Primary prevention

Exposure to radiocontrast may cause AKI.[5] However, the association is controversial because population studies do not replicate risk.[36][37][38] Evidence regarding the prevention of contrast-induced AKI is weak, and often conflicting:

  • Administration of normal saline at a dose of 1 mL/kg/hour for several hours before and after the contrast is believed to be beneficial in the prevention of contrast nephropathy.[53] However, a large study did not show benefit in patients at risk of contrast-induced nephropathy according to current guidelines.[54] The UK National Institute for Health and Care Excellence (NICE) recommends use of intravenous volume expansion only for inpatients considered at particularly high risk, for example if they have preexisting renal impairment.[55][Evidence C]

  • Probucol, atrial natriuretic peptide, and high-dose statins reduced the risk of contrast-induced AKI in small studies, but remain experimental.[56][57][58]

Sodium bicarbonate is unlikely to be superior to saline for the prevention of contrast-induced injury.[59][60] Studies assessing the efficacy of acetylcysteine administration before contrast exposure show no significant benefit, and this approach should be abandoned.[60][61]

Treatment during cardiac surgery:

  • Sodium nitroprusside has been shown to be associated with improved renal function when given during the rewarming period of nonpulsatile coronary pulmonary bypass in the course of coronary artery bypass grafting surgery.[62]

  • One large meta-analysis of 4605 adult patients undergoing cardiac surgery with cardiopulmonary bypass and receiving different forms of therapy, concluded that fenoldopam, atrial natriuretic peptide, and brain natriuretic peptide showed evidence of nephroprotection, although none reduced all-cause mortality.[63] These interventions are hard to justify based on overall evidence.

  • One study analyzing the effect of high-dose perioperative atorvastatin in patients undergoing elective coronary artery bypass grafting, valvular heart surgery, or ascending aortic surgery suggested no benefit.[64] In a similar patient population, AKI was more common among those randomized to perioperative rosuvastatin than to placebo.[65]

  • Levosimendan, a calcium sensitizer used to improve cardiac output, appears to prevent AKI in patients undergoing cardiac surgery.[66][67]

  • Results from one meta-analysis suggest that preoperative intra-aortic balloon pump support for high-risk patients undergoing coronary artery bypass grafting surgery lessens the risk of postoperative AKI.[68]

  • Compared with on-pump coronary artery bypass grafting, off-pump surgery appears to reduce the risk of postoperative AKI.[49]

Critically ill patients in intensive care unit setting:

  • It is unclear whether a chloride-sparing intravenous fluid strategy reduces the incidence of AKI in critically ill patients.[69][70] Larger randomized studies remain necessary to alter practice.[70]

Severe metabolic acidosis:

  • One trial reported improved outcome and reduced mortality among a subset of critically ill patients with AKI who received sodium bicarbonate infusion for correction of metabolic acidemia.[71] However, sodium bicarbonate was not associated with clinical benefit in unselected critically ill patients with severe acidemia.

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