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.