BCCCP: Contrast‐Induced Nephropathy Critical Care Questions

Question 1 of 10

1. Question

A 65-year-old man with type 2 diabetes mellitus, chronic kidney disease stage 3 (baseline serum creatinine 1.8 mg/dL; eGFR 45 mL/min/1.73 m²), and sepsis requiring vasopressor support is admitted to the ICU. He undergoes an iodinated contrast–enhanced CT scan to evaluate for possible intra-abdominal infection. Given his multiple risk factors for contrast-associated acute kidney injury (CA-AKI) and the initiation of isotonic crystalloid hydration 12 hours before and continued 12 hours after contrast administration, which monitoring strategy is MOST critical for assessing prophylaxis efficacy and detecting early renal injury?

Serial serum creatinine measurements at 24, 48, and 72 hours post-contrast combined with continuous hourly urine output monitoring.
Serum creatinine measurements at 48 and 72 hours post-contrast with daily fluid balance monitoring.
Daily serum creatinine measurements for 3 days post-contrast with monitoring for peripheral edema.
Baseline and 72-hour post-contrast eGFR re-evaluation combined with twice-daily blood pressure monitoring.

Question 2 of 10

2. Question

A 72-year-old man with acute decompensated heart failure and stage 3 chronic kidney disease (baseline creatinine 1.0 mg/dL, current 1.8 mg/dL) requires urgent CT angiography with contrast to rule out pulmonary embolism. Because of volume overload, aggressive intravenous hydration is contraindicated. Which of the following statements about using high-dose ascorbic acid or theophylline for contrast-induced nephropathy (CIN) prophylaxis aligns best with current evidence and guideline recommendations?

Neither high-dose ascorbic acid nor theophylline is routinely recommended as a primary prophylactic agent when hydration is contraindicated or insufficient.
High-dose ascorbic acid is recommended as a primary alternative to hydration due to its antioxidant properties.
Theophylline is recommended to improve renal blood flow when hydration is not feasible.
Both high-dose ascorbic acid and theophylline are recommended as effective substitutes for intravenous hydration.

Question 3 of 10

3. Question

A 68-year-old man with chronic kidney disease (baseline eGFR 35 mL/min/1.73 m2), type 2 diabetes mellitus, and chronic heart failure with reduced ejection fraction weighing 70 kg (BMI 25 kg/m2) presents with acute decompensated heart failure complicated by cardiogenic shock. He is hypotensive on vasopressors and scheduled for urgent cardiac catheterization with iodinated contrast. Given his high risk for contrast-induced nephropathy (CIN), which supportive care strategy should be prioritized to minimize CIN risk while maintaining hemodynamic stability?

Administer aggressive intravenous isotonic saline at 1.5 mL/kg/hr (~105 mL/hr) for 6 hours before and 6 hours after the procedure to maximize renal perfusion.
Discontinue all nephrotoxic medications, including loop diuretics and beta-blockers, immediately before catheterization.
Provide individualized isotonic saline hydration at 0.5–1 mL/kg/hr (35–70 mL/hr) guided by hemodynamic and volume monitoring, minimize contrast volume with low- or iso-osmolar agents, and withhold only non-essential nephrotoxins.
Administer N-acetylcysteine 600 mg orally twice daily starting the day before the procedure and give a loop diuretic immediately post-procedure to promote diuresis.

Question 4 of 10

4. Question

A 68-year-old male with stage 3 chronic kidney disease (baseline serum creatinine 1.5 mg/dL) and NYHA Class III heart failure (on enalapril 10 mg daily and furosemide 40 mg daily) presents to the ICU with acute respiratory distress and pulmonary edema confirmed on chest X-ray. He weighs 70 kg. Despite his volume overload, he requires a CT pulmonary angiogram to evaluate for pulmonary embolism. Considering his risk factors, which of the following is the most appropriate strategy to prevent contrast-induced nephropathy while minimizing risks of volume overload and electrolyte disturbances?

Administer 1 L of isotonic saline over 4 hours before and after contrast administration, then monitor serum creatinine daily.
Infuse sodium bicarbonate 154 mEq/L in D5W at 3 mL/kg/h for 1 hour before contrast, then 1 mL/kg/h for 6 hours afterward, plus oral N-acetylcysteine 600 mg twice daily.
Use an iso-osmolar contrast agent at the lowest effective volume, coordinate dosing with radiology, and monitor fluid balance, serum electrolytes, and renal function closely.
Hold nephrotoxic medications (e.g., NSAIDs, ACE inhibitors) 24 hours before and 48 hours after contrast administration.

Question 5 of 10

5. Question

A 72-year-old, 80 kg man with stage 3 chronic kidney disease (baseline creatinine 1.8 mg/dL) underwent coronary angiography and received prophylactic sodium bicarbonate infusion (154 mEq/L at 3 mL/kg/hr) plus isotonic saline (0.9% NaCl at 1 mL/kg/hr) for 12 hours to prevent contrast-induced nephropathy. Twelve hours after initiation, he develops acute dyspnea, bilateral crackles, 3+ lower extremity pitting edema, and blood pressure of 165/90 mm Hg. Arterial blood gas shows pH 7.54, PaCO₂ 48 mm Hg, HCO₃⁻ 36 mEq/L. Serum K⁺ is 3.5 mEq/L, and urine output remains adequate. Considering his volume overload and metabolic alkalosis, which of the following is the MOST appropriate immediate management?

