CHA2DS2-VASc score as a novel predictor for contrast-induced nephropathy after percutaneous coronary intervention in acute coronary syndrome

Background CHA2DS2-VASc score, used for atrial fibrillation to assess the risk of embolic complications, have shown to predict adverse clinical outcomes in acute coronary syndrome (ACS), irrespective of atrial fibrillation. This study envisaged to assess the predictive role of CHA2DS2-VASc score for contrast-induced nephropathy (CIN) in patients with ACS undergoing percutaneous coronary intervention (PCI). Methods A total of 300 consecutive patients with ACS undergoing PCI were enrolled in this study. CHA2DS2-VASc score was calculated for each patient. These patients were divided into two groups as Group 1 (with CIN) and Group 2 (without CIN). CIN was defined as increase in serum creatinine level ≥0.5 mg/dL or ≥25% increase from baseline within 48 h after PCI. After receiver operating characteristic curve analysis, the study population was again classified into two groups: CHA2DS2-VASc score ≤3 group (Group A) and score ≥4 group (Group B). Results CIN was reported in 41 patients (13.6%). Patients with CIN had a higher frequency of hypertension, diabetes mellitus, and had a lower left ventricular ejection fraction and baseline estimated glomerular filtration rate. Receiver operating characteristic curve analysis showed good predictive value of CHA2DS2-VASc score for CIN (area under the curve 0.81, 95% CI 0.73–0.90). Patients with a CHA2DS2-VASc score of ≥4 had a higher frequency of CIN as compared with patients with score ≤3 (56.8% vs 4.8%; p = 0.0001) with multivariate analysis demonstrating CHA2DS2-VASc score of ≥4 to be an independent predictor of CIN. Conclusion In patients with ACS undergoing PCI, CHA2DS2-VASc score can be used as a novel, simple, and a sensitive diagnostic tool for the prediction of CIN

Clinical characteristics of adverse reaction to radiocontrast media in children - A single center experience

PURPOSE: Radiocontrast media are widely used in medical imaging to improve diagnostic accuracy. However, studies on the adverse reactions of radiocontrast media in children are limited. We aimed to describe the characteristics of adverse reactions to radiocontrast media among children who had a computed tomography scan or magnetic resonance imaging in a tertiary university hospital. METHODS: We retrospectively collected data on adverse reactions to radiocontrast media by the reporting system of a tertiary university hospital. We selected data from children under the age of 19 from July 2011 to December 2017 and analyzed their characteristics. We focused mainly on the characteristics of the index case which is defined by the first adverse event of each subject. RESULTS: During the period, a total of 88,050 radiocontrast media-enhanced imaging studies were performed and 184 cases of adverse reactions were reported. A total of 71 were identified as index cases. Forty-nine (69.0%) were male and the mean age was 12.7±3.2 years. The incidence of radiocontrast media-related adverse reactions was 0.09% and severe reactions were 0.002%. The most common clinical feature was skin manifestations (54.9%), followed by gastrointestinal symptoms (40.8%) and neuropsychiatric symptoms (7.4%). CONCLUSION: Adverse reactions to radiocontrast media rarely occur in children and the incidence of severe reactions is low. Most reactions are mild and are related to the skin and gastrointestinal system. This report would provide good evidence for establishing a management strategy in children scheduled for imaging studies using radiocontrast media.

Radiocontrast media-induced acute generalized exanthematous pustulosis: A safe administration of alternative radiocontrast media using patch tests

Acute generalized exanthematous pustulosis (AGEP) is rarely caused by radiocontrast media (RCM). The role of skin tests for the diagnosis and evaluation of cross-reactivity in a delayed type of RCM-induced hypersensitivity have yet to be determined. Here, we report a case of iodixanol-induced AGEP where we safely administered alternative RCM using patch tests. A 44-year-old woman had coronary artery angiography (CAG) for the evaluation of ischemic heart disease. She was on regular hemodialysis because of end-stage renal disease. She was given iodixanol (Visipaque) during CAG. Approximately 1 day after CAG, she developed AGEP. The patient was rehospitalized for CAG again after 1 year. We performed skin tests to choose safe alternative RCM. Intradermal tests with iodixanol, iohexol (Bonorex) and Iopamidol (Pamiray) showed negative responses. Patch tests showed a positive response to iodixanol, equivocal to iohexol, and negative to Iopamidol. We finally chose Iopamidol and performed CAG successfully without any adverse reaction. Patch tests may be a useful tool for the diagnosis and choice of safe alternatives in RCM-induced delayed-type hypersensitivity reactions such as AGEP.

