Ongoing advances in catheter-based technologies for the treatment of coronary artery disease have resulted in a steady increase in the volume of percutaneous coronary interventional procedures. This trend is likely to continue well into the next decade, and may be particularly pronounced among a high-risk population of patients. These high-risk patients, whether elderly, diabetic, presenting with preexisting renal insufficiency, congestive heart failure, prior bypass surgery, or diffuse atherosclerotic disease are at increased risk of renal compromise from contrast exposure and catheter manipulations within the aorta. Enhanced physician awareness of the renal implications of percutaneous coronary interventions, in conjunction with careful patient selection, risk assessment, and evolving renal protective strategies will help to minimize the incidence of renal complications and the associated increases in morbidity, mortality, and health care costs.