Primary prevention

Prevention of AKI in high-risk patients

Acutely ill patients in hospital are at increased risk of AKI, particularly if they have risk factors (e.g., chronic kidney disease, diabetes mellitus, heart failure, or advanced age). You should:[3]

  • Use early warning scores (e.g., NEWS2) to help identify patients at risk of AKI because their clinical condition is deteriorating or they are at risk of deteriorating.

  • Ensure patients at risk of AKI who are admitted to hospital have their serum creatinine level monitored, with a system in place to recognise and respond to acute creatinine changes which meet criteria for AKI.[64]

  • Ensure a system of urine output monitoring is in place to recognise and respond to oliguria (urine output <0.5 ml/kg/hour)

  • Seek advice from a pharmacist about optimising medicines and drug dosing for patients with or at risk of AKI.[3]

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 by large population studies that have failed to demonstrate this risk.[38][39][40]​ The evidence regarding the prevention of CI-AKI is weak, and often conflicting.[65][66]

The UK National Institute for Health and Care Excellence (NICE) recommends that you:[3]

  • Measure kidney function within 3 months of offering iodinated contrast for non-emergency imaging in adults assessed as being at increased risk of kidney injury.

  • Encourage oral hydration before and after procedures using intravenous iodinated contrast agents in adults at increased risk of CI-AKI (e.g., CKD, diabetes, heart failure, and advanced age [≥75 years]).

  • Consider intravenous volume expansion only if the patient is particularly high risk (e.g., eGFR less than 30 ml/min/1.73 m2, kidney transplant).

  • Do not delay emergency imaging to undertake a risk assessment.

In 2023, the UK Royal College of Radiologists and Royal College of Emergency Medicine issued the following joint recommendations in relation to emergency iodinated intravenous contrast CT scans:[67]

  • Measurement of renal function or administration of intravenous fluid should not be considered prerequisites for emergency imaging.

  • Age, pre-existing renal disease, diabetes mellitus, or medications such as metformin should not delay emergency scanning.

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

Drugs evaluated for prevention of CI-AKI include N-acetylcysteine, high-dose statins, probucol, allopurinol, and alprostadil, but benefits remain uncertain and such therapies should not be used routinely.[68]​​​[69]​[70]​[71]​[72]​[73]​[74]​

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).

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