NEFROTOXICIDADE POR CONTRASTE IODADO:

(1)

NEFROTOXICIDADE POR

CONTRASTE IODADO:

IMPLANTA

Ç

ÃO DE BOAS PR

Á

TICAS

Dra. Luciana Baptista

Médica Radiologista Hospital Nove de Julho

LANCHE CLINICO H9J

Dr. Fernando Alves Moreira

Dr. Eduardo Bianco

(2)

Importância do Contraste

• Melhor definição diagnóstica

• Rapidez diagnóstica e Conduta Terapêutica

• Avaliação funcional

(3)

(4)

(5)

(6)

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

(7)

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

(8)

Volumes 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

(9)

CONTRASTE IODADO EM

RADIOLOGIA

Ideal

→

_SEM

Rea

(10)

Rea

ç

ões Adversas aos MC

Classifica

ç

_ç

ão

_ão

-

_-

Etiologia

_Etiologia

•

• Rea

Rea

ç

ão Anafilact

ó

ide = Idiossincr

á

ticas

•

• Rea

Rea

ç

ões Não

-

idiossincr

á

ticas

--

Efeitos T

ó

xicos Diretos:

osmotoxicidade

quimiotoxicidade

toxicidade direta

ó

rgão

-

espec

í

fica

--

Rea

ç

ões Vasomotoras

•

(11)

Rea

ç

ões Adversas aos MC

Classifica

ç

ão

–

Grau Severidade

•

• Leve

Leve

: nausea, vômito, tosse, calor, cefal

é

ia,

tontura, prurido, urtic

á

ria limitada

•

• Moderada

Moderada

: vômitos intensos, hipertensão,

hipotensão, urtic

á

ria extensa, dispn

é

ia,

broncoespasmo

•

• Grave

Grave

: inconsciência, convulsões, EAP,

colapso vascular, arritmias, PCR

(12)

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 Doses

(13)

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.

(14)

Segurança – Implicações

• Atualmente Eventual Reação Adversa

• Cuidado!! pode ser anaflactóide /

fatal

• Consentimento Informado

• Coleta de dados clinico-laboratoriais

(15)

Fatores de Risco

•

• Alergia a iodo

Alergia a iodo

•

• IR pr

IR pr

é

via

•

• DMID

DMID

•

• ICC e IAM pr

ICC e IAM pr

é

vios

•

• Idade avan

Idade avan

ç

ada

•

• Desidrata

Desidrata

ç

ão

•

• Mieloma M

Mieloma M

ú

ltiplo

•

• Feocromocitoma

Feocromocitoma

Identificar pacientes de risco

(16)

Altera

ç

ões funcionais orgânicas

influenciadas pelos MC

•

• Efeitos na coagula

Efeitos na coagula

ç

ão

•

• Efeitos na viscosidade sangu

Efeitos na viscosidade sangu

í

nea

•

• Efeitos na fun

Efeitos na fun

ç

ão cardiovascular

•

• Efeitos na fun

Efeitos na fun

ç

ão pulmonar

•

• Efeitos na barreira

Efeitos na barreira

hemato

-

encef

á

lica

•

• Efeitos na fun

Efeitos na fun

ç

ão hep

á

tica

•

• Efeitos na fun

Efeitos na fun

ç

ão tireoidiana

•

• Efeitos nas paredes dos vasos

Efeitos 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)

•

(17)

Viscosid

ade e Osmolalidade

PB Persson et al. KI 2005; 68:14 PB 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 H

₂

0 V

is

co

si

ty

, m

P

ax

s,

3

7 °C

(18)

Viscosid

ade

•

37

37 º

º

C

_MC

_é

_{melhor tolerado}

•

37

37 º

º

C

_{MC tem viscosidade reduzida}

(<50%) que 20

º

C

•

(19)

TABELA COMPARATIVA DE CONTRASTES

IÔNICOS 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 +

(20)

TABELA COMPARATIVA DE CONTRASTES

NÃO

-

IÔNICOS 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

(21)

Peter Aspelin et al, NEJM 2003; 348:6

Study

Study Medium Used Medium Used

(Mean Volume)

(Mean Volume) ProcedureProcedure

Base Base- -Line Line Serum Serum Creatinin Creatinin e e Increase in Serum Increase in Serum Creatinine Creatinine Defining Defining Contrast Contrast- -Meduim

Meduim--Induced Induced Nephropathy Nephropathy Day on Which Day on Which Peak Serum Peak Serum Creatinine Creatinine Increase Was Increase Was Measured Measured Incidence of Incidence of Contrast Contrast- -Medium

Medium--Induce Induce Nephropathy

Nephropathy

mg/dl

mg/dl No./total no. (%)No./total no. (%) Barrett et sl.

Barrett et sl.77

Low

Low--osmolar osmolar

contrast contrast mediums mediums (100ml) (100ml) Angiocardiography, Angiocardiography, intravenous intravenous pyelography, pyelography, computed computed tomography tomography ≥ ≥_1.4_1.4 _>25%_>25% ₂₂ _{3/24 (12)}_{3/24 (12)} Rudnick et al.

Rudnick et al.88 _{lohexol (140 ml)}_{lohexol (140 ml)} _{Angiocardiography}_{Angiocardiography} ≥≥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) Angiocardiography Angiocardiography _≥_≥ 1.5 1.5 >0.5 mg/dl>0.5 mg/dl 11--55 6/20 (30)6/20 (30) Manske et al.

Manske et al.1010 _{iopamidol (30}_{iopamidol (30}lohexol or lohexol or ml) ml) Angiocardiography Angiocardiography 5.9 5.9±±_1.6_1.6 _>25%_>25% ₂₂ 21/42 (50)21/42 (50) Wang et al. Wang et al.1111 Low

Low--osmolar osmolar

contrast contrast medioums (122 medioums (122 ml) ml) Angiocardiography Angiocardiography _≥_≥ 2.0 2.0 >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) angiography angiography ≥ ≥_1.5_1.5 <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/IRC

contraste baixa osmolalidade

(22)

Frequência de Nefropatia por Contraste

Iodado em pacientes IR e DM

Rudnick et al 1995

0

0.60

5.70

19.70

0

5

10

15

20

25 -RI-DM

-RI+DM

+RI-DM

+RI+DM

(23)

J Trauma. 2011 Feb;70(2):415-9; discussion 419-20.

Posttraumatic contrast-induced acute kidney injury: minimal consequences or significant threat?

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.edu Abstract

BACKGROUND: 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