Macdonald D Blair, Hurrell Casey D, Costa Andreu F, McInnes Matthew D F, O'Malley Martin, Barrett Brendan J, Brown Pierre Antoine, Clark Edward G, Hadjivassiliou Anastasia, Kirkpatrick Iain Donald Craik, Rempel Jeremy, Jeon Paul, Hiremath Swapnil
Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Canadian Association of Radiologists, Ottawa, ON, Canada.
Can J Kidney Health Dis. 2022 May 24;9:20543581221097455. doi: 10.1177/20543581221097455. eCollection 2022.
Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations.
Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada.
The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations.
The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration.
We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment.
Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.
碘化造影剂是使用最为频繁的药物之一。在加拿大，2019年进行了超过540万例计算机断层扫描（CT）检查，其中50%为增强扫描。碘化造影剂给药后发生的急性肾损伤（AKI）在历史上被视为一种常见的医源性并发症，可通过对患者进行筛查、采取预防策略以及对肾功能进行随访评估来处理。加拿大放射学会（CAR）最初于2007年发布了关于预防造影剂肾病的指南，并于2012年进行了更新。然而，该领域的新进展带来了更安全的造影剂以及临床实践的变化，促使对早期建议进行全面修订。
已发表的文献，包括临床试验、回顾性队列研究系列、综述文章和病例报告，以及来自加拿大各地放射科医生和肾病科医生的专家意见。
CAR的领导层组建了一个由放射科医生和肾病科医生组成的工作组，他们在造影剂给药及与造影剂相关的急性肾损伤患者管理方面具有专业知识。我们对已发表的文献进行了全面回顾，以评估关于造影剂作为急性肾损伤病因的证据，并为基于证据的建议提供依据。基于现有文献，工作组制定了共识性建议。
工作组制定了21条建议，涉及筛查、碘化造影剂的选择、预防、用药考虑以及造影剂给药后管理。与2012年指南的主要变化包括：（1）将筛查简化为简单问卷，且不因需要测量肌酐而推迟急诊检查；（2）仅对估算肾小球滤过率（eGFR）低于30 mL/min/1.73 m²的患者考虑预防措施；（3）除eGFR低于30 mL/min/1.73 m²时的二甲双胍外，不建议常规停用任何药物以降低急性肾损伤风险；（4）碘化造影剂给药后不需要常规随访血清肌酐测量值。
我们未进行正式的系统评价或荟萃分析。我们未在临床环境中评估我们的具体建议。
鉴于碘化造影剂在诊断和治疗中的重要性，以及造影剂使用后急性肾损伤的低风险，这些指南旨在简化大多数临床环境中碘化造影剂使用的流程。随着可能改变或补充所提供建议的新证据出现，工作组将修订这些指南。
