Perspective
Guidelines for Contrast Media from the European
Society of Urogenital Radiology
T his perspective will present all
guidelines produced to date by the
Contrast Media Safety Committee
of the European Society of Urogenital Radiol-
ogy, but attention is focused on the use of gad-
olinium-based contrast media for radiography
and CT and the use of dialysis to remove con-
trast media after injection in patients with end-
stage renal failure.
Methods Used by the Committee
Guidelines can be produced by opinion-
based methods, in which a group of experts
simply reach consensus on a protocol, or by
evidence-based methods that rely on careful
analysis of scientific evidence to determine
which principles should be considered [1, 2].
The Contrast Media Safety Committee of the
European Society of Urogenital Radiology
(ESUR) have used both the so-called Delphi
process and consensus after review of the liter-
ature, as well as a combination of the two. Two
members of the committee make the first
drafts independent of the background of the
material (answers to questionnaire, review of
literature). The draft is harmonized into the
ESUR style by the chairman and the secretary
of the committee before presentation to all
members. The committee meets and discusses
Received April 24, 2003; accepted after revision July 2, 2003.
1
Department of Diagnostic Radiology, Copenhagen University Hospital at Herlev, Herlev Ringvej 75, DK-2730 Herlev, Denmark. Address correspondence to H. S. Thomsen
(heth@herlevhosp.kbhamt.dk).
AJR 2003;181:1463–1471 0361–803X/03/1816–1463 © American Roentgen Ray Society
AJR:181, December 2003
the text in principle and the guidelines in de-
tail. Then the document is presented to the par-
ticipants at one of the European Symposia on
Urogenital Radiology, after which the final
document is released. More than 300 doctors
are involved in the process. An important issue
during the entire process is that the resulting
guidelines should be easy to implement in
daily practice.
Renal Adverse Reactions
Contrast medium–induced nephrotoxicity is
defined as an impairment in renal function (an
increase in serum creatinine by > 25% or 0.5
mg/dL [44 µmol/L]) occurring within 3 days af-
ter the intravascular administration of contrast
media and the absence of an alternative cause
[3]. It is considered an important cause of noso-
comial renal failure. Diagnostic and interven-
tional procedures using contrast media are
performed with increasing frequency. In addi-
tion, the patient population subjected to these
procedures is progressively older and has more
comorbid conditions [4]. Prevention of this iat-
rogenic condition is important to avoid the sub-
stantial morbidity and even mortality that can
sometimes be associated with contrast me-
dium–induced nephrotoxicity. Even a small de-
crease in renal function may exacerbate the
Henrik S. Thomsen1
morbidity and mortality caused by coexisting
conditions such as acquired sepsis, bleeding,
coma, and respiratory failure that are more
frequent in patients with acute renal failure
[5]. Therefore, several measures have been
tried to reduce the frequency of contrast me-
dium–induced nephropathy. No measure has
yet resulted in avoidance of its occurrence in
all patients.
Several measures have been recommended
to reduce the incidence of contrast medium–
induced nephropathy [6]. They include volume
expansion; hydration with IV administration
of normal saline solution (NaCl, 0.9%) or a
half-strength saline solution (NaCl, 0.45%);
infusion of mannitol; administration of atrial
natriuretic peptide, loop diuretics, calcium
antagonists, theophylline, dopamine, dopa-
mine-1 receptor antagonist fenoldopam, and
acetylcysteine; use of low-osmolar nonionic
contrast media instead of high-osmolar ionic
contrast media; use of isoosmolar contrast me-
dia instead of low-osmolar contrast media; use
of gadolinium-based contrast media instead of
iodine-based contrast media for radiography
and CT; hemodialysis soon after contrast ad-
ministration; injection of a small volume of
contrast medium; and avoiding short intervals
(< 48 hr) between procedures requiring intra-
vascular administration of contrast media.
1463

