Dr. Sudhir Kale is the head of radiology and lead consultant at Aster CMI hospital in Bangalore, India. He has over 14 years of experience in cross-sectional imaging and specializes in whole body CT/MRI. He is certified and trained in MR-guided HIFU surgeries and has authored chapters in textbooks. Dr. Kale has participated in various research projects involving neuroimaging and has reported on imaging for professional cricket and soccer players in India. He regularly presents at CME conferences on advanced applications like coronary, neuro, and sports injury imaging.

1. Dr Sudhir Kale Profile
• “Head of the Department and Lead Consultant
Radiology”- Aster CMI hospital Bangalore.
• Postgraduation from Barnard institute of
Radiology- Madras Medical college
• 14 yrs experience in cross sectional imaging.
• Certified and Trained in MR guided HIFU surgeries
• Strengths: Whole body CT / MRI imaging.
• About 55 platform presentations in CME, state and
national conferences.
• He is well-versed with advanced applications
including Coronary imaging, Neuro imaging, Gastro
Imaging, Liver segmentation and sports injuries.

2. • Author of MR HIFU chapter in book on Text book
and Atlas of fibroids, already in press probable
release June 2016.
• He has been associated in Research Projects in
Neuro Radiology (Multiple Sclerosis, Peripheral
Vascular Disease, Fibroids and Cartilage Mapping).
• Life member IRIA, ICRI and IACI.
• Has reported cross sectional imaging for NCA
(national cricket academy) and KSCA. Many Indian,
international and IPL players.

3. Contrast Media and Prevention of
Contrast Induced Nephropathy
Dr Sudhir Kale
Chief Radiologist
Aster CMI hospital Bangalore

4. Objectives
 Patient selection strategies
 Contrast Media in Renal Impaired patients
 Prevention of contrast induced nephropathy (CIN).

5. CT - Contrast Agents
• Compounds used to improve the visibility of internal
bodily structures in an image.
• Types:
– Radiographic agents based on iodine
• Ionic or non-ionic agents
• High osmolar (HOCM) and low osmolar, iso-
osmolar (LOCM)

6. CT - Contrast Agents
IONIC
NON-IONIC
1. IOHEXOL
2. IOPAMIDOL
3. IOPROMIDE
4. IOVERSOL
IODIXANOL
(VISIPAQUE)
X

7. Commonly used iodinated contrast agents
NameName TypeType IodineIodine
ContentContent
OsmolalityOsmolality
IonicIonic
DiatrizoateDiatrizoate
(Hypaque 50)(Hypaque 50)
IonicIonic
MonomerMonomer
300300 15501550
HighHigh
OsmolarOsmolar
MetrizoateMetrizoate
(Isopaque Coronar(Isopaque Coronar
370)370)
IonicIonic 370370 21002100
Ioxaglate (Hexabrix)Ioxaglate (Hexabrix) IonicIonic 320320 580580
LowLow
OsmolarOsmolarNon-Non-
IonicIonic
Iopamidol (IsovueIopamidol (Isovue
370)370)
Non-ionicNon-ionic
monomermonomer
370370 796796
IohexolIohexol
(Omnipaque 350)(Omnipaque 350)
Non-ionicNon-ionic 350350 884884
IodixanolIodixanol Non-ionicNon-ionic 320320 290290 IsoIso

8. PATIENT FOR
CONTRAST STUDY
RADIOLOGY
DEPARTMENT
?

9. Patient selection and Preparation strategies
Clinical history: {ARC information }
1.Allergy / Asthma: H/o prior allergic-like reactions to
contrast media is associated with an upto 5 fold increased
likelihood of experiencing subsequent reaction.
2.Renal insufficiency: Contrast induced nephrotoxicity and
Nephrogenic systemic fibrosis.
3.Cardiac Status: Significant cardiac disease increases risk
for contrast reactions. Angina or congestive heart failure
symptoms , Aortic stenosis, Primary pulmonary
hypertension or severe cardiomyopathy

