (M/F), and SCr is needed to
determine GFR.
Risk factors for Contrast Induced Nephropathy
Methods to identify patients at risk include use of a patient questionnaire, review of complete medical
history, and measurement of SCr.
Diabetes mellitus
Renal disease or solitary kidney
Sepsis or acute hypotension
Dehydration or volume contraction
Age > 70 years
Organ transplant
Cardiovascular disease (hypertension, congestive heart disease, cardiac or peripheral vascular disease)
Nephrotoxic medications (loop diuretics, amphotericin B, aminoglycosides, vancomycin, cancer and
immune suppressant chemotherapy, Metformin, Glucophage, Avandamet, Metaglip, Glucovance,
Fortamet, Riomet)
Human immunodeficiency syndrome or acquired immunodeficiency syndrome
The risk of Contrast Induced Nephropathy is greatest in patients with GFR less than 30
mL/min and no IV contrast should be administered. Consider other imaging modalities or
non-contrast CT scan. In addition, if the SCr is 1.6 to 1.9 a radiologist should OK the use of IV
contrast, regardless of a good GFR level. Any patient with a SCr above 2.0 should not receive
any IV contrast.
A GFR level of 60 mL/min or greater is acceptable for Isovue 370, unless other contraindications are
presented; i.e. allergy to iodine.
With a GFR of 59 mL/min to 30 mL/min, then Preventative Measures, recommended by a radiologist
should be instituted (see below).
Preventative measures including, but not limited to, the following:
1. Fluid volume loading is the single most important protective measure, before and after IV
contrast.
a.
b.
c.
d.
Outpatients – For patients instructed to drink water as an oral contrast agent, have them follow
the pre-exam prep. Follow the exam with one 12 oz glass of water. If the patient is instructed to
drink Redicat for an oral prep, then have them drink two 12 oz glasses of water after the exam is
finished.
Inpatients – For patients instructed to drink water as an oral contrast agent, have them follow
the pre-exam prep. Follow the exam with one 12 oz glass of water. If the patient is instructed to
drink Redicat for an oral prep, then have them drink two 12 oz glasses of water after the exam is
finished. If the patient is not able to take water or Redicat orally, then administer 500 mL of IV
hydration using normal saline (0.9% Sodium Chloride injection USP), 250 mL pre and 250 mL post
scan. Consult with patients nurse regarding hydration; if hydration is already being given then it
is not necessary to exceed 500 mL volume.
ER patients – For patients instructed to drink water as an oral contrast agent, have them follow
the pre-exam prep. Follow the exam with one 12 oz glass of water. If the patient is instructed to
drink Redicat for an oral prep, then administer 500 mL of IV hydration using normal saline (0.9%
Sodium Chloride injection USP), 250 mL pre and 250 mL post scan. Consult with patients nurse
regarding hydration; if hydration is already being given then it is not necessary to exceed 500 mL
volume.
If the patient is not able to take water or Redicat orally (i.e. trauma, patient is unconscious,
patient not able to follow instructions), then administer 500 mL of IV hydration using normal
saline (0.9% Sodium Chloride injection USP), 250 mL pre and 250 mL post scan. Consult with
patients nurse regarding hydration; if hydration is already being given then it is not necessary to
exceed 500 mL volume.
2. Nephrotoxic medications (Metformin, Glucophage, Avandamet, Metaglip, Glucovance) should
be discontinued the day of the scan and held for 72 hours after the study, pending lab results.
The ordering physician will control the orders for the labs and the results to the patients. The
technologist should remind the patient of the 72 hour hold after the scan.
3. Contrast media volume and frequency of administration should be minimized while still
maintaining satisfactory image quality.
4. Use of low-osmolar contrast media in patients with GFR between 60 mL/min and 30 mL/min
(Isovue 370).
5. Acetylcysteine (Mucomyst) follow protocol below. Ordering physician will write the prescription
for Mucomyst.
6. Alternative imaging not requiring contrast media should be considered.
MUCOMYST PROTOCOL
RX:
4 Mucomyst (acetylcysteine) pills/capsules 600 mg each
st
1 pill – take orally between 12:00 – 1:00 pm the day before the exam.
2nd pill – take orally at bedtime night before the exam.
3rd pill – as soon as patient wakes on the morning of the exam.
4th pill – patient to take after the exam is over. Outpatients will bring the pill with them to the
appointment; the technologist will remind them to take the pill after the exam is finished.
Inpatients will receive the pill from their nurse after the exam.