Clinical guideline for prevention of contrast-induced nephropathy (CIN) in patients undergoing cardiac catheterisation at South Manchester University Hospital, Wythenshawe

June 2004

  1. All patients should have their renal function measured and documented on the procedure request card or letter and in the notes at the time of listing for any cardiac catheterisation procedure involving contrast medium. This is the responsibility of the clinician listing the patient for the procedure.

  2. All patients should be encouraged to drink adequate fluids up to two hours prior to attending the catheter labs, and immediately following the procedure for 12 hours. This regime should be amended by the clinician for patients with severe heart failure.

  3. In all procedures, the doctor should minimise the amount of contrast used.

  4. Patients listed for elective procedures who are identified as being at high risk of CIN on the basis of a serum creatinine reading of greater than 120 mmol/l, should receive the following additional treatment:

a) Hydration therapy

Patients should be asked to drink 1 litre of clear fluids in the 12 hours before, and a further 1 litre in the 12 hours after the procedure. Two hours before the procedure patients should be commenced on intravenous normal saline at a dose of 1ml/kg/hr. Intravenous fluids should be continued until the patient is drinking normally. This hydration protocol should be amended by the supervising clinician for patients with severe heart failure.

b) Cessation of NSAIDs

Patients at high risk of CIN should be asked to stop taking any NSAIDs for 48 hours before the procedure, and should be advised to take paracetamol instead if required.

c) Non-ionic contrast medium

All high risk patients should receive the iso-osmolar contrast medium Visipaque rather than standard hyper-osmolar contrast medium Omnipaque.

d) N-acetylcysteine

All high risk patients should receive N-acetylcysteine (NAC) tablets at a dose of 1200mg twice a day on the day before and the day of the procedure.

e) Measurement of serum creatinine 3 days after the procedure

All high risk patients should attend Wythenshawe hospital or their GP practice to have renal function measured on the third day after the procedure. Patients will be issued with a letter for their GP explaining the need for the test, importance of seeing the result and action required for an abnormal result. Tests performed at Wythenshawe hospital should be done via F2/F5 and the results seen by ward staff.

Ensuring that these measures are instituted is the combined responsibility of the persons listing the patient for and performing the procedure.

Diabetic patients with a serum creatinine less than 120 mmol/l are not considered high risk. As per current recommendations, metformin should be omitted on the day of and for 48 hours post-procedure in all diabetic patients.

  1. Patients undergoing emergency procedures deemed at high risk of CIN (creatinine >120 mmol/l or creatinine unknown but history of renal disease, previous procedure within 48 hours or clinically dehydrated) should be treated similarly except:

i) an initial bolus of intravenous fluids in the form of 500mls intravenous normal saline over 1 hour should be given. This should be followed by further saline at 1ml/kg/hr until drinking normally. This hydration protocol should be amended by the supervising clinician for patients with severe heart failure.

ii) NAC should be given immediately before and 12 hours post-procedure.