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Copyright (c) 2024 Bshayer Saleh ud Alrush, Hasna mohammed Alshammari, Hend Mohammed Hakami, Ali Abdullah Ali Khobrani, Saleh Mater Alosaimi, Turki Hassan Alamri, Aziz Hamoud Sari Al-Otaibi, Norh Ahmed Ahmed Algope, Neam Albandari Abdallah Aldawsary, Tahani Mohammed Hakami, Fawaz Nawaz Alanazi, Saad Abdullah Alanazi, Mohammed Saud Saad Alsaedi
This work is licensed under a Creative Commons Attribution 4.0 International License.
Preventing Contrast-Induced Nephropathy: A Narrative Review of an Interdisciplinary Protocol Integrating Radiology, Nursing, Pharmacy, and Physiotherapy
Corresponding Author(s) : Bshayer Saleh ud Alrush
Saudi Journal of Medicine and Public Health,
Vol. 1 No. 2 (2024)
Abstract
Background: Contrast-Induced Nephropathy (CIN) is a significant iatrogenic complication following intravascular contrast media administration, associated with increased morbidity, mortality, and healthcare costs. Its prevention is a quintessential model for interdisciplinary care, requiring precise coordination beyond the radiology suite.
Aim: This narrative review aims to synthesize evidence on developing and implementing a collaborative, multi-disciplinary protocol for CIN prevention, integrating the specialized roles of radiology, nursing, pharmacy, and physiotherapy.
Methods: A systematic literature search of PubMed, EMBASE, CINAHL, and the Cochrane Library (2010-2024) was conducted. Keywords included contrast-induced nephropathy, acute kidney injury, hydration protocols, pharmacist-led medication review, interdisciplinary communication, and preventive nephrology. Included studies were systematic reviews, randomized controlled trials, observational studies, and quality improvement reports.
Results: Effective CIN prevention hinges on a systematized pathway: risk stratification guided by radiologists and informed by pharmacist-led medication reconciliation (e.g., withholding nephrotoxic agents); nurse-driven, protocol-based intravenous hydration; and physiotherapy-guided monitoring of volume status and mobility to prevent fluid overload. The integration of these roles into a single protocol significantly improves guideline adherence, reduces CIN incidence, and enhances patient safety.
Conclusion: CIN prevention is maximized not by isolated interventions but through a structured, collaborative framework. This review advocates for standardized, interdisciplinary protocols as the standard of care for at-risk patients undergoing contrast-enhanced procedures.
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- Abassi, Z., Rosen, S., Lamothe, S., & Heyman, S. N. (2019). Why have detection, understanding and management of kidney hypoxic injury lagged behind those for the heart?. Journal of Clinical Medicine, 8(2), 267. https://doi.org/10.3390/jcm8020267
- Andreucci, M., Faga, T., Riccio, E., Sabbatini, M., Pisani, A., & Michael, A. (2016). The potential use of biomarkers in predicting contrast-induced acute kidney injury. International journal of nephrology and renovascular disease, 205-221. https://doi.org/10.2147/IJNRD.S105124
- Aycock, R. D., Westafer, L. M., Boxen, J. L., Majlesi, N., Schoenfeld, E. M., & Bannuru, R. R. (2018). Acute kidney injury after computed tomography: a meta-analysis. Annals of emergency medicine, 71(1), 44-53. https://doi.org/10.1016/j.annemergmed.2017.06.041
