Abstract：
The increasing number of examinations and interventional radiological procedures that require the administration of contrast medium (CM) in patients at risk for advanced age and/or comorbidities highlights the problem of CM-induced renal toxicity. A multidisciplinary group consisting of specialists of different disciplines-radiologists, nephrologists and oncologists, members of the respective Italian Scientific Societies-agreed to draw up this position paper, to assist clinicians increasingly facing the challenges posed by CM-related renal dysfunction in their daily clinical practice.The major risk factor for acute renal failure following CM administration (post-CM AKI) is the preexistence of renal failure, particularly when associated with diabetes, heart failure or cancer.In accordance with the recent guidelines ESUR, the present document reaffirms the importance of renal risk assessment through the evaluation of the renal function (eGFR) measured on serum creatinine and defines the renal risk cutoff when the eGFR is < 30 ml/min/1.73 m2 for procedures with intravenous (i.v.) or intra-arterial (i.a.) administration of CM with renal contact at the second passage (i.e., after CM dilution with the passage into the pulmonary circulation).The cutoff of renal risk is considered an eGFR < 45 ml/min/1.73 m2 in patients undergoing i.a. administration with first-pass renal contact (CM injected directly into the renal arteries or in the arterial district upstream of the renal circulation) or in particularly unstable patients such as those admitted to the ICU.Intravenous hydration using either saline or Na bicarbonate solution before and after CM administration represents the most effective preventive measure in patients at risk of post-CM AKI. In the case of urgency, the infusion of 1.4% sodium bicarbonate pre- and post-CM may be more appropriate than the administration of saline.In cancer patients undergoing computed tomography, pre- and post-CM hydration should be performed when the eGFR is < 30 ml/min/1.73 m2 and it is also advisable to maintain a 5 to 7 days interval with respect to the administration of cisplatin and to wait 14 days before administering zoledronic acid.In patients with more severe renal risk (i.e., with eGFR < 20 ml/min/1.73 m2), particularly if undergoing cardiological interventional procedures, the prevention of post-CM AKI should be implemented through an internal protocol shared between the specialists who treat the patient.In magnetic resonance imaging (MRI) using gadolinium CM, there is a lower risk of AKI than with iodinated CM, particularly if doses < 0.1 mmol/kg body weight are used and in patients with eGFR > 30 ml/min/1.73 m2. Dialysis after MRI is indicated only in patients already undergoing chronic dialysis treatment to reduce the potential risk of systemic nephrogenic fibrosis.
摘要：
越来越多的检查和介入放射学程序需要在有高龄和/或合并症风险的患者中施用造影剂（CM），这凸显了CM引起的肾毒性问题。由不同学科的专家组成的多学科小组-放射科医生，肾脏病学家和肿瘤学家，各自的意大利科学协会成员同意起草这份立场文件，帮助临床医生在日常临床实践中日益面对CM相关肾功能不全带来的挑战。CM给药后急性肾功能衰竭的主要危险因素（后CMAKI）是肾衰竭的存在，特别是当与糖尿病有关时，心力衰竭或癌症。根据最近的准则，本文件重申了通过评估血清肌酐测得的肾功能（eGFR）进行肾脏风险评估的重要性，并定义了当eGFR<30ml/min/1.73m2时的肾脏风险截止值，用于静脉内（i.v.）或动脉内（i.a.）施用CM并在第二次通过肾脏接触（即，CM稀释后进入肺循环)。在接受首次通过肾接触（CM直接注射到肾动脉或肾循环上游的动脉区）的患者中，或在特别不稳定的患者（例如ICU收治的患者）中，肾脏风险的截止值被认为是eGFR<45ml/min/1.73m2。在CM给药之前和之后，使用盐水或碳酸氢钠溶液进行静脉水化是有CM后AKI风险的患者的最有效预防措施。在紧急情况下，在CM之前和之后输注1.4%碳酸氢钠可能比施用盐水更合适。在接受计算机断层扫描的癌症患者中，当eGFR<30ml/min/1.73m2时，应进行CM前和后水合，并且还建议相对于顺铂的给药保持5至7天的间隔，并在施用唑来膦酸之前等待14天。在肾脏风险更严重的患者中(即，eGFR<20ml/min/1.73m2)，特别是如果接受心脏介入手术，CM后AKI的预防应通过治疗患者的专家之间共享的内部方案来实施.在使用钆CM的磁共振成像(MRI)中，AKI的风险比碘化CM低，特别是如果使用剂量<0.1mmol/kg体重，并且eGFR>30ml/min/1.73m2的患者。MRI后透析仅适用于已经接受慢性透析治疗的患者，以降低系统性肾源性纤维化的潜在风险。