10. Patient selection and Preparation strategies
4. Miscellaneous:
 Para-protienemias particularly multiple myeloma predispose
patients to irreversible renal failure – High osm contrast media) –
tubular protein precipitation.
 Pheochromocytoma: Hypertensive crisis, more chances in direct
intra-arterial injections in renal or adrenal arteries.
 Sickle cell disease

11. Patient Care Forum
If any risk factor, then:
RADIOLOGIST + REFERRING Doctor
Risk Vs BenefitAlternative Imaging

12. Serum Creatinine
 Adult Male (>18 yrs) : 0.7 to 1.4 mg/dl.
 Adult Female (>18 yrs) : 0.6 to 1.2 mg/dl.
 Pediatric age group 1 to 15 yrs: 0.3 to 0.7 mg/dl.
 Neonate: 0.2 to 0.5 mg/dl

13. eGFR Calculation is preferred in
the present guidelines
Estimated GFR

14. MDRD Calculator for eGFR

15. Cockcroft Gault eGFR Calculator

16. eGFR calculation by MDRD

17. Renal Toxicity
Risk Factors
– 5 - 10 fold increase with pre-existing renal
insufficiency (increased creatinine)
– Dehydration
– CHF
– Age > 70
– Taking nephrotoxic drugs (nonsteroidal inflammatory
agents, gentomycin etc.)

18. Reddinger W. Contrast Media. http://www.e-radiography net/contrast_media/CT_contrast_media pdf. Accessed January 7, 2014.
Properties of Contrast Media

19. CM: Osmolality and Viscosity
• Low osmolality contrast media are hyperosmolar to blood
• Iodixanol is the only contrast media not hyperosmolar
to blood
Jo SH, Youn TJ, Koo BK, et al. Renal Toxicity Evaluation and Comparison Between Visipaque (Iodixanol) and Hexabrix (Ioxaglate) in Patients With Renal Insufficiency Undergoing
Coronary Angiography: The RECOVER Study: A Randomized Controlled Trial. Journal of the American College of Cardiology. 2006;48(5):924-930.
CIN- Contrast Induced Nephropathy
Higher association between CIN and
osmolality than between CIN and viscosity,
ionicity and chemotoxicity
Higher association between CIN and
osmolality than between CIN and viscosity,
ionicity and chemotoxicity

20. Currently VISPAQUE (IODIXANOL) is the
contrast media with least incidence of CIN
Jo SH, Youn TJ, Koo BK, et al. Renal Toxicity Evaluation and Comparison Between Visipaque (Iodixanol) and Hexabrix (Ioxaglate) in Patients With Renal Insufficiency Undergoing
Coronary Angiography: The RECOVER Study: A Randomized Controlled Trial. Journal of the American College of Cardiology. 2006;48(5):924-930.
CIN- Contrast Induced Nephropathy

21. Correlation Between CIN Incidence
and Osmolality
Davidson C, Stacul F, McCullough PA, et al. Contrast medium use. Am J Cardiol. 2006;98(6A):42K-58K.
VISIPAQUE
(IODIXANOL)
IOHEXOL
IONIC CM

22. Incidence of CIN Lower in Iodixanol
(VISIPAQUE) compared to iopromide
Nguyen SA, Suranyi P, Ravenel JG, et al. Iso-osmolality versus low-osmolality iodinated contrast medium at intravenous contrast-enhanced CT: effect on kidney function. Radiology.
2008;248(1):97-105.
SCr levels after CM administration were significantly lower in the Visipaque than in the LOCM group, as was the
incidence of CIN
SCr levels after CM administration were significantly lower in the Visipaque than in the LOCM group, as was the
incidence of CIN

23. Incidence of CIN Lower in Iodixanol
Than LOCM Ioversol
The overall incidence of CIN with Visipaque was less than a third of that seen with the LOCM; in
patients undergoing PCI the difference was even more pronounced
The overall incidence of CIN with Visipaque was less than a third of that seen with the LOCM; in
patients undergoing PCI the difference was even more pronounced
Hernandez F, Mora J, Suberviola V et al. Comparison of iodixanol versus ioversol for prevention of contrast induced nephropathy in diabetic patients undergoing coronary
angiography or intervention. Eur Heart J 2007; 28 (Suppl 1): 454

