Contrast induced nephropathy primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

2011 ACCF/AHA/SCAI Guideline Recommendations: Pre-procedural Considerations [2]

Contrast-Induced Acute Kidney Injury

Class I

1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI.[1][2] (Level of Evidence: C)

2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.[3][4][5][6] (Level of Evidence: B)

3. In patients with chronic kidney disease (CKD) (creatinine clearance <60 mL/min), the volume of contrast media should be minimized.[7][8][9] (Level of Evidence: B)

Class III: No Benefit

1. Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced acute kidney injury.[10][11][12][13][14] (Level of Evidence: A)

Guideline Resource

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions

Prevention

Hydration with or without bicarbonate

Administration of sodium bicarbonate 3 mL/kg per hour for 1 hour before , followed by 1 mL/kg per hour for 6 hours after contrast was found superior to plain saline on one randomized controlled trial of patients with a creatinne of at least 1.1 mg/dL (97.2 µmol/L) .[15] To make the solution, the study used 154 mL of 1000 mEq/L sodium bicarbonate to 846 mL of 5% dextrose. This is approximately three 50 ml ampules of bicarbonate in 850 ml of water with 5% dextrose. This was subsequently corroborated by a multi-center randomized controlled trial, which also demonstrated that IV hydration with sodium bicarbonate was superior to 0.9% normal saline[16]. The renoprotective effects of bicarbonate are thought to be due to urinary alkalinization, which creates an environment less amenable to the formation of harmful free radicals.[4].

Alternatively, one randomized controlled trial of patients with a creatinine over 1.6 mg per deciliter (140 µmol per liter) or creatinine clearance below 60 ml per minute used 1 ml/kg of 0.45 percent saline per per hour for 6-12 hours before and after the contrast.[5]

Methylxanthines

Adenosine antagonists such as the methylxanthines theophylline and aminophylline, may help although studies have conflicting results.[17] The best studied dose is 200 mg of theophylline given IV 30 minutes before contrast administration.[18][19]

N-acetylcysteine

N-acetylcysteine (NAC) 600 mg orally twice a day, on the day before and of the procedure if creatinine clearance is estimated to be less than 60 mL/min [1.00 mL/s]) may reduce nephropathy.[20]. A randomized controlled trial found higher doses of NAC (1200-mg IV bolus and 1200 mg orally twice daily for 2 days) benefited (relative risk reduction of 74%) patients receiving coronary angioplasty with higher volumes of contrast[21].

Since publication of the meta-analyses, two small and underpowered negative studies, one of IV NAC[22] and one of 600 mg give four times around coronary angiography[23], found statistically insignificant trends towards benefit.

Some authors believe the benefit is not overwhelming.[24] The strongest results were from an unblinded randomized controlled trial that used NAC intravenously.[25] A systematic review by Clinical Evidence concluded that NAC is "likely to beneficial" but did not recommend a specific dose.[26] One study found that the apparent benefits of NAC may be due to its interference with the creatinine laboratory test itself.[27] This is supported by a lack of correlation between creatinine levels and cystatin C levels.

ACT Trial which is a randomized, placebo controlled trial randomized 2308 patients undergoing angiography with at least one risk factor for contrast induced nephropathy. Patients were randomized to receive either high dose of NAC or placebo on the day before and after the procedure. No difference was noted in rates of developing nephropathy between the two groups[14]. Therefore short-term use of NAC for the prevention of contrast induced nephropathy should be avoided[28].

In a series, 15% of patients receiving NAC intravenously had allergic reactions[25].

Prophylactic hemodialysis

Patients with chronic renal insufficiency and a creatinine over 309.4 µmol/L (3.5 mg.dl) who have elective coronary catheterization, a randomized controlled trial found benefit from prophylactic hemodialysis[29]

Other interventions

Other pharmacological agents, such as furosemide, mannitol, dopamine, and atrial natriuretic peptide have been tried, but have either not had beneficial effects, or had detrimental effects.[5][30]

REMEDIAL II Trial which is a randomized, multicenter, investigator-driven trial involving patients who are at high risk (GFR ≤30 mL · min−1 · 1.73 m−2 and/or a risk score ≥11) for contrast induced nephropathy tested the strategy of forced diuresis. These patients were randomized to receive either NAC + saline or NAC + saline + furosemide. Rates of developing nephropathy was lower among the group receiving diuretic as furosemide reduces the contrast exposure and renal reuptake while promoting accelerated elimination of contrast[31].

Choice of contrast agent

The osmolality of the contrast agent has traditionally been believed to be of great importance in contrast-induced nephropathy. Ideally, the contrast agent should be iso-osmolar to blood. Modern iodinated contrast agents are non-ionic.

  • Hypo-osmolar, non-ionic contrast agents are beneficial if iso-osmolar, nonionic contrast media is not available due to costs.[33]

References

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