Preventing CIAKI in CKD Patients: A Case Study on Risk Reduction and Management Strategies

Abstract

Contrast-induced acute kidney injury is a severe complication in patients with chronic kidney disease undergoing contrast-based imaging studies, which includes coronary angiography. This case report presents the preventive measures implemented in a 65-year-old stage 3 CKD patient who had undergone coronary angiography. The patient was protected from CIAKI by providing him with hydration before the procedure, minimizing the contrast volume, and utilizing pharmacological interventions. This study hence places much weight on the preventive efforts and personalized patient care for those at a risk that predisposes them to CIAKI.

Introduction

Contrast-induced AKI, or contrast nephropathy, is defined as acute renal damage due to the exposure of the kidneys to contrast agents commonly used in several types of diagnostic imaging and interventional procedures. It ranks among the most frequent causes of hospital-acquired AKI; it is often seen in patients with pre-existing CKD.

Patients with CKD are bound to have weak kidneys, and therefore, risk is enhanced for CIAKI. Preventive measures, therefore, play a crucial role in limiting the risk of renal impairment in such patients. This was a case study on the prevention of CIAKI among a patient with stage 3 CKD after a coronary angiography. Talk about measures taken in such a patient; hydration, pharmacological interventions, and minimizing contrast volumes.

Patient Information

• Age: 65 years

• Gender: Male

• Medical History: Chronic kidney disease (CKD) stage 3 (estimated GFR: 45 mL/min/1.73 m²), Hypertension, well controlled with medication, Type 2 diabetes mellitus, on oral hypoglycemic agents, History of coronary artery disease (CAD)

• Social History: Non-smoker, occasional alcohol use, Physically active, adheres to a low-sodium diet for hypertension management.

• Family History: Father died of heart disease at age 68. No known family history of kidney disease

Clinical Findings

Chief Complaint

• The patient presented with recurrent episodes of chest pain suggestive of angina. A coronary angiogram was recommended to assess the extent of coronary artery disease.

Physical Examination

• Blood pressure: 130/80 mmHg

• Pulse: 78 bpm, regular

• No signs of fluid overload (normal jugular venous pressure, no edema)

• Kidney function stable (baseline creatinine: 1.8 mg/dL)

Timeline

Initial Consultation

• Date: March 2024

• Event: The patient presented with chest pain, and a coronary angiogram was advised to assess the extent of coronary artery disease.

Pre-Procedure Assessment

• Date: April 2024

• Event: The nephrologist and cardiologist reviewed the patient’s CKD status.

• Action: A risk assessment for CIAKI was conducted, and preventive strategies were implemented.

Coronary Angiography

• Date: April 2024

• Event: Coronary angiogram performed with reduced contrast volume.

• Outcome: No immediate signs of kidney function deterioration post-procedure.

Follow-Up

• Date: May 2024

• Event: Kidney function tests showed stable creatinine and estimated GFR, indicating successful prevention of CIAKI.

Diagnostic Assessment

Cause of being at high risk for CIAKI: Pre-existing CKD stage 3.

Conditions that are accompanied by this include hypertension and diabetes mellitus, which share a common link with the patient being at an elevated risk of developing contrast nephropathy.

Preventive Strategies

Pre-procedural Hydration

The patient was given intravenous isotonic saline 12 hours before the procedure and continued for 12 hours after the procedure to avoid adequate hydration from putting at risk contrast-induced nephropathy.

Contrast Volume Reduction

The use of contrast during the coronary angiography was kept at a minimum. High-resolution imaging by the interventional cardiologist was ensured to minimize large doses of contrast as much as possible.

Pharmacological Interventions

N-acetylcysteine (NAC) was administered orally before and after the procedure as a possible nephroprotective agent although its efficacy is ambiguous.

Intravenous sodium bicarbonate infusion was also used because some studies hypothesize that infusion can decrease CIAKI through urine alkalinization.

Post-Procedure Monitoring

Following the procedure, serum creatinine and GFR were monitored closely for this was the main reason for early detection of CIAKI.

Follow-Up and Outcomes

Short-Term Outcome

The patient was stable post-angiogram and maintained kidney function. Serum creatinine was noted at 48 hours post-procedure and showed no rise; in fact, the creatinine remained within baseline at 1.8 mg/dL. Estimated GFR remained stable at 45 mL/min/1.73 m².

Long-Term Outcome

After a follow-up of a month, kidney function was stable. There were no symptoms of CIAKI or worsening CKD in the patient. Blood pressure and diabetes control remained good, consequently lowering the chance of further complications with the kidneys in the future.

Discussion

This case again proves the importance of preventive measures in high-risk patients undergoing contrast-based procedures. In CKD patients, CIAKI risk is increased due to decreased kidney function. As seen in this case, hydration therapy, minimization of contrast volume, and pharmacological interventions can work together to limit the chances of developing CIAKI.

Key Factors in CIAKI Prevention

Hydration Therapy

Hydration with isotonic saline remains the most evidence-based and effective strategy for the prevention of CIAKI. Hydration increases urine flow dilutes the contrast agent and promotes its excretion from the body.

Reducing Contrast Exposure

Using the minimum amount of contrast that will not impair the quality of the diagnostic procedure is critical in preventing CIAKI. Modern imaging technologies can assist in achieving this goal.

Pharmacological Measures

Although the role of NAC and sodium bicarbonate as an agent is still controversial, in this case, these interventions have been chosen for extra coverage. Further, larger randomized controlled trials are required to establish their efficacy.

Monitoring

Rapid assessment of renal function after contrast exposure always is mandatory to detect an early sign of CIAKI. In this case, the stable renal function after the procedure implied successful prevention of CIAKI.

Takeaway

This case demonstrates that patients with CKD if managed with proper preventive strategies, can be managed effectively for contrast-based procedures such as coronary angiography with minimal risk for CIAKI. The "triple play" of pre-procedure hydration, reduced contrast volume, and pharmacological interventions together went in a positive direction.

Best Practices for Preventing CIAKI

1. Hydration Therapy: Initiation of IV saline hydration at least 12 hours before the procedure.

2. Minimize Contrast Volume: Use of the lowest effective dose of contrast media.

3. Pharmacological Protection: Consider the use of agents such as NAC and sodium bicarbonate, although efficacy continues to be under investigation.

4. Close Monitoring: Assessment of kidney function frequently before and following the procedure.

Patient’s Perspective

It was rather an expression of concern, he exhibited about the various risks posed by contrast media given his existing kidney disease. He found solace in the proactive approach used by the medical team with explanations of preventive strategies. On leaving the hospital, he was glad to note no apparent worsening in his condition and resumed his usual activities without any complications set in by the situation. Again, good communication should be in place; the patient himself stressed the need for education about risk and preventive measures, and alleviation of anxiety related to the procedure.

Conclusion

The prevention of CIAKI is a significant concern in any patient with CKD who undergoes procedures based on contrast. Such evidence is consequently illustrated by this case report on the efficacy of a combined approach to prevention, which was achieved by hydration therapy, minimization of contrast volume, and certain pharmacologic interventions. Therefore, proper precautions taken before administration could significantly reduce the risks even in high-risk patients, such as in this case with CKD. Further, more effective pharmacologic agents and improved imaging modalities will be developed with further investigations, which would improve the treatment results in patients who would be diagnosed in the future.

References

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