Copyright ©The Author(s) 2017.
World J Radiol. Sep 28, 2017; 9(9): 339-349
Published online Sep 28, 2017. doi: 10.4329/wjr.v9.i9.339
Table 1 Risk factors that predispose patients to contrast medium reactions
Patients with a prior history of allergy to CM (3-6 folds)
Patients with a prior history of allergic reactions to drugs and foods
Patients with generalized atopic tendencies (e.g., asthma and hay fever)
Dehydration states
Age extremes (less than 5 yr and older than 60 yr)
Serious illness and chronic debilitating conditions, e.g., CVS diseases and renal failure
Certain co-medications, e.g., β-blockers and metformin
Patient’s anxiety due to public concerns about CM-induced reaction
Table 2 Co-morbidities indicating renal profile checkup prior to contrast agent administration
Age extremesOlder than 60 yr and less than 5 yr
History of relevant renal disordersAnatomic variations: Solitary kidney and horse-shoe kidney
Renal surgeries
Renal endangering medications, e.g., NSAIDs and chemotherapy
Renal-induced nephropathy (prior)
History of prior renal dialysis
Renal malignancies
Nephropathy-associated chronic diseasesE.g., uncontrolled DM, hypertension and hyperuricemia
Drugs interfering with renal excretionsMetformin
Table 3 Common elective premedication protocols for high-risk patients to develop iodinated contrast medium hypersensitivity reactions
Lasser protocolGreenberger protocol1IV protocols (in descending order of desirability)
Oral prednisone 50 mg at 13/7 and 1 h before contrast medium injectionOral methylprednisolone 32 mg at 12 and 2 h before contrast medium injection +/-Methylprednisolone sodium succinate 40 mg
hydrocortisone sodium succinate 200 mg
every 4 h till examination
+ diphenhydramine 50 mg IV - 1 h
+ (oral/IM or IV) diphenhydramine 50 mg just 1 h before examination+/- (oral/IM or IV) diphenhydramine 50 mg just 1 h before examinationNo corticosteroids at all
(not preferable)
Only diphenhydramine 50 mg IV
Table 4 Severity scale, signs, symptoms and management options of adverse reactions to contrast media
Category of reactionSymptomsTreatment
Mild (self-limited without evidence of progression)Hives, rashes and sweatsPatient reassurance usually suffices in some cases
Nasal symptomsClose observation till resolution of symptoms
Nausea, vomitingMay require symptomatic treatment in some cases
Headache and/or Dizziness
Self limited anxiety
Moderate (signs and symptoms are more pronounced)Generalized or diffuse erythemaRequires prompt treatment
Tachycardia/bradycardiaRequires close, careful observation for possible progression to a life-threatening event
Bronchospasm, wheezing and/or dyspnea
Hypo- or hyper-tension
Voice hoarseness
Severe (sign and symptoms are often life-threatening)Laryngeal edema (severe or rapidly progressing)Requires hospitalization and aggressive treatment by emergency teams
Profound hypotension
Clinically manifest arrhythmias
Cardiopulmonary arrest
Table 5 The criteria for diagnosing contrast induced-acute kidney injury
Absolute serum creatinine increase of greater than or equal to 3.0 mg/dL (> 26.4 μmol/L)
An increase in the percentage of serum creatinine of greater than or equal to 50%
Urine output reduced to less than or equal to 0.5 mL/kg per hour for at least 6 h
Table 6 European medicines agency nephrogenic systemic fibrosis-risk stratification categorization of gadolinium-based contrast agent
GBCA NSF-risk classScientific (generic) name
Highest risk of NSFGadodiamide (Omniscan®)
Gadopentetatedimeglumine (Magnevist®)
Gadoversetamide (Optimark®)
Intermediate risk of NSFGadobenatedimeglumine (Multihance®)
Gadofosvesettrisodium (Vasovist®, Ablavar®)
Gadoxetate disodium (Primovist®, Eovist®)
Lowest risk of NSFGadobutrol (Gadovist®)
Gadoteratemeglumine (Dotarem®)
Gadoteridol (Prohance®)
Table 7 Strategies for safe clinical practice of contrast media to reduce risk for renal complications in patients with renal problems
Patients with SCr ≥ 2 g/dL and/or eGFR ≤ 60 mL/min per 1.73 m2Withhold contrast whenever possible and use alternative imaging modalities if feasible
Adequate hydration
Patients with end-stage renal disease who still produce urineConsider alternative diagnostic study if feasible
Avoid use of CM whenever possible
Use lowest possible dose of contrast
Use intermediate to low osmolar and/or low risk GBCA
followed by prompt dialysis if the patient is already undergoing dialysis
Patients with end-stage renal disease who are anuricCan receive routine volumes of intravenous contrast material without risk for further renal damage or the need for urgent dialysis
Table 8 Practical guidelines for safe contrast media-metformin interaction
Renal function (eGFR-indexed)Action
Patients with normal renal function (eGFR ≥ 60 mL/min per 1.73 m2)No need to withhold metformin
Patients with compromised renal function (eGFR ≥ 30 but ≤ 60 mL/min per 1.73 m2)Withhold metformin for 48 h
Re-institution after renal function monitoring
Patients with compromised renal function (eGFR < 30 mL/min per 1.73 m2)Have not to be on metformin
Consult nephrologist