What are the concerns with using Intravenous (IV) contrast in a patient undergoing Hemodialysis (HD) due to Impaired renal function?

From the Guidelines

Intravenous contrast can be safely administered to hemodialysis patients without significant concerns about contrast-induced nephropathy, as these patients already have established kidney failure. For iodinated contrast used in CT scans, no special timing relative to dialysis is necessary, though some nephrologists prefer dialysis within 24 hours after contrast administration to remove the contrast and minimize any potential adverse effects 1. The use of iso-osmolar or low-osmolar iodinated contrast media is recommended in patients at increased risk of contrast-induced acute kidney injury (CI-AKI), rather than high-osmolar iodinated contrast media 1.

When administering intravenous contrast to hemodialysis patients, it is essential to:

• Use the lowest possible dose of contrast medium in patients at risk for CI-AKI 1
• Provide intravenous fluids prior to and after the administration of iodinated contrast media to prevent CI-AKI 1
• Avoid using oral fluids alone in patients at increased risk of CI-AKI 1
• Consider alternative imaging methods in patients at increased risk for CI-AKI 1

For gadolinium-based contrast agents used in MRI, caution is warranted due to the risk of nephrogenic systemic fibrosis (NSF). If gadolinium is deemed necessary, use macrocyclic agents (such as gadobutrol, gadoterate meglumine, or gadoteridol) which have the lowest risk of NSF, and schedule dialysis within 24 hours after administration. The standard dialysis prescription does not need modification for contrast removal. Always ensure proper hydration status before contrast administration, and be vigilant for allergic reactions which can occur regardless of kidney function. Communication between the radiologist and nephrologist is essential to coordinate optimal timing of imaging and dialysis sessions.

From the FDA Drug Label

5.3 Contrast-Induced Acute Kidney Injury Acute kidney injury, including renal failure, may occur after iodixanol administration Risk factors include: pre-existing renal impairment, dehydration, diabetes mellitus, congestive heart failure, advanced vascular disease, elderly age, concomitant use of nephrotoxic or diuretic medications, multiple myeloma/paraproteinaceous diseases, repetitive and/or large doses of an iodinated contrast agent. Use the lowest necessary dose of iodixanol in patients with renal impairment Adequately hydrate patients prior to and following iodixanol administration. Do not use laxatives, diuretics, or preparatory dehydration prior to iodixanol administration.

The use of IV contrast, such as iodixanol, in a patient on hemodialysis is a concern due to the risk of contrast-induced acute kidney injury. Patients with pre-existing renal impairment are at higher risk. To minimize this risk, it is recommended to:

• Use the lowest necessary dose of iodixanol
• Adequately hydrate patients prior to and following administration
• Avoid using laxatives, diuretics, or preparatory dehydration prior to administration 2 2.

From the Research

Concerns with IV Contrast in Patients on Hemodialysis

• The use of intravenous iodinated contrast agents in patients on hemodialysis is a concern due to the risk of contrast-induced nephropathy (CIN) 3, 4, 5, 6.
• CIN is defined as a decline in kidney function occurring after administration of iodinated contrast agents, and it can lead to more permanent renal insufficiency, dialysis, and death 3.
• Hemodialysis can efficiently remove contrast media from the blood, but it does not offer any protection against contrast media-induced nephrotoxicity 4, 5.
• The effectiveness of hemodialysis in removing contrast media depends on several factors, including blood and dialysate flow rate, permeability of dialysis membrane, duration of hemodialysis, and molecular size of the contrast medium 4, 5.
• Peritoneal dialysis is also effective in removing contrast agents from the body, but it takes longer than hemodialysis 4, 5.
• Hemofiltration may decrease the risk of contrast-induced nephropathy and have some long-term benefits, but additional studies are needed to better define the appropriate population for this treatment 4.
• There is no need to schedule dialysis in relation to the injection of iodinated or MR contrast media or the injection of contrast agent in relation to the dialysis program 5.
• The choice of contrast agent may also play a role in the risk of CIN, with some studies suggesting that certain agents may be safer than others in patients with preexisting renal impairment 7.