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renal.contrast-induced-aki.v1PRODUCTION
renal.contrast-induced-aki.v1

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

nephrologyacutesubacuteadultpediatric
Hard-required inputs
0 / 11
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm AKI by KDIGO 2012 + temporal relationship to contrast (≤72h) + exclude alternate causes (KDIGO 2012 AKI)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Contrast-temporal Cr rise + no clear alternate cause

Patient inputs (12)

Age-stratified risk; pediatric protocols differ (KDIGO 2012 AKI)

KDIGO staging + 48-72h post-contrast rise definition (KDIGO 2012 AKI)

Pre-contrast baseline mandatory; compute Cr ratio (KDIGO 2012 AKI)

eGFR <30 = highest CI-AKI risk + AVOID gadolinium Group I (KDIGO 2024 CKD; ACR)

DM amplifies CI-AKI risk (Mehran component)

HF + volume status component of Mehran (Mehran 2004)

Hold metformin pre-contrast if eGFR <30 or AKI (FDA label 2016)

Volume status assessment pre-contrast hydration (KDIGO 2012 AKI)

Contrast volume + osmolar load drives risk; iso vs low-osmolar choice (ESUR)

Distinguish CI-AKI (often bland sediment) from ATN superimposition / AIN (KDIGO 2012 AKI)

AEIOU screening for refractory hyperkalemia (KDIGO 2012 AKI)

NSAIDs / aminoglycosides / vancomycin / chemo amplify CI-AKI risk

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationalsevereCKD_diabetic_high_risk
    High-risk CI-AKI substrate — eGFR <30-45 + DM + Mehran score ≥16; reservation of contrast for emergent indication only (KDIGO 2012 AKI; Mehran 2004; PRESERVE NEJM 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereHF_high_risk
    HF (NYHA III-IV / EF <40%) + CI-AKI risk — balance pre-hydration vs decompensation; coordinate cardiology + nephrology (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevolume_depleted_high_risk
    Volume depletion at time of contrast — diuretic overshoot, GI losses, NPO status, dehydration → amplified CI-AKI risk (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_volume_contrast
    High-volume contrast administration (>140 mL or volume:eGFR ratio >3:1) — increased CI-AKI risk; multi-step PCI or staged angiography mitigates (KDIGO 2012 AKI; Mehran 2004)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremehran_ge_16
    Very-high Mehran score (≥16) — predicts CI-AKI risk 57% + dialysis risk 12% (Mehran 2004)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiodinated_vs_gadolinium_NSF
    Gadolinium NSF risk — eGFR <30 + Group I gadolinium (gadodiamide, gadopentetate, gadoversetamide) contraindicated; macrocyclic Group II preferred if essential (ACR Group I/II/III)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereSARS_CoV_2_post_CT_AKI
    COVID-19 + contrast-enhanced CT for PE or pulmonary evaluation → CI-AKI overlapping with COVID-AKI multiorgan; differentiate from COVID-direct kidney injury (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateclassic_CI_AKI_48_72h
    Classic CI-AKI — Cr rise ≥0.3 mg/dL or ≥1.5× baseline at 48-72h post iodinated contrast; bland sediment; recovery 7-10d (KDIGO 2012 AKI; ESUR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiso_vs_low_osmolar_choice
    Contrast agent selection — iso-osmolar (iodixanol) vs low-osmolar (iohexol/iopamidol) for high-risk; AVOID high-osmolar (ESUR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric
    Pediatric CI-AKI — weight-based contrast dosing + caution in neonates / CKD pediatric patients (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepreventive_strategy_failed
    CI-AKI despite optimal prevention (hydration + minimal contrast + iso-osmolar) — recover supportively; flag for future imaging strategy review (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

CI-AKI — risk-stratified prevention + supportive management (PRESERVE NEJM 2018 negative for NaHCO3+NAC; KDIGO 2012 AKI; ACR)
axis: ci_aki_prevention_and_supportive_managementstep 1 - Step 1 — Pre-contrast risk assessment + Mehran score
Selected step "Step 1 — Pre-contrast risk assessment + Mehran score" — All patients undergoing iodinated contrast (KDIGO 2012 AKI; Mehran 2004)
  • mehran_score_documentation
    first line
    risk_stratification
    triggers: pre_contrast_planning
    Mehran score components: eGFR, DM, HF, age >75, anemia, hypotension, contrast volume, IABP — risk-stratifies CI-AKI; schema-blocked calc

outpatient playbook — drug actions (3)

  1. 1. resume metformin
    Half prior dose 48h post-contrast if Cr stable • PO • daily
    trigger: Cr stable post-contrast
    FDA 2016
  2. 2. restart SGLT2i
    Per indication once Cr stable • PO • daily
    trigger: Cr recovered to baseline ± 0.3 mg/dL
    KDIGO 2024 CKD — preserve renoprotective benefits
  3. 3. restart ACEi/ARB
    Half prior dose; recheck Cr+K at 1-2 wk • PO • daily
    trigger: Cr stable for ≥1 wk
    KDIGO 2024 CKD — long-term renoprotection

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cr rise ≥0.3 mg/dL or ≥1.5× baseline within 48-72h post iodinated contrast (KDIGO 2012 AKI; ESUR); Recent iodinated contrast (CT angiography, coronary angiography, PCI, urography) (KDIGO 2012 AKI); Pre-existing CKD (eGFR <60) ± DM — highest-risk substrate (KDIGO 2012 AKI; PRESERVE NEJM 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Contrast-Induced / Contrast-Associated AKI (CI-AKI / CA-AKI)** (renal.contrast-induced-aki.v1).
Phenotype framing: 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)
Scope: Confirm AKI by KDIGO 2012 + temporal relationship to contrast (≤72h) + exclude alternate causes (KDIGO 2012 AKI)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CI-AKI — risk-stratified prevention + supportive management (PRESERVE NEJM 2018 negative for NaHCO3+NAC; KDIGO 2012 AKI; ACR)** — step "Step 1 — Pre-contrast risk assessment + Mehran score".
1. mehran_score_documentation (risk_stratification, first line) — Mehran score components: eGFR, DM, HF, age >75, anemia, hypotension, contrast volume, IABP — risk-stratifies CI-AKI; schema-blocked calc

