Immediate and delayed hypersensitivity after intra-arterial injection of iodinated contrast media: a prospective study in patients with coronary angiography

Adverse reactions to radiological contrast media: Prevention and treatment

Radiological contrast media, both iodinated and gadolinium-based, can lead to adverse reactions. Type A reactions are related to the pharmacological characteristics of the contrast, including side, secondary and toxic effects. Post-contrast acute kidney injury is the most frequent adverse reaction to iodinated contrast media. Less frequently, thyroid, neurological, cardiovascular, haematological, and salivary gland effects are also detected. With gadolinium-based contrast agents, nausea is the most frequent reaction, but there is also a risk of producing nephrogenic systemic fibrosis and cerebral deposits of uncertain significance. The most effective way of avoiding type A reactions is to decrease the dose and frequency of contrast media administration, especially in patients with pre-existing renal insufficiency. To prevent post-contrast acute kidney injury, adequate hydration of the patient should be maintained orally or intravenously, avoiding prolonged periods of liquid fasting. On the other hand, hypersensitivity reactions are dose-independent and clinically can range from mild cutaneous reactions to anaphylaxis. This article proposes an algorithm that differentiates between nonspecific reactions and true hypersensitivity reactions, as well as levels of severity. It also provides a treatment scheme for immediate reactions adjusted to the severity level, with a focus on the management of anaphylaxis and an early intramuscular administration of adrenaline. Finally, it sets out recommendations for the management of patients with previous hypersensitivity reactions who require elective or urgent contrast administration, favouring the use of alternative contrast media with confirmed tolerance instead of the indiscriminate use of premedication.

Flow diagram of the differential diagnosis and clinical decision making in a rare case of contrast-induced encephalopathy following cardiac catheterization: a case report

BACKGROUND

Contrast-induced encephalopathy (CIE) is considered as an uncommon complication following cardiac catheterization. Due to the varied manifestations, CIE has no formal diagnostic criteria. In fact, the incidence of CIE may be greatly underestimated because of the difficulty in its differential diagnosis with other cerebrovascular complications. Thus, making a flow diagram according to patients' clinical symptoms and examinations after cardiac catheterization to help clinicians diagnose CIE is important and needed.

CASE PRESENTATION

In this report, we describe a case of probable CIE in a 66-year-old Chinese man with hypertension who underwent cardiac catheterization with stents placement in the bifurcation lesion, during which 80 ml iopromide contrast was used. About 2 h following the procedure, the patient lost his consciousness suddenly and suffered from a status epilepticus. Malignant arrhythmias were not found through continuous electrocardiogram monitoring, but mild ST-segment elevation was displayed in leads I and aVL. The echocardiography, plasma glucose and electrolyte levels were normal. Emergency re-angiography with percutaneous transluminal coronary angioplasty was performed in the culprit lesion, which involved 60 ml iopromide contrast. However, the patient remained unconsciousness and epilepticus. Non-contrast computed tomography (CT) of the head showed cortical and subarachnoid enhancement as well as prolonged retention of contrast media in the middle cerebral artery. With supportive treatment of intravenous hydration, sedative and dehydrant, the patient recovered 3 h later and finally discharged without any neurological deficits.

CONCLUSIONS

CIE is an acute reversible encephalopathy induced by contrast media. It is exceptionally challenging to make the diagnosis of CIE following cardiac catheterization since there is a lack of consensus on the definition of CIE. Via this case we reviewed the related literatures, through which a flow diagram of the differential diagnosis and clinical decision making was given, which could help to differentiate CIE from other neurological complications following cardiac catheterization.

A systematic review of the incidence of hypersensitivity reactions and post-contrast acute kidney injury after ioversol: part 2-intra-arterial administration

Objectives

To evaluate the incidence of adverse drug reactions (ADRs), including hypersensitivity reactions (HSRs) and post-contrast acute kidney injury (PC-AKI), after intra-arterial (IA) administration of ioversol.

Methods and materials

A systematic literature search was performed (1980–2021) and studies documenting IA use of ioversol, and reporting safety outcomes were selected. Key information on study design, patients’ characteristics, indication, dose, and type of safety outcome were extracted.

Results

Twenty-eight studies (including two pediatric studies) with 8373 patients exposed to IA ioversol were selected. Studies were highly heterogenous in terms of design, PC-AKI definition, and studied population. PC-AKI incidence after coronary angiography was 7.5–21.9% in a general population, 4.0-26.4% in diabetic patients, and 5.5–28.9% in patients with chronic kidney disease (CKD). PC-AKI requiring dialysis was rare and reported mainly in patients with severe CKD. No significant differences in PC-AKI rates were shown in studies comparing different iodinated contrast media (ICM). Based on seven studies of ioversol clinical development, the overall ADR incidence was 1.6%, comparable to that reported with other non-ionic ICM. Pediatric data were scarce with only one study reporting on PC-AKI incidence (12%), and one reporting on ADR incidence (0.09%), both after coronary angiography.

