Contrast in patient with renal failure?

[nwbgn]

Hello, just wanted to know your thoughts on performing a lumbar ESI on a patient with history of renal failure. Patient is elderly with neurogenic claudication type symptoms from moderate central canal stenosis with creatinine in the 6's. Would you do interlaminar ESI and rely on LOR and AP / lat fluoro alone, no contrast, or some other technique I am overlooking? Thanks in advance.

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[willabeast]

one ml of iohexol 240 will not box anyone's kidneys. you could get confirmation from patient's nephrologist.

 

[nwbgn]

Thanks, but one (important) thing I forgot to mention was that his renal failure became much worse (and never really improved) after he received contrast for an imaging study he had in the past, so he is quite adverse to the idea of receiving any contrast.

 

[SSdoc33]

CT scan with IV dye is very different than 1 mL of non-ionic contrast extravascular. you will not have a problem. personally, id do a TFESI, but ILESI with no contrast would also work is the patient doesnt listen to reason.

 

[willabeast]

a caudal without contrast is IMHO a very safe procedure, if they feel no pressure when you inject you are probably in a vein, if they do feel pressure you are probably in the right place.

Thanks, but one (important) thing I forgot to mention was that his renal failure became much worse (and never really improved) after he received contrast for an imaging study he had in the past, so he is quite adverse to the idea of receiving any contrast.

CT scan with IV dye is very different than 1 mL of non-ionic contrast extravascular. you will not have a problem. personally, id do a TFESI, but ILESI with no contrast would also work is the patient doesnt listen to reason.

 

[emd123]

Even the Rathmell safe ESI recommendations listed in the other thread, leaves a carve out for the occasional IL or TF esi without contrast IF there's a severe contrast allergy.

I agree. If only 1 in 500 TF or Il ESIs we do is without contrast Theres a pretty low chance anything will happen as a result of opting out of contrast that infrequently. Balance that with a known allergy.

But as far as renal failure patients, if they're anuric, on dialysis you're not going to kill kidneys that are already killed. In the milder renal failure patients (Cr 1.5-2 range) anytime I've asked nephro about it, they didn't seem too worried about 1 cc of contrast versus the 50 cc given in a Ct or more for angiogram.

 

[specepic]

thoughts
1) ILESI with LOR only*
2) clear with nephr. use of cx
3) not fond of caudal w/o cx, so damn vascular vs ILESI almost never in a vessel
4) meds renally dosed i.e. renal dose gabapentin

 

[nwbgn]

I was thinking ILESI with methylprednisolone vs. caudal with dexamethasone due to potential vasculature. I did not think of TFESI due to inability to use LOR to localize, as well as the proximity to radicular arteries. Thanks to all for your replies.

 

[ampaphb]

any chance you could get away with using gad?

 

[CptNemo]

Here's a nephrologists opinion: Even if 1 mL of iodinated contrast got to the vasculature it would get diluted in 3000 mL of plasma. It would seem implausible that so little contrast could cause any kidney problems even in someone with CKD. In general, the more contrast you give IV, the higher the risk... I can't recall ever seeing a case of CIN due to <50 mL being used (and usually it's >100 mL).

 

[hyperalgesia]

I was thinking ILESI with methylprednisolone vs. caudal with dexamethasone due to potential vasculature. I did not think of TFESI due to inability to use LOR to localize, as well as the proximity to radicular arteries. Thanks to all for your replies.

ILESI with dexa and NS, no local. Could also use a catheter to help confirm epidural vs false LOR. If pt is against contrast, don't use it.

 

[pmrrmp]

I had a similar patient last year. Spoke to the nephrologist who had no problems with the small amount of contrast used for epidurals.

 

[seamonkey]

You should be much more worried about platelet dysfunction in a renal failure patient.

 

[clubdeac]

Here's a nephrologists opinion: Even if 1 mL of iodinated contrast got to the vasculature it would get diluted in 3000 mL of plasma. It would seem implausible that so little contrast could cause any kidney problems even in someone with CKD. In general, the more contrast you give IV, the higher the risk... I can't recall ever seeing a case of CIN due to <50 mL being used (and usually it's >100 mL).

Cpt, wouldn't gad be more dangerous in renal failure patients than omnipaque? Nephrogenic Systemic Fibrosis

 

[CptNemo]

Cpt, wouldn't gad be more dangerous in renal failure patients than omnipaque? Nephrogenic Systemic Fibrosis

Theoretically, yes.

I'm not sure how much gad you would actually use. There is some evidence that the risk is also dose dependent.

However, to the you the truth, the risk is thought to be very low in patients not on dialysis. The risk is much higher in dialysis patients, but still <5% (though obviously too high to safely use in this population w/o causing harm and getting sued). We don't ever use gad in pts with a GFR <15 mL/min or on dialysis (and very rarely in pts w/ GFR <30). I haven't seen a case of NSF since med school (~10 yrs ago). Probably because the event rate is so low, we don't have much good data on NSF.