Radiation Exposure… Comorbidity for the Patient?

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LT T ooM uchR adiationCanCauseM ajor P roblems

cyberchalky.wordpress.com Turtlepedi.wikia.com DialysisPatientsAreR outinelyExposedto HeavyDosesofR adiation

•Averagedosesequalto1,000 chest x- raysayear •CKD patientshavefrequentteststo m onitortheirkidneys •M anydialysispatientshaveother comorbiditiesalongw ithkidneydisease

Picard, 2011 Comm onComorbiditesofR enalPatients

• • Hypertension • AIDS • KidneyT ransplant • Hepatitis • CoronaryArteryDisease • COPD • Hyper/Hypo-thyroidism • GER D • CongestiveHeartFailure • KidneyS tones • HeartAttack • L upus • S troke • O besity • UTI • Cancer Comm onT estsDialysisPatients U ndergo •IntravenousPyelograms(IVP ) •ComputedAxialTomography(CT ) •CardiacP erfusion(N uclearS tressTest) •CoronaryAngiography •P ercutaneousCoronaryIntervention (Angioplasty)

Picard, 2011 • InastudyperformedbyDr.M arcoBrambillaof M aggioredellaCaritaU niversityHospitalinN ovara, Italy,106 dialysispatientsweretrackedforthree years. • R esearchersfoundthatpatientshadtestsperformed regularlytoimagetheirkidneys. • Alongw ithteststhatimagedthekidneys,thepatients alsohadotherimagingtestsperformedforother healthproblems. • T hesetestsexposedthepatienttodifferentlevelsof radiation.

Picard, 2011 •35outofthe106participantswereexposedto over50 m S v •17received100 m S vperyear •T heglobalaverageformedicalradiationdoses is0.3m S v(InternationalAtomicEnergy Agency)

Georgescu, 2011 O therTestsforDialysisAccess M aintenance

•Angiogram •Angioplasty •T hrombectomy •S tentP lacement •T unneledCatheterP lacement •T unneledCatheterExchange •AccessoryVesselCoiling •Venography P atientR ayD.Eight

Interventional Center Radiation doses over a 4 year period (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 hesamepatienthad42 otherimaging examsinthesamefacilityovera9 year period

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 imesForT heIntervention N ephrologyCenter

Tunneled Tunneled Catheter Angiogram Exchange Thrombectomy Placement

(mGy) 6.993 6.444 21.715 7.933

(mGym2) 0.1145 0.09718 0.31211 0.17705

Fluoro Time Minutes 4.07 1.52 9.48 1.99

*10 random exams over a 6 month period from each category were evaluated to get averages. Half dose radiation is used. •AccordingtoDr.Brambilla,youngerdialysis patientsandpatientswaitingonthetransplant listreceivedthem ostradiation. •CT scansproducethem ostradiationtothe patient. •100 timesmoreradiationthanplainx-ray •W hileCT isaveryusefultool,theyoftendo notgiveinformationofclinicalsignificance.

Picard, 2011 CancerR isksandR adiation

•T hereisgrowingconcernaboutradiation exposureandcancerrisks •Expertswantaregistrythatcantrackthe amountofradiationpatientsreceive •Cum ulativedosesshouldbeavailabletoordering physicians •R ecomm endationsshouldbem adebyimaging professionals •Alternativesshouldbeconsidered •T hisisextremelyimportantforpatientswith chronicillnesses,especiallydialysispatients Picard, 2011 R adiationExposures

•R isksmeasuredinm illiSeiverts(mS v) •R ecomm endedannualdoselimitforgeneral publicis1m S v •Exposuresvaryw ithbodypartimaged •CT oftheabdomenexposespatientsto30 m S v •HeadCT exposespatientsto2 m S v •M amm ogramsexposepatientstolessthan1 m S v

Picard, 2011 •AccordingtoastudyperformedonCanadian heartpatients,cancerrisksincreaseby3% for each10 m S vofradiationexposure.

Picard, 2011 •A 2009 studyintheArchivesofInternal M edicineestimate2% ofallcancersintheU .S. aredirectresultsfrom CT scans •R esearchersestimate • AbdomenandP elvisCT scaused14,000 cancers • ChestCT scaused4,100 cancers • HeadCT caused4,000 cancers • CT angiographycaused2,700 cancers •2/3oftheseradiationrelatedcancersoccurred inw omen

Picard, 2011 •T hereisnosafelevelofradiationexposure •Inotherw ords,thereisnosafethreshold •W hatcouldbeanacceptablelimitforone person,maycausecancerinanotherperson Comm onComorbiditesofR enalPatients

• • Diabetes Hepatitis • • Hypertension COPD • • KidneyT ransplant GER D • • CoronaryArteryDisease KidneyS tones • • Hyper/Hypo-thyroidism L upus • • CongestiveHeartFailure O besity • • HeartAttack UTI • • S troke Cancer • AIDS • R adiationExposure? Annualradiationexposurelimitshavebeenset forthosew orkinginradiation

NDT Resource Center •S imilartooccupationalexposurelimits, registriesforpatientswouldhelpdoctors closelyw atchpatientexposurelevelsandknow how m uchradiationthepatienthasreceived. •T heFDA hasclassifiedx-rayradiationasa knowncarcinogen.Guidelinesonm aximum dosesandindicationsshouldbeputintoplace.

Johnson, 2008 HealthHazardsRadiationExposureM ay Cause

S• tochasticEffectsL ong-term,low-level(chronic) N on-StochasticEffects exposurestoradiation • Exposurestohighlevelsof • Damageatthecellularlevel radiationoverashorttime • ChangesinDN A-M utations (acute)exposure • T eratogenicM utations • Burns • GeneticM utation • R adiationsickness (Radiationpoisoning) •1 in143 w omen20 yearsofagew hohaveaCT angiographyscanw illgetcancerintheirlifetime (Lungorbreast) •1 in715chancefora60-year-oldw oman •1 in1911 chancefora60-year-oldm an •Effectsmaynotm anifestfor5-20 yearsafterthe scan.

Johnson, 2008 Am ericanCollegeofR adiology

•Foundingm emberoftheImageGently™ (pediatricdosereduction) •Foundingm emberofImageW isely® (adult dosereduction)campaigns •S upporterofAL AR A concept •DevelopedAppropriatenessCriteria®

American College of Radiology, 2016 ImageW isely® P ledge

•P utpatient’ssafety,healthandw elfarefirst •ConveytheprinciplesofImageW iselyprogram totheimagingteam •Comm unicateoptimalpatientimagingstrategies toreferringphysicians •R outinelyreview imagingprotocols •M onitorradiationdoseindices

Image Wisely, 2016 ImageW isely®

•P atientimagingrecordcardtologw hat imagingtestshavebeenperformedand w hen •Encouragespatientstoask: • W hytheexamisneeded? • How w illtheexamimprovehealthcare? • W hatnon-radiologicalternativesareavailable?

Image Wisely, 2016 ImageW isely®

•U ltimategoalisforelectronicrecordofx-ray examhistory

Image Wisely, 2016

Conclusion

• R isksandbenefitsoftheradiationexposureshouldbe takenintoaccountw henorderingdiagnosticimaging procedures. • Effortstolimittheamountofradiationchronicpatients areexposedtoisextremelyimportant. • T rackingexposuresanddedicationfrom imaging professionalscanprotectourpatientsfrom unnecessaryradiation.