Conclusions

After ioversol IA administration, PC-AKI incidence was highly variable between studies, likely reflecting the heterogeneity of the included study populations, and appeared comparable to that reported with other ICM. The rate of other ADRs appears to be low. Well-designed studies are needed for a better comparison with other ICM.

Key Points

• PC-AKI incidence after IA administration of ioversol appears to be comparable to that of other ICM, despite the high variability between studies.

• The need for dialysis after IA administration of ioversol is rare.

• No obvious difference was found regarding the safety profile of ioversol between IA and IV administration.

Establishing a Predictive Nomogram for Cervical Lymph Node Metastasis in Patients With Papillary Thyroid Carcinoma

Objectives

The purpose of this study was to establish a nomogram for predicting cervical lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC).

Materials and Methods

A total of 418 patients with papillary thyroid carcinoma undergoing total thyroidectomy with cervical lymph node dissection were enrolled in the retrospective study from January 2016 to September 2019. Univariate and multivariate Logistic regression analysis were performed to screen the clinicopathologic, laboratory and ultrasound (US) parameters influencing cervical lymph nodes metastasis and develop the predicting model.

Results

CLNM was proved in 34.4% (144/418) of patients. In the multivariate regression analysis, Male, Age < 45 years, Tumor size > 20mm, multifocality, ambiguous boundary, extracapsular invasion and US-suggested lymph nodes metastasis were independent risk factors of CLNM (p < 0.05). Prediction nomogram showed an excellent discriminative ability, with a C-index of 0.940 (95% confidence interval [CI], 0.888-0.991), and a good calibration.

Conclusion

The established nomogram showed a good prediction of CLNM in patients with PTC. It is conveniently used and should be considered in the determination of surgical procedures.

Incidence and risk factors of late adverse reactions to low-osmolar contrast media: A prospective observational study of 10,540 exposures

PURPOSE

To evaluate the incidence and risk factors of late adverse reactions (ARs) to non-ionic low-osmolar contrast media (LOCM).

METHODS

The occurrence of late AR was monitored on day 1 and from day 7 to day 28 in all patients who received enhanced computed tomography using LOCM during a 5-week study period in a single tertiary hospital. Patients who experienced late AR were followed up for three years.

RESULTS

Among the total 10,540 LOCM exposures, 315 ARs (3.0%) were reported; acute ARs occurred in 108 LOCM exposures (1.0%) and late ARs occurred in 207 LOCM exposures (2.0%) (90.9% within one week, 9.1% developed afterwards by day 20). Previous history of drug allergy (odds ratio [OR] = 4.59; 95% confidence interval [CI] 2.17-9.71) and allergic diseases (OR = 2.54; 95% CI 1.32-4.91) were risk factors of late ARs to LOCM. Although the recurrence rate was lowered with premedication from 8.5% to 1.7% (8/94 vs. 3/178; p = 0.016), LOCM change did not make difference compared to reuse of the culprit LOCM (2/38 vs. 9/234; p = 0.655). In patients with a history of late AR to LOCM, the risk of recurrent reactions decreased with longer time intervals between exposures (OR = 0.86; 95% CI: 0.77-0.97; p = 0.025) and with the use of antihistamine premedication (OR = 0.27; 95% CI: 0.06-0.99; p = 0.049).

CONCLUSIONS

Late ARs to LOCM occurred mostly within one week. The use of premedication may be helpful in reducing the recurrence of late ARs.

Cross-reactivity among iodinated contrast agents: should we be concerned?

Background

Although several papers deal with "cross-reactivity" in patients with iodinated contrast medium (ICM) hypersensitivity reactions (HSRs), there is no in-depth knowledge of this phenomenon. To define ICM-groups as potential reaction partners and to identify any potential clinical relevance in patients with ICM-HSRs.

Methods

The literature database PubMed was searched for eligible papers dealing with ICM-allergy and "cross-reactivity". The data presented by the papers was analyzed and individual patient data was extracted for re-evaluation based on a definition for both 'polyvalent reactivity' and 'cross-reactivity' as well as for chemical structure-dependent ICM-groups.

Results

Twenty-five original papers (with n=340 extracted patients) formed the study population. Incidences of polyvalent reactivity were non-significantly higher than incidences of cross-reactivity (both range from 0% to 100%). Crossover evaluation in reaction pairings (culprit ICM A with ICM B versus culprit ICM B with ICM A) showed concordance of only 30%. Data support rather non-cross-reactivity (individual reaction pattern) than cross-reactivity constellations.

Conclusions

The obtained results favour an individual reaction pattern, rather than a reactivity driven by chemical structures and so-called cross-reactivity.

Pharmacological prevention of delayed hypersensitivity reactions caused by iodinated contrast media

Background

Delayed hypersensitivity reactions (DHRs) to radiocontrast media (RCM) occur in approximately 0.5–23.0% of patients and are thought to be caused by T cell-mediated mechanisms. However, an optimal pharmacological preventive strategy is not yet established in patients with histories of delayed reactions to RCM.