Setting playbook (outpatient) — Pre-procedure risk stratification + protocol selection + post-procedure recovery + future-imaging optimization (KDIGO 2012 AKI; ESUR)
2. resume metformin Half prior dose 48h post-contrast if Cr stable PO daily — Cr stable post-contrast (FDA 2016)
3. restart SGLT2i Per indication once Cr stable PO daily — Cr recovered to baseline ± 0.3 mg/dL (KDIGO 2024 CKD — preserve renoprotective benefits)
4. restart ACEi/ARB Half prior dose; recheck Cr+K at 1-2 wk PO daily — Cr stable for ≥1 wk (KDIGO 2024 CKD — long-term renoprotection)

Non-pharmacologic actions:
- Permanent CI-AKI flag in chart for future imaging (KDIGO 2012 AKI)
- Future imaging optimization: prefer US / MRI without gad first; minimize contrast volume; iso-osmolar agents (ESUR)
- Avoid future combined contrast + nephrotoxin (KDIGO 2012 AKI)
- Vaccinations per ACIP 2026

AVOID / contraindication checks:
- Do_NOT_use_NaHCO3_or_NAC_for_CI_AKI_prophylaxis (PRESERVE NEJM 2018)
- Avoid_furosemide_forced_diuresis (KDIGO 2012 AKI)
- Avoid_low_dose_dopamine (KDIGO 2012 AKI)
- HOLD_metformin_if_egfr_lt_30_or_acute_aki (FDA 2016)
- AVOID_Group_I_gadolinium_if_egfr_lt_30_due_to_NSF (ACR)
- Minimize_contrast_volume_in_CKD (KDIGO 2012 AKI; ESUR)
- Hold_nephrotoxic_co_exposures_NSAID_aminoglycoside_vancomycin_peri_contrast (KDIGO 2012 AKI)

Monitoring

Regimen monitoring:
- Cr at baseline and 48 72h post contrast (KDIGO 2012 AKI)
- Cr q24h during AKI recovery phase 7 to 10 days (KDIGO 2012 AKI)
- BMP for K acid base (KDIGO 2012 AKI)
- UOP daily (KDIGO 2012 AKI)
- watch for NSF in gadolinium exposed eGFR lt 30 (ACR)

Setting (outpatient) monitoring:
- eGFR + UACR at 3 mo post-CI-AKI episode (KDIGO 2024 CKD)
- BP at each visit (KDIGO 2024 CKD)
- K + Cr 1-2 wk after RAS resumption (KDIGO 2024 CKD)

Follow-up plan: 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)
- Close-out criterion: Med reconciliation + future-imaging plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Pre-procedure risk stratification + protocol selection + post-procedure recovery + future-imaging optimization (KDIGO 2012 AKI; ESUR)

Disposition criteria:
- Continue nephrology q3-6 mo if eGFR <60 (KDIGO 2024 CKD)
- Transition to PCP if full Cr recovery + no proteinuria (KDIGO 2012 AKI)

Escalation triggers (move to higher acuity):
- Sustained eGFR <60 at 3 mo → neph.ckd.core.v1 (KDIGO 2024 CKD)
- Recurrent CI-AKI on repeat exposure → nephrology evaluation (KDIGO 2012 AKI)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] High-risk CI-AKI substrate — eGFR <30-45 + DM + Mehran score ≥16; reservation of contrast for emergent indication only (KDIGO 2012 AKI; Mehran 2004; PRESERVE NEJM 2018)
- [SEVERE] HF (NYHA III-IV / EF <40%) + CI-AKI risk — balance pre-hydration vs decompensation; coordinate cardiology + nephrology (KDIGO 2012 AKI)
- [SEVERE] Volume depletion at time of contrast — diuretic overshoot, GI losses, NPO status, dehydration → amplified CI-AKI risk (KDIGO 2012 AKI)

Citations

- KDIGO 2012 AKI Guideline + PRESERVE (NEJM 2017, negative for IV NaHCO3 + acetylcysteine) + AMACING (Lancet 2017) + SMART balanced crystalloid (NEJM 2018) + KDIGO 2024 CKD [PMID:22890468](https://pubmed.ncbi.nlm.nih.gov/22890468/)
- Cited evidence (PMID 29130810) [PMID:29130810](https://pubmed.ncbi.nlm.nih.gov/29130810/)
- Cited evidence (PMID 28233565) [PMID:28233565](https://pubmed.ncbi.nlm.nih.gov/28233565/)
- Cited evidence (PMID 29485925) [PMID:29485925](https://pubmed.ncbi.nlm.nih.gov/29485925/)
- Cited evidence (PMID 38490803) [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2012 AKI Guideline + PRESERVE (NEJM 2017, negative for IV NaHCO3 + acetylcysteine) + AMACING (Lancet 2017) + SMART balanced crystalloid (NEJM 2018) + KDIGO 2024 CKD — PMID:22890468
  • Cited evidence (PMID 29130810) — PMID:29130810
  • Cited evidence (PMID 28233565) — PMID:28233565
  • Cited evidence (PMID 29485925) — PMID:29485925
  • Cited evidence (PMID 38490803) — PMID:38490803