Electronic Consultation Support System for Radiocontrast Media Hypersensitivity Changes Clinicians' Behavior

PURPOSE: Patients with a history of radiocontrast media (RCM) hypersensitivity can be overlooked, resulting in repeated reactions. Therefore, a consultation support system for RCM hypersensitivity has been in operation at Seoul National University Bundang Hospital since December 2011. We analyzed the effect of this system on physicians' practice. METHODS: A retrospective study was conducted on patients with previous RCM reactions (December 1, 2010 to November 30, 2012). The control period was December 2010 to November 2011, and the intervention period was December 2011 to November 2012. The primary outcome was the composite outcome of premedication and consultation. Premedication was defined as preventive medication prescribed by the physician who ordered RCM-enhanced computed tomography (CT) at the same time. The secondary outcome was the recurrence rate after using the consultation support system. RESULTS: A total of 189 clinicians prescribed 913 CT scans during the control period and 225 clinicians performed 1,153 examinations during the intervention period. The odds ratio (OR) of achieving the composite outcome increased significantly after use of the consultation support system (OR, 1.54; 95% confidence interval [CI], 1.15–2.05). Clinicians in both medical (OR, 1.48; 95% CI, 1.06–2.07) and surgical (OR, 2.07; 95% CI, 1.24–3.46) departments showed significant changes in their behavior, whereas those in the emergency department did not (OR, 1.07; 95% CI, 0.41–2.78). Professors (OR, 1.47; 95% CI, 1.06–2.04) and trainees (OR, 1.97, 95% CI, 1.22–3.18) showed significant changes in their behavior toward patients with previous RCM reactions. The behavior of 86 clinicians who ordered CT scans during both the control and intervention periods was unchanged. CONCLUSIONS: The consultation support system for those with previous RCM hypersensitivity reactions changed physicians' practice patterns and decreased recurrent RCM hypersensitivity reactions as well.

Ultrassonografia modo B e Doppler na avaliação renal de cães submetidos à tomografia computadorizada após administração intravenosa de diferentes meios de contraste iodado / B-mode and Doppler ultrasonography in the renal evaluation of dogs undergoing computed tomography after intravenous administration of different iodinated contrast media

A nefropatia induzida por contraste (NIC) é uma doença de caráter agudo, secundária à administração intravascular de meios de contraste iodado (MCI). Dentre os mecanismos fisiopatológicos desta enfermidade destacam-se a vasoconstrição intrarrenal prolongada, consequente redução da perfusão renal, hipóxia e isquemia medulares, associada ao dano tubular renal devido à citotoxicidade do contraste. Frente à existência de poucas informações relacionadas a estes mecanismos na literatura médico-veterinária, objetivaram-se comparar os efeitos renais da administração intravenosa de MCI não iônicos de diferentes osmolaridades, em grupos de cães com fatores de risco para o desenvolvimento da NIC, por meio das avaliações ultrassonográficas modo B, Doppler colorido, de amplitude e pulsado, pareada aos exames laboratoriais, a fim de estimar indiretamente o potencial nefrotóxico de cada contraste. Constituíram-se dois grupos de acordo com o MCI utilizado: o grupo GIH [11 cães receberam iohexol (baixa osmolaridade)] e o grupo GID [sete cães receberam iodixanol (isosmolar)]. Administrou-se a dose de 600mgI/kg/IV em ambos. Avaliaram-se os seguintes aspectos renais antes da administração do MCI (momento basal) e após 1h30min, 24 horas e 48 horas: morfometria (comprimento e volume), morfologia, ecogenicidade cortical e perfusão renais e resistência vascular intrarrenal (índices hemodinâmicos de resistividade e pulsatilidade). Realizou-se ainda exame de urina e se mensuraram as razões gama-glutamil transferase:creatinina (GGT:C) e proteína:creatinina (RPC) urinárias e a concentração sérica de creatinina. Os grupos apresentaram comportamentos similares para comprimento, volume, RPC, exame de urina e creatinina sérica. Em relação ao índice de pulsatilidade (IP), os grupos apresentaram comportamentos não similares, mas sem diferenças significantes entre o momento basal e os demais. Para o índice de resistividade (IR) e a razão GGT:C urinária, os grupos revelaram comportamentos não similares e se constataram aumentos significantes do IR e da razão GGT:C urinária no período de 1h30min após a administração do contraste, somente para o grupo que recebeu iohexol. Concluiu-se que o IR pode ser utilizado para monitorar a hemodinâmica intrarrenal, visto que junto com a razão GGT:C urinária, demonstrou a existência de maior potencial nefrotóxico do iohexol, quando comparado ao iodixanol. Dessa forma, considera-se o uso do iodixanol, opção favorável para cães com fatores de risco para o desenvolvimento da NIC.(AU)

