Primary prevention

Prevention of contrast-induced AKI

Intravenous iodinated contrast has previously been reported to cause contrast-induced AKI (CI-AKI).[5] However, the association has been questioned more recently by large population studies that have failed to demonstrate this risk.[40][41][42] The evidence regarding the prevention of CI-AKI is weak, and often conflicting.[57][58]

The patient’s’ kidney function must be measured within 3 months of offering iodinated contrast for non-emergency imaging.

In 2019, the UK National Institute for Health and Care Excellence (NICE) recommendations on preventing CI-AKI were updated.[3]

  • The updated guidance now recommends that you should encourage oral hydration, rather than previously recommended intravenous volume expansion, before and after procedures using intravenous iodinated contrast agents in adults at increased risk of contrast-induced AKI.

Patients at increased risk of CI-AKI include those people with:

  • Chronic kidney disease (eGFR <40 mL/min/1.73 m2). Consider temporarily stopping ACE inhibitors and angiotensin-II receptor antagonists if the patient has an eGFR <40 mL/min/1.73 m2 

  • Diabetes, but only if the patient has concomitant chronic kidney disease (eGFR <40 mL/min/1.73 m2

  • Heart failure

  • Kidney transplant

  • Age ≥75 years

  • Hypovolaemia

  • Increasing volume of iodinated contrast agent 

  • Intra-arterial administration of contrast agent with first pass kidney exposure (e.g., contrast injected into the left side of the heart or directly into the renal arteries).

However, it is important to stress that risk assessment should not delay emergency imaging. Consider intravenous volume expansion with either isotonic sodium bicarbonate or normal saline (0.9% sodium chloride) for inpatients having iodinated contrast agents if they have particularly high risk factors, including:

  • eGFR <30 mL/min/1.73 m2

  • Kidney transplant

  • Large volume of contrast agent

  • Intra-arterial administration of contrast agent. 

Discuss patients on renal replacement therapy or with a kidney transplant with the renal team before offering iodinated contrast but do not delay emergency imaging. 

Do not use N-acetylcysteine to prevent contrast-induced AKI.[59][60][61]

Prevention of perioperative AKI

Identify patient risk factors for AKI prior to surgery, including:

  • Sepsis

  • Hypovolaemia

  • Intraperitoneal surgery

  • Chronic kidney disease (eGFR <60 ml/min/1.73 m2)

  • Diabetes

  • Heart failure

  • Age ≥65 years

  • Liver disease

  • Nephrotoxins (e.g., NSAIDs, aminoglycoside antibiotics such as gentamicin).

Secondary prevention

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