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Evaluation of Safety Guidelines on the Use of Iodinated Contrast Material: Conundrum Continued
Estelle C Nijssen1, Patty J Nelemans2, Roger J Rennenberg3
1From the Departments of Radiology and Nuclear Medicine.
Insights
Patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m face higher risks of contrast-induced nephropathy (CIN) and mortality after iodinated contrast media. Prophylactic hydration shows similar complication risks in this group compared to those with eGFR 30-59 mL/min/1.73 m.
Area of Science:
- Nephrology
- Radiology
- Clinical Trials
Background:
- Updated guidelines recommend prophylaxis for estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m to prevent contrast-induced nephropathy (CIN).
- Limited data exist on CIN risk and prophylactic intravenous hydration efficacy in patients with eGFR <30 mL/min/1.73 m.
Purpose of the Study:
- To evaluate the risk of CIN and other adverse outcomes in patients with eGFR <30 mL/min/1.73 m following iodinated contrast administration.
- To assess the efficacy of prophylactic intravenous hydration in mitigating these risks.
- To determine if the benefits of hydration outweigh its potential complications in this population.
Main Methods:
- Retrospective analysis of patients with eGFR <30 mL/min/1.73 m undergoing procedures with intravascular iodinated contrast material.
- Comparison with patients prospectively enrolled in the AMACING trial (eGFR 30-59 mL/min/1.73 m with risk factors).
- Outcomes included CIN, 35-day dialysis, 35-day mortality, and complications of prophylactic intravenous hydration.
Main Results:
- Patients with eGFR <30 mL/min/1.73 m had significantly higher CIN (13.6% vs 2.7%) and 35-day mortality (9.2% vs 0.0%) compared to the AMACING cohort.
- Dialysis rates were similar (0.9% vs 0.0%).
- Complication rates for prophylactic intravenous hydration were comparable (5.9% vs 5.5%).
Conclusions:
- Postcontrast CIN and mortality are significantly elevated in patients with eGFR <30 mL/min/1.73 m, even with prophylactic hydration.
- The risk of complications from prophylactic hydration is substantial and similar across both eGFR groups.
- Further randomized trials are needed to confirm hydration efficacy versus complication risk, though feasibility may be limited.
Objectives:
Recently, safety guidelines for the use of intravascular iodinated contrast material have been updated, and the recommended threshold for giving prophylaxis to prevent contrast-induced nephropathy (CIN) has been reduced to estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m. Data on this population in the context of CIN, especially evidence for efficacy of the recommendation of prophylactic intravenous hydration, are lacking. The aim of the current study was to test implicit assumptions underlying the guideline update: (1) patients with eGFR <30 mL/min/1.73 m, as opposed to former high-risk patients with eGFR ≥30 mL/min/1.73 m, are at high risk of CIN and other unfavorable outcomes after intravascular iodinated contrast material administration; (2) prophylactic intravenous hydration mitigates this risk; and (3) the risk of administering prophylactic intravenous hydration does not outweigh the positive preventive effect.
Materials And Methods:
Retrospectively, data were collected from all patients with eGFR <30 mL/min/1.73 m referred for an elective procedure with intravascular iodinated contrast material administration and excluded from the AMACING trial (A MAastricht Contrast-Induced Nephropathy Guideline trial). We compared these patients with those prospectively included in the AMACING trial (with eGFR 30-59 mL/min/1.73 m and risk factors). Main outcomes were CIN (defined as an increase in serum creatinine by more than 25% or 44 μmol/L within 2-6 days postcontrast exposure), dialysis and mortality within 35 days postcontrast exposure, and complications of prophylactic intravenous hydration.
Results:
A total of 28,803 patients referred for an elective procedure with intravascular iodinated contrast administration were prospectively screened for inclusion in the AMACING trial. One hundred fifty-seven (0.5%) patients had eGFR <30 mL/min/1.73 m, and 155 received intravascular iodinated contrast material. Standard prophylaxis was given to 119/155 of these patients. Data on 2- to 6-day serum creatinine, 35-day dialysis 35-day mortality, and complications of prophylactic intravenous hydration were available for 59/119 (50%), 118/119 (99%), 119/119 (100%), and 119/119 (100%) standard prophylaxis patients, respectively. Incidences in eGFR <30 mL/min/1.73 m versus AMACING patients are as follows: CIN 13.6% versus 2.7% (P = 0.0019); 35-day dialysis 0.9% versus 0.0% (P = 0.2646); 35-day mortality 9.2% versus 0.0% (P < 0.0001); complications of prophylactic intravenous hydration 5.9% versus 5.5% (P = 0.8529).
Conclusions:
Postcontrast incidences of CIN and mortality at 35 days are significantly higher in the population with eGFR <30 mL/min/1.73 m than in the former high-risk population with eGFR 30 to 59 mL/min/1.73 m, even after prophylactic intravenous hydration. The risk of complications of prophylactic intravenous hydration is similar and substantial in both populations. Obtaining evidence from a randomized trial that efficacy of prophylactic intravenous hydration outweighs the risk of complications is important but may not be feasible.
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