KDIGO Clinical Practice Guideline for Acute Kidney Injury
Other risk factors of CI-AKI

Other risk factors of CI-AKI

Besides pre-existing kidney disease with renal function impairment, other risk factors for developing CI-AKI include diabetes, hypertension, CHF, advanced age, volume depletion, hemodynamic instability, use of concurrent nephrotoxic medications, and large volume or high osmolality of the contrast agent.^408,412 Although there is doubt that diabetes by itself is an independent risk factor, in a patient with CKD it acts as a risk multiplier.³⁹⁸ Metabolic syndrome, prediabetes, and hyperuricemia have been identified as new risk factors for CI-AKI, while the use of ACE-I and angiotensin-receptor blockers (ARB), renal transplantation, diabetes mellitus with normal renal function, low-osmolar contrast media, multiple myeloma, female gender, and cirrhosis have been classified as conflicting risk factors for CI-AKI.⁴¹³ There are conflicting data on the impact of ACE-I or ARB but, overall, there is currently insufficient evidence to recommend discontinuation of these medications prior to contrast-media administration.

When possible, the administration of contrast media should be delayed in patients with circulatory collapse or CHF until their hemodynamic status is corrected. Repeated exposure should be delayed for 48 hours in patients without risk factors for CI-AKI, and for 72 hours in those with diabetes mellitus or pre-existing chronic renal dysfunction. If acute renal dysfunction develops after contrast-media administration, repeated exposure should preferably be delayed until the SCr level has returned to baseline levels.⁴¹⁴

Concurrent nephrotoxic medication—including, in particular, NSAIDs, aminoglycosides, amphotericin B, high

Table 15 | CI-AKI risk-scoring model for percutaneous coronary intervention

Note: Low risk: cumulative score < 5; high risk: cumulative score > 16. CHF, congestive heart failure; eGFR, estimated glomerular filtration rate; IABP, intraaortic balloon pump; SCr, serum creatinine. Reprinted from Mehran R, Aymong ED, Nikolsky E et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 2004; 44: 1393–1399 et al.,⁴¹⁸ copyright 2004, with permission from American College of Cardiology Foundation; accessed http://content.onlinejacc.org/cgi/content/full/44/7/1393

doses of loop diuretics, and antiviral drugs like acyclovir and foscarnet—should preferably be stopped. A recent study using a so-called forced euvolemic diuresis protocol including mannitol and furosemide led to a significantly increased risk of CI-AKI.⁴¹⁵ It can be advised that such strategy should be abandoned, and that furosemide therapy should preferably be stopped before angiography.