Kidney madness

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We're back from lunch here in San Francisco, and this afternoon the topic on everyone's tongue is kidneys -- specifically, contrast-induced nephropathy, nephrogenic systemic fibrosis and the prevention of both wherever possible. Dr. Steven Weisbord, a nephrologist, was appropriately set to deliver the majority of the session's ten-minute presentations, but he was unexpectedly unable to make the meeting. Instead his colleague walked the crowd through his slides. The first set posed the question, "Which patients are at high risk for CIN?" According to the results of a study by Weisbord, clinical factors associated with clinically significant CIN -- defined as CIN resulting in readmission or death within 30 days of contrast administration -- include an eGFR of less than 40, baseline liver diease and use of diuretics. Everyone knows CIN can be prevented by keeping high-risk patients hydrated with intravenous fluids, both before and after contrast administration. So Weisbord's second study looked at what, exactly, should be used to hydrate them. Obviously diuretics are out of the question. Studies have shown that isotonic saline is superior to hypotonic saline. Now, some people think sodium bic could be better than both. Research on the topic is promising, but so far inconclusive. Then Stanford's Bob Herfkens, MD, took the podium to discuss how best to treat contrast-challenged patients, advising the crowd to remember "the options aren't just non-contrast versus contrast. There's contrast-enhanced CT versus MR, versus MR with contrast, versus MR without contrast. There are many permutations to defining what tools we have." Who'd've thought there were situations in which gadolinium would come off looking like the hero?