Iodine-131 Therapy and the Dialysis Patient M.J. Bohan and R.L. Richardson Yale-New Haven Hospital...
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Transcript of Iodine-131 Therapy and the Dialysis Patient M.J. Bohan and R.L. Richardson Yale-New Haven Hospital...
Iodine-131 Therapyand the Dialysis Patient
M.J. Bohan and R.L. Richardson
Yale-New Haven Hospital
Radiation Safety Office
YNHH RSO - HPS 2006
The Problem Thyroid cancer and hyperthyroid patients with
renal failure present a number of radiation safety and medical physics challenges
Unfortunately, there is not a lot of published sources of information in the literature that address the issues presented by these patients
YNHH RSO - HPS 2006
Health Physics Issues Potential for increased occupational
exposures
Potential for contamination control and waste disposal issues
Early patient release issues - dose to family and the public
YNHH RSO - HPS 2006
Medical Physics Issues How much longer in advance should you
recommend iodine dietary restrictions and removal of replacement hormone?
Uptake studies may be misinterpreted due to poor systemic washout at 24 - 48 hrs
Altered excretion kinetics results in greatly increased whole body dose
YNHH RSO - HPS 2006
Case Study Number 1 Female thyroid cancer patient with end stage
renal disease on hemodialysis
Written directive - Administer 5.6 GBq (152 mCi) Hemodialysis on regular schedule at 48 hrs post
administration Patient isolated at hospital for first two dialysis
sessions and then was followed as an outpatient for the next week
YNHH RSO - HPS 2006
YNHH RSO - HPS 2006
Patient WB ∞ Dose EstimatesInfinite Whole Body
Dose Estimates
Eff. T 1/2
(days)
Dose
(Gy)
Normal - 5.62 GBq
Patient (152 mCi) 0.33 0.17
Hemodialysis
Effective 1.5 0.78
Hemodialysis
ActualField
Measurements 1.6MIRD - Pamphlet 11 (1975), I-131 (TB <-- TB), 9.9E-6 rad/uCi-hr
YNHH RSO - HPS 2006
Case Study Number 2 Two years later, same patient, now on
peritoneal dialysis Written directive - Administer 11 GBq (296 mCi) Peritoneal dialysis on regular schedule at home Patient isolated dialysis wastes in garage CAPD every 4-6 hours during the day NIPD at night only, for first two days After day 2, CCPD continuously
(CAPD - Continuous Ambulatory Peritoneal Dialysis)(NIPD - Nocturnal Intermittent Peritoneal Dialysis)(CCPD - Continuous Cycle Peritoneal Dialysis)
YNHH RSO - HPS 2006
YNHH RSO - HPS 2006
Patient WB ∞ Dose EstimatesInfinite Whole Body
Dose Estimates
Eff. T 1/2
(days)
Dose
(Gy)
Normal - 11 GBq
Patient (296 mCi) 0.33 0.33
Peritoneal Dialysis
Effective 1.5 1.5
Peritoneal Dialysis
ActualField
Measurements 1.8MIRD - Pamphlet 11 (1975), I-131 (TB <-- TB), 9.9E-6 rad/uCi-hr
YNHH RSO - HPS 2006
Case Study Number 3 New male patient on peritoneal dialysis with
about 15% of normal renal function
Written directive - Administer 1.2 GBq (31.3 mCi) Peritoneal dialysis on regular schedule at home Patient isolated dialysis wastes on porch NIPD at night only
YNHH RSO - HPS 2006
Hours
YNHH RSO - HPS 2006
Patient WB ∞ Dose EstimatesInfinite Whole Body
Dose Estimates
Eff. T1/2
(days)
Dose
(Gy)
Normal - 1.2 GBq
Patient (31.3 mCi) 0.33 0.035
Peritoneal Dialysis
Effective 1.5 0.16
Peritoneal Dialysis
Actual
T1/2 ≈ 1 day
Field
Measurements 0.12MIRD - Pamphlet 11 (1975), I-131 (TB <-- TB), 9.9E-6 rad/uCi-hr
YNHH RSO - HPS 2006
Lessons Learned If you give a dialysis patient a dose which would be appropriate
for a normal patient, the whole body dose is extremely high
Because the I-131 continues to re-circulate in dialysis patients, you should be able to titrate the administered dose based on the calculated whole body dose and lower their dose without compromising their thyroid uptake
If patients have partial kidney function, you should take it into account when calculating the adjusted dose
Reducing the administered dose also helps with patient release issues
YNHH RSO - HPS 2006
Consider Changing the Hemodialysis Scheduling Modification of the hemodialysis schedule will
dictate the administered dose
Schedule 1: 48 hrs post administration, MWF
Schedule 2: 48 hrs @ 24 hr post adm, TThSaMWF
Schedule 3: 24 hrs @ first 3 days then release from isolation with outpatient hemodialysis on Sa, then back to normal MWF
YNHH RSO - HPS 2006
Estimated Whole Body Doses for 100 mCi Rx Normal Pt. - 0.11 Gy
48 hr @ 48 hr - 0.80 Gy (14%)
48 hr @ 24 hr - 0.59 Gy (19%)
24 hr @ 1st 3days - 0.47 Gy (23%)
Mon Wed Fri Sun Fri Sun Tue Thur
YNHH RSO - HPS 2006
Contamination/Waste Issues
Hemodialysis systems are self contained and use copious amounts of water to wash the blood. Residual contamination levels are usually low and easily cleaned up. Cartridges and tubing will retain low levels of activity and should be held for decay
YNHH RSO - HPS 2006
Occupational Dose Issues Hemodialysis nurses must stay close to the dialysis
machine and service it periodically
You need to train them in time and distance controls to minimize their occupational dose
Measured Occupational Doses
5.6 GBq (152 mCi) on in-patient hemodialysis
First Dialysis - Nursing Dose 18 mrad
Second Dialysis - Nursing Dose 42 mrad
YNHH RSO - HPS 2006
References
Jimenez, R.G., et al., Iodine-131Treatment of Thyroid Papillary Carcinoma in patients Undergoing Dialysis for Chronic Renal Failure: A Dosimetric Method, Thyroid, Vol. 11, NO. 11, 2001
Mars, D.R., et al, Iodine Retention and Thyroid Dysfunction in Patients on Hemodialysis and Continuous Ambulatory Peritoneal Dialysis, Am. J. Kidney Dis., June 1986, 7(6):471-6)
Magne, N., et al, Disposition of Radioiodine 131-I therapy for Thyroid Carcinoma in a Patient with Severely Impared Renal Function on Chronic Dialysis: A Case Report, Jpn. J. Clininal Oncology 2002; 32(6) 202-205
Kaptein, E.M., Radioiodine Dosimetry in Patients with End-stage Renal Disease Receiving Continuous Ambulatory Peritoneal Dialysis Therapy, J Clin Endocrinol Metab. 2000 Sep;85(9):3058-64
Sisson, J.C., Practical Dosimetry of 131-I Patients with Thyroid Carcinoma, Cancer Biotherapy & Radiopharmaceuticals, Vol. 17, No. 1, 2002
Thomas, S.R., Options for Radionuclide Therapy: From Fixed Activity to Patient-Specific Treatment Planning, Cancer Biotherapy & Radiopharmaceuticals, Vol. 17, No. 1, 2002
Kaptein, E.M., Radioiodine Dosimetry in Patients with End-Stage Renal Disease Receiving Continuous Ambulatory Peritoneal Dialysis Therapy, The Journal of Clinical Endocrinology & Metabolism, Vol. 85, No. 9, 2000