24. Decreased from usage of ionic HOCM to non-ionic
LOCM.
Reference Prevalence (%) Relative Risk Conventional/ Non-
ionic
Conventional Media Non-ionic media
Overall prevalence of reactions
Katayama et al 12.7 3.1 4.1
Palmer
Low risk 3.8 1.2 3.2
High risk 10.3 1.3 7.9
Wolf et al 4.1 0.7 5.9
Prevalence of severe reactions
Katayama et al 0.22 0.04 5.5
Palmer
Low risk 0.09 0.00 Incalculable
High risk 0.36 0.03 12.0
All 0.09 0.02 4.5
Wolf et al 0.04 0.00 Incalculable
Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. AJR Am J Roentgenol. 1991;157(6):1153-1161.
Non-Ionic media has Lower Adverse
Reactions

25. CT contrast protocol in renal impaired
patients to prevent CIN:
1. Assess Serum creatinine and eGFR
2. If serum creatinine >1.4 or eGFR : 30 to 60 ml/min
3. Plan for Visipaque contrast media (LOCM).
4. Adequate hydration prior and after the procedure.
5. Sodium bicarbonate infusion (Pre procedure)
6. N-acetylcysteine

26. KDIGO Protocol for prevention of
contrast induced nephropathy
1) IV FLUID
1). Normal Saline 12 h pre and for 12 hr post contrast
administration
2). Tab Mucomix 600 mg-1.2gm 12 hrs on day -1,0,+1
day.
For same day examinations:
3). Normal Saline or Isotonic NaHCO3 @ 3 mL/kg/hr for 1-3
hr pre and for 6 hr post contrast administration

27. MRI contrast agents in renal Impaired
patients
1. Extracellular fluid agents
 Gadopentetate(Magnevist)
 Gadodiamide (Omniscan)
 Gadoversetamide (OptiMARK)
 Gadobenate (MultiHance)
2. Blood Pool Agents
– Albumin-binding gadolinium complexes - Gadofosvest (Ablavar, formerly Vasovist)
– Polymeric gadolinium complexes – Gadomelitol
• Hepatobiliary (liver) agents
– Gadoxetic acid
MRI contrast agents are Gadolinum-Based

28. Nephrogenic systemic fibrosis
• Nephrogenic systemic fibrosis (NSF) is a rare disease
seen in patients with severe renal impairment after
administration of gadolinium-based MRI contrast agents.
• Release of free gadolinium ions may then deposit in
different tissues and result in inflammation and fibrosis
• Patients with NSF can have systemic involvement of
other organs, including the lungs, liver, muscles and
heart.
• Can Cause contractures and joint involvement

29. Risk of NSF with Different Gadolinium containing
Contrast Media:
1. High-risk gadolinium-containing contrast agents
 Optimark,
 Omniscan,
 Magnevist.
2. Medium-risk gadolinium-containing contrast agents
 Vasovist,
 Primovist
 MultiHance.
3. Low-risk gadolinium-containing contrast agents
 Dotarem,
 ProHance
 Gadovist.

30. Nephrogenic systemic fibrosis
• Avoid if eGFR is <30ml/min
• eGFR <30 ml/min (if clinical situation demands)
– take informed consent (risk of NSF <1/10,000 patients with
eGFR <30 ml/min)
– maximum dose of 0.1mmol/kg
– adequate hydration must be provided.
– A low or medium risk agent with higher relaxivity like Multihance
should be used in half dose, and should not be repeated for at
least seven days

31. Key Take-Away Points
•ARC Information once you decide on contrast study.
•Any risk factor, discuss with Referring Doctor for
alternative imaging or assess Risk Vs benefit.
•Use creatinine value to get eGFR.
•Discuss with referring doctor if eGFR is <60
•Hydration, Sodium bicarbonate and N acetyl cysteine for
prevention of CIN.
•CT Contrast : Visipaque (Iodixanol) is the choice
•MR contrast : Use Multihance. Take informed consent (risk
of NSF <1/10,000 patients with eGFR <30 ml/min).

32. THANK YOU