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Objective: To investigate the effect of remote ischemic preconditioning (RIPC) on contrast-induced acute kidney injury (CI-AKI) in patients with chronic total occlusion (CTO) after percutaneous coronary intervention (PCI). Methods: A total of 282 patients undergoing PCI at Zhongda Hospital Affiliated to Southeast University between June 2017 and January 2019 were prospectively enrolled. The patients were randomly divided into RIPC group ( n =142) and control group ( n =140). CI-AKI was defined as an increase in level of cystatin C (CysC)≥10% above baseline at 24 h after contrast administration. Baseline characteristics and the incidence of CI-AKI were compared between the two groups. The multivariate logistic regression analysis was further used to analyze the independent risk factors of CI-AKI. Results: There were no significant differences in age, gender, smoking, hypertension, diabetes, stroke and old myocardial infarction, coronary artery bypass graft surgery, previous PCI history and laboratory test indicators, target vessel and pathological characteristics of CTO lesions, contrast agent dosage, J-CTO (Multicenter CTO Registry in Japan) score, SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score, PCI success rate and stent number between the two groups ( P >0.05). The incidence of CI-AKI was significantly lower (18.3% vs 29.3%, P =0.036) in RIPC group than that of control group. Multivariate logistic analysis found that creatinine [odds ratio ( OR )=1.018,95% CI : 1.006-1.030, P =0.003], CysC ( OR =5.200, 95% CI :2.714-9.963, P< 0.001),contrast agent dosage ( OR =1.013,95% CI : 1.007-1.019, P< 0.001) and J-CTO score ( OR =1.834, 95% CI : 1.145-2.939, P =0.012) were independent risk factors of CI-AKI. However, RIPC was an independent protective factor of CI-AKI ( OR =0.391, 95% CI : 0.199-0.765, P =0.006). Conclusion: RIPC before contrast agent administration prevents CI-AKI in CTO patients undergoing PCI.