- Davenport, M. S., Perazella, M. A., Yee, J., Dillman, J. R., Fine, D., McDonald, R. J., ... & Weinreb, J. C. (2020). Use of intravenous iodinated contrast media in patients with kidney disease: consensus statements from the American College of Radiology and the National Kidney Foundation. Radiology, 294(3), 660-668. https://doi.org/10.1148/radiol.2019192094
- Ehmann, M. R., Mitchell, J., Levin, S., Smith, A., Menez, S., Hinson, J. S., & Klein, E. Y. (2023). Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis. Intensive Care Medicine, 49(2), 205-215. https://doi.org/10.1007/s00134-022-06966-w
- Fähling, M., Seeliger, E., Patzak, A., & Persson, P. B. (2017). Understanding and preventing contrast-induced acute kidney injury. Nature Reviews Nephrology, 13(3), 169-180. https://doi.org/10.1038/nrneph.2016.196
- Franklin, B. J., Gandhi, T. K., Bates, D. W., Huancahuari, N., Morris, C. A., Pearson, M., ... & Goralnick, E. (2020). Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Quality & Safety, 29(10), 1-2. https://doi.org/10.1136/bmjqs-2019-009911
- Guo, Y., Xu, X., Xue, Y., Zhao, C., Zhang, X., & Cai, H. (2022). Mehran 2 contrast-associated acute kidney injury risk score: is it applicable to the Asian percutaneous coronary intervention population?. Clinical and Applied Thrombosis/Hemostasis, 28, 10760296221116353. https://doi.org/10.1177/10760296221116353
- Hansell, L., Milross, M., Delaney, A., Tian, D. H., & Ntoumenopoulos, G. (2021). Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review. Journal of physiotherapy, 67(1), 41-48. https://doi.org/10.1016/j.jphys.2020.12.002
- Heyman, S. N., Rosen, S., & Rosenberger, C. (2008). Renal parenchymal hypoxia, hypoxia adaptation, and the pathogenesis of radiocontrast nephropathy. Clinical Journal of the American Society of Nephrology, 3(1), 288-296. DOI: 10.2215/CJN.02600607
- Hirano, K., Kobayashi, D., Shimbo, T., & Komatsu, Y. (2023). Impact of a continuous quality improvement program on contrast-induced nephropathy in outpatients with chronic kidney disease: an interrupted time-series study. Nephrology Dialysis Transplantation, 38(5), 1249-1259. https://doi.org/10.1093/ndt/gfac268
- James, M. T., Samuel, S. M., Manning, M. A., Tonelli, M., Ghali, W. A., Faris, P., ... & Hemmelgarn, B. R. (2013). Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circulation: Cardiovascular Interventions, 6(1), 37-43. https://doi.org/10.1161/CIRCINTERVENTIONS.112.974493
- Killu, K., Coba, V., Blyden, D., Munie, S., Dereczyk, D., Kandagatla, P., & Tang, A. (2020). Sonographic assessment of intravascular fluid estimate (SAFE) score by using bedside ultrasound in the intensive care unit. Critical Care Research and Practice, 2020(1), 9719751. https://doi.org/10.1155/2020/9719751
- Kooiman, J., Sijpkens, Y. W., van Buren, M., Groeneveld, J. H. M., Ramai, S. R. S., van der Molen, A. J., ... & Huisman, M. V. (2014). Randomised trial of no hydration vs. sodium bicarbonate hydration in patients with chronic kidney disease undergoing acute computed tomography–pulmonary angiography. Journal of Thrombosis and Haemostasis, 12(10), 1658-1666. https://doi.org/10.1111/jth.12701
- LaForge, J. M., Urso, K., Day, J. M., Bourgeois, C. W., Ross, M. M., Ahmadzadeh, S., ... & Kaye, A. D. (2023). Non-steroidal anti-inflammatory drugs: clinical implications, renal impairment risks, and AKI. Advances in therapy, 40(5), 2082-2096. https://doi.org/10.1007/s12325-023-02481-6
