Coronary angiography with renal dysfunction

Red Flags

eGFR <30 mL/min/1.73 m² with planned coronary angiography — high CA-AKI risk; strongly consider alternative diagnostics or carefully limit contrast volume^[1]
Acute kidney injury within 48 h of contrast (creatinine rise ≥0.3 mg/dL or ≥50% baseline) — CA-AKI; pause nephrotoxins and reassess^[2]
Diabetes plus eGFR <60 — additive CA-AKI risk; mandatory hydration protocol and minimum-volume contrast^[1]
Decompensated heart failure with planned angiography — IV hydration may worsen pulmonary oedema; balance with diuresis under monitoring^[1]

First-line treatment

Interventions

Peri-procedural isotonic IV hydration^[1]
0.9% saline 1 mL/kg/h for 6–12 h pre- and 6–12 h post-procedure (reduce in HF). Single most effective preventive measure
Minimum-volume low-osmolar or iso-osmolar contrast^[1]
Limit contrast to <30 mL or <3× eGFR; iso-osmolar agents (iodixanol) preferred in eGFR <30; low-osmolar agents acceptable in eGFR 30–60
Pause nephrotoxic medications^[2]
Hold NSAIDs, aminoglycosides, and metformin (where eGFR <30) on the day of contrast and for 48 h post; do NOT routinely stop ACEi/ARB or SGLT2 inhibitors

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
N-acetylcysteine (oral)^[1]	Antioxidant prophylaxis	600–1200 mg PO BD on day before and day of procedure (4 doses total)	—	Optional adjunct; KDIGO permits with hydration despite mixed evidence; low cost and minimal harm
Sodium bicarbonate (alternative hydration)^[1]	Isotonic alkalinising fluid	150 mEq sodium bicarbonate in 1 L D5W; 3 mL/kg/h × 1 h pre, then 1 mL/kg/h × 6 h post	—	Equivalent to saline in major trials; choose by local availability; do not combine with saline

N-acetylcysteine (oral)^[1]

Antioxidant prophylaxis

Adult: 600–1200 mg PO BD on day before and day of procedure (4 doses total)
Paediatric: —

Optional adjunct; KDIGO permits with hydration despite mixed evidence; low cost and minimal harm

Sodium bicarbonate (alternative hydration)^[1]

Isotonic alkalinising fluid

Adult: 150 mEq sodium bicarbonate in 1 L D5W; 3 mL/kg/h × 1 h pre, then 1 mL/kg/h × 6 h post
Paediatric: —

Equivalent to saline in major trials; choose by local availability; do not combine with saline

Safety-net

Drink fluids freely on the day before and day after the angiogram unless told otherwise — staying well hydrated protects the kidneys^[1]
Pause ibuprofen and other anti-inflammatories for at least 48 hours before and after — they raise the risk of contrast-induced kidney injury^[2]
Hold metformin on the day of the procedure if your eGFR is <30; restart 48 hours after, only if a follow-up creatinine confirms stable kidney function^[2]

Referral criteria

eGFR <30 with planned non-emergent coronary angiographyNephrology and interventional cardiology shared decision making; consider stress imaging or coronary CTA as alternative^[1]
Post-procedural CA-AKI with creatinine rise persisting at 7 daysNephrology^[2]
Acute pulmonary oedema during peri-procedural hydrationCardiology and emergency department; cease hydration, give IV diuretic^[1]

Clinical summary

Pre- and peri-procedural strategies to prevent contrast-associated AKI in patients with chronic kidney disease undergoing coronary angiography or PCI.

References

1.CSI Practice Guidelines for Angiography in Patients with Renal Dysfunction; KDIGO 2024 CKD Clinical Practice Guideline (CIN/CA-AKI definitions) (2020)
2.KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International (2024)