Of all these measures, extracellular volume
expansion and the use of low-osmolar contrast
media have been found to be most systemati-
cally effective [3, 7, 8]. Patients with preexist-
ing renal impairment or multiple myeloma [9]
should receive adequate hydration before con-
trast medium administration. This can be
achieved with the IV injection of 100 mL/hr of
0.9% saline solution starting 4 hr before con-
trast administration and continuing for 24 hr
afterward [6]. In a hot climate, more fluid
should be given. This regime is suitable for pa-
tients who are not in congestive heart failure
and who are not allowed to drink or eat before
undergoing an interventional or surgical proce-
dure. If there is no contraindication to oral ad-
ministration, free fluid intake should be
encouraged. At least 500 mL of water or soft
drinks orally before and 2,500 mL for 24 hr af-
ter contrast administration should be recom-
mended (Appendix 1). This fluid intake should
secure diuresis of at least 1 mL/min in a non-
dehydrated patient. In addition, the concurrent
administration of nephrotoxic drugs such as
gentamicin and nonsteroidal antiinflammatory
drugs should be avoided.
The main factors in the pathophysiology are
considered to be a reduction in renal perfusion
caused by a direct effect of contrast media on
the kidney and toxic effects on the tubular cells,
although the latter effect is controversial [10].
Experimental studies have indicated that the en-
dogenous vasoactive peptide endothelin may
play an important role in mediating these
events. Therefore, it was expected that endothe-
lin antagonists [11] would reduce the incidence
of contrast medium–induced nephropathy in
man, but a clinical study has shown the opposite
effect [12]: a nonselective endothelin receptor
antagonist and IV hydration exacerbated con-
trast medium–induced nephropathy compared
with hydration alone. A similar discrepancy has
been reported with regard to atrial natriuretic
peptide [13]. Calcium-channel antagonists and
adenosine antagonists are also not advanta-
geous. Dopamine protected against contrast-in-
duced decrease in renal function in patients with
baseline serum creatinine greater than 1.9 mg/
dL (170 µmol/L) in one study [14], whereas in
another study it conferred no additional benefit
compared with saline solution alone in prevent-
ing contrast medium–induced nephropathy
[15]; dopamine had a deleterious effect on re-
covery. In another study, the administration of
200 mg of theophylline was shown to have a
preventive effect [16], but theophylline has side
effects. Administration of the antioxidant ace-
tylcysteine has also been shown both to be ef-
1464
Thomsen
fective in preventing contrast medium–induced
nephropathy in some studies [17–19] and to be
without any effect in others [8, 20]. The
dopamine-1 receptor antagonist fenoldopam
has been shown to reduce the incidence of
contrast medium–induced nephropathy in pa-
tients with baseline serum creatinine greater
than 2.0 mg/dL (180 µmol/L) with or without
diabetes mellitus who are undergoing percuta-
neous coronary intervention [21], whereas in a
randomized trial it had no effect [8]. It is ap-
propriate to conclude that the efficacy of these
drugs in the prevention of contrast medium–in-
duced nephropathy remains debatable. Further
studies are required. However, the administra-
tion of frusemide and mannitol should be
avoided [1, 6, 7].
A recent multicenter study included 129 pa-
tients who underwent angiography with either
an isoosmolar dimer or a nonionic monomer
after randomization; those patients had serum
creatinine levels between 1.5 mg/dL (132
µmol/L) and 3.5 mg/dL (308 µmol/L) due to
diabetes mellitus [22]. Contrast medium–in-
duced nephropathy was seen in only 3% of the
patients after the dimer and in 26% after the
monomer. Chalmers and Jackson [23] found,
