NEFROTOXICIDADE POR NEFROTOXICIDADE POR CONTRASTE IODADO: CONTRASTE IODADO:

IMPLANTAIMPLANTAÇÇÃO DE BOAS PRÃO DE BOAS PRÁÁTICASTICAS

Dra. Luciana Baptista

Médica Radiologista Hospital Nove de Julho

LANCHE CLINICO H9J

Dr. Fernando Alves MoreiraDr. Fernando Alves MoreiraDr. Eduardo BiancoDr. Eduardo Bianco

Importância do Contraste

• Melhor definição diagnóstica

• Rapidez diagnóstica e Conduta Terapêutica

• Avaliação funcional (Radiologia Contrastada EED / TC - TGI)

CBR 2010

• Prof Erik Paulson: Duke University

• Diretor da divisão de imagem abdominal

• Coordena grupos estudo abdome agudo e estadiamento do câncer de pâncreas

• CONTRASTE É FUNDAMENTAL

• EUA: Pressão gerências reduzir o uso

Tipos de Contraste

• VO – Iodado Iônico / Bário (mínimo 1000ml)

• VR – Iodado Iônico (250 / 500 ml)

• EV – Iodado não-iônico: depende do IMC e tipo de exame

• Atualmente H9J: - Iopamiron 370 (EV) – iodado não-iônico- Urografina 292 (VO) – iodado iônico (50 ml)

Volumes de contraste em TCVolumes de contraste em TC• TC Crânio: 40 ml

• TC Pescoço: 60 ml

• TC Tórax TEP: 80 ml

• TC Abdome: 90 - 100 ml

• AngioTC Carótidas / Crânio: 90 ml

• AngioTC Coronária: 90 ml – Revasc 120 ml

• AngioTC torax + abdome + MMII: 140 ml

• Permitido 1 à 3 ml / kg

CONTRASTE IODADO EM CONTRASTE IODADO EM RADIOLOGIARADIOLOGIA

Ideal Ideal →→ SEMSEM

ReaReaçção Adversa ão Adversa

ReaReaçções Adversas aos MCões Adversas aos MCClassificaClassificaçção ão -- EtiologiaEtiologia

•• ReaReaçção Anafilactão Anafilactóóide = Idiossincride = Idiossincrááticasticas

•• ReaReaçções Nãoões Não--idiossincridiossincrááticasticas-- Efeitos TEfeitos Tóóxicos Diretos:xicos Diretos:osmotoxicidadeosmotoxicidadequimiotoxicidadequimiotoxicidadetoxicidade direta toxicidade direta óórgãorgão--especespecííficafica

-- ReaReaçções Vasomotorasões Vasomotoras

•• ReaReaçções Combinadasões Combinadas

ReaReaçções Adversas aos MCões Adversas aos MCClassificaClassificaçção ão –– Grau SeveridadeGrau Severidade

•• LeveLeve: nausea, vômito, tosse, calor, cefal: nausea, vômito, tosse, calor, cefalééia, ia, tontura, prurido, urtictontura, prurido, urticáária limitadaria limitada

•• ModeradaModerada: vômitos intensos, hipertensão, : vômitos intensos, hipertensão, hipotensão, urtichipotensão, urticáária extensa, dispnria extensa, dispnééia, ia, broncoespasmobroncoespasmo

•• GraveGrave: inconsciência, convulsões, EAP, : inconsciência, convulsões, EAP, colapso vascular, arritmias, PCRcolapso vascular, arritmias, PCR

OBJECTIVE. The purpose of this study was to determine the frequency and characteristics

of adverse effects of low-osmolar iodinated and gadolinium contrast agents in a singlecenter

experience with a large number of cases.

MATERIALS AND METHODS. A retrospective review of all intravascular doses of

low-osmolar iodinated and gadolinium contrast materials administered from 2002 through

2006 was conducted. Adverse effects were identified through the use of radiologist and nurse

event recording. Adverse effects were examined for type and severity of reaction, treatment

required, and outcome.

RESULTS. A total of 456,930 contrast doses (298,491 low-osmolar iodinated, 158,439

gadolinium) were administered over the study period. A total of 522 cases of adverse effects

(0.11% of total) were identified (458 low-osmolar iodinated, 64 gadolinium). The most common

adverse effects were hives (274, 52.5%) and nausea (92, 17.6%). Of all adverse effects,

79 of low-osmolar iodinated and 15 of gadolinium contrast material necessitated treatment.

