From the Guidelines
Avoid contrasted CT scans in ESRD patients on dialysis when the clinical benefit does not outweigh the risks, particularly for routine follow-ups or non-urgent situations. For ESRD patients on dialysis, contrast administration should be limited to cases where the diagnostic information is crucial and cannot be obtained through alternative imaging methods, as stated in the ACR Appropriateness Criteria for renal failure 1. When contrast is necessary, use the lowest possible dose and consider scheduling the scan just before a dialysis session.
Specific precautions to consider:
- Use iso-osmolar or low-osmolar contrast agents, as recommended by the ACR Manual on Contrast Media 1.
- Ensure proper hydration before and after the procedure to minimize the risk of contrast-induced nephropathy (CIN) and volume overload.
- Schedule dialysis within 24 hours post-contrast administration, preferably within 4-6 hours if possible, to reduce the risk of systemic effects and electrolyte imbalances.
The main concern with contrast use in ESRD patients is the risk of CIN, even though these patients are already on dialysis, as well as the potential for worsening residual renal function and increasing the risk of volume overload and electrolyte imbalances 1. Additionally, the use of gadolinium-based contrast agents in MRI should be avoided in patients with severe renal dysfunction, including those on dialysis, due to the risk of nephrogenic systemic fibrosis, as noted in the ACR Appropriateness Criteria for imaging of right upper quadrant pain 1.
Alternative imaging methods to consider include:
- Non-contrast CT
- MRI without gadolinium
- Ultrasound, depending on the clinical question at hand, as these methods can provide diagnostic information without the risks associated with contrast agents 1.
From the Research
Contexts to Avoid Contrasted Computed Tomography (CT) Scan
In patients with End-Stage Renal Disease (ESRD) on dialysis, a contrasted Computed Tomography (CT) scan should be avoided in the following contexts:
- Risk of Contrast-Induced Nephropathy (CIN): The use of iodinated contrast agents can increase the risk of CIN in patients with chronic kidney disease (CKD) and ESRD 2.
- Gadolinium-Based Contrast Agents (GBCA) Exposure: GBCA exposure can increase the risk of Nephrogenic Systemic Fibrosis (NSF) in patients with reduced renal function, including those with AKI, CKD stage 3 or greater, or patients on dialysis 2.
- Alternative Imaging Modalities: Alternative imaging modalities should be considered in patients with reduced renal function to avoid the risks associated with contrast agents 2.
- Immediate Removal of Contrast by Dialysis: Immediate removal of contrast by dialysis is not recommended unless an individual's cardiopulmonary status is dependent on strict volume management 2.
Specific Patient Populations
- Elderly Patients: Elderly patients with diabetic nephropathy and ESRD may have an increased risk of early initiation of dialysis, and the occurrence of pneumonia is also associated with early dialysis 3.
- Patients with Lupus Nephritis (LN-ESRD): The choice of dialysis modality (hemodialysis or peritoneal dialysis) may affect the risks of disease activity, infection, cardiovascular events, and mortality in patients with LN-ESRD 4.
Clinical Considerations
- Assessment of Bone Mineral Density: The diagnosis and management of osteoporosis in ESRD patients may differ from the general population, and standard diagnostic tools such as dual energy X-ray absorptiometry (DEXA) have been widely used for the assessment of bone mineral deficiency status in ESRD patients 5.
- Abdominal Emergencies: The causes of acute abdominal pain in ESRD patients differ significantly from the general population and depend on the renal replacement therapy modality 6.