in patients with nephropathy of various causes,
a 25% increase in 4% and 10% of patients after
an isoosmolar nonionic dimer or a low-osmolar
nonionic monomer, respectively. Taking the his-
tory of contrast medium–induced nephropathy
into account, we must await further studies be-
fore a definitive conclusion can be reached.
There is reason to believe that future studies of
the dimer iodixanol will provide conflicting
data [24].
Prophylactic Hemodialysis
Hemodialysis and peritoneal dialysis
safely remove both iodinated and gadolin-
ium-based contrast media [25]. The effective-
ness of hemodialysis depends on many
factors, including blood and dialysate flow
rate; permeability of dialysis membrane; du-
ration of hemodialysis; and molecular size,
protein binding, hydrophilicity, and electric
charge of the contrast medium. Generally,
several hemodialysis sessions are needed for
removal of all contrast medium, and at least 3
weeks are required for continuous ambula-
tory peritoneal dialysis to remove the agent
completely. The role of hemodialysis in pre-
venting contrast medium–induced nephropa-
thy is not well defined. The cost of
hemodialysis and the associated risks, includ-
ing venous cannulation and the possibility of
heparin-induced bleeding, could be justified
only if hemodialysis prevented contrast me-
dium–induced nephropathy.
Thirty patients with moderately reduced re-
nal function (mean serum creatinine level,
2.5 ± 0.15 mg/dL [212 ± 14 µmol/L]) were
randomly assigned to receive either hemodialy-
sis for 3 hr starting as soon as possible or no he-
modialysis after administration of a nonionic
monomeric contrast medium [26]. All patients
were well hydrated before and after examina-
tion by means of the IV infusion of a normal
saline solution. The incidence of contrast me-
dium–induced nephropathy in the hemodialy-
sis group was 53% and in the control group
was 40%. The poor efficacy of hemodialysis in
preventing contrast medium–induced nephrop-
athy is related to the rapid onset of renal injury
after the administration of contrast medium
[27]. One hundred thirteen patients with
chronic renal impairment (serum creatinine >
2.5 mg/dL [200 µmol/L]) were randomly
assigned to either hemodialysis or no hemodi-
alysis after the injection of nonionic mono-
meric contrast media [28]. All patients received
saline infusion according to the same protocol
as the previous study. The hemodialysis began
30–280 min after the radiographic procedure.
The incidence of contrast medium–induced
nephropathy in the hemodialysis group was
24% and in the no-hemodialysis group was
16%. No significant difference was seen be-
tween the two groups in relation to clinically
important events (stroke, pulmonary edema,
myocardial infarction, and death). Hemodialy-
sis may cause deterioration of renal function
through activation of inflammatory reactions
and the release of vasoactive substances that
may induce acute hypotension. Thus, the strat-
egy of performing hemodialysis immediately
after the administration of contrast media in pa-
tients with reduced renal function does not di-
minish the rate of complications. Relating the
time of the contrast medium injection to the di-
alysis schedule is unnecessary (Appendix 2).
Gadolinium-Containing Contrast Media Instead of
Iodinated Contrast Media for Radiography of Patients
with Increased Risk of Contrast Medium–Induced
Nephropathy
Gadolinium-based contrast agents are known
be safe and not nephrotoxic in the usual MRI
doses of up to 0.3 mmol/kg body weight. There-
fore, it has been suggested that gadolinium-
based contrast media could be used in place of
iodinated agents for radiologic examinations in
patients with significant renal impairment [29].
At the kilovoltage used for digital angiography,
the attenuation of X-ray beams by gadolinium
is approximately the same as for iodine. At the
AJR:181, December 2003