- Lambert, P., Chaisson, K., Horton, S., Petrin, C., Marshall, E., Bowden, S., ... & Brown, J. (2017). Reducing acute kidney injury due to contrast material: how nurses can improve patient safety. Critical care nurse, 37(1), 13-26. https://doi.org/10.4037/ccn2017178
- McCullough, P. A., Choi, J. P., Feghali, G. A., Schussler, J. M., Stoler, R. M., Vallabahn, R. C., & Mehta, A. (2016). Contrast-induced acute kidney injury. Journal of the American College of Cardiology, 68(13), 1465-1473. https://doi.org/10.1016/j.jacc.2016.05.099
- Mehran, R., Dangas, G. D., & Weisbord, S. D. (2019). Contrast-associated acute kidney injury. New England Journal of Medicine, 380(22), 2146-2155. DOI: 10.1056/NEJMra1805256
- Nusca, A., Piccirillo, F., Viscusi, M. M., Giannone, S., Mangiacapra, F., Melfi, R., ... & Grigioni, F. (2022). Contrast-induced acute kidney injury in diabetic patients and SGLT-2 inhibitors: a preventive opportunity or promoting element?. Journal of Cardiovascular Pharmacology, 80(5), 661-671. DOI: 10.1097/FJC.0000000000001329
- Nyman, U., Björk, J., Bäck, S. E., Sterner, G., & Grubb, A. (2016). Estimating GFR prior to contrast medium examinations—what the radiologist needs to know!. European radiology, 26(2), 425-435. https://doi.org/10.1007/s00330-015-3842-9
- Pistolesi, V., Regolisti, G., Morabito, S., Gandolfini, I., Corrado, S., Piotti, G., & Fiaccadori, E. (2018). Contrast medium induced acute kidney injury: a narrative review. Journal of Nephrology, 31(6), 797-812. https://doi.org/10.1007/s40620-018-0498-y
- Ronco, C., Kellum, J. A., & Haase, M. (2012). Subclinical AKI is still AKI. Critical care, 16(3), 313. https://doi.org/10.1186/cc11240
- Silver, S. A., Shah, P. M., Chertow, G. M., Harel, S., Wald, R., & Harel, Z. (2015). Risk prediction models for contrast induced nephropathy: systematic review. Bmj, 351. https://doi.org/10.1136/bmj.h4395
- Sterns, R. H. (2015). Disorders of plasma sodium—causes, consequences, and correction. New England Journal of Medicine, 372(1), 55-65. DOI: 10.1056/NEJMra1404489
- Subramaniam, R. M., Suarez-Cuervo, C., Wilson, R. F., Turban, S., Zhang, A., Sherrod, C., ... & Bass, E. B. (2016). Effectiveness of prevention strategies for contrast-induced nephropathy: a systematic review and meta-analysis. Annals of internal medicine, 164(6), 406-416. https://doi.org/10.7326/M15-1456
- Takura, T., Nitta, K., Tsuchiya, K., & Kawanishi, H. (2023). Long-term effects of contrast media exposure on renal failure progression: a retrospective cohort study. BMC nephrology, 24(1), 135. https://doi.org/10.1186/s12882-023-03194-2
- Tennant, M. F. H., Perme, C., & Butcher, A. (2023). Cutting-edge physical therapy in mechanical circulatory support: critical care physical therapy perspectives. Texas Heart Institute Journal, 50(4), e238180.
- Weisbord, S. D., Gallagher, M., Jneid, H., Garcia, S., Cass, A., Thwin, S. S., ... & Palevsky, P. M. (2018). Outcomes after angiography with sodium bicarbonate and acetylcysteine. New England Journal of Medicine, 378(7), 603-614. DOI: 10.1056/NEJMoa1710933
- White, K. C., Nasser, A., Gatton, M. L., & Laupland, K. B. (2023). Current management of fluid balance in critically ill patients with acute kidney injury: a scoping review. Critical Care and Resuscitation, 25(3), 126-135. https://doi.org/10.1016/j.ccrj.2023.06.002
- Zhou, F., Lu, Y., Xu, Y., Li, J., Zhang, S., Lin, Y., & Luo, Q. (2023). Correlation between neutrophil-to-lymphocyte ratio and contrast-induced acute kidney injury and the establishment of machine-learning-based predictive models. Renal Failure, 45(2), 2258983.
