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renal.contrast-induced-aki.v1

Contrast-Induced / Contrast-Associated AKI (CI-AKI / CA-AKI)

nephrologyacutesubacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (aki, aki_on_ckd); every evidence.pmid re-sourced and live-verified via PubMed; isotonic-saline RxCUI corrected to 9863; lactated_ringers marked non_pharm (no single-ingredient CUI). Practice-changing modern view: PRESERVE (NEJM 2017, 29130810) — IV sodium bicarbonate + N-acetylcysteine NOT effective for CI-AKI prevention; AMACING (Lancet 2017, 28233565) questions universal IV hydration in low-risk; only isotonic IV hydration for high-risk substrates retains support (KDIGO 2012 AKI). PMID anchors (live-verified PubMed 2026-05-22): 22890468 KDIGO 2012 AKI, 29130810 PRESERVE, 28233565 AMACING, 29485925 SMART, 38490803 KDIGO 2024 CKD. Prior placeholder PMIDs were fabricated/mis-attributed and have been removed. Regimen: risk-assess (eGFR/DM/HF/volume) -> isotonic hydration -> minimize contrast volume + iso/low-osmolar -> AVOID NaHCO3+NAC -> hold metformin if eGFR<30 -> serial Cr -> 7-10d recovery. Sibling routing: renal.aki.v1, renal.aki.intrinsic.atn.v1, renal.ckd-progression.v1.

Entry points (5)

  • lab_abnormality
    Cr rise ≥0.3 mg/dL or ≥1.5× baseline within 48-72h post iodinated contrast (KDIGO 2012 AKI; ESUR)
    cr_rise_48_72h_post_contrast
  • history
    Recent iodinated contrast (CT angiography, coronary angiography, PCI, urography) (KDIGO 2012 AKI)
    recent_iodinated_contrast_exposure
  • history
    Pre-existing CKD (eGFR <60) ± DM — highest-risk substrate (KDIGO 2012 AKI; PRESERVE NEJM 2018)
    ckd_diabetic_pre_contrast
  • history
    HF + volume depletion + nephrotoxic co-exposure pre-contrast (KDIGO 2012 AKI)
    hf_volume_depleted_pre_contrast
  • history
    Recent gadolinium with eGFR <30 — NSF risk evaluation (ACR Group I/II/III)
    gadolinium_exposure_low_egfr

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age-stratified risk; pediatric protocols differ (KDIGO 2012 AKI)
  • creatininerequired
    lab • used at CONTEXT
    KDIGO staging + 48-72h post-contrast rise definition (KDIGO 2012 AKI)
  • baseline_creatininerequired
    lab • used at CONTEXT
    Pre-contrast baseline mandatory; compute Cr ratio (KDIGO 2012 AKI)
  • egfr_pre_contrastrequired
    lab • used at CONTEXT
    eGFR <30 = highest CI-AKI risk + AVOID gadolinium Group I (KDIGO 2024 CKD; ACR)
  • diabetesrequired
    history • used at CONTEXT
    DM amplifies CI-AKI risk (Mehran component)
  • heart_failurerequired
    history • used at CONTEXT
    HF + volume status component of Mehran (Mehran 2004)
  • metformin_userequired
    history • used at CONTEXT
    Hold metformin pre-contrast if eGFR <30 or AKI (FDA label 2016)
  • recent_contrast_volumerequired
    history • used at INITIAL_WORKUP
    Contrast volume + osmolar load drives risk; iso vs low-osmolar choice (ESUR)
  • concurrent_nephrotoxin_exposure
    history • used at CONTEXT
    NSAIDs / aminoglycosides / vancomycin / chemo amplify CI-AKI risk
  • sbprequired
    vital • used at CONTEXT
    Volume status assessment pre-contrast hydration (KDIGO 2012 AKI)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Distinguish CI-AKI (often bland sediment) from ATN superimposition / AIN (KDIGO 2012 AKI)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    AEIOU screening for refractory hyperkalemia (KDIGO 2012 AKI)

12-phase flow (12)

