Intravenous Contrast Administration in Hemodialysis Per the ACR Contrast Guide: Renal Dialysis Patients and Use of Iodinated Contrast Medium Patients with anuric end-stage chronic kidney disease who do not have a functioning transplant can receive intravascular iodinated contrast medium without risk of further renal damage because their kidneys are no longer functioning. However, there is a theoretical risk of converting an oliguric patient on dialysis to an anuric patient on dialysis by exposing him or her to intravascular iodinated contrast medium. This remains speculative, as there are no conclusive outcomes data in this setting. Patients receiving dialysis are also at theoretical risk from the osmotic load imposed by intravascular iodinated contrast medium because they cannot readily clear the excess intravascular volume. This osmotic load can theoretically result in pulmonary edema and anasarca, an issue that may have been more significant in the past when high-osmolality IV contrast media were utilized. Complications were not observed in one study of patients on dialysis who received intravascular nonionic iodinated contrast medium [91], though the number of patients in that study was small. In patients at risk for fluid overload, low osmolality or iso-osmolality contrast media should be employed with dosing as low as necessary to achieve a diagnostic result. Most low-osmolality iodinated contrast media are not protein-bound, have relatively low molecular weights, and are readily cleared by dialysis. Unless an unusually large volume of contrast medium is administered, or there is substantial underlying cardiac dysfunction, there is no need for urgent dialysis after intravascular iodinated contrast medium administration [91]. 91. Younathan CM, Kaude JV, Cook MD, Shaw GS, Peterson JC. Dialysis is not indicated immediately after administration of nonionic contrast agents in patients with end-stage renal disease treated by maintenance dialysis. AJR AM J Roentgenol. 1994;163(4):969-971. Based on this, for anuric patients on chronic HD it is OK to administer IV contrast with the general recommendation that the patient should undergo dialysis within 24-48 hours to reduce the intravascular volume load. As above, there is no need for more urgent dialysis and this is concordant with our current policy. As a point of clarification, for oliguric patients either on HD or PD (patients who make more than 1-2 cups of urine daily or approximately 100 mL), or acutely ill inpatients who are on temporary dialysis where there is some expectation that renal function could be recovered, IV contrast administration should be avoided. Interrogation of patient records and discussion with the clinical team may be warranted to differentiate these two scenarios.