Efficacy of N-acetylcysteine and hydration versus placebo and hydration in decreasing contrast-induced renal dysfunction in patients undergoing coronary angiography with or without concomitant percutaneous coronary intervention

The place of hydration using intravenous fluid in patients at risk of developing contrast-associated nephropathy

There has been a significant rise in the incidence of contrast-associated nephropathy caused by administration of contrast media during cardiac interventions. This is one of the major complications of percutaneous coronary interventions, which may proceed to acute renal failure. Risk factors, including pre-existing renal dysfunction, older age and use of high osmolar contrast media, predispose patients to the development of contrast-associated nephropathy. Different risk-reduction strategies have been used to prevent contrast-associated nephropathy, including use of low osmolar contrast media, N-acetylcysteine, alkalisation of tubular fluid with intravenous sodium bicarbonate, and oral and intravenous hydration with isotonic solution. Hydration using intravenous saline is one of the main treatments used to prevent the development of nephropathy in patients receiving contrast media during cardiac interventions. Prehydration, before administering contrast media, seems to be crucial. The results of studies of the relative efficacy of sodium bicarbonate and/or N-acetylcysteine in reducing the development of contrast-associated nephropathy are not consistent and any beneficial effects may depend on the pre-existing state of the kidney. This review discusses hydration of patients who are at risk of developing contrast-associated nephropathy using intravenous fluid.

Latest Clinical Evidence About Effect of Acetylcysteine on Preventing Contrast-Induced Nephropathy in Patients Undergoing Angiography: A Meta-Analysis

Contrast-induced nephropathy (CIN) is a serious complication of angiographic procedures. It is the third most common cause of hospital acquired acute renal injury. As there are currently no approved therapies for CIN, prevention could be the best strategy to address this issue. Acetylcysteine may indirectly play an antioxidant role by inducing the synthesis of glutathione. Acetylcysteine can also reduce renal vasoconstriction induced by contrast medium stimulation by stabilizing nitric oxide and acting directly or indirectly on renal cortex and medulla microcirculation. To evaluate the effect of acetylcysteine on the prevention of CIN in patients after angiography, we systematically searched and analyzed the clinical data of patients including the incidence of CIN and change in serum creatinine (SCr) at 48 hours after angiography from selected articles. The result showed that acetylcysteine significantly reduces the incidence of CIN (risk ratios: 0.78, 95% CI: 0.68-0.90, I ² = 37.3%) and the level of SCr (standardized mean difference: -0.53, 95% CI: -0.93 to -0.12, I ² = 91.5%) after angiography compared with the control group. Overall, the use of acetylcysteine in patients after angiography was associated with a significant reduction of CIN and the level of SCr.

Pharmacological interventions for the prevention of contrast-induced acute kidney injury in high-risk adult patients undergoing coronary angiography: a systematic review and meta-analysis of randomised controlled trials

Objective

Quantify the efficacy of strategies to prevent contrast-induced acute kidney injury (CI-AKI) in high-risk patients undergoing coronary angiography (CAG) with or without percutaneous coronary intervention (PCI).

Background

CI-AKI remains a common problem. The renoprotective efficacy of existing pharmacological agents remains uncertain in high-risk populations.

Methods

Systematic review and meta-analysis of randomised controlled trials (RCTs) to compare different strategies versus hydration in patients with chronic kidney disease (CKD) undergoing CAG±PCI. Primary outcome was incident CI-AKI. Fixed-effects meta-analyses estimated ORs, 95% CIs and heterogeneity.

Results

Forty-eight RCTs were included. Seven pharmacological strategies were evaluated by multiple RCTs and 10 by one RCT each. These had varying risk of bias; >25% of trials were at high risk of performance bias. Five strategies significantly reduced the odds of CI-AKI: N-acetylcysteine (NAC) (27 trials, 5694 participants; OR=0.77, 95% CI 0.65 to 0.91, p=0.002, I²=36%), ascorbic acid (four trials, 759 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.01, I²=0%), statin (two trials, 3234 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.75, I²=0%), trimetazidine (two trials, 214 participants; OR=0.27, 95% CI 0.10 to 0.71, p=0.01, I²=0%) and nicorandil (two trials, 389 participants; OR=0.47, 95% CI 0.23 to 0.94, p=0.03, I²=52%). Theophylline had a similar, but non-significant, effect. A subgroup analysis found that the benefit of NAC was highest in patients requiring a high-contrast dose.