Most treatments were performed in the radiology department alone. Only 16 cases of adverse

effects necessitated transfer for further observation or treatment. Epinephrine was used to

manage an adverse effect in nine instances. Thirty-two of the adverse effects of low-osmolar

iodinated contrast material (6.9%) occurred in patients with a history of allergy who received

premedication. Only two of these premedication reactions necessitated transfer to the emergency

department. The one death in the study period occurred after administration of low-osmolar

iodinated contrast material. The patient had no symptoms during the contrast administration

or imaging but died suddenly within 30 minutes of receiving the dose.

CONCLUSION. Both iodinated and gadolinium contrast agents are associated with a

very low rate of adverse effects. Most adverse effects are mild and can be managed in the radiology

department. Transfer for additional treatment or observation is rarely needed.

Frequency and Severity of Adverse Effects of Iodinated and Gadolinium Contrast Materials: Retrospective Review of 456,930 DosesChristopher H. Hunt; Robert P. Hartman; Gina K. Hesley AJR 2009; 193:1124–1127

Inflamm Allergy Drug Targets. 2009 Mar;8(1):17-20.

Adverse reactions to iodinated contrast media administered at the time of endoscopic retrograde cholangiopancreatography(ERCP).

Pan JJ, Draganov PV.Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA.AbstractAdverse reactions after intravascular administration of iodine contrast media are common and prophylactic regiments consisting of the use of steroids and low osmolality contrast media are highly effective in significantly decreasing the adverse reactions rate. The same type of contrast media are also used for opacification of the biliary tree and the pancreatic duct at the time of endoscopic retrograde cholangiopancreatography (ERCP). Systemic absorption of contrast media after ERCP routinely occurs. Although the adverse reaction rate appears to be very low the exact incidence remains unknown due to the retrospective nature of all reports. Despite the lack of formal recommendations, numerous prophylactic regiments are routinely used prior to ERCP in patients with history of prior reaction to intravascular contrast media. Moreover, the use of prophylaxis has even expanded to patients with no prior reaction to intravascular contrast media who are somehow perceived to be at increase risk (e.g. shellfish allergy). Recently, the first large scale prospective study reported exceedingly low incidence of adverse reaction to high oslmolality iodine-containing contrast media administered at the time of ERCP done without prophylactic premedication even in patients considered to be at the highest risk (prior severe reaction to intravascular contrast media administration). These data suggest that the use of prophylactic regiments prior to ERCP appears to be unnecessary.

Segurança – Implicações

• Atualmente Eventual Reação Adversa

• Cuidado!! pode ser anaflactóide / fatal

• Consentimento Informado

• Coleta de dados clinico-laboratoriais

• Checagem de Pedido Médico

Fatores de RiscoFatores de Risco

•• Alergia a iodoAlergia a iodo•• IR prIR prééviavia•• DMIDDMID•• ICC e IAM prICC e IAM prééviosvios•• Idade avanIdade avanççadaada•• DesidrataDesidrataççãoão•• Mieloma MMieloma Múúltiploltiplo•• FeocromocitomaFeocromocitoma

Identificar pacientes de riscoIdentificar pacientes de risco

AlteraAlteraçções funcionais orgânicas ões funcionais orgânicas influenciadas pelos MCinfluenciadas pelos MC

•• Efeitos na coagulaEfeitos na coagulaççãoão•• Efeitos na viscosidade sanguEfeitos na viscosidade sanguííneanea•• Efeitos na funEfeitos na funçção cardiovascularão cardiovascular•• Efeitos na funEfeitos na funçção pulmonarão pulmonar•• Efeitos na barreira Efeitos na barreira hematohemato--encefencefáálicalica•• Efeitos na funEfeitos na funçção hepão hepááticatica•• Efeitos na funEfeitos na funçção tireoidianaão tireoidiana•• Efeitos nas paredes dos vasosEfeitos nas paredes dos vasos•• Efeitos em testes laboratoriais: Efeitos em testes laboratoriais: FERRO, COBRE, PROTEFERRO, COBRE, PROTEÍÍNA TOTAL E FOSFATASE NA TOTAL E FOSFATASE

((DEVEM SER MEDIDOS APDEVEM SER MEDIDOS APÓÓS 12S 12--24h) 24h)

•• Efeitos na funEfeitos na funçção renalão renal

ViscosidViscosidade e Osmolalidadeade e Osmolalidade

PB Persson et al. KI 2005; 68:14PB Persson et al. KI 2005; 68:14--2222

4

5

6

7

200

8

9

10

300 400 500 600 700 800

Iotrolan

Iodixanol

Iomeprol

Iopamidol

Iopromide

Iohexol

Osmolality, mOsm/kg H20

Viscosity, m

Paxs, 37°C

ViscosidViscosidadeade

•• 3737ººCC MC MC éé melhor toleradomelhor tolerado

•• 3737ººCC MC tem viscosidade reduzida MC tem viscosidade reduzida (<50%) que 20(<50%) que 20ººCC

•• Osmolalidade não Osmolalidade não éé um problema!!um problema!!

