A 70-year-old man with CKD (eGFR 18 mL/min) develops acute kidney injury after IV contrast for CT scan. Serum creatinine rises from 3.2 to 4.9 mg/dL over 48 hours. What is the most important preventive strategy to reduce contrast-induced nephropathy in high-risk CKD patients?
- A IV isotonic saline (0.9%) pre-hydration + minimising contrast volume ✓
- B N-acetylcysteine 600 mg PO twice daily for 2 days
- C Isotonic sodium bicarbonate infusion pre- and post-contrast
- D Prophylactic haemodialysis post-contrast
Correct answer: A. IV isotonic saline (0.9%) pre-hydration + minimising contrast volume
Explanation
Current evidence (PRESERVE trial, NEJM 2018) shows that intravenous isotonic sodium chloride (0.9% saline) pre- and post-procedure with use of the lowest possible contrast volume is the most effective evidence-based strategy to prevent contrast-associated nephropathy. The PRESERVE trial found no benefit of sodium bicarbonate over normal saline, and no benefit of N-acetylcysteine. Prophylactic haemodialysis does not protect renal function and may cause harm. Pre-hydration with isotonic saline at 1 mL/kg/h 6–12 hours before and after contrast remains the standard.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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