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Contrast-induced nephropathy

Key sources
The following summarized guidelines for the evaluation and management of contrast-induced nephropathy are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the Canadian Association of Radiologists (CAR 2022), the European Society of Cardiology (ESC 2021), the European Society for Vascular Surgery (ESVS 2017), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2012), the European Renal Best Practice Foundation (ERBP 2012), and the European Society of Intensive Care Medicine (ESICM 2010).
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Guidelines

1.Screening and diagnosis

Definitions: use the same definition and grading for contrast-induced nephropathy as for AKI.
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  • Differential diagnosis

2.Classification and risk stratification

Risk assessment: as per CAR 2022 guidelines, use a simple screening questionnaire to detect stable outpatients without a current (3-6 months depending on institutional preference)EGFR on file and without a provided history of CKD on the requisition to identify patients with AKI or severe CKD.
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3.Diagnostic investigations

Estimated glomerular filtration rate
Obtain a current eGFR (within 7 days for inpatients, or upon presentation for emergency room patients), if indicated based on risk assessment, but do not delay emergent imaging.
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Obtain an indicated contrast-enhanced imaging without delay if the patient is in an emergent presentation (such as suspected acute stroke, PE, acute aortic syndrome, bowel ischemia or perforation, and other conditions). Do not delay emergent imaging to obtain eGFR measurement and do not withhold contrast required for an accurate diagnosis of the emergent pathology.
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4.Medical management

General principles: evaluate and treat contrast-associated AKI according to published evidence-based guidelines on AKI.
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5.Preventative measures

Renal function monitoring
Obtain a baseline serum creatinine before an intervention encompassing a risk for contrast-induced nephropathy.
Consider obtaining a repeat serum creatinine 12-72 hours after contrast media administration in high-risk patients.
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  • Restriction of contrast medium use

  • Discontinuation of medications

  • Intravenous and oral fluids

  • N-acetylcysteine

  • Other agents

  • RRT

6.Follow-up and surveillance

Serial creatinine assessment
Obtain a follow-up serum creatinine measurement 48-72 hours after intra-arterial iodinated contrast media administration in all patients with an eGFR ≤ 30 mL/min/1.73 m². Do not obtain routine serum creatinine measurement in the remainder of patients as the risk of AKI is extremely low.
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Instruct any at-risk patient to seek medical attention and kidney function testing if they develop increased shortness of breath, peripheral edema, or note a marked decline in urine output in the days following the imaging test.
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