Conclusions

Several drugs are renoprotective in patients with CKD undergoing CAG±PCI. The evidence is strongest for NAC. We recommend that NAC should be used when a high dose of contrast is anticipated.

Trial registration number

PROSPERO registration CRD42014014704.

Open Science Framework link: https://osf.io/vxg7d/?view_only=62bad0404b18405abd39ff2ead2575a8

Effectiveness of contrast-associated acute kidney injury prevention methods; a systematic review and network meta-analysis

BACKGROUND

Different methods to prevent contrast-associated acute kidney injury (CA-AKI) have been proposed in recent years. We performed a mixed treatment comparison to evaluate and rank suggested interventions.

METHODS

A comprehensive Systematic review and a Bayesian network meta-analysis of randomised controlled trials was completed. Results were tabulated and graphically represented using a network diagram; forest plots and league tables were shown to rank treatments by the surface under the cumulative ranking curve (SUCRA). A stacked bar chart rankogram was generated. We performed main analysis with 200 RCTs and three analyses according to contrast media and high or normal baseline renal profile that includes 173, 112 & 60 RCTs respectively.

RESULTS

We have included 200 trials with 42,273 patients and 44 interventions. The primary outcome was CI-AKI, defined as ≥25% relative increase or ≥ 0.5 mg/dl increase from baseline creatinine one to 5 days post contrast exposure. The top ranked interventions through different analyses were Allopurinol, Prostaglandin E1 (PGE1) & Oxygen (0.9647, 0.7809 & 0.7527 in the main analysis). Comparatively, reference treatment intravenous hydration was ranked lower but better than Placebo (0.3124 VS 0.2694 in the main analysis).

CONCLUSION

Multiple CA-AKI preventive interventions have been tested in RCTs. This network evaluates data for all the explored options. The results suggest that some options (particularly allopurinol, PGE1 & Oxygen) deserve further evaluation in a larger well-designed RCTs.

Effectiveness of N-Acetylcysteine for the Prevention of Contrast-Induced Nephropathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Conflicting results have been obtained in trials that have evaluated the prophylactic efficacy of N‐acetylcysteine (NAC) pretreatment in the prevention of contrast‐induced nephropathy (CIN). In this meta‐analysis of randomized controlled trials, we aimed to assess the effectiveness of NAC treatment for the prevention of CIN.

Methods and Results

PubMed, EMBASE, and the Cochrane Library were electronically searched from inception to January 2016 for all relevant studies. The weighted relative risk (RR) and corresponding 95% CI for incident CIN were estimated using random effects models. Standard methods for assessing statistical heterogeneity and publication bias were used. The study included 11 480 participants and 1653 cases of CIN. The incidence of CIN was 12.8% in the NAC group versus 16.0% in the control group (RR: 0.76, 95% CI: 0.66–0.88, P=0.0002). In the patients undergoing coronary angiography, the incidence of CIN in the NAC group versus the control group was 13.7% versus 17.2% (RR: 0.74, 95% CI: 0.63–0.87, P=0.0002); in those undergoing peripheral angiography, the incidence was 6.4% versus 5.8% (RR: 1.00, 95% CI: 0.42–2.40, P=1.00); in those undergoing computed tomography, the incidence was 7.7% versus 14.8% (RR: 0.51, 95% CI: 0.29–0.89, P=0.02).

Conclusions

Our meta‐analysis showed an inverse and significant association between NAC supplementation and risk of CIN in patients undergoing coronary angiography and computed tomography, while a protective role for NAC in patients undergoing peripheral angiography was not obvious.

Strategies Preventing Contrast-Induced Nephropathy After Coronary Angiography: A Comprehensive Meta-Analysis and Systematic Review of 125 Randomized Controlled Trials