kilovoltage used for CT, the attenuation by gad-
olinium is approximately double that of iodine.
Therefore, in theory gadolinium could replace
iodine as a radiographic contrast agent. How-
ever, the dose requirement for a satisfactory di-
agnostic study differs between MRI and
radiography because different properties of gad-
olinium are being used in the two techniques.
The commonly used dose for body CT is 150
mL of a 300 mg I/mL (2.38 mmol I/mL) solu-
tion. The standard dose for contrast-enhanced
MRI is 0.2 mL/kg of body weight of a 0.5
mmol/mL gadolinium-based contrast agent. For
body CT, a patient weighing 70 kg would re-
ceive 120 mmol of the iodinated agent molecule
and 360 mmol of iodine. For MRI, this same
70-kg patient would receive 7 mmol of the gad-
olinium-based agent molecule and 7 mmol of
gadolinium [29]. Thus, the number of iodinated
contrast agent molecules administered would be
almost 17 times that of gadolinium-containing
molecules, and the number of iodine atoms ad-
ministered is 51 times that of gadolinium.
In a study involving 64 patients who under-
went MRI with a gadolinium-based agent and a
radiographic examination with an iodinated
agent, the authors concluded that gadolinium
chelates are significantly less nephrotoxic than
iodinated agents [30]. Eleven of the 64 patients
had a significant increase in serum creatinine
level after IV or intraarterial administration of
iodine-based contrast media, whereas none had
increased serum creatinine levels after IV ad-
ministration of a gadolinium-based contrast
agent. However, the molar doses and concen-
trations of the iodine and gadolinium atoms
were not comparable. Albrecht and Dawson
[31] studied 15 patients receiving 0.3 mmol/
kg of body weight of gadopentetate dimeglu-
mine; five underwent abdominal CT, five ab-
dominal digital subtraction angiography, and
five excretory urography. Generally, the im-
age quality was inferior to that obtained sub-
sequently with standard doses of an iodinated
contrast medium (50–150 mL of a 300 or 350
mg I/mL solution).
During recent years, gadolinium-based con-
trast agents have been used for examinations
such as CT, excretory urography, digital sub-
traction angiography of various parts of the
body (e.g., hepatic, renal, and peripheral arter-
ies), endoscopic retrograde cholangiography,
cystography, urethrocystography, and retro-
grade pyelography, as well as during percuta-
neous nephrostomy and biliary tract drainage.
Kaufmann et al. [32] examined 14 patients
with abnormal serum creatinine levels who un-
derwent digital subtraction vena cavography
AJR:181, December 2003
Guidelines for Contrast Media
with a gadolinium-based contrast agent (a
maximum of 0.4 mmol/kg of body weight) for
filter placement, thrombolysis, or diagnosis.
Three of the 14 patients had a significant in-
crease in serum creatinine (> 0.5 mg/dL [44
µmol/mL]), but there were other potential con-
current causes that might account for the dete-
rioration of renal function. Serum creatinine
transiently increased from 4.0 to 9.3 mg/dL
(350 to 820 µmol/L) after lower extremity ar-
teriography with 80 mL of 0.5 mmol/mL (0.44
mmol/kg of body weight) of gadoteridol in a
patient with diabetic nephropathy [33]. The
deterioration was thought to most likely be due
to the contrast agent. Thirty-one patients with
azotemia or previous severe adverse reaction
to iodinated contrast media have undergone
digital subtraction angiography with between
20 and 60 mL of 0.5 mmol/mL of gadopen-
tetate dimeglumine [34]. In nine cases, CO2
was also used, and in eight cases between 6
and 40 mL (mean, 17.8 mL) of iohexol 350
mg I/mL was used. In no case did a patient’s
serum creatinine level increase more than 0.5
mg/dL (44 µmol/L) within 48 hr. In another
study [35], renal function deteriorated in one
(6%) of 18 azotemic patients after undergoing
