An audit looking at the protection of patients from post-contrast - acute kidney injury (PC-AKI) following angiographic procedures

Audit tool to ensure stable outpatients are assessed for increased risk of PC-AKI prior to angiography and are managed appropriately before and after the procedure.

Iodine-based contrast media (ICM), can lead to adverse drug reactions (ADRs), including post-contrast acute kidney injury (PC-AKI). The risk of PC-AKI varies, depending on route of administration and pre-existing risk factors. It is increased in angiographic procedures due to contrast administration through the intra-arterial route due to larger volume of injected contrast and potential for renal embolization [1]. RCR endorsed RANZR guidelines [1]  on prevention of PC-AKI.

The aims of the audit are to:

1. Raise awareness of PC-AKI
2. Ensure departments have appropriate policies to assess those at increased risk
3. Ensure departments are managing patients pre-and post procedure according to RCR endorsed RANZR guidelines

Prior to planned angiographic procedures patients should:

• Be assessed for risk factors for development of CI-AKI including: kidney disease, renal transplant, diabetes, on metformin
• If risk factors identified, up to date* renal function should be provided on the request if eGFR <30 or presence of AKI, pre and post-procedure IV hydration with 0.9% saline should be given if eGFR <45 metformin should be ceased for 48hrs after the procedure
  
  *The time elapsed between renal function testing and contrast media administration should be governed by clinical judgment based upon the likelihood that renal function has deteriorated to a clinically significant degree since the renal function was assessed

Target

• 95% compliance

Indicators: 

• The number of patients assessed for risk factors for CI-AKI

• The number of patients who had up to date renal function provided on the request

• The number of patients who had IV hydration administered appropriately

Number of patients who had metformin withheld when necessary

Data items to be collected: 

Declared on the radiology request:

• Assessment for risk factors of CI-AKI :
• Any kidney disease
• Renal Transplant
• Diabetes mellitus
• eGFR if any of the above risk factors present
  
  From patient records/case notes:
• Intravenous administration of IV fluids (0.9% saline) prior to and after procedure (from the radiology records/ case notes)
• Evidence of metformin cessation when appropriate 

Suggested number: 

Retrospective review of the patient notes and radiology records of 30 consecutive outpatients attending for an angiographic procedure.

- Introduction of patient checklist to include assessment of risk factors for CI-AKI into radiology requests

- Department policy altered to admit high risk patients for intravenous fluid administration expansion prior to and after procedure

• Diary of angiographic procedures within department
• Review of casenotes
• Time to review case notes and patientpathology records: 6 hours
• Data analysis: 4 hours

1.    RANZCR. The Royal Australian and New Zealand College of Radiologists (2018) Iodinated Contrast Media Guideline. 2018. 

A Shaw, B Smith & D Howlett. Updated by H Bailey