Discontinue the sodium bicarbonate infusion, administer furosemide 40 mg IV, and decrease the 0.9% sodium chloride infusion rate to 50 mL/hr.
Continue the sodium bicarbonate infusion at a reduced rate, administer potassium chloride 20 mEq IV, and maintain the current 0.9% sodium chloride infusion rate.
Administer acetazolamide 500 mg IV, discontinue the 0.9% sodium chloride infusion, and initiate continuous renal replacement therapy (CRRT).
Increase the 0.9% sodium chloride infusion rate to 200 mL/hr, administer sodium bicarbonate 50 mEq IV bolus, and monitor urine output closely.

Question 6 of 10

6. Question

A 68-year-old male (70 kg) in the ICU is on assist-control ventilation and a norepinephrine infusion at 0.1 mcg/kg/min for septic shock. He underwent a contrast-enhanced CT scan 24 hours ago; since then his serum creatinine has risen from 1.0 to 4.8 mg/dL, and his urine output is 0.3 mL/kg/hr over the past 6 hours. He has hyperkalemia (K⁺ 6.1 mEq/L) and new pulmonary edema, consistent with severe contrast-induced acute kidney injury (AKI). Nephrology is considering renal replacement therapy (RRT). As the critical care pharmacist, which action should you prioritize in the multidisciplinary discussion?

Recommend immediate initiation of continuous RRT to correct hyperkalemia and volume overload.
Order a potassium-binding resin (e.g., sodium polystyrene sulfonate) to lower serum potassium before RRT.
Recommend intravenous loop diuretic therapy (e.g., furosemide) to augment urine output and manage volume overload.
Review the medication profile for nephrotoxins, adjust or discontinue them immediately.

Question 7 of 10

7. Question

A 65-year-old man underwent a contrast-enhanced CT scan two days ago. His baseline serum creatinine was 1.0 mg/dL; it is now 3.5 mg/dL. He is anuric (<100 mL urine output in 24 hours) and has significant pulmonary and peripheral edema that has not responded to aggressive diuretic therapy. His laboratory values are: potassium 5.2 mEq/L, bicarbonate 22 mEq/L. Based on this presentation of contrast-associated acute kidney injury (CA-AKI), which of the following is the most appropriate indication for initiating renal replacement therapy?

Isolated rise in serum creatinine to 3.5 mg/dL
Anuria with refractory volume overload despite aggressive diuretics
Development of uremic pericarditis (chest pain and friction rub)
Mild hyperkalemia (serum potassium 5.2 mEq/L) without ECG changes

Question 8 of 10

8. Question

A 68-year-old man in the ICU underwent percutaneous coronary intervention requiring iodinated contrast 3 days ago. He developed contrast-associated acute kidney injury (CA-AKI), with serum creatinine peaking at 2.1 mg/dL (baseline 1.0 mg/dL). Over the past 48 hours, his creatinine has fallen to 1.5 mg/dL, and urine output remains stable at 1.2 mL/kg/hr. He has been receiving balanced isotonic crystalloid (Plasma-Lyte) at 150 mL/hr. Hemodynamics are stable (MAP 75 mmHg) without vasopressors, central venous pressure is 8 mmHg, and a passive leg-raise test indicates no further fluid responsiveness. As the critical care pharmacist during morning rounds, which of the following is the MOST appropriate next step in managing his supportive therapy to optimize renal recovery and prevent complications?

Discontinue intravenous fluids immediately to prevent potential fluid overload.
Continue the current fluid rate of 150 mL/hr for another 24 hours and reassess creatinine.
Gradually taper the IV fluid rate by 25% every 12 hours while monitoring dynamic volume status and adjust medication dosages based on the improving GFR.
Initiate a low-dose furosemide infusion to promote additional diuresis given improving renal function.

Question 9 of 10

9. Question

A 68-year-old man (weight 75 kg) with chronic kidney disease (baseline serum creatinine 1.8 mg/dL; eGFR ≈40 mL/min/1.73 m²) undergoes emergent PCI for STEMI during which he receives 150 mL of iodinated contrast. He is hemodynamically stable with no signs of volume overload. Which immediate intervention is most critical to mitigate his risk of contrast-associated acute kidney injury?

Begin intravenous isotonic saline at 1 mL/kg/hr (75 mL/hr) for 12 hours post-contrast administration.
Administer intravenous N-acetylcysteine (1200 mg twice daily for 48 hours).
Switch to an iso-osmolar contrast agent for any subsequent imaging studies.
Calculate the contrast-volume to creatinine-clearance ratio to guide future dosing.

Question 10 of 10

10. Question

A 65-year-old man is being discharged from the ICU after recovering from contrast-induced nephropathy (CIN) following coronary angiography. His serum creatinine has stabilized but remains elevated above baseline. He has a history of hypertension and type 2 diabetes mellitus. As the clinical pharmacist, which discharge plan is MOST critical for mitigating long-term renal complications and ensuring a safe transition of care?

Discontinue all NSAIDs, instruct the patient to avoid future contrast studies, encourage oral fluid intake as tolerated, and schedule outpatient renal function testing in 6 months.
Perform a thorough medication reconciliation to identify and discontinue all nephrotoxic agents, provide clear instructions to maintain oral hydration of 1.5–2 L daily, and coordinate outpatient renal function monitoring within 1–2 weeks.
Provide education on avoiding all over-the-counter and herbal medications, reinforce avoidance of future contrast exposure, share the current medication list with the primary care provider, and schedule renal function labs in 8 weeks.
Recommend acetaminophen for pain control, refer the patient to a nephrologist for follow-up in 3 months, advise against herbal supplements, and plan renal function testing 4 weeks after discharge.