What are the guideline sources, guidelines and references for Contrast-induced nephropathy ?
Guideline 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 Canadian Association of Radiologists (CAR 2022), the European Society of Cardiology (ESC 2021), the European Society for Vascular Surgery (ESVS 2017), the European Renal Best Practice Foundation (ERBP 2012), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2012), and the European Society of Intensive Care Medicine (ESICM 2010). 1 2 3 4 5 6 Guidelines 1. Screening and diagnosis Definitions: use the same definition and grading for contrast-induced nephropathy as for AKI. Differential diagnosis: consider assessing other possible causes of AKI in patients developing changes in kidney function after administration of intravascular contrast media. 2. Classification and risk stratification Risk assessment: https://web.pathway.md/diseases/recOeCICsG9BGM1Sw 1/5 6/23/23, 3:36 AM Contrast-induced nephropathy Pathway 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) estimated GFR on file and without a provided history of CKD on the requisition to identify patients with AKI or severe CKD. E Show 2 more As per KDIGO 2012 guidelines, assess the risk for contrast-induced AKI and, in particular, screen for preexisting impairment of kidney function in all patients being considered for a procedure requiring intravascular administration of iodinated contrast medium. 3. Diagnostic investigations eGFR: Obtain a current estimated GFR (within 7 days for inpatients, or upon presentation for emergency room patients), if indicated based on risk assessment, but do not delay emergent imaging. E Obtain an indicated contrast-enhanced imaging without delay if the patient is in an emergent presentation (such as suspected acute stroke, pulmonary embolism, acute aortic syndrome, bowel ischemia or perforation, and other conditions). Do not delay emergent imaging to obtain estimated GFR measurement and do not withhold contrast required for an accurate diagnosis of the emergent pathology. E 4. Medical management General principles: evaluate and treat contrast-associated AKI according to published evidence- based guidelines on AKI. E 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. C Restriction of contrast medium use: As per CAR 2022 guidelines, assess the overall risk of worsening AKI with contrast versus the benefit of improved diagnostic capability and therapeutic intervention for the use of IV or intra- arterial contrast in the setting of preexisting AKI. E Show 6 more As per ESC 2021 guidelines, use low- or iso-osmolar contrast media (at the lowest possible volume) for invasive strategies in patients with CKD presenting with myocardial infarction. A https://web.pathway.md/diseases/recOeCICsG9BGM1Sw 2/5 6/23/23, 3:36 AM Contrast-induced nephropathy Pathway As per ERBP 2012 guidelines: Balance the risk for contrast-induced nephropathy against the benefit of administering contrast. Consider obtaining alternative imaging modalities not requiring contrast administration in patients at increased risk for contrast-induced nephropathy if those modalities yield the same diagnostic accuracy. As per KDIGO 2012 guidelines: Consider obtaining alternative imaging methods in patients at increased risk for contrast- induced AKI. Administer the lowest possible dose of contrast medium in patients at risk for contrast-induced AKI. Administer either iso-osmolar or low-osmolar iodinated contrast media, rather than high- osmolar iodinated contrast media, in patients at increased risk of contrast-induced AKI. B Discontinuation of medications: do not discontinue metformin before contrast administration and/or re-test kidney function afterward in patients with an estimated GFR > 30 mL/min/1.73 m . D Show 2 more Intravenous and oral fluids: As per CAR 2022 guidelines, do not initiate oral or IV hydration in patients with an estimated GFR > 30 mL/min/1.73 m receiving IV or intra-arterial iodinated contrast media. D Show 2 more As per ESC 2021 guidelines, consider offering pre- and post-hydration with isotonic saline if the expected contrast volume is > 100 mL in invasive strategies in patients with CKD and myocardial infarction. C Consider using tailored hydration regimens as an alternative to the pre- and post-hydration regimen. C As per ESVS 2017 guidelines, consider administering isotonic sodium chloride or sodium bicarbonate solutions for volume expansion before contrast administration in patients at increased risk of contrast-induced nephropathy. C As per ERBP 2012 guidelines: Administer either isotonic sodium chloride or sodium bicarbonate solutions for volume expansion in patients at increased risk for contrast-induced nephropathy. B Consider using the oral route