  1. 1FRAME
    Confirm AKI by KDIGO 2012 + temporal relationship to contrast (≤72h) + exclude alternate causes (KDIGO 2012 AKI)
    inputs: creatinine, baseline_creatinine
    advance: Contrast-temporal Cr rise + no clear alternate cause
  2. 2ENTRY
    Cr rise 48-72h post iodinated contrast OR NSF concern post-gadolinium (KDIGO 2012 AKI; ACR)
    inputs: creatinine
    advance: CI-AKI suspected
  3. 3CONTEXT
    Risk substrate: eGFR pre-contrast, DM, HF, volume status, concurrent nephrotoxins, metformin, contrast volume + osmolar load (KDIGO 2012 AKI; ESUR)
    inputs: egfr_pre_contrast, diabetes, heart_failure, metformin_use, sbp
    advance: Risk substrate documented
  4. 4RED_FLAGS
    Severe pre-existing CKD eGFR <30 (highest CI-AKI risk + gadolinium NSF risk); volume depletion + emergent contrast indication; emergent CT with no time for hydration (KDIGO 2012 AKI; ACR)
    inputs: egfr_pre_contrast
    advance: High-risk status flagged + mitigation plan in place
  5. 5INITIAL_WORKUP
    BMP, UA, baseline + 48-72h post-contrast Cr, calculate Mehran score, review contrast volume + agent (KDIGO 2012 AKI; ESUR; Mehran 2004)
    inputs: urinalysis, potassium, recent_contrast_volume
    actions: panel.renal, panel.cbc
    advance: CI-AKI confirmed vs alternate cause
  6. 6BRANCHING_WORKUP
    Renal US if persistent / progressive AKI to exclude obstruction; consider AIN if eosinophilia / rash / fever; cholesterol embolization workup if post-angiography livedo / blue toes (KDIGO 2012 AKI)
    advance: Alternate causes excluded
  7. 7DIFFERENTIAL
    CI-AKI sub-phenotypes: classic 48-72h Cr rise / iso vs low-osmolar / high-volume contrast / Mehran high-risk / gadolinium NSF / SARS-CoV-2 post-CT AKI / pediatric / preventive-strategy-failure (KDIGO 2012 AKI; ESUR; ACR)
    advance: Sub-phenotype assigned
  8. 8RISK_STRATIFICATION
    Mehran score for CI-AKI prediction; KDIGO stage 1-3; ACR contrast risk group; gadolinium NSF risk if eGFR <30 (KDIGO 2012 AKI; ACR)
    inputs: creatinine
    actions: calc.ckd_epi_2021
    advance: Risk + stage documented
  9. 9TREATMENT
    Supportive: volume support (isotonic crystalloid if hypovolemic); hold nephrotoxic co-exposures; AVOID NaHCO3+NAC (PRESERVE-negative); hold metformin if eGFR <30; serial Cr monitoring; recovery 7-10d (PRESERVE NEJM 2018; KDIGO 2012 AKI)
    inputs: sbp
    advance: Supportive plan executed; preventive ineffectives explicitly de-emphasized
  10. 10DISPOSITION
    ICU if combined with shock / multiorgan failure; ward if isolated stage 2-3 with refractory AKI; outpatient if stage 1 with downtrending Cr (KDIGO 2012 AKI)
    advance: Level-of-care + recovery plan set
  11. 11MONITORING
    Cr q24h × 7-10d; UOP daily; BMP for K + acid-base; hold nephrotoxins until Cr recovery within 0.3 mg/dL of baseline (KDIGO 2012 AKI)
    inputs: creatinine
    actions: panel.renal
    advance: Cr trajectory documented
  12. 12FOLLOWUP
    Re-introduce held meds (metformin, ACEi/ARB) once Cr stable ≥1 wk; flag contrast-allergy / CI-AKI in chart for future imaging; future imaging optimization (US/MRI without gad first) (KDIGO 2012 AKI; KDIGO 2024 CKD; ACR)
    advance: Med reconciliation + future-imaging plan documented