Radiation Exposure Comorbidity for the Dialysis Patient?c.ymcdn.com/sites/ · PDF...
Transcript of Radiation Exposure Comorbidity for the Dialysis Patient?c.ymcdn.com/sites/ · PDF...
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?
•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
Conclusion
• R isksandbenefitsoftheradiationexposureshould betakenintoaccountw henorderingdiagnosticim agingprocedures.
• Effortstolim ittheam ountofradiationchronicpatientsareexposed toisextrem ely im portant.
• T rackingexposuresanddedicationfrom im agingprofessionalscanprotectourpatientsfromunnecessary radiation.