Contrast Study Planned
Patient to receive iodinated contrast media
All Pathways
NephrologyRisk Assessment
Contrast-Induced AKI Prevention (ACR/NKF)
Contrast-Induced AKI Prevention (ACR/NKF): Contrast Study Planned → Assess Kidney Function → eGFR-Based Risk → Low Risk (eGFR ≥45) → Proceed with Contrast.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Assess Kidney Function
Check eGFR (within 3-6 months if stable)
- Use CKD-EPI 2021 equation
- If AKI suspected, use most recent creatinine
- Consider point-of-care creatinine if urgent
03Decision eGFR-Based Risk
Stratify CI-AKI risk by kidney function
- Low risk: eGFR ≥45 (IV) or ≥30 (IV without risk factors)
- Moderate risk: eGFR 30-44
- High risk: eGFR <30 or AKI or dialysis-dependent
04Action Low Risk (eGFR ≥45)
Minimal CI-AKI risk with IV contrast
- IV contrast: Proceed without specific prophylaxis
- Intra-arterial with renal first-pass: Consider if eGFR ≥30
- Encourage oral hydration if able
- No nephrotoxin hold needed routinely
05Action Proceed with Contrast
Implement prevention protocol
- Pre-hydration: NS 1 mL/kg/hr × 6-12h (or 3 mL/kg × 1h if urgent)
- Use iso-osmolar (iodixanol) or low-osmolar contrast
- Minimize volume (contrast/eGFR ratio <3.7)
- Post-hydration: Continue 6-12h
- Hold nephrotoxins (NSAIDs, aminoglycosides)
- Hold metformin for 48h or until Cr stable
06Action Post-Contrast Monitoring
Assess for CI-AKI development
- Recheck creatinine at 48-72h post-contrast
- CI-AKI definition: SCr rise ≥0.3 mg/dL or ≥50% within 48-72h
- Most cases self-limited, peak at 3-5 days
- Resume metformin if creatinine stable
- Nephrology follow-up if CI-AKI develops
07Outcome No CI-AKI
Creatinine stable at 48-72h
08Outcome CI-AKI Developed
Supportive care, avoid repeat contrast, nephrology if severe
09Action Moderate Risk (eGFR 30-44)
Prophylactic measures recommended
- IV hydration: 1-1.5 mL/kg/hr NS starting 3-12h pre-procedure
- Continue 6-12h post-procedure
- Use lowest contrast volume possible
- Consider iso-osmolar contrast
- Hold metformin day of procedure
10Decision Benefit vs Risk Assessment
Is contrast study essential?
- Clinical urgency of diagnosis
- Alternative imaging modalities
- Patient preference and goals of care
- Discuss with radiology
- Path rejoins step 05Shared downstream outcome
11Action Defer/Alternative Imaging
Avoid contrast if possible
- Non-contrast CT may suffice
- MRI with gadolinium (different risk profile if eGFR ≥30)
- Ultrasound
- Nuclear medicine studies
- Reassess need for contrast study
12Warning High Risk (eGFR <30 or AKI)
Significant CI-AKI risk - careful assessment
- Consider alternative imaging (non-contrast CT, MRI, US)
- If contrast essential: Nephrology consult
- Aggressive IV hydration protocol
- Minimize contrast volume (<100 mL or <4 mL/kg)
- Use iso-osmolar or low-osmolar contrast
- Consider N-acetylcysteine (evidence weak)
13Action Dialysis-Dependent
Different considerations for ESRD on HD
- Not at risk for CI-AKI (no kidney function to protect)
- Proceed with contrast if indicated
- Coordinate with dialysis schedule
- No need for emergent dialysis post-contrast
- Timing dialysis around contrast does not reduce risk
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
Guideline Source
ACR/NKF Consensus on Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- eGFR may not reflect acute kidney function
- Does not address gadolinium-based contrast
- Risk in intra-arterial administration higher than IV
- Emergency imaging may override prevention protocols
Applicable Regions
EUUSglobal
EU: ESUR guidelines align with this approach
US: ACR/NKF consensus widely adopted
Version 1Next review: 2027-01-01
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eGFR (CKD-EPI 2021)
Estimated glomerular filtration rate using CKD-EPI 2021 equation (race-free)
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Frequently Asked Questions
What is the Contrast-Induced AKI Prevention (ACR/NKF)?
The Contrast-Induced AKI Prevention (ACR/NKF) is a risk assessment clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on ACR/NKF Consensus on Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease.
What guideline is the Contrast-Induced AKI Prevention (ACR/NKF) based on?
This algorithm is based on ACR/NKF Consensus on Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease (DOI: 10.1148/radiol.2019192094).
What are the limitations of the Contrast-Induced AKI Prevention (ACR/NKF)?
Known limitations include: eGFR may not reflect acute kidney function; Does not address gadolinium-based contrast; Risk in intra-arterial administration higher than IV; Emergency imaging may override prevention protocols. Individual patient factors may require deviation from these recommendations.
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