References
Abassi, Z., Rosen, S., Lamothe, S., & Heyman, S. N. (2019). Why have detection, understanding and management of kidney hypoxic injury lagged behind those for the heart?. Journal of Clinical Medicine, 8(2), 267. https://doi.org/10.3390/jcm8020267
Andreucci, M., Faga, T., Riccio, E., Sabbatini, M., Pisani, A., & Michael, A. (2016). The potential use of biomarkers in predicting contrast-induced acute kidney injury. International journal of nephrology and renovascular disease, 205-221. https://doi.org/10.2147/IJNRD.S105124
Aycock, R. D., Westafer, L. M., Boxen, J. L., Majlesi, N., Schoenfeld, E. M., & Bannuru, R. R. (2018). Acute kidney injury after computed tomography: a meta-analysis. Annals of emergency medicine, 71(1), 44-53. https://doi.org/10.1016/j.annemergmed.2017.06.041
Davenport, M. S., Perazella, M. A., Yee, J., Dillman, J. R., Fine, D., McDonald, R. J., ... & Weinreb, J. C. (2020). Use of intravenous iodinated contrast media in patients with kidney disease: consensus statements from the American College of Radiology and the National Kidney Foundation. Radiology, 294(3), 660-668. https://doi.org/10.1148/radiol.2019192094
Ehmann, M. R., Mitchell, J., Levin, S., Smith, A., Menez, S., Hinson, J. S., & Klein, E. Y. (2023). Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis. Intensive Care Medicine, 49(2), 205-215. https://doi.org/10.1007/s00134-022-06966-w
Fähling, M., Seeliger, E., Patzak, A., & Persson, P. B. (2017). Understanding and preventing contrast-induced acute kidney injury. Nature Reviews Nephrology, 13(3), 169-180. https://doi.org/10.1038/nrneph.2016.196
Franklin, B. J., Gandhi, T. K., Bates, D. W., Huancahuari, N., Morris, C. A., Pearson, M., ... & Goralnick, E. (2020). Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Quality & Safety, 29(10), 1-2. https://doi.org/10.1136/bmjqs-2019-009911
Guo, Y., Xu, X., Xue, Y., Zhao, C., Zhang, X., & Cai, H. (2022). Mehran 2 contrast-associated acute kidney injury risk score: is it applicable to the Asian percutaneous coronary intervention population?. Clinical and Applied Thrombosis/Hemostasis, 28, 10760296221116353. https://doi.org/10.1177/10760296221116353
Hansell, L., Milross, M., Delaney, A., Tian, D. H., & Ntoumenopoulos, G. (2021). Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review. Journal of physiotherapy, 67(1), 41-48. https://doi.org/10.1016/j.jphys.2020.12.002
Heyman, S. N., Rosen, S., & Rosenberger, C. (2008). Renal parenchymal hypoxia, hypoxia adaptation, and the pathogenesis of radiocontrast nephropathy. Clinical Journal of the American Society of Nephrology, 3(1), 288-296. DOI: 10.2215/CJN.02600607
Hirano, K., Kobayashi, D., Shimbo, T., & Komatsu, Y. (2023). Impact of a continuous quality improvement program on contrast-induced nephropathy in outpatients with chronic kidney disease: an interrupted time-series study. Nephrology Dialysis Transplantation, 38(5), 1249-1259. https://doi.org/10.1093/ndt/gfac268
James, M. T., Samuel, S. M., Manning, M. A., Tonelli, M., Ghali, W. A., Faris, P., ... & Hemmelgarn, B. R. (2013). Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circulation: Cardiovascular Interventions, 6(1), 37-43. https://doi.org/10.1161/CIRCINTERVENTIONS.112.974493
Killu, K., Coba, V., Blyden, D., Munie, S., Dereczyk, D., Kandagatla, P., & Tang, A. (2020). Sonographic assessment of intravascular fluid estimate (SAFE) score by using bedside ultrasound in the intensive care unit. Critical Care Research and Practice, 2020(1), 9719751. https://doi.org/10.1155/2020/9719751
Kooiman, J., Sijpkens, Y. W., van Buren, M., Groeneveld, J. H. M., Ramai, S. R. S., van der Molen, A. J., ... & Huisman, M. V. (2014). Randomised trial of no hydration vs. sodium bicarbonate hydration in patients with chronic kidney disease undergoing acute computed tomography–pulmonary angiography. Journal of Thrombosis and Haemostasis, 12(10), 1658-1666. https://doi.org/10.1111/jth.12701