CO2 angiography supplemented with 0.5
mmol/mL of gadodiamide (20–100 mL; mean
volume, 55 mL; 0.13–0.40 mmol/kg). The af-
fected patient received 70 mL of gadodiamide
(0.3 mmol/kg of body weight).
After injections of 80–440 mL of gadodia-
mide during arteriography, the serum creatinine
level increased 0.6 mg/dL (53 µmol/mL) or
more in eight (40%) of 20 patients with a pre-
procedural serum creatinine of 1.3–6.3mg/dL
(115–548 µmol/mL) [36]. In three of the eight
patients, the creatinine values did not return to
the baseline value. After peripheral gadolinium
arteriography, angioplasty, and stent placement,
a patient with renal insufficiency (serum creati-
nine level, 3.9 mg/dL [340 µmol/L]) developed
acute renal failure and acute pancreatitis [37].
Acute pancreatitis has been seen both after in-
traarterial [33] and IV [38] injection of a gado-
linium-based contrast agent.
According to experimental data from the
study of animals, gadolinium-based contrast
media have more nephrotoxic potential than io-
dinated contrast media in equivalent X-ray at-
tenuating doses. For example, in an
experimental model of renal ischemia in pigs,
0.5 mmol/mL of gadopentetate dimeglumine (3
mL/kg of body weight) caused severe impair-
ment of renal function; the low-osmolar gadodi-
amide caused less deterioration in renal
function, and the low-osmolar iohexol (3 mL of
190 mg I/mL per kg body weight) caused even
less [39]. Three milliliters per kilogram of body
weight of iohexol (70 mg I/mL), which for an-
giography is isoattenuating with 0.4 mmol/mL
of gadopentetate dimeglumine, caused no
change in renal function.
Nephrotoxicity of the gadolinium-based
contrast agents has now been described in both
man and animals when high doses (> 0.3
mmol/kg) are used. Use of such doses of the
gadolinium agents in patients with impaired
renal function is not recommended. Their use
for radiography and CT is also not an ap-
proved indication anywhere in the world. A
major drawback with using gadolinium-based
contrast agents for CT or radiography is that
commercially available contrast media have
only one gadolinium atom per molecule and a
low molar concentration. In comparison,
iodinated monomers for radiographic exami-
nations contain three iodine atoms per mole-
cule and have molar concentration five times
that of gadolinium in four of the five gadolin-
ium-based contrast agents available on the
market. Hence, image quality is generally infe-
rior when gadolinium-based contrast media
are used for radiography. A position statement
on the use of gadolinium-based contrast media
for radiography has been issued in Europe
(Appendix 3).
Metformin-Induced Lactic Acidosis and the
Intravascular Administration of Contrast Media
Biguanide metformin (dimethylbiguanide) is
used in patients with non–insulin dependent di-
abetes mellitus and was introduced into clinical
practice in 1957. Approximately 90% of met-
formin is eliminated via the kidneys in 24 hr.
Renal insufficiency (glomerular filtration rate <
70 mL/min, or serum creatinine > 1.6 mg/dL
[140 µmol/L]) will lead to retention of these
biguanides in the tissues and to the potential de-
velopment of fatal lactic acidosis [40].
Contrast media should be used with care in
patients receiving metformin. Contrast media
can induce a reduction in renal function lead-
ing to retention of metformin that may induce
lactic acidosis because the onset of renal injury
after the administration of contrast medium is
quite rapid [27]. However, no conclusive evi-
dence exists indicating that the intravascular
use of contrast media precipitates the develop-
ment of metformin-induced lactic acidosis in
patients with normal serum creatinine levels
(< 1.5 mg/dL [130 µmol/L]). The complica-
tion was almost always observed in non–insu-
lin dependent diabetic patients with abnormal
renal function before the injection of contrast
1465

