Can I give contrast to a patient with end stage renal disease or who’s on dialysis?

The short answer: almost certainly yes. And you don’t need to schedule urgent dialysis afterwards to remove the contrast.

Radiologists will tell you all the time that you can’t order a study with contrast because of someone’s creatinine, and so you may have to argue back, and advocate for your patient to get the study they need. I was inspired to write this post after our radiologist refused to perform a CTA on a patient on HD who turned out to have an actively bleeding 18-cm  hematoma. That’s a problem!

Think about it this way: a patient who is on dialysis does NOT have working kidneys, right? That’s why they’re on dialysis. Therefore, you do not have to protect their kidneys from contrast. The same is most likely true for patients on peritoneal dialysis, although I’m not sure if there are guidelines on this. There is an argument for preserving even residual renal function in ESRD patients, but…most of the time we are ordering CT scans for acute or urgent reasons, so you can do that risk-benefit assessment.

What you DO want to avoid is giving a patient on the cusp of needing dialysis, with CKD-IV or V, a huge contrast load. You don’t want to push them over the edge. Before giving them a CT torso with contrast, or sending them for cardiac catheterization, think about giving a little fluid beforehand and discussing with the renal experts. If it is a life/death situation, I’d probably lean towards giving contrast and hoping they don’t need dialysis permanently afterwards–but make sure there are no other alternatives and your consultants are on the same page as you.

What about MRI contrast? 

Most radiology departments have low-dose gadolinium protocols these days to avoid the feared nephrogenic systemic fibrosis (NSF). Anecdotally, nephrologists are more wary of approving gadolinium, and may be more likely to recommend dialysis after gadolinium load, but again, if there is a truly urgent need for an MRI study, the benefits likely outweigh the risks.

Do you need to schedule urgent dialysis after your patient gets contrast? 

Probably not, but the data is mixed. For example, this prospective study from NEJM suggests CVVH may help (in ICU patients), while other, small studies (here and very small study here) for HD. According to the American College of Radiology’s own 2016 guidelines:  “Unless an unusually large volume of contrast medium is administered or there is substantial underlying cardiac dysfunction, there is no need for urgent dialysis after intravascular iodinated contrast medium administration.”

Fun fact: a recent study from Hopkins in Annals of Emergency Medicine showed that contrast itself was not associated with higher incidence of AKI in patients getting CT scans, even in patients with CKD and on dialysis. (Of course, the doctors were more judicious with ordering CT scans in patients with CKD, and tended to give them fluids beforehand.)

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