for hydration if adequate intake of fluid and salt is assured. C As per KDIGO 2012 guidelines: Administer IV isotonic sodium chloride or sodium bicarbonate solution for volume expansion in patients at increased risk for contrast-induced AKI. B Do not use oral uids alone in patients at increased risk of contrast-induced AKI. D As per ESICM 2010 guidelines, administer isotonic crystalloids for prophylactic volume expansion in patients at risk of contrast-induced nephropathy. B Consider administering isotonic sodium bicarbonate solution, especially for emergency procedures. B N-acetylcysteine: https://web.pathway.md/diseases/recOeCICsG9BGM1Sw 3/5 6/23/23, 3:36 AM Contrast-induced nephropathy Pathway As per CAR 2022 guidelines, do not use N-acetylcysteine for the prophylaxis of contrast- associated AKI. D As per ERBP 2012 guidelines, consider administering oral N-acetylcysteine only in patients receiving appropriate fluid and salt loading. C Do not use oral N-acetylcysteine as the only method for the prevention of contrast-induced nephropathy. C As per KDIGO 2012 guidelines, consider administering oral N-acetylcysteine together with IV isotonic crystalloids in patients at increased risk of contrast-induced AKI. C As per ESICM 2010 guidelines, avoid using N-acetylcysteine as prophylaxis against contrast- induced nephropathy in critically ill patients. D Updated evidence: ACT In patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced AKI (age > 70 years, renal failure, diabetes mellitus, HF, or hypotension), acetylcysteine was not superior to placebo with respect to a contrast-induced AKI. ACT Investigators. Circulation. 2011 Sep 13. Other agents: As per CAR 2022 guidelines, do not use other pharmacological agents, such as statins, theophylline, prostaglandin E1, nicorandil, ascorbic acid, allopurinol, alpha-tocopherol, fenoldopam, natriuretic peptides, or trimetazidine, for the prevention of contrast-induced AKI. D As per ERBP 2012 guidelines: Avoid using theophylline for the prevention of contrast-induced nephropathy. D Do not use fenoldopam for the prevention of contrast-induced nephropathy. D As per KDIGO 2012 guidelines: Avoid using theophylline for the prevention of contrast-induced AKI. D Do not use fenoldopam for the prevention of contrast-induced AKI. D As per ESICM 2010 guidelines: Do not use fenoldopam for prophylaxis of contrast-induced nephropathy. D Consider administering theophylline to minimize the risk of contrast-induced nephropathy, especially in acute interventions when hydration is not feasible. C Renal replacement therapy: As per CAR 2022 guidelines, do not use any form of post-iodinated contrast media administration RRT, either dialysis or continuous RRT, to reduce the risk of contrast-associated AKI. D As per ERBP 2012 guidelines, do not use prophylactic intermittent hemodialysis or hemofiltration for the sole purpose of preventing contrast-induced nephropathy. D https://web.pathway.md/diseases/recOeCICsG9BGM1Sw 4/5 6/23/23, 3:36 AM Contrast-induced nephropathy Pathway As per KDIGO 2012 guidelines, avoid using prophylactic intermittent hemodialysis or hemo ltration for contrast-media removal in patients at increased risk for contrast-induced AKI. D As per ESICM 2010 guidelines, consider performing periprocedural continuous venovenous hemofiltration in an ICU environment to limit contrast-induced nephropathy after coronary interventions in high-risk patients with advanced chronic renal insufficiency. C 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 estimated GFR 30 mL/min/1.73m . Do not obtain routine serum creatinine measurement in the remainder of patients as the risk of AKI is extremely low. 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. E References 1. D. Blair Macdonald, MD, FRCPC et al. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. CAR. 2022 May. Open 2. Ad-hoc working group of ERBP, Danilo Fliser, Maurice Laville et al. A European Renal Best Practice ERBP position statement on the Kidney Disease Improving Global Outcomes KDIGO clinical practice guidelines on acute kidney injury: part 1 definitions, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012 Dec;27 12 4263 72. Open 3. Michael Joannidis, Wilfred Druml, Lui G Forni et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM. Intensive Care Med. 2010 Mar;36 3 392 411. Open 4. Arif Khwaja. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120 4):c179 84. Open 5. Jean-Philippe Collet, Holger Thiele, Emanuele Barbato et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42 14 1289 1367. Open 6. V Riambau, D B ckler, J Brunkwall et al. Editor's Choice Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Jan;53 1 4 52. Open https://web.pathway.md/diseases/recOeCICsG9BGM1Sw 5/5