Contrast-induced nephropathy (CIN) is an acute disease, secondary to intravascular administration of iodinated contrast media (ICM). The most important mechanisms of this nephropathy are intrarenal prolonged vasoconstriction, medular hypoxia, and ischemia associated with renal tubular damage due to contrast cytotoxicity. Owing to the limited information available in veterinary literature regarding these mechanisms this study aims to compare the renal effects of intravenous administration of two nonionic ICM of different osmolarities in groups of dogs with risk factors for CIN development, by using a B-mode, color, power- and pulsed-wave Doppler ultrasonography, and other laboratory tests, in order to indirectly estimate the nephrotoxic potential of each contrast. The following two groups were established according to the nonionic ICM used: the GIH group [11 dogs administered iohexol (low osmolarity)] and the GID group [seven dogs administered iodixanol (iso-osmolarity)]. Both the groups were administered the same dose (600mgI/kg/IV). The following renal aspects were evaluated before administration of ICM (baseline) and after 1h30min, 24h, and 48h: renal morphometry (length and volume), renal morphology, cortical echogenicity, renal perfusion, and intrarenal vascular resistance (resistive and pulsatility indices); in addition, urinalysis was performed, and urinary gamma-glutamyl transferase:creatinine ratio (GGT:C), urinary protein:creatinine ratio (UPC), and serum creatinine were also measured. Both groups showed similar characteristics with respect to the length, volume, UPC ratio, urinalysis, and serum creatinine levels. No similarity was observed with respect to the pulsatility index (PI) in both the groups and there were no significant differences between baseline and 1h30min, 24h and 48h time points. With respect to the IR and urinary GGT:C, both groups showed no similarity, and significant increases were observed in the resistive index (RI) and urinary GGT:C only in the GIH group, 1h30min after contrast administration. In conclusion, RI can be used to monitor intrarenal hemodynamics, and along with the urinary GGT:C, revealed that iohexol had higher nephrotoxic potential than iodixanol. Thus, iodixanol is considered a favorable option for dogs with risk factors for CIN development.(AU)

The efficacy of single premedication with antihistamines for radiocontrast media hypersensitivity

BACKGROUND: Single premedication with antihistamines for radiocontrast media (RCM) hypersensitivity is frequently used in real world at the emergent situation although its efficacy is not proven. OBJECTIVE: To evaluate the effect of intravenous antihistamines as a premedication in general population who had experience of mild adverse reactions to iodinated RCM. METHODS: A retrospective observational study on 14,785 subjects who had RCM-enhanced computed tomography scans between January 2014 and December 2015 in Seoul National University Hospital Gangnam Healthcare Center, Seoul, South Korea. RESULTS: Among 453 subjects who had a history of mild RCM-induced hypersensitivity reactions, 273 subjects had a single premedication of intravenous antihistamine. When comparing antihistamine-premedication group and nonpremedication group, there is no protective effect of antihistamines on the incidence rate and severity of hypersensitivity (10.6% vs. 11.7%, p = 0.729). CONCLUSION: The clinical efficacy of a single premedication of antihistamines for mild RCM-induced hypersensitivity was not confirmed.

A study of adverse drug reactions to radio contrast media in a tertiary care teaching rural hospital.

