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Prevention of contrast-associated acute kidney injury in CKD — MSRA MCQ

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ModerateNephrologyPrevention of contrast-associated acute kidney injury in CKDMSRA

A 76-year-old man with CKD G4 is due to have a non-urgent outpatient contrast-enhanced CT abdomen to investigate iron-deficiency anaemia and weight loss. His eGFR has been stable at 27 mL/min/1.73 m² for 4 months. He is clinically euvolaemic and has had no recent acute illness. He takes ramipril 10 mg once daily for hypertension; his BP is 132/76 mmHg. He is not taking NSAIDs and is not on renal replacement therapy. Which is the most appropriate plan to reduce the risk of contrast-associated acute kidney injury?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Proceed as an outpatient after encouraging oral hydration and temporarily withholding ramipril

Explanation lettering: E = shown as B · D = shown as C · B = shown as D · C = shown as E

This man has CKD with an eGFR of 27 mL/min/1.73 m², which is below the NICE threshold associated with a small increased risk of contrast-associated acute kidney injury. For adults having intravenous iodine-based contrast, NICE recommends encouraging oral hydration before and after the procedure. NICE also advises considering temporary cessation of ACE inhibitors or ARBs in people with CKD whose eGFR is below 30 mL/min/1.73 m². In this clinically stable patient without heart failure or another compelling short-term indication to continue ramipril, temporarily withholding it is the most guideline-concordant plan. A is attractive because oral hydration is appropriate, but it misses the additional consideration to interrupt renin–angiotensin system blockade at eGFR below 30 mL/min/1.73 m². B is inappropriate because intravenous volume expansion is reserved for inpatients at particularly high risk; this is a stable outpatient receiving standard intravenous contrast. C is not indicated: CKD alone should not lead to automatic cancellation of clinically indicated non-urgent contrast imaging. E is required for people on renal replacement therapy, including transplant recipients, not for all patients with CKD G4.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — recommendations (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — recommendations 1.2.7 to 1.2.10 (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations