Audit on the prevention of post-contrast acute kidney injury post contrast-enhanced CT [QSI Refs: CT-802, XR-513]
Descriptor
Audit tool to ensure all patients are accurately risk assessed prior to contrast-enhanced computerised tomography (CECT) and renal protection regimens are implemented where appropriate.
Background
Iodine-based contrast media (ICM), commonly used in contrast-enhanced computerised tomography (CECT), can lead to significant adverse drug reactions (ADRs), the most common of which is post-contrast acute kidney injury (PC-AKI).[1] Recent guidelines on the prevention of PC-AKI, including the RCR endorsed Royal Australian and New Zealand College of Radiologists’ (RANZCR) 2018 Iodinated Contrast Guidelines, includes updates to many key recommendations.[2] This audit can help ensure that local practices are based on current evidence.
The Cycle
The standard
Prior to all non-emergency CECT: [2]
- The patient should be assessed for known risk factors (kidney disease, diabetes, taking metformin).
- An up-to-date estimated glomerular filtration rate (eGFR) is required only if any risk factors are present. eGFRs are considered up-to-date as long as clinical judgement finds it unlikely that the renal function has deteriorated significantly since then.
- If eGFR <30 or <45 and there is acutely deteriorating renal function, consider renal protection (first line = pre- and post-procedural 0.9% IV saline).
- Cease metformin 48h before CECT if eGFR <30 or is unknown or have deteriorating renal function.
- Non-anuric patients (producing >100mL/day urine) on dialysis requires a consultation between their referring professional, renal physician, and/or radiologist.
- Do not offer dose reduction.
Target
100% compliance for all standards.
Assess local practice
Indicators
% of records meeting the standards.
Data items to be collected
For each record:
- Whether the patient was assessed for risk factors
- Whether an up-to-date eGFR was provided in patients with risk factors present
- If an eGFR was obtained for the CECT, whether this was appropriate (i.e. patient had risk factors)
- Was renal protection given. If yes, was this appropriate (i.e. met eGFR requirements) and was the recommended first line strategy followed
- If patient was on metformin, was this ceased in time. If yes, was this appropriate.
- If the patient was non-anuric and on dialysis, did a consultation between their referring professional, renal physician, and/or radiologist occur and have been documented in patient notes and radiology system
- Whether dose reduction was offered.
Suggested number
Retrospective review of the patient notes and radiology records of 30 each consecutive outpatients and inpatients attending for non-emergency CECT.
Suggestions for change if target not met
- Ensure the department develops a written renal protection protocol for CECT based on up-to-date guidelines (i.e. RCR endorsed RANZCR 2018 guidelines). [2]
- Implement a checklist of recommended RFs as a part of the electronic request, which when filled in will advise whether the patient requires an up-to-date eGFR prior to ICM administration.
- Engage local nephrology team.
- Engage and inform referrers from primary and secondary care about the protocol change.
References
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McDonald JS, McDonald RJ, Comin J, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology 2013;267(1):119–28. https://doi.org/10.1148/radiol.12121460.
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RANZCR. The Royal Australian and New Zealand College of Radiologists (2018) Iodinated Contrast Media Guideline 2018.
Co-authors
Magdalena Szewczyk-Bieda, Rebecca Greenhalgh, Karl Drinkwater
Submitted by
YiFan Jia