A 70-year-old man undergoes coronary angiography with 180 mL iodinated contrast. Baseline creatinine is 142 µmol/L (eGFR 42). Forty-eight hours later, creatinine rises to 215 µmol/L. Urine output has been adequate. Urinalysis shows granular casts. The most appropriate preventive strategy that should have been used pre-procedure is:

• A N-acetylcysteine (NAC) 1200 mg oral twice daily
• B IV isotonic saline hydration (1 mL/kg/h for 12 hours before and 6–12 hours after) with use of minimum contrast volume ✓
• C Sodium bicarbonate infusion is superior to normal saline for prevention
• D Prophylactic haemodialysis to remove contrast before it damages tubules

Explanation

Contrast-induced AKI prevention centres on adequate IV isotonic (0.9% NaCl) hydration, beginning before the procedure, as this is the only intervention with consistent RCT evidence for benefit. N-acetylcysteine was widely used but the PRESERVE trial (2018) showed NAC was not superior to placebo. Sodium bicarbonate was similarly shown to be non-superior to saline in the PRESERVE trial. Prophylactic dialysis does not prevent contrast nephropathy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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