LaForge, J. M., Urso, K., Day, J. M., Bourgeois, C. W., Ross, M. M., Ahmadzadeh, S., ... & Kaye, A. D. (2023). Non-steroidal anti-inflammatory drugs: clinical implications, renal impairment risks, and AKI. Advances in therapy, 40(5), 2082-2096. https://doi.org/10.1007/s12325-023-02481-6
Lambert, P., Chaisson, K., Horton, S., Petrin, C., Marshall, E., Bowden, S., ... & Brown, J. (2017). Reducing acute kidney injury due to contrast material: how nurses can improve patient safety. Critical care nurse, 37(1), 13-26. https://doi.org/10.4037/ccn2017178
McCullough, P. A., Choi, J. P., Feghali, G. A., Schussler, J. M., Stoler, R. M., Vallabahn, R. C., & Mehta, A. (2016). Contrast-induced acute kidney injury. Journal of the American College of Cardiology, 68(13), 1465-1473. https://doi.org/10.1016/j.jacc.2016.05.099
Mehran, R., Dangas, G. D., & Weisbord, S. D. (2019). Contrast-associated acute kidney injury. New England Journal of Medicine, 380(22), 2146-2155. DOI: 10.1056/NEJMra1805256
Nusca, A., Piccirillo, F., Viscusi, M. M., Giannone, S., Mangiacapra, F., Melfi, R., ... & Grigioni, F. (2022). Contrast-induced acute kidney injury in diabetic patients and SGLT-2 inhibitors: a preventive opportunity or promoting element?. Journal of Cardiovascular Pharmacology, 80(5), 661-671. DOI: 10.1097/FJC.0000000000001329
Nyman, U., Björk, J., Bäck, S. E., Sterner, G., & Grubb, A. (2016). Estimating GFR prior to contrast medium examinations—what the radiologist needs to know!. European radiology, 26(2), 425-435. https://doi.org/10.1007/s00330-015-3842-9
Pistolesi, V., Regolisti, G., Morabito, S., Gandolfini, I., Corrado, S., Piotti, G., & Fiaccadori, E. (2018). Contrast medium induced acute kidney injury: a narrative review. Journal of Nephrology, 31(6), 797-812. https://doi.org/10.1007/s40620-018-0498-y
Ronco, C., Kellum, J. A., & Haase, M. (2012). Subclinical AKI is still AKI. Critical care, 16(3), 313. https://doi.org/10.1186/cc11240
Silver, S. A., Shah, P. M., Chertow, G. M., Harel, S., Wald, R., & Harel, Z. (2015). Risk prediction models for contrast induced nephropathy: systematic review. Bmj, 351. https://doi.org/10.1136/bmj.h4395
Sterns, R. H. (2015). Disorders of plasma sodium—causes, consequences, and correction. New England Journal of Medicine, 372(1), 55-65. DOI: 10.1056/NEJMra1404489
Subramaniam, R. M., Suarez-Cuervo, C., Wilson, R. F., Turban, S., Zhang, A., Sherrod, C., ... & Bass, E. B. (2016). Effectiveness of prevention strategies for contrast-induced nephropathy: a systematic review and meta-analysis. Annals of internal medicine, 164(6), 406-416. https://doi.org/10.7326/M15-1456
Takura, T., Nitta, K., Tsuchiya, K., & Kawanishi, H. (2023). Long-term effects of contrast media exposure on renal failure progression: a retrospective cohort study. BMC nephrology, 24(1), 135. https://doi.org/10.1186/s12882-023-03194-2
Tennant, M. F. H., Perme, C., & Butcher, A. (2023). Cutting-edge physical therapy in mechanical circulatory support: critical care physical therapy perspectives. Texas Heart Institute Journal, 50(4), e238180.
Weisbord, S. D., Gallagher, M., Jneid, H., Garcia, S., Cass, A., Thwin, S. S., ... & Palevsky, P. M. (2018). Outcomes after angiography with sodium bicarbonate and acetylcysteine. New England Journal of Medicine, 378(7), 603-614. DOI: 10.1056/NEJMoa1710933
White, K. C., Nasser, A., Gatton, M. L., & Laupland, K. B. (2023). Current management of fluid balance in critically ill patients with acute kidney injury: a scoping review. Critical Care and Resuscitation, 25(3), 126-135. https://doi.org/10.1016/j.ccrj.2023.06.002
Zhou, F., Lu, Y., Xu, Y., Li, J., Zhang, S., Lin, Y., & Luo, Q. (2023). Correlation between neutrophil-to-lymphocyte ratio and contrast-induced acute kidney injury and the establishment of machine-learning-based predictive models. Renal Failure, 45(2), 2258983.