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Radiation Exposure…Comorbidity for the DialysisPatient?

T ooM uchR adiationCanCauseM ajorP roblem s

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DialysisP atientsAreR outinely ExposedtoHeavy DosesofR adiation

•Averagedosesequalto1,000 chest x-raysayear

•CKD patientshavefrequentteststom onitortheirkidneys

•M any dialysispatientshaveothercom orbiditiesalongw ithkidney disease

Picard, 2011

Com m onCom orbiditesofR enalP atients

• Diabetes

• Hypertension

• Kidney T ransplant

• Coronary Artery Disease

• Hyper/Hypo-thyroidism

• CongestiveHeartFailure

• HeartAttack

• S troke

• AIDS

• Hepatitis

• CO P D

• GER D

• Kidney S tones

• L upus

• O besity

• U T I

• Cancer

Com m onT estsDialysisP atientsU ndergo

•IntravenousP yelogram s(IVP )

•Com puted AxialT om ography (CT )

•CardiacP erfusion(N uclearS tressT est)

•Coronary Angiography

•P ercutaneousCoronary Intervention(Angioplasty)

Picard, 2011

• Inastudy perform ed by Dr.M arcoBram billaofM aggioredellaCaritaU niversity HospitalinN ovara,Italy,106 dialysispatientsw eretrackedforthreeyears.

• R esearchersfound thatpatientshadtestsperform edregularly toim agetheirkidneys.

• Alongw ithteststhatim agedthekidneys,thepatientsalsohad otherim agingtestsperform ed forotherhealthproblem s.

• T hesetestsexposed thepatienttodifferentlevelsofradiation.

Picard, 2011

•35 outofthe106 participantsw ereexposedtoover50 m S v

•17received100 m S vperyear

•T heglobalaverageform edicalradiationdosesis0.3 m S v(InternationalAtom icEnergyAgency)

Georgescu, 2011

O therT estsforDialysisAccessM aintenance

•Angiogram•Angioplasty• T hrom bectom y• S tentP lacem ent• T unneledCatheterP lacem ent• T unneledCatheterExchange•Accessory VesselCoiling•Venography

P atientR ay D.Eight

Interventional Nephrology Center Radiation doses over a 4 yearperiod

(mGy) (mGym2) Fluoro Time (Minutes)

Procedure 1 46 1.34 7.3

Procedure 2 11.4 0.199 2.1

Procedure 3 24.3 0.701 3.6

Procedure 4 14.1 0.417 2.7

Procedure 5 41.9 1.08 5.3

Procedure 6 49.6 0.809 7.9

Procedure 7 6.58 0.0977 1.5

Procedure 8 16.3 0.284 2

Procedure 9 21.3 0.32 3.4

Procedure 10 29.6 0.514 3.9

Procedure 11 34.8 0.605 5.7

Procedure 12 38.5 0.669 3.6

Procedure 13 17.1 0.298 2.1

Procedure 14 3.17 0.0469 0.6

Total Radiation 354.65 7.3806 51.7

T hesam epatienthad42 otherim agingexam sinthesam efacility overa9 yearperiod

Chest X-ray 14

Abdominal X-ray 7

CT Scan 7

Nuclear Medicine Scan 4

Ultrasound (No radiation) 6

MRI Scan (No radiation) 2

Echo (No radiation) 2

AverageR adiationDosesandFluoroT im esForT heInterventionN ephrology Center

AngiogramTunneled Catheter

Exchange ThrombectomyTunneled Catheter

Placement

(mGy) 6.993 6.444 21.715 7.933

(mGym2) 0.1145 0.09718 0.31211 0.17705

Fluoro TimeMinutes 4.07 1.52 9.48 1.99

*10 random exams over a 6 month period from each categorywere evaluated to get averages. Half dose radiation is used.

•AccordingtoDr.Bram billa,youngerdialysispatientsandpatientsw aitingonthetransplantlistreceivedthem ostradiation.

•CT scansproducethem ostradiationtothepatient.•100 tim esm oreradiationthanplainx-ray•W hileCT isavery usefultool,they oftendonotgiveinform ationofclinicalsignificance.