media. Serum creatinine levels should always
be monitored to check that they are within nor-
mal range before the administration of met-
formin is resumed. The check should be done
at least 48 hr after the administration of the
contrast medium (Appendix 4).
Nonrenal Adverse Reactions
Nonrenal adverse reactions to intravascular
contrast media are not frequent and are generally
classified as either idiosyncratic or chemotoxic.
Idiosyncratic (i.e., anaphylactoid) reactions oc-
cur unpredictably and independently of the dose
or concentration of the agent. Most anaphylactic
reactions relate to release of active mediators.
Conversely, chemotoxic-type effects relate to
dose, the molecular toxicity of each agent, and
the physiologic characteristics of the contrast
agents (i.e., osmolality, viscosity, hydrophilicity,
calcium-binding properties, and sodium con-
tent). Other reactions to injection of contrast me-
dia (e.g., sudden cardiopulmonary arrest) are
difficult to categorize specifically into either of
the two major reaction types. Chemotoxic ef-
fects of contrast media are more likely in pa-
tients who are debilitated or medically unstable.
Acute reaction to contrast media can be di-
vided into minor, intermediate, and severe life-
threatening reactions. Minor reactions include
flushing, nausea, arm pain, pruritus, vomiting,
headache, and mild urticaria. Such reactions
are usually mild in severity, of short duration,
and self-limiting and generally require no spe-
cific treatment. Intermediate reactions are
more serious degrees of the same symptoms,
moderate degrees of hypotension, and bron-
chospasm. The reactions usually respond
readily to appropriate therapy. Severe life-
threatening reactions include severe manifesta-
tion of all the symptoms described as minor
and intermediate reactions, plus convulsions,
unconsciousness, laryngeal edema, severe
bronchospasm, pulmonary edema, severe car-
diac dysrhythmias and arrest, and cardiovascu-
lar and pulmonary collapse. The prevalence of
adverse reactions with low-osmolar contrast
media is less than with high-osmolar contrast
media by a factor of 5–6 [41]. Lethal reactions
rarely occur.
Several factors predispose a patient to ad-
verse reactions to contrast material. The inci-
dence of severe adverse reactions increases in
the presence of these risk factors, particularly
previous contrast medium reaction, allergy,
and bronchial asthma. Lasser et al. [42], in a
randomized study of 6,763 patients, found
that corticosteroid prophylaxis reduces the in-
1466
Thomsen
cidence of all reactions to ionic contrast me-
dium. The data indicating a protective effect
of corticosteroid prophylaxis when nonionic
agents are used are less established. In a
smaller randomized trial of 1,155 patients
and control subjects, Lasser et al. [43]
showed a significant decrease from 4.9% to
1.7% in all reactions when a steroid was
given rather than a placebo before nonionic
contrast media. The frequency of moderate
and severe reactions after steroids was also
less, but the numbers were small and no sta-
tistically significant difference was found.
Katayama et al. [41] reported no beneficial
effect of steroid premedication in the non-
ionic contrast media group. However, the pa-
tients received steroids IV only immediately
before the administration of contrast medium
[43], so the steroids did not have time (≈ 6 hr)
to take effect. Wolf et al. [44] found that the
nonionic agent iohexol provided better pro-
tection against reaction than did a corticoster-
oid plus ionic contrast medium, but those
authors did not evaluate the effect of using
corticosteroids with nonionic agents.
In view of the findings by Wolf et al.,
Dawson and Sidhu [45] suggested that corti-
costeroid prophylaxis should be abandoned.
This suggestion was subsequently strongly
contested [46–50]; and currently opinion is
divided as to whether corticosteroid prophy-
laxis should be used with nonionic agents.
This division was reflected in a survey from
the United Kingdom that showed that 55%
of responders used corticosteroid prophy-
laxis and 45% did not [51]. In a survey per-
formed by the European Society of
Urogenital Radiology [52], asthma was con-
sidered a significant risk factor; and only
48% of the responders give corticosteroid
prophylaxis to these patients. Administration
of a very short course of steroids is relatively
safe and inexpensive but should be avoided
in patients with diabetes mellitus, active tu-
berculosis, and peptic ulcer disease and in
the presence of systemic infection [53, 54].
Both in the United States and Europe, a wide
variety of regimes, with different doses,
numbers of doses, and frequency, are used
for corticosteroid prophylaxis, if it is given at
all [52, 55]. On the basis of the results of a
survey and review of literature, European
guidelines for prevention of generalized re-
actions to contrast media have been proposed
(Appendix 5). However, even in patients who
receive both corticosteroid premedication
and low-osmolar contrast media, severe ad-
verse reactions may still occur [43].
Late Adverse Reactions
Late adverse reactions to intravascular
iodinated contrast media are defined as reac-
tions occurring 1 hr to 1 week after injection.
Such reactions have received increasing inter-
est during the past decade, but their prevalence
remains uncertain and their pathophysiology is
not fully understood [56]. The reactions in-
clude symptoms such as nausea, vomiting,
headache, itching, skin rash, musculoskeletal
pain, and fever. A significant proportion of
these reactions is unrelated to the contrast me-
dium. However, allergylike skin reactions are
well-documented side effects of contrast me-
dia, with an incidence of approximately 2%.
Late reactions appear to be more common af-
ter nonionic dimers. Most late skin reactions
after contrast medium exposure are probably
T-cell-mediated allergic reactions. Patients at
increased risk of late skin reactions are those
with a history of previous contrast medium re-
action and those undergoing interleukin-2
treatment. Most skin reactions are self-limiting
and resolve within a week. Treatment is symp-
tomatic and similar to the treatment of other
drug-induced skin reactions (Appendix 6).
Extravasation
Extravasation of contrast material is a well-
recognized complication of contrast-enhanced
imaging. The introduction of automated power
injection has increased the incidence because
power injection may result in extravasation of
large volumes in a short period of time [57]
and may lead to severe tissue damage. Infants,
young children, and unconscious and debili-
tated patients are particularly at risk of extrava-
sation during contrast media injection.
Fortunately, most extravasations result in mini-
mal swelling or erythema and have no long-
term sequelae. However, severe skin necrosis
and ulceration may occur. Large volumes (>
50 mL) of high-osmolar contrast media are
known to induce significant tissue damage.
Compartment syndrome may be associated
with the extravasation of large volumes. Con-
servative treatment is often adequate, but in se-
rious cases the advice of a plastic surgeon is
recommended (Appendix 7).
Guidelines
The guidelines produced by the European
Society of Urogenital Radiology (Appendices
1–7) can be found on the Internet at
www.esur.org [58]. These guidelines have
been adopted by many radiologists in Europe
and have been endorsed by some European
AJR:181, December 2003

