Osteodystrophy | Arteriography/angioplasty | Myeloma | Ultrasound | Preventing contrast nephropathy

Dialysis patients/osteodystrophy

There is no need for any routine screening.  Where hyperparathyroidism is being quantitated, a hand XR alone will usually suffice (request 'hand XR for hyperparathyroidism' in Edinburgh).  Views of the pelvis may be justified in some circumstances - explain these on the request form if so. 


Renal Arteriography and Angioplasty

MR Angiography has greatly reduced use of conventional angiography. However concerns about Gadolinium-containing MR contrast media and Nephrogenic Systemic Fibrosis (Nephrogenic Sclerosing Dermopathy) mean that MRA be used very cautiously if at all in dialysis patients and patients with severe renal failure.

For conventional angiography, patients admitted on day of procedure, earlier if less fit.  Overnight stay not routinely required for diagnostic angiograms, usually suitable for day case unit. Should stay overnight for interventions. 
 
 

Pre-Procedure


Investigations – recent results to be available for


Observations


Fluid management

Ensure patient well hydrated and good urine output prior to contrast (if pre-dialysis) - if in doubt put up 6hrly 500mls N Saline.  Do not fluid overload dialysis patients.  Avoid diuretics.  Beware that after stenting/angioplasty, some patients may become polyuric.


Consent

Should be done in OPD for diagnostic studies.  Radiologist should obtain consent for interventional studies, need to warn of risks of contrast, and catheter-related complications including embolism, arterial occlusion, bleeding from puncture site, loss of renal function, occasional need for surgery after intervention.


Post-procedure

Myeloma skeletal survey

(In Edinburgh, request in these words)  - includes CXR, lateral skull, lumbar spine, pelvis, upper femur; plus 2 views of any symptomatic region.


Ultrasound

The most requested and most frequently useful investigation, but observer dependent - speak to the operator if any question.  Renal length averages 11 cm in adults, but there is some variability in measurement, and differences of up to 1cm in repeated measurements are common.  Figures showing 95th centiles are from O'Neill, Am.J.Kid.Dis. 35:1021-38 (2000).

Preventing contrast nephropathy

This is rare in the absence of its chief risk factors:

The use of lower doses and less hyper-osmolar contrast media reduces risk.

Testing of several putative protective treatments has shown them to be harmful – this includes marnnitol, diuretics, and dopamine.  The use of N-Acetyl Cysteine (NAC) prophylactically probably does no serious harm, but the evidence that it prevents severe acute renal failure is weak.

If a patient is at increased risk, does this alter the balance of risk for doing/not doing the rest?  If not:


Principles for prevention of contrast-associated nephropathy

 

Some regimens for preventing contrast-associated nephropathy
IV saline/bicarbonate


Oral NAC protocol
(in addition to fluid regimen)


Immediate Saline/ IV NAC regimen

 

 

 

Acknowledgements:   Angela Webster was the main author for this page. Revised by ANT and Paddy Gibson November 2006. The last modified date is shown in the footer.

 

 

Daughter pages of this page

Proteinuria in renal disease << >> Renal biopsy