Objective

We aimed to evaluate the efficacy of pharmacological prevention in patients with histories of delayed reactions to non-ionic low-osmolar RCM when re-exposed to RCM.

Methods

A retrospective review of electronic medical records of 117 patients with previous histories of DHRs to RCM who visited an allergy clinic for the prevention of reactions after the re-exposure to RCM was conducted. The effects of pharmacological prevention were compared according to the symptom scores of previous reactions based on their intensities and durations with electronic medical records (EMRs).

Results

Of the 117 patients who experienced DHRs after RCM injection, we confirmed the outcomes of RCM re-exposure in 101 patients. For pharmacological prevention, 92 patients (91.1%) received steroids before RCM injection and among them, 50 patients (49.5%) received additional steroids after RCM injection. With this pharmacological prevention, patients of symptoms improved or no recurrence, recurrence of similar previous symptoms, and recurrence of worse symptoms were 98 (97.0%), 2 (2.0%), and 1 (1.0%), respectively. The proportions of no recurrence after pharmacological prevention were lower in patients with severe reactions and higher symptom scores.

Conclusion

Pharmacological prevention showed a beneficial effect in most patients with delayed hypersensitivity to RCM. Further investigations are needed to establish an effective protocol for the prevention of delayed reactions to RCM.

Post-contrast acute kidney injury in a hospitalized population: short-, mid-, and long-term outcome and risk factors for adverse events

Objectives

To investigate the prognosis including major adverse kidney events within 30 days (MAKE30) and 90-day and 1-year adverse outcome in hospitalized patients with post-contrast acute kidney injury (PC-AKI) to identify high-risk factors.

Methods

This retrospective observational study included 288 PC-AKI patients selected from 277,898 patients admitted to hospitals from January 2015 to December 2015. PC-AKI was defined according to the 2018 guideline of European Society of Urogenital Radiology. Multivariable Cox regression and logistic regression analyses were used to analyze main outcome and risk factors.

Results

PC-AKI patients with AKI stage ≥ 2 had much higher incidence of MAKE30 than those with AKI stage 1 (RR = 7.027, 95% CI 4.918–10.039). Persistent renal dysfunction, heart failure, central nervous system failure, baseline eGFR < 60 mL/min/1.73 m², oliguria or anuria, blood urea nitrogen ≥ 7.14 mmol/L, respiratory failure, and shock were independent risk factors of 90-day or 1-year adverse prognosis (p < 0.05). Compared with transient renal dysfunction, PC-AKI patients with persistent renal dysfunction had a higher all-cause mortality rate (RR = 3.768, 95% CI 1.612–8.810; RR = 4.106, 95% CI 1.765–9.551) as well as combined endpoints of death, chronic kidney disease, or end-stage renal disease (OR = 3.685, 95% CI 1.628–8.340; OR = 5.209, 95% CI 1.730–15.681) within 90 days or 1 year.

Conclusions

PC-AKI is not always a transient, benign creatininopathy, but can result in adverse outcome. AKI stage is independently correlated to MAKE30 and persistent renal dysfunction may exaggerate the risk of long-term adverse events.

Key Points

• PC-AKI can result in adverse outcome such as persistent renal dysfunction, dialysis, chronic kidney disease (CKD), end-stage renal disease (ESRD), or death.

• AKI stage is independently correlated to MAKE30.

• Persistent renal dysfunction may exaggerate the risk of long-term adverse events.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06690-3) contains supplementary material, which is available to authorized users.

Drug hypersensitivity reactions in Asia: regional issues and challenges

There are geographical, regional, and ethnic differences in the phenotypes and endotypes of patients with drug hypersensitivity reactions (DHRs) in different parts of the world. In Asia, aspects of drug hypersensitivity of regional importance include IgE-mediated allergies and T-cell-mediated reactions, including severe cutaneous adverse reactions (SCARs), to beta-lactam antibiotics, antituberculous drugs, nonsteroidal anti-inflammatory drugs (NSAIDs) and radiocontrast agents. Delabeling of low-risk penicillin allergy using direct oral provocation tests without skin tests have been found to be useful where the drug plausibility of the index reaction is low. Genetic risk associations of relevance to Asia include human leucocyte antigen (HLA)-B*1502 with carbamazepine SCAR, and HLA-B*5801 with allopurinol SCAR in some Asian ethnic groups. There remains a lack of safe and accurate diagnostic tests for antituberculous drug allergy, other than relatively high-risk desensitization regimes to first-line antituberculous therapy. NSAID hypersensitivity is common among both adults and children in Asia, with regional differences in phenotype especially among adults. Low dose aspirin desensitization is an important therapeutic modality in individuals with cross-reactive NSAID hypersensitivity and coronary artery disease following percutaneous coronary intervention. Skin testing allows patients with radiocontrast media hypersensitivity to confirm the suspected agent and test for alternatives, especially when contrasted scans are needed for future monitoring of disease relapse or progression, especially cancers.