Picard, 2011

CancerR isksandR adiation

•T hereisgrow ingconcernaboutradiationexposureandcancerrisks

•Expertsw antaregistry thatcantracktheam ountofradiationpatientsreceive•Cum ulativedosesshouldbeavailabletoorderingphysicians

• R ecom m endationsshouldbem adeby im agingprofessionals

•Alternativesshouldbeconsidered• T hisisextrem ely im portantforpatientsw ithchronicillnesses,especially dialysispatients

Picard, 2011

R adiationExposures

• R isksm easuredinm illiS eiverts(m S v)• R ecom m endedannualdoselim itforgeneralpublicis1 m S v

•Exposuresvary w ithbody partim aged•CT oftheabdom enexposespatientsto30 m S v•HeadCT exposespatientsto2 m S v• M am m ogram sexposepatientstolessthan1m S v

Picard, 2011

•Accordingtoastudy perform edonCanadianheartpatients,cancerrisksincreaseby 3% foreach10 m S vofradiationexposure.

Picard, 2011

•A 2009 study intheArchivesofInternalM edicineestim ate2% ofallcancersintheU .S .aredirectresultsfrom CT scans

•R esearchersestim ate• Abdom enand P elvisCT scaused 14,000 cancers• ChestCT scaused 4,100 cancers• HeadCT caused4,000 cancers• CT angiography caused2,700 cancers

•2/3 oftheseradiationrelatedcancersoccurredinw om en

Picard, 2011

•T hereisnosafelevelofradiationexposure

•Inotherw ords,thereisnosafethreshold

•W hatcouldbeanacceptablelim itforoneperson,m ay causecancerinanotherperson

Com m onCom orbiditesofR enalP atients

• Diabetes

• Hypertension

• Kidney T ransplant

• Coronary Artery Disease

• Hyper/Hypo-thyroidism

• CongestiveHeartFailure

• HeartAttack

• S troke

• AIDS

• Hepatitis

• CO P D

• GER D

• Kidney S tones

• L upus

• O besity

• U T I

• Cancer

• R adiationExposure?

Annualradiationexposurelim itshavebeensetforthosew orkinginradiation

NDT Resource Center

•S im ilartooccupationalexposurelim its,registriesforpatientsw ouldhelpdoctorsclosely w atchpatientexposurelevelsandknowhow m uchradiationthepatienthasreceived.

•T heFDA hasclassifiedx-ray radiationasaknow ncarcinogen. Guidelinesonm axim umdosesandindicationsshould beputintoplace.

Johnson, 2008

HealthHazardsR adiationExposureM ayCause

S tochasticEffects• L ong-term ,low -level(chronic)exposurestoradiation

• Dam ageatthecellularlevel

• ChangesinDN A-M utations• T eratogenicM utations

• GeneticM utation

N on-S tochasticEffects• Exposurestohighlevelsof

radiationoverashorttim e(acute)exposure

• Burns

• R adiationsickness(R adiationpoisoning)

•1 in143 w om en20 yearsofagew hohaveaCTangiography scanw illgetcancerintheirlifetim e(L ungorbreast)

•1 in715 chancefora60-year-oldw om an

•1 in1911 chancefora60-year-oldm an

•Effectsm ay notm anifestfor5-20 yearsafterthescan.

Johnson, 2008

Am ericanCollegeofR adiology

•Foundingm em beroftheIm ageGently™(pediatricdosereduction)

•Foundingm em berofIm ageW isely® (adultdosereduction)cam paigns

•S upporterofAL AR A concept

•DevelopedAppropriatenessCriteria®

American College of Radiology, 2016

Im ageW isely® P ledge

•P utpatient’ssafety,healthandw elfarefirst

•Convey theprinciplesofIm ageW isely programtotheim agingteam

•Com m unicateoptim alpatientim agingstrategiestoreferringphysicians

•R outinely review im agingprotocols

•M onitorradiationdoseindices

Image Wisely, 2016

Im ageW isely®

•P atientim agingrecordcardtologw hatim agingtestshavebeenperform edandw hen

•Encouragespatientstoask:• W hy theexam isneeded?• How w illtheexam im provehealthcare?• W hatnon-radiologicalternativesareavailable?

Image Wisely, 2016

Im ageW isely®

•U ltim ategoalisforelectronicrecordofx-rayexam history

Image Wisely, 2016

Conclusion

• R isksandbenefitsoftheradiationexposureshould betakenintoaccountw henorderingdiagnosticim agingprocedures.

• Effortstolim ittheam ountofradiationchronicpatientsareexposed toisextrem ely im portant.

• T rackingexposuresanddedicationfrom im agingprofessionalscanprotectourpatientsfromunnecessary radiation.