This systematic review with meta-analysis sought to determine the strength of evidence for the effects of hydration (sodium bicarbonate [SB] and normal saline [NS]), supplementations ( N-acetylcysteine [NAC] and vitamin C), and some common drugs (adenosine antagonists [AAs], statins, loop diuretics, and angiotensin-converting enzyme inhibitors [ACEIs]) on the incidence of contrast-induced nephropathy (CIN) and requirement for hemodialysis after coronary angiography. After screening, a total of 125 trials that reported outcomes were identified. Pooled analysis indicated beneficial effects of SB versus NS (odds ratio [OR] = 0.73; 95% confidence interval [CI]: 0.56-0.94; P = .01), NAC (OR = 0.79; 95% CI: 0.70-0.88; P = .001), vitamin C (OR = 0.64; 95% CI: 0.45-0.89; P = .01), statins (OR = 0.45; 95% CI: 0.35-0.57; P = .001), AA (OR = 0.28; 95% CI: 0.14-0.47; P = .001), loop diuretics (OR = 0.97; 95% CI: 0.33-2.85; P = .9), and ACEI (OR = 1.06; 95% CI: 0.69-1.61; P = .8). Overall, hydration with SB, use of supplements, such as NAC and vitamin C, and administration of statins and AA should always be considered for the prevention of CIN after coronary angiography.

N-acetylcysteine for the prevention of contrast-induced nephropathy in patients with pre-existing renal insufficiency or diabetes: a systematic review and meta-analysis

PURPOSE

To identify benefit of N-acetylcysteine (NAC) on patients with pre-existing renal insufficiency or diabetes.

BACKGROUND

NAC administration is a common method for prevention of contrast-induced nephropathy (CIN). Nevertheless, its benefit on patients with pre-existing renal insufficiency or diabetes remains uncertain and controversial.

METHODS

Randomized controlled trials (RCTs) to evaluate the efficacy of NAC for the prevention of CIN in patients with pre-existing renal insufficiency or diabetes were searched from the databases of MEDLINE, EMBASE, and Cochrane library. Pooled odds ratio (OR) with 95% confidence interval (95% CI) were calculated using fixed-effects model by the Mantel-Haenszel test.

RESULTS

Twenty RCTs involving 3466 subjects (1756 assigned to NAC and 1710 assigned to the control) were included in the pre-existing renal dysfunction group. Pooled analysis suggested a significant reduction in CIN among this group (OR, 0.76; 95% CI, 0.61-0.93; p = 0.008). However, the nine trials comparing NAC versus control among patients with diabetes (NAC, 367 subjects; control, 358 subjects) showed no benefit of NAC for prevention of CIN (OR = 0.87; 95% CI, 0.58-1.30; p = 0.50). No significant heterogeneity was detected (p = 0.07; I2 = 34% for the group of pre-existing renal dysfunction; p = 0.40; I2 = 5% for the group of diabetes).

CONCLUSION

Our results suggest that NAC decreases the incidence of contrast-induced nephropathy among patients with pre-existing renal insufficiency. The benefit was not existed in patients with diabetes.

Neutrophil Gelatinase-Associated Lipocalin as an Early Marker of Contrast-Induced Nephropathy After Coronary Angiography

We investigated whether serum neutrophil gelatinase-associated lipocalin (NGAL) was an early predictive biomarker of contrast-induced nephropathy (CIN) in patients with chronic kidney disease (n = 100) undergoing coronary catheterization. Serum creatinine (SCr) levels were measured at baseline, 24 hours, and 48 hours post procedure. Serum NGAL was measured preprocedure, 4 hours, and 24 hours post procedure. The frequency of CIN was 11%. In patients with CIN, SCr achieved significance only at 48 hours ( P = .006), whereas serum NGAL increased ≥25% from baseline at 24 hours in 7 of 11 patients with CIN ( P = .04) but did not change in the other 4. However, serum NGAL also rose ≥25% in 12 of 89 non-CIN patients. This subgroup could have had “incipient CIN.” Serum NGAL delta value at baseline, 24 hours was superior to SCr for early diagnosis of CIN. In conclusion, serum NGAL is an early predictive biomarker for CIN.

Effect of preoperative N-acetylcysteine on postoperative blood loss parameters in cardiac surgery patients

Purpose. To determine if recent preoperative exposure to n-acetylcysteine (NAC), Mucomyst, increases postoperative blood loss in cardiac surgery patients. Methods. Retrospective review of cardiac surgery patients who underwent a cardiac catheterization within four days of surgery and whose serum creatinine was ≥1.0 mg/dL. The study groups were those who received NAC in the pericatheterization period versus those who did not. The primary endpoint was postoperative chest tube output at 24, 48, and 72 hours. Secondary endpoints included number of transfusions and other bleeding parameters. Results. Mean blood loss in the first 24 hours was 962 ± