Navigating nephrotoxic waters: A comprehensive overview of contrast-induced acute kidney injury prevention

Table 1 Clinical pearls for contrast-induced acute kidney injury in every day clinical practice

Risk factors-complications

Serum creatinine elevation occurs within 48-72 hours after the injection of the CM, with the first 24 hours post-exposure are crucial to the development of CI-AKI

Patients with preexisting CKD, elderly, and renal transplant recipients are at increased risk for CI-AKI development

Renal function via serum creatinine and eGFR calculation should be evaluated in high-risk patients before exposure to CM for CI-AKI risk assessment

Other notable complications of CM exposure: Myocardial infarction, shock, stroke, death, longer in-hospital stays

Prevention

CM considerations: Apply non-ionic, hypo-osmolar CM at lowest dose, prewarm at 37 °C

Discontinue nephrotoxic drugs: Non-steroidal anti-inflammatory drugs, aminoglycosides, metformin

Periprocedural hydration with normal saline in patients at risk:

Three mL/kg/hour 1 hour before to 4 hours after the procedure

One mL/kg/hour 12 hours before to 12 hours after the procedure

Individualized use of specialized systems (RenalGuard/DyeVert) in coronary procedures

CI-AKI: Contrast-induced acute kidney injury; CM: Contrast medium; CKD: Chronic kidney disease; eGFR: Estimated glomerular filtration rate.

Table 2 Clinical evidence on the role of RenalGuard for the prevention of contrast-induced acute kidney injury in patients at risk

Ref.	Patients	Study design	Preventive strategy	Outcome
Briguori et al[79]	702	RCT	RenalGuard	Less CI-AKI, PE and 1-month MAE
			LVEDP-guided hydration
Katoh et al[84]	60 (Japanese)	Observational	RenalGuard	High UFR associated with less CI-AKI
Chorin et al[85]	300	Observational	RenalGuard	Net decrease in eGFR and CI-AKI incidence
			Isotonic saline
Visconti et al[78]	48	Non-randomized	RenalGuard	Protective against CI-AKI (OR 0.71)
			SB
Briguori et al[86]	400	Observational	RenalGuard	Effective in reaching the target UFR (≥ 450 mL/h)
Barbanti et al[87]	112	RCT	RenalGuard	Reduced incidence of CI-AKI
			Isotonic saline
Briguori et al[88]	292	RCT	RenalGuard (NAC + SB)	Lower CI-AKI and in-hospital dialysis incidence
			NAC + SB
Arbel et al[80]	136	RCT	RenalGuard-active	Similar CI-AKI incidence
			RenalGuard-sham	Increased long-term mortality in active group
Mauler-Wittwer et al[81]	259	RCT	RenalGuard	Similar CI-AKI incidence at day 3
			Isotonic saline	No difference in secondary outcomes
Voigtländer-Buschmann et al[82]	100	RCT	RenalGuard	Similar CI-AKI incidence
			Isotonic saline	Similar 30-day and 12-month mortality rates
Ben-Haim et al[89]	58	Non-randomized	RenalGuard	RenalGuard was an independent predictor of lower Renal CM accumulation score
			Isotonic saline
			None
Mirza et al[90]	1205	RCT	RenalGuard (non-automated)	Significantly lower incidence of CI-AKI with RenalGuard
			Isotonic saline

CI-AKI: Contrast-induced acute kidney injury; LVEDP: Left ventricular end diastolic pressure; PE: Pulmonary edema; MAE: Major adverse events; UFR: Urinary flow rate; eGFR: Estimated glomerular filtration rate; SB: Sodium bicarbonate; OR: Odds ratio; NAC: N-acetyl Cysteine; CM: Contrast medium; RCT: Randomized clinical trial.