Contrast induced nephropathy

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chocomorsel said:
Yes. It’s definitely a thing. What makes you think otherwise?
Click to expand...
The fact that over the years there hasn't been a convincing piece of evidence that modern day, low osmolar contrast leads to a measurable increase in dialysis.

emcrit.org

Contrast Nephropathy, myth thereof

CONTENTS Venous injection of contrast (e.g. for CT scan) The birth of the contrast nephropathy myth Current lack of evidence regarding contrast nephropathy Weighing the risks vs. benefits of using contrast (Renalism) The attention given to contrast nephropathy is insane Intra-arterial contrast...
emcrit.org emcrit.org
 
Ronin786 said:
The fact that over the years there hasn't been a convincing piece of evidence that modern day, low osmolar contrast leads to a measurable increase in dialysis.

emcrit.org

Contrast Nephropathy, myth thereof

CONTENTS Venous injection of contrast (e.g. for CT scan) The birth of the contrast nephropathy myth Current lack of evidence regarding contrast nephropathy Weighing the risks vs. benefits of using contrast (Renalism) The attention given to contrast nephropathy is insane Intra-arterial contrast...
emcrit.org emcrit.org
Click to expand...

Is dialysis the best endpoint here? How about increased Cr?
 
Ronin786 said:
The fact that over the years there hasn't been a convincing piece of evidence that modern day, low osmolar contrast leads to a measurable increase in dialysis.

emcrit.org

Contrast Nephropathy, myth thereof

CONTENTS Venous injection of contrast (e.g. for CT scan) The birth of the contrast nephropathy myth Current lack of evidence regarding contrast nephropathy Weighing the risks vs. benefits of using contrast (Renalism) The attention given to contrast nephropathy is insane Intra-arterial contrast...
emcrit.org emcrit.org
Click to expand...
Interesting links. Gotta read up on those.

I’ve never understood this to be not a “one hit” thing though. It’s a “multiple hit” situation. As in one dose of contrast, one dose of vancomycin, one dose of an ACE or whatever doesn’t lead to the AKI that may potentially lead to dialysis, but it is a contributing factor.
 
chocomorsel said:
While I am no research expert, you are showing us a link to a meta analysis, of 28 observational studies.
IDK. Kinda weak.
Click to expand...

There are no “good” studies. Until someone does a massive prospective RCT we will never know. But that will never happen because you can’t randomize critically ill patients to get saline in stead of contrast if they need a contrast study to diagnose potentially life threatening pathology. You have to make decisions based off the data you have. The original data showing evidence of harm was far lower quality than this. You do the best with what you’ve got.
 
I agree that the studies are not especially high caliber. However, it is worth taking into the account the concept that one thing we are perpetually guilty of doing in medicine is taking one fact and forcefully extrapolating it to another. In medical school (which is always quite behind actual clinical trends) we all likely learned about contrast nephropathy which was ultimately in the context of older contrast agents.

An analogous situation would be the widespread belief of the extreme danger of metformin-induced lactic acidosis in patients undergoing surgery or any sort of procedure with a chance for transient renal impairment (such as IV contrast lol), which was all extrapolated from phenformin studies and has essentially been debunked at this point.
 
eikenhein said:
Is dialysis the best endpoint here? How about increased Cr?
Click to expand...
Dialysis is the best endpoint we have because it signifies a clinically relevant kidney toxin. Creatinine is just a poor marker of kidney function or deterioration. The random fluctuations make it quite difficult to glean any causation.
 
chocomorsel said:
While I am no research expert, you are showing us a link to a meta analysis, of 28 observational studies.
IDK. Kinda weak.
Click to expand...
You are correct. You are no research expert.
Could you imagine approaching an ethics board looking to do a prospective RCT on administration of IA or IV CM?
These studies are likely the best we will ever get
 
Newtwo said:
You are correct. You are no research expert.
Could you imagine approaching an ethics board looking to do a prospective RCT on administration of IA or IV CM?
These studies are likely the best we will ever get
Click to expand...
I know you are being snarky but you can at least attempt to find a retrospective study starting with patients who end up on dialysis and work your way backwards.
But ok.
 
chocomorsel said:
I know you are being snarky but you can at least attempt to find a retrospective study starting with patients who end up on dialysis and work your way backwards.
But ok.
Click to expand...
That's a pretty bad study design though. Patients who end up on dialysis are probably also going to be the same patients who require a contrast CT for whatever reason.

If you want something retrospective, here you go:
www.ncbi.nlm.nih.gov

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration - PubMed

In the largest well-controlled study of acute kidney injury following contrast administration in the ED to date, intravenous contrast was not associated with an increased frequency of acute kidney injury.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Close to 18,000 patients over a 5 year period to see whether there was any correlation with kidney injury.
 
eikenhein said:
Is dialysis the best endpoint here? How about increased Cr?
Click to expand...
Creatinine is a very poor marker.

The RIFLE criteria is laughable. Do people still talk about that?
 
In our ICU, we still get a lot of pushback from rads re: contrasted studies in pts with even the smallest creatinine bump. Most of our intensivists don't believe in contrast nephropathy, but some are pretty wary (seems age-dependent). As an academic institution, they still have to deal with the steady onslaught of fresh residents that bring up CIN when pining for the extra information contrast would afford.
 
ButterButter said:
In our ICU, we still get a lot of pushback from rads re: contrasted studies in pts with even the smallest creatinine bump. Most of our intensivists don't believe in contrast nephropathy, but some are pretty wary (seems age-dependent). As an academic institution, they still have to deal with the steady onslaught of fresh residents that bring up CIN when pining for the extra information contrast would afford.
Click to expand...
Creatinine is not only filtered, but also secreted. Hence a number of factors influence it, including DIET, or medications.

Effect of a Cooked Meat Meal on Serum Creatinine and Estimated Glomerular Filtration Rate in Diabetes-Related Kidney Disease | Diabetes Care | American Diabetes Association

OBJECTIVE. Fasting is not routinely recommended for renal function tests, despite the known effects of cooked meat on creatinine. We therefore studied variation
care.diabetesjournals.org care.diabetesjournals.org

Hence small creatinine bumps don't matter. Also, there is the concept of risks vs benefits. Since true CIN is RARE, do NOT withhold contrast studies that are important for the patient (e.g. to rule out PE).
 
That 100000 patient study was pretty convincing. A few big studies made up about 50000 patients and they all used pretty good propensity matching, included patients with starting egfrs from 15-30 (where there was no difference in AKI) or specifically only studied patients with CKD

This is not to mention there was never any evidence for CIN in the first place. The original studies were done in the 60s with high osmolar contrast (which is no longer in use) and no control group
 
Should also consider difference between IV and IA contrast. IA is much higher contrast load to the kidneys and may cause CIN, a lot of recent research really looks at IV contrast and suggests it may not be a meaningful issue. There's probably enough data to allow a proper RCT for IV contrast to get past an IRB if anybody or institution wanted to give it a go.
 
urge said:
Creatinine is a very poor marker.
Click to expand...

by itself, yeah. when correlated to a reliable GFR (not calculated but Cr clearance) useful enough. granted, most patients haven't had a 24 hr Cr clearance but worth looking through the record for, especially for patients likely to need a contrast study and therefore at risk for CKD.
 
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