Trends, Burden, and Impact of Infections on Outcomes Among Patients With Alcohol-Associated Hepatitis: A Nationwide Analysis.

Dose and select GI/hepatology drugs by GFR, and treat imaging contrast as a procedure-specific decision rather than a contraindication. KDIGO 2024 Chapter 4 gives practice points, not graded recommendations. Nephrotoxin stewardship (PP 4.1.1-4.1.3): people with CKD may be more susceptible to nephrotoxic effects, always weigh benefits versus potential harms before prescribing; monitor eGFR, electrolytes and drug levels in those on medications with narrow therapeutic windows, potential adverse effects or nephrotoxicity; review and limit OTC medicines and dietary/herbal remedies. The guideline names two GI-relevant nephrotoxins in Table 31: NSAIDs (reduced prostaglandin-dependent kidney blood flow, acute interstitial nephritis, nephrotic syndrome; alternative = acetaminophen) and proton pump inhibitors (AKI and CKD via tubulointerstitial/acute interstitial nephritis; alternative = H2-receptor antagonists). On NSAIDs the guideline is deliberately conditional, not prohibitive: indiscriminate chronic OTC NSAID use is associated with higher risk of kidney failure and should be discouraged, but 'judicious NSAID use, under careful supervision of a nephrologist, may be preferred to other pain medications such as opioids.' For acute gout specifically (PP 3.14.3), low-dose colchicine or intra-articular/oral glucocorticoids are preferable to NSAIDs (colchicine dose adjustment considered at CKD G5; e.g. prednisolone 30 mg orally for 3-5 days as an alternative). Dosing (PP 4.2.1-4.2.5): consider GFR for renally cleared drugs; validated eGFRcr equations suffice for most drug dosing; use creatinine+cystatin C or measured GFR where more accuracy is needed (narrow therapeutic range, drug toxicity, unreliable eGFRcr); use non-BSA-indexed eGFR at extremes of body weight; adapt dosing when GFR or volume of distribution is not at steady state. Stewardship (PP 4.3.1-4.3.3): perform medication review periodically and at transitions of care; consider planned discontinuation of metformin, ACEi, ARBs and SGLT2i 48-72 hours before elective surgery, but note that failure to restart is itself a source of harm, so a clear documented restart plan must be communicated (PP 4.3.2). Anticoagulation (Rec 3.16.1, 1C): NOACs are recommended in preference to vitamin K antagonists for thromboprophylaxis in atrial fibrillation in CKD G1-G4; NOAC dose adjustment for GFR is required, with caution at G4-G5 (PP 3.16.2); duration of pre-procedure NOAC hold depends on procedural bleeding risk, the specific NOAC, and GFR (PP 3.16.3, Figure 44). Imaging (PP 4.4.1): image on general-population indications, with individualized risk/benefit, the guideline explicitly warns against harm from delayed, omitted or suboptimal imaging driven by fear of contrast. Iodinated contrast: assess AKI risk with validated tools for intra-arterial cardiac procedures (PP 4.4.1.1); manage intravenous contrast per radiology-society consensus statements in people with AKI or GFR <60 (CKD G3a-G5) undergoing elective investigation (PP 4.4.1.2), which the Work Group summarizes as, use low- or iso-osmolar media at the minimum diagnostic dose; withdraw nonessential potentially nephrotoxic medications (NSAIDs, diuretics, aminoglycosides, amphotericin, platins, zoledronate, methotrexate) in people with AKI or eGFR <30 for 24-48 hours before and 48 hours after contrast; at eGFR >30 without AKI metformin need not be stopped and no post-procedure GFR testing is needed, whereas with AKI or eGFR ≤30 metformin should be stopped at or before injection and not restarted for at least 48 hours and only if GFR is stable and use has been reassessed; consider withholding RAASi ≥48 hours before elective contrast-enhanced CT in at-risk people; avoid dehydration in non-dialysis people with eGFR <30 or AKI receiving IV contrast; N-acetylcysteine, ascorbic acid, furosemide, dopamine, fenoldopam and calcium channel blockers have not shown consistent benefit, and prophylactic peri-contrast hemodialysis is potentially harmful and is not recommended. Gadolinium (PP 4.4.2.1): for GFR <30 (CKD G4-G5) requiring gadolinium, preferentially offer ACR group II and III agents, greatest NSF risk is in AKI, KRT and CKD G4-G5, most unconfounded cases involved group I agents, and no case has been reported since 2012.