Dr. Allison Rixey is a chief radiology resident physician in Rochester, MN.
Dr. Sasha Selby is an emergency medicine resident physician in Rochester, MN.
Dr. Sara Hevesi is an emergency medicine consultant physician in Rochester, MN.
The final Mayo EM residency journal club of the 2020-2021 academic year was held on June 29th. This journal club was hosted by EM resident and journal club team member, Sasha Selby, at the party room of the beautiful Berkman Apartment building (right across the street from the ER and overlooking the rolling hills of Rochester). We discussed evidence behind the long standing dogma of contrast induced nephropathy. We reviewed one standard journal article from the Radiology literature, a meta analysis from the Emergency Medicine literature and a FOAMed piece from the EmCrit website. We were grateful to have this event combined with the radiology residency and the authors of the radiology article, Dr. and Dr. McDonald, were also in attendance to share their perspective and wisdom.
Dr. Allison Rixey presented on the Radiology article “Intravenous Contrast Material Exposure Is Not an Independent Risk Factor for Dialysis or Mortality”(1). This study is a retrospective, propensity score-matched study proposing that administration of intravenous iodinated contrast does not increase risk for AKI, need for emergent dialysis, or short term mortality. Patients within the large cohort were identified as high risk if they had pre-existing diabetes mellitus, congestive heart failure, or chronic or acute kidney injury. Even among these patients that have been historically suspected to have increased risk of AKI following IV contrast administration, there was no significant difference in incidence of AKI, need for emergent dialysis, or 30 day mortality between groups that had contrast enhanced versus non-contrast enhanced CT scans. Although patients who developed AKI had higher rates of dialysis and mortality, contrast material exposure was not an independent risk factor for either outcome for dialysis.
Dr. Sasha Selby presented on the Annals of Emergency Medicine article “Acute Kidney Injury After Computed Tomography: A Meta-Analysis” (2). CT quality is enhanced with IV contrast and this added information can be lifesaving in an emergency situation. There was a prehistoric theoretical risk to using IV contrast as it was thought it may induce renal dysfunction and precipitate acute kidney injury. A meta-analysis of all the major journal databases was conducted in order to compare the actual risk of AKI and the need for renal replacement therapy (dialysis) and effect on mortality in contrast versus non-contrast CT patients. Of over 107,335 subjects and over 28 studies, no significant difference was found between those receiving contrast versus non-contrast CT imaging. The conclusion of this article was that CT contrast is not associated with renal injury in this large meta-analysis.
Dr. Paige Cardin presented on the EmCrit piece from May 2019 written by Josh Farkas, MD entitled “Contrast Nephropathy, myth thereof” (3). This post reviews the history of contrast induced nephropathy as a clinical entity, evidence (or lack of evidence) supporting this and a discussion of the risks and benefits to using IV contrast. This post pointed out that “contrast induced nephropathy” was introduced in the 1950s, at which point the contrast dye that was used (50% diodone, a high osmolar contrast dye that we no longer use) probably was damaging. However, this started a dogma that has been widely held since then. They review that contrast dye likely does not actually cause an increase in creatinine, as this level fluctuates naturally regardless of if patients have received contrast or not (citing another study done by the Drs. McDonald). Even if the creatinine level were to increase, this doesn’t necessarily reflect true renal damage/injury and evidence has shown that it does not cause the need for renal replacement therapy. The summary of this post was that there is no evidence proven risk of using contrast dye while there is clearly benefit to using this to help make diagnoses of life threatening conditions. The article ends with a very helpful algorithm, linked below.
It was incredible to have the authors of the Radiology paper (and our colleagues) present for this discussion. The Doctors McDonald added some excellent viewpoints into finding your research passion, how to create quality publications and the challenges in changing dogma. We discussed that many other academic institutions have already done away with creatinine screening in Emergency Department patients. It appears that Mayo Clinic may follow their lead soon, and all in attendance were in support of this much needed change.
Food for this event was Nupa, a Greek restaurant in town. We enjoyed delicious gyros and pitas. Several additional guests joined us via Zoom. Special appearances were made by various pets, significant others and babies of those in attendance!
The next journal club will be July 23rd at 6pm. This journal club will start as a pool party at one of the EM consultants homes. We will be discussing Emergency Department treatment for CHF exacerbations and risk stratification. We hope to see you there!
1. McDonald RJ, McDonald JS, Carter RE, Hartman RP, Katzberg RW, Kallmes DF, Williamson EE. Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality. Radiology. 2014 Dec;273(3):714-25. doi: 10.1148/radiol.14132418. Epub 2014 Sep 9. PMID: 25203000.
2. Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. PMID: 28811122.
3. Farkas J. Contrast nephropathy, myth thereof. Available at: https://emcrit.org/ibcc/contrast/ .