Table 4.

Recommended requisition form for contrast enhanced investigations in our department.

Name	Consent∗
Age	Baseline ( not more than 1 week old) serum creatinine (mg/dL) = eGFR calculated (mL/min/1.73 m2) = If < 45 mL/min/1.73 m2 defer CECT/IVP, take preventive measures
Sex	H/o contrast allergy, drug allergy, or allergic condition; if yes, defer Ix and preventive measures taken
Weight	(1) Preexisting renal disease	Y/N	Type of disease
Clinical indication for IVP/CECT	(2) Dehydration on history or clinical exam	Y/N
Ix required IVP/CECT study and ID	(3) H/o previous contrast (within 2 wks)	Y/N	IV or IA, type of CM
Any significant past or present medical illness	(4) H/o heart failure	Y/N	Past/present
	(5) H/o renal surgery	Y/N	Type of surgery
Hb/TLC/CRP	(6) H/o diabetes mellitus	Y/N	Recent fasting blood sugar level
	(7) H/o hypertension	Y/N	Blood pressure = mm of Hg
	(8) H/o nephrotoxic drug intake	Y/N	Type of drug
If one of the risk factors 1–4 or two of risk factors 5–8 or subnormal renal function (eGFR 46 to 90 mL/min/1.73 m2) or if volume of administered IV contrast is equal to or more than 100 mL
Repeat S creatinine after 2-3 days of Ix, postprocedural S. Creatinine level =
Postprocedural S. Creatinine raised Yes/No % increase =
If increase > 25% or is by an absolute value of 0.5 mg/dL, CIN is diagnosed; Group allotted: CIN or No CIN
If CIN present, serum creatinine is repeated weekly and refer to nephrologist if there is clinical deterioration
If not, send back to referring clinician

^∗Consent to be taken on separate form, Ix: investigation.