Is receiving intravenous (IV) contrast significant for someone with End-Stage Renal Disease (ESRD) on dialysis?

From the Guidelines

Receiving intravenous (IV) contrast is generally considered safe for patients with End-Stage Renal Disease (ESRD) who are on regular dialysis. For these patients, the kidneys have already failed, so there is minimal concern about contrast-induced nephropathy that would typically worry physicians in patients with functioning kidneys, as noted in the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 1. The timing of contrast administration relative to dialysis is important. Ideally, the contrast should be given shortly before a scheduled dialysis session so that the contrast material can be removed from the body during the next dialysis treatment, typically within 24 hours of administration. This approach helps minimize any potential systemic effects from the contrast material.

Some key considerations for patients with ESRD on dialysis include:

• Informing their nephrologist about the planned contrast study so the dialysis schedule can be adjusted if necessary
• Monitoring for symptoms like hives, itching, swelling, or breathing difficulties during and after contrast administration, as allergic reactions to contrast media can occur in any patient, regardless of kidney function
• Following a reasonable hydration regimen, such as isotonic crystalloid (1.0 to 1.5 mL/kg per hour) for 3 to 12 hours before the procedure and continuing for 6 to 24 hours after the procedure, as suggested by studies on hydration to reduce the risk of contrast-induced AKI 1
• Minimizing the volume of contrast media, as the correlation between the volume of contrast media and the risk of contrast-induced AKI has been documented in several studies 1

It's also important to note that the use of N-acetyl-L-cysteine is not recommended for the prevention of contrast-induced AKI, as studies have shown no clear evidence of benefit 1. Overall, with proper planning and monitoring, IV contrast can be safely administered to patients with ESRD on dialysis.

From the Research

Significance of Receiving IV Contrast for ESRD Patients on Dialysis

• Receiving intravenous (IV) contrast can be significant for someone with End-Stage Renal Disease (ESRD) on dialysis due to the risk of contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF) 2, 3, 4.
• The use of iodinated contrast media can increase the risk of CIN, while gadolinium-based contrast agents (GBCA) can increase the risk of NSF in patients with reduced renal function 2, 4.
• Strategies to avoid CIN include isotonic volume expansion and the use of the lowest dose of low-osmolar or iso-osmolar contrast media possible 2, 3.

Recommendations for IV Contrast Use in ESRD Patients

• The current literature does not support the use of prophylactic hemodialysis to reduce CIN, unless an individual's cardiopulmonary status is dependent on strict volume management 2, 5.
• For patients with ESRD on dialysis, it is recommended to avoid the use of GBCA and consider alternative imaging modalities 2, 4.
• If GBCA is absolutely necessary, the use of the lowest dose possible of the newer macrocylic, ionic agents (e.g., gadoterate meglumine) is recommended, along with immediate postprocedural hemodialysis (HD) in patients already on HD or peritoneal dialysis 2, 6.

Safety of IV Contrast in ESRD Patients

• Nonionic contrast material can be given safely to patients with ESRD who are being maintained on hemodialysis, without the need for immediate postprocedural dialysis 5.
• A retrospective observational study found no cases of NSF in 1129 patients with ESRD who underwent 1461 Gd-MRI scans, regardless of the dose of HD 6.