TABELA COMPARATIVA DE CONTRASTES TABELA COMPARATIVA DE CONTRASTES IÔNICOS COMERCIALIZADOS NO BRASILIÔNICOS COMERCIALIZADOS NO BRASIL

CONT.

Nome comercial

FABRIC IODO

mgI/ml

OSM.

mOsm/kg

VISC.

Cp a 37C

CONC

(%)

APRES.

(ml)

COMP.

Telebrix 30 Guerbet 300 1650 5,2 68 30, 50, 100 Ioxitalamato de Meglumina

Telebrix

Coronar

Guerbet 350 2060 7,5 74,7 50, 100 Ioxitalamato de Meglumina +

Ioxitalamato de Sódio

Hexabrix Guerbet 320 680 7,6 59 50, 100 Ioxaglato de Meglumina + Ioxaglato

de Sódio

Conray Mallinckrodt 282 1400 4,0 60 50, 100 Iotalamato de Meglumina

Reliev Justesa 282 1247 4,1 60 30, 50e 100 Diatrizoato de Meglumina

Pielograf Justesa 370 2100 9,0 76 30, 50e100 Diatrizoato de Meglumina +

Diatrizoato de Sódio

TABELA COMPARATIVA DE CONTRASTES TABELA COMPARATIVA DE CONTRASTES NÃONÃO--IÔNICOS COMERCIALIZADOS NO BRASILIÔNICOS COMERCIALIZADOS NO BRASIL

CONTRASTE

(Nome comercial)

FABRIC. IODO

mgI/ml

OSMOL

Mosm/kg

VISC.

Cp a 37C

CONC.

(%)

APRES.

(ml)

COMPOS.

Henetix guerbet 300

350

695

915

6,0

10,0

66 50 Iobitridol

Monom.

Iopamiron schering 300

370

680

870

4,5

9,1

61,2

75,5

10,20e50

25e50

Iopamidol

Monom.

Omnipaque Amersham

health

300

350

709

862

6,3

10,4

64,7

75,5

20e50

20e50

Iohexol

Monom.

Optiray Mallinckrodt 240

320

350

502

702

792

3,0

5,8

9,0

51

68

74

Ser:125

Ser:50,

75,100e125

Fr:50e100

Ioversol

Monom.

Visipaque GE/Farmasa 320 290 20,0 67 50,100e

200

Iodixanol

dimérico

Peter Aspelin et al, NEJM 2003; 348:6

StudyStudyMedium Used Medium Used (Mean Volume)(Mean Volume)

ProcedureProcedure

BaseBase--Line Line Serum Serum CreatininCreatinin

ee

Increase in Serum Increase in Serum Creatinine Creatinine Defining Defining ContrastContrast--

MeduimMeduim--Induced Induced NephropathyNephropathy

Day on Which Day on Which Peak Serum Peak Serum Creatinine Creatinine Increase Was Increase Was MeasuredMeasured

Incidence of Incidence of ContrastContrast--

MediumMedium--Induce Induce NephropathyNephropathy

mg/dlmg/dl No./total no. (%)No./total no. (%)

Barrett et sl.Barrett et sl.77LowLow--osmolar osmolar contrast contrast mediums mediums (100ml)(100ml)

Angiocardiography, Angiocardiography, intravenous intravenous pyelography, pyelography, computed computed tomographytomography

≥≥1.41.4 >25%>25% 22 3/24 (12)3/24 (12)

Rudnick et al.Rudnick et al.88 lohexol (140 ml)lohexol (140 ml) AngiocardiographyAngiocardiography ≥≥1.51.5<1.5<1.5 >0.5 mg/dl>0.5 mg/dl 11--33 34/102 (33)34/102 (33)

18/148 (12)18/148 (12)

Taliercio et al.Taliercio et al.99 lopamidol (134 lopamidol (134 ml)ml)