health authorities. The guidelines represent a
broad consensus of opinion among European
radiologists. It seems appropriate to conclude,
nearly 10 years after the European Society of
Urogenital Radiology established its Contrast
Media Safety Committee, that guidelines
based on consensus are well received and have
a great impact on the treatment of patients. De-
spite research, significant areas of uncertainty
[59] still reflect the paucity of relevant infor-
mation in the literature.
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APPENDIX 1. European Society of Urogenital Radiology Simple Guidelines to Avoid Contrast Medium Nephrotoxicity

Definition Contrast medium nephrotoxicity is a condition in which an impairment in renal function

(an increase in serum creatinine by more than 25% or 0.5 mg/dL [44 µmol/L]) occurs within
3 days after the intravascular administration of a contrast medium in the absence of an
alternative cause.

Risk factors Look for • Elevated serum creatinine levels, particularly as a result of diabetic nephropathy.
• Dehydration.
• Congestive heart failure.
• Age older than 70 years.
• Concurrent administration of nephrotoxic drugs (e.g., nonsteroidal antiinflammatory drugs).

In patients with risk Do • Make sure the patient is well hydrated (give at least 100 mL oral [e.g., soft drinks] or IV
factors [normal saline] depending on the clinical situation) per hour starting 4 hr before to 24 hr
after contrast administration; in warm areas, increase the fluid volume).
• Use low- or isoosmolar contrast media.
• Stop administration of nephrotoxic drugs for at least 24 hr.
• Consider alternative imaging techniques that do not require the administration of iodinated
contrast media.

Do not • Give high-osmolar contrast media.

• Administer large doses of contrast media.
• Administer mannitol and diuretics, particularly loop-diuretics.
• Perform multiple studies with contrast media in a short period of time.
(Reprinted with permission from [3])

1468 AJR:181, December 2003


APPENDIX 2. European Society of Urogenital Radiology Simple Guidelines on Dialysis and Contrast Media Administration
Patients
On hemodialysis
[all contrast media can be removed
by hemodialysis]
On continuous ambulatory peritoneal
dialysis (CAPD) [all contrast media can be
removed by peritoneal dialysis]
With severely reduced renal function
(Reprinted with permission from [25])
APPENDIX 3. European Society of Urogenital Radiology (ESUR) Position Statement on the Use of Gadolinium-Based Contrast
Media for Radiography
Legal position
Uses of gadolinium-based contrast
media for radiographic examinations
reported in the literature
ESUR position
(Reprinted with permission from [29])
AJR:181, December 2003
Guidelines for Contrast Media
Recommendations
• Avoid osmotic and fluid overload.
• Correlation of the time of contrast media injection with the hemodialysis session is
unnecessary.
• Extra hemodialysis session for removal of contrast media is unnecessary.
Radiography:
• To protect residual renal function, please refer to European Society of Urogenital Radiology
guidelines to avoid contrast medium–induced nephrotoxicity.
• Hydration should be considered only after careful evaluation of fluid balance of the patient.
• Hemodialysis is not recommended.
MRI:
• To protect residual renal function, use only doses up to 0.3 mmol/kg of body weight of
gadolinium-based contrast agents.
• Hemodialysis is not recommended.
• Please refer to European Society of Urogenital Radiology guidelines to avoid contrast
medium–induced nephrotoxicity (hydration, use small doses of low-osmolar contrast media).
• Hemodialysis is unnecessary.
• In MRI examinations, avoid doses > 0.3 mmol/kg of body weight of gadolinium-based
contrast agents.
Gadolinium-based contrast media are not approved for radiography.
• Significant renal impairment
• Prior severe generalized adverse reaction to iodinated contrast media
• Imminent thyroid treatment with radioactive iodine
1. The use of gadolinium-based contrast media for radiographic examinations is not
recommended to avoid nephrotoxicity in patients with renal impairment because they
are more nephrotoxic than iodinated contrast media in equivalent X-ray attenuating doses.
2. The use of gadolinium-based contrast medium in approved IV doses up to 0.3 mmol/kg
body weight will not give diagnostic radiographic information in most cases.
Appendixes continue
1469
APPENDIX 4. European Society of Urogenital Radiology Guidelines for the Administration of Contrast Media to Diabetic
Patients Taking Metformin Thomsen

Serum creatinine level Should be measured in every diabetic patient treated with biguanides before intravascular
administration of contrast media.

Contrast medium Low-osmolar agents should always be used in these patients.

Elective studies a) If the serum creatinine level is normal, the radiologic examination should be performed and
intake of metformin stopped from the time of the study. The use of metformin should not be
resumed for 48 hr and should be restarted only if renal function and serum creatinine level
remain within the normal range.

b) If renal function is abnormal, the metformin should be stopped and the contrast study
should be delayed for 48 hr. Metformin should be restarted 48 hr later only if renal function
and serum creatinine level are unchanged.

