Chronic kidney disease (CKD) is a complex disease affecting more than 20 million individuals in the United States. Progression of CKD is associated with a number of serious complications, including increased incidence of cardiovascular disease, hyperlipidemia, anemia, and metabolic bone disease. CKD patients should be assessed for the presence of these complications and receive optimal treatment to reduce their morbidity and mortality. A multidisciplinary approach is required to accomplish this goal.

Disclosure: Nothing to report.The frequency of radiocontrast administration is dramatically increasing, with over 80 million doses delivered annually worldwide. Although recently developed radiocontrast agents are relatively safe in most patients, contrast nephropathy (CN) is still a major source of in-hospital and long-term morbidity and mortality, particularly in patients with preexisting kidney disease. Multiple protocols for CN prevention have been studied; however, strict guidelines have not been established, in part because of conflicting efficacy data for most prevention approaches. In this work, we critically review the major trials that have addressed common CN prophylaxis strategies, including type of radiocontrast media, N-acetylcysteine administration, extracellular fluid volume expansion, and hemofiltration/hemodialysis. We conclude with evidence-based recommendations for CN prevention, which emphasize concurrent NaHCO 3 infusion and N-acetylcysteine administration. These guidelines should be helpful to hospitalists, who frequently order radiocontrast studies, and could therefore have a significant impact on prevention of CN. KEYWORDS: acute kidney injury, N-acetylcysteine, NaHCO 3 , nephrotoxicity, radioiodinated contrast.Since contrast nephropathy (CN) was recognized more than 50 years ago, 1 there have been continuous efforts to chemically modify radiocontrast agents to be less nephrotoxic. Although radiocontrast media have indeed become safer, which reduces the likelihood of CN per procedure, the indications for radiocontrast administration have dramatically increased, since over 80 million doses are delivered in the world annually. 2,3 Furthermore, the number of patients with CN risks, which are mainly chronic renal insufficiency (CRI) and diabetes (Table 1), has also grown. Currently, more than 26 million people are estimated to have CRI in the United States 4 and 200 million people have diabetes worldwide. 5The combination of increased radiocontrast administration frequency and greater prevalence of at-risk patients is likely to result in continued increases in CN events. The incidence of CN varies between studies, depending on risk factors of the cohort and definition of CN, but figures have been reported to be as high as 50% in studies enriched with CRI and diabetic patients. However, a very recent study disputes such high incidence rates by demonstrating that patients receiving no radiocontrast media had a similar frequency of serum creatinine increases compared to a comparable group of historical CN patients. 6 This study emphasizes that conventional definitions of CN, eg, 25% increase in serum creatinine above baseline, may be too conservative. A retrospective study of 7586 patients showed 22% inhospital mortality in patients who developed CN vs. 1.4% in those who did not, after adjusting for comorbidities. Oneand 5-year mortality rates were also higher in the CN group (12.1% vs. 3.7% and 44.6% vs. 14.5%, respectively). 7 Another study of 1826 patients, who underwent coronary artery inte...

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