AngiocardiographyAngiocardiography≥≥1.51.5 >0.5 mg/dl>0.5 mg/dl 11--55 6/20 (30)6/20 (30)

Manske et al.Manske et al.1010lohexol or lohexol or iopamidol (30 iopamidol (30

ml)ml)

AngiocardiographyAngiocardiography5.95.9±±1.61.6 >25%>25% 22 21/42 (50)21/42 (50)

Wang et al.Wang et al.1111LowLow--osmolar osmolar contrast contrast

medioums (122 medioums (122 ml)ml)

AngiocardiographyAngiocardiography≥≥2.02.0 >0.5 mg/dl or >0.5 mg/dl or

>25%>25% 22 15/39 (38)15/39 (38)

Lautin et al.Lautin et al.1414 lohexol or lohexol or ioxaglate (78 ml)ioxaglate (78 ml)

Peripheral (femoral) Peripheral (femoral) angiographyangiography

≥≥1.51.5<1.5<1.5

>0.3 mg/dl and >0.3 mg/dl and >20%>20% 11--33 4/15 (27) 4/15 (27)

11/60 (18)11/60 (18)

*To convert values for creatinine to micromoles per liter, multiply by 88.4. The plus-minus value is the mean ±SD.

Nefropatia Contraste DM/IRCNefropatia Contraste DM/IRCcontraste baixa osmolalidadecontraste baixa osmolalidade

Frequência de Nefropatia por Contraste Frequência de Nefropatia por Contraste Iodado em pacientes IR e DMIodado em pacientes IR e DM

Rudnick et al 1995

00.60

5.70

19.70

0

5

10

15

20

25

-RI-DM -RI+DM +RI-DM +RI+DM

Rudnick et al 1995

J Trauma. 2011 Feb;70(2):415-9; discussion 419-20.Posttraumatic contrast-induced acute kidney injury: minimal consequences or significantthreat?Matsushima K, Peng M, Schaefer EW, Pruitt JH, Kashuk JL, Frankel HL.Division of Trauma, Acute Care and Critical Care Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA 17036, USA. kmatsushima@hmc.psu.eduAbstractBACKGROUND: Recent enthusiasm for the use of iodinated contrast media and progressive adaption of modern imaging techniques suggests an increased risk of contrast-induced acute kidney injury (CIAKI) in trauma patients. We hypothesized that CIAKI incidence would be higher than that previously reported.METHODS: A 1-year retrospective review of our prospective database was performed. Low-osmolar, nonionic, iodinated intravascular (IV) contrast was used exclusively. CIAKI was defined as serum creatinine>0.5 mg/dL, or >25% increase from baseline within 72 hours of admission. The association between CIAKI and risk factors was explored.RESULTS: Of 3,775 patients, 1,184 (31.4%) received IV contrast and had baseline and follow-up serum creatinine. Median age was 38 years (range, 18-95 years) and median Injury Severity Score (ISS) was 16. A total of 8% of patients had history of diabetes mellitus. CIAKI was identified in 78 (6.6%). CONCLUSION: Current trauma management places patients at substantial risk for CIAKI, and risk stratification can be assessed by common clinical criteria. IV contrast dose alone is not an independent associated risk factor. How these data would be extrapolated to an older cohort remains to be determined

Radiology 2008 Radiology 2008 –– Brian R HertsBrian R Herts

•• AspAspééctos Mctos Méédicodico--legaislegais

-- Pedido MPedido Méédicodico

-- Protocolos e PadronizaProtocolos e Padronizaççõesões

-- Consentimento InformadoConsentimento Informado

-- Esclarecimento Exame e OrientaEsclarecimento Exame e Orientaçções aos Pacientesões aos Pacientes

CONTRASTE IODADO EM CONTRASTE IODADO EM RADIOLOGIARADIOLOGIA

PACIENTES QUE REALIZAREM EXAME COM CONTRASTE VENOSO

PACIENTES HAS / DM

CARIMBO

CONTRASTE IODADO EM CONTRASTE IODADO EM RADIOLOGIARADIOLOGIA

Dra. Maria Alice (Nefro) / Dr. Carlos (UTI)Dra. Maria Alice (Nefro) / Dr. Carlos (UTI)

•• Medidas ProfilMedidas Profilááticas e Tratamento de Nefrotoxicidadeticas e Tratamento de Nefrotoxicidade

AndrAndrééia / Maria Cristina (Farmacia)ia / Maria Cristina (Farmacia)

•• Dados ClinicoDados Clinico--Laboratoriais Laboratoriais -- ResultadosResultados