Emergency cases a) If the serum creatinine is normal, the study may proceed as suggested for elective patients.

b) If the renal function is abnormal (or unknown), the physician should weigh the risks and
benefits of contrast administration. Alternative imaging techniques should be considered. If contrast
media administration is deemed necessary, the following precautions should be implemented:
• Metformin therapy should be stopped.
• The patient should be hydrated (e.g., ≥ 100 mL/hr of soft drinks or IV saline up to 24
hr after contrast medium administration; in hot areas, more fluid should be given).
• Monitor renal function (serum creatinine), serum lactic acid, and pH of blood.
• Look for symptoms of lactic acidosis (vomiting, somnolence, nausea, epigastric pain,
anorexia, hyperpnea, lethargy, diarrhea, and thirst). Blood test results indicative of
lactic acidosis: pH < 7.25 and lactic acid > 5 mmol.
(Reprinted with permission from [40])

APPENDIX 5. European Society of Urogenital Radiology Guidelines on Prevention of Generalized Contrast Medium Reactions
in Adults
A. Risk factors for reactions • Previous generalized contrast medium reaction, either moderate (e.g., urticaria,
bronchospasm, moderate hypotension) or severe (e.g., convulsions, severe bronchospasm,
pulmonary edema, cardiovascular collapse)
• Asthma
• Allergy requiring medical treatment

B. To reduce the risk of generalized • Use nonionic agents.

contrast medium reactions

C. Premedication is recommended in • When ionic agents are used.

high-risk patients (defined in A) • When nonionic agents are used, opinion is divided about the value of premedication.

Recommended premedication • Corticosteroids

Prednisolone 30 mg orally or
Methylprednisolone 32 mg orally 12 and 2 hr before administration of contrast medium
Corticosteroids are not effective if given < 6 hr before contrast medium
• Antihistamines H1 and H2 may be used in addition to corticosteroids, but opinion is divided.

D. Remember for all patients • Have resuscitation drugs in the examination room.
• Observe patients for 20–30 min after contrast medium injection.

E. Extravascular administration • When absorption or leakage into the circulation is possible, take the same precautions as for
intravascular administration.
(Reprinted with permission from [52])

1470 AJR:181, December 2003

 Guidelines for Contrast Media

APPENDIX 6. European Society of Urogenital Radiology Guidelines for Late Adverse Reactions to Intravascular Iodinated
Contrast Media

Definition: A late adverse reaction to intravascular iodinated contrast medium is defined as a reaction that
occurs 1 hr to 1 week after contrast medium injection.

Reactions: A variety of late symptoms (e.g., nausea, vomiting, headache, musculoskeletal pains, fever)
have been described after administration of contrast medium, but many are not related to
contrast medium.

Skin reactions of similar type to other drug eruptions are true late adverse reactions. They are
usually mild to moderate and self-limiting.

Risk factors for skin reactions: • Previous contrast medium reaction

• Interleukin-2 treatment

Management: Symptomatic and similar to the management of other drug-induced skin reactions

Prophylaxis: • Generally not recommended

• Patients who have had a previous serious late adverse reaction can be given oral steroids
(see European Society of Urogenital Radiology Guidelines on Prevention of Generalized
Adverse Reactions).

Recommendations: Tell patients who have had a previous contrast medium reaction or who are receiving
interleukin-2 treatment that a late skin reaction is possible and that they should contact a
doctor if they have a problem.
(Reprinted with permission from [56])

APPENDIX 7. European Society of Urogenital Radiology Simple Guidelines for Prevention and Management of Extravasation of
Contrast Media
Risk factors relate to: • The technique
• Use of a power injector
• Less optimal injection sites including lower limb and small distal veins
• Large volume of contrast medium
• High-osmolar contrast medium

• The patient who

• is unable to communicate.
• has fragile or damaged veins.
• has arterial insufficiency.
• has compromised lymphatic or venous drainage.

To reduce the risk • IV technique should always be careful, preferably using plastic catheters for power
injection.
• Use low-osmolar contrast medium.

Types of injuries • Most injuries are minor.

• Severe injuries include skin ulceration, soft-tissue necrosis, and compartment syndrome.

Treatment • Conservative treatment is adequate in most cases:

• limb elevation
• ice packs
• careful monitoring
• If a serious injury is suspected, seek the advice of a surgeon.

(Reprinted with permission from [57])

AJR:181, December 2003 1471