Intravenous urography in multiple myeloma

Iodine-based contrast media, multiple myeloma and monoclonal gammopathies: literature review and ESUR Contrast Media Safety Committee guidelines

Objectives

Many radiologists and clinicians still consider multiple myeloma (MM) and monoclonal gammopathies (MG) a contraindication for using iodine-based contrast media. The ESUR Contrast Media Safety Committee performed a systematic review of the incidence of post-contrast acute kidney injury (PC-AKI) in these patients.

Methods

A systematic search in Medline and Scopus databases was performed for renal function deterioration studies in patients with MM or MG following administration of iodine-based contrast media. Data collection and analysis were performed according to the PRISMA statement 2009. Eligibility criteria and methods of analysis were specified in advance. Cohort and case-control studies reporting changes in renal function were included.

Results

Thirteen studies were selected that reported 824 iodine-based contrast medium administrations in 642 patients with MM or MG, in which 12 unconfounded cases of PC-AKI were found (1.6 %). The majority of patients had intravenous urography with high osmolality ionic contrast media after preparatory dehydration and purgation.

Conclusions

MM and MG alone are not risk factors for PC-AKI. However, the risk of PC-AKI may become significant in dehydrated patients with impaired renal function. Hypercalcaemia may increase the risk of kidney damage, and should be corrected before contrast medium administration. Assessment for Bence-Jones proteinuria is not necessary.

Key Points

• Monoclonal gammopathies including multiple myeloma are a large spectrum of disorders.

• In monoclonal gammopathy with normal renal function, PC-AKI risk is not increased.

• Renal function is often reduced in myeloma, increasing the risk of PC-AKI.

• Correction of hypercalcaemia is necessary in myeloma before iodine-based contrast medium administration.

• Bence-Jones proteinuria assessment in myeloma is unnecessary before iodine-based contrast medium administration.

Renal failure following radiologic procedures

Radiologic procedures that employ intravascular contrast material with or without angiography may lead to renal failure. In procedures that use intravenous contrast alone, the mechanism of renal injury is not precisely known, but direct toxicity to renal tubular cells is likely to be a major factor. Ionic and nonionic contrast agents are both capable of causing this adverse reaction. Renal failure occurring during angiography may also be secondary to the effects of radiocontrast, but the additional possibility that micro cholesterol emboli have been dislodged from atheroma located on the intima of large vessels must be considered. The acute or subacute development of renal failure in the presence of skin changes (livido reticularis), hypertension, multiple organ failure or dysfunction, and a fatal outcome favors the later diagnosis.

Effect of urinary pH and diatrizoate on Bence Jones protein nephrotoxicity in the rat

Both low urinary pH and radiocontrast agents may intensify myeloma nephrotoxicity. To study the effects of these factors, we determined inulin clearances (CIn) before and after infusions of human Bence Jones protein (BJP) in male Sprague-Dawley rats in a dose previously shown to be nephrotoxic. Rats that drank 0.15 M NaHCO3 for 48 hr before study had no change in CIn (+3 +/- 20%) after BJP unlike those that drank 0.15 M NH4Cl (-33 +/- 14%, P less than 0.05); urinary pH differed (7.6 +/- 0.1 vs. 6.2 +/- 0.1, P less than 0.05), but urinary flow rates did not. The acidifying regimen was used in all subsequent groups. Infusion of diatrizoate (DTZ) after BJP produced a further decrease in CIn (-85 +/- 8%, P less than 0.05). In contrast, infusion of albumin, which raised plasma protein concentration to that seen in BJP-infused rats, did not change CIn (+39 +/- 17%). Infusion of beta-lactoglobulin also led to a greater decrease in CIn after DTZ (-35 +/- 9 vs. -67 +/- 8%, P less than 0.05), but myoglobin did not (-58 +/- 7 vs. -54 +/- 12%). Urinary pH and flow rate did not differ between any DTZ-infused group and its appropriate control. These data suggest that aciduria independent of urinary flow rate increases the nephrotoxicity of BJP. In this setting, DTZ further intensifies the nephrotoxicity of BJP as well as some but not all filterable proteins.

Radiologic contrast-induced nephropathy

Contrast nephropathy is the third most common cause of hospital-acquired renal insufficiency. While its exact pathogenesis is unclear, patients with existing renal disease are now known to be at increased risk for developing this complication. Identification of these patients by determination of serum creatinine levels may enable avoidance of contrast exposure or initiation of suitable therapy to minimize this complication if exposure to contrast is unavoidable.

Acute renal failure following intravenous pyelography (IVP) in a patient with diffuse hypergammaglobulinemia: a case report

A 65-year-old woman with polyclonal hypergammaglobulinemia developed acute renal failure requiring hemodialysis after an intravenous pyelogram (IVP). An increased risk of renal injury after IVP for patients with polyclonal hypergammaglobulinemia has not been previously recognized, although a parallel risk to patients with myeloma has been well established. At autopsy, immunoperoxidase staining of the bone marrow demonstrated plasma cell subpopulations with intracellular staining for IgG, IgA, and IgM and chi and lambda light chains, proving that this patient did not have occult myeloma. Immunoperoxidase staining of casts in renal tubules also demonstrated polyclonal immunoglobulins.

Renal failure following major angiography

Acute renal failure following angiography with contrast agents is known to occur, but the circumstances and frequency of its occurrence are not well described. A retrospective review of consecutive angiographic procedures performed over a six month interval revealed a 12 per cent incidence of renal failure following angiography. The degree of failure was severe in approximately 30 per cent of these cases and was associated with a significant mortality even though renal function usually recovered. The occurrence of renal failure was associated with the presence of renal insufficiency, impaired liver function, diabetes mellitus, hypoalbuminemia and proteinuria at the time of angiography to a statistically significant level. Furthermore, combinations of these factors, particularly preexisting combined renal insufficiency and impaired liver function, were associated with an increased incidence of acute renal failure. It is concluded that angiography poses a significant hazard to patients with underlying medical problems, particularly those involving the excretory routes of the contrast agent.

Malignant lymphoma with "myeloma kidney" acute renal failure

The first cases of malignant lymphoma with a "myeloma kidney" type of acute renal failure are presented. With appropriate therapy, both patients regained partial renal function; the first after three months of dialysis. It is suggested that the term paraproteinemic nephropathy is preferable to "myeloma kidney."