Background: Most common ADRs associated with radiocontrast media are rash, fever, nausea, vomiting and shivering. Rarely life threatening anaphylaxis and acute hypersensitivity reaction may also occur. Very few studies are carried out in India focusing on this aspect. Aims & Objective: To study and report the Adverse Drug Reactions (ADR) caused by radio contrast media in a tertiary care teaching rural hospital. Material and Methods: Two hundred and fifty seven patients from Radiology department were observed for occurrence of adverse drug events (ADEs) from 01 Jul 2012 to 31 Jul 2012. ADEs were either spontaneously reported or elucidated from personal interviews were analysed. Results: Total 8 (3.11%) out of 257 patients who had undergone for ionic radio contrast dye investigation had a single event of ADR. Total occurrence rate of ADR is 3.11%. Most common ADR was rash followed by shivering, nausea, vomiting and fever with use of ionic contrast media. All Adverse Drug Reactions, according to WHO-UMC and Naranjo’s scale were of “probable” category. All the ADRs were at level-3 according to Modified Hartwig and Siegel severity scale. All the ADRs according to Modified Schumock and Thornton criteria for Preventability of an ADR are of “not preventable” category. All the ADRs were of “Bizarre” type. All the patients were treated with antihistaminic and steroids. Conclusion: It is recommended to use non-ionic contrast media instead of ionic media by all the health care professionals. Treatment with steroids and antihistaminic in patients who develop ADRs due to radiocontrast media can be effective.

Management of adverse reaction to iodinated radiocontrast media

Application of iodinated radiographic contrast media (RCM) has increased recently because of the number of computed tomography examinations using RCM is increasing rapidly. The awareness regarding potential adverse reactions due to contrast media and the necessary precautions to be taken is of utmost importance both for radiologists and referring physicians since the adverse reactions including hypersensitivity reactions to RCM are still unpredictable and reported in significantly increasing number among exposed patients year by year. In 2011, Korean guideline for the safe use of RCM was published by the Korean Society of Radiology and Korean Academy of Asthma, Allergy and Clinical Immunology. On behalf of these organizations a committee named Korean Network of Allergists & Radiologists for Research of Radio-contrast Media-associated Adverse Reactions (KOAR3A) was formed and collaborated to develop guidelines. Its major purpose is to provide a clinically practical and evidence-based manual full of useful information regarding patient screening, premedication, recognition of adverse reactions, and emergency treatment of such reactions in daily practice as well as other problems, especially kidney toxicity and endocrine problems in consultation with the corresponding medical specialists.

A Study of Radiocontrast Media Induced Nephrotoxicity

PURPOSE: This study was aimed at determining whether tri-iodinated compounds with greater solubility and low osmolality, Na or meglumine ioxaglate(Hexabrix 320, Guerbet Lab., France) had deleterious effects on renal function after cardiac angiography for the evaluation of congenital heart disease(CHD) and determining whether correction of dehydration using iv hydration given before cardiac angiography were effective in prventing renal dysfunction. METHODS: For the study of radiocontrast media induced nephrotoxicity, 21 children with various CHDs admitted to the hospital for the evaluation of their CHDs. None of them had any evidence of renal dysfunction before study. They were devided into 2 groups, one was low-dose group(ioxaglate given, < 2.0 mL/kg) and the other one was high-dose group(>2.0 mL/kg). Renal function studies including serum creatinine(Scr), fractional excretion of sodium(FENa) and urinary beta2-microglobulin excreton(mg of beta2- microglobulin per gm creatinine) were done before and after ioxaglate administration. For the study of hydration effect on radiocontrast media induced nephrotoxicity, 9 children with CHDs were subjected. Thery were hydated with 5% D/S 1 hr before cardiac angiography using high-dose ioxaglate(> 2.0 mL/kg) and maintained on fluid therapy during the examination. Renal function studies were done before and after ioxaglate administration. Statistical analyses were done using Wilcoxon signed rank test. RESULTS: 1) Scr level and FENa were not increased significantly after administration of ioxaglate in both of low-dose and high-dose group. 2) A significant increase of urinary beta2M per creatinine excretion(mg/gm creatinine) was observed after administration of ioxaglate n the high-dose group(0.24 vs 0.57, p0.05) 3) Hydration before ioxaglate administration made urinary B2M per creatinine excretion insignificant even in patients who received high-dose ioxaglate, more than 3.0 ml/kg(0.22 vs 0.27, p>0.55). 4) Uric acid and/or calcium oxalate crystaluria appeared after ioxaglate administration, particularly in patients with dehydration. CONCLUSIONS: Ioxaglate, a low osmolality ionic dimer contrast media, could induce renal tubular dysfunction, which depended on dose used. Correction of dehydration before ioxaglate administration significantly reduced the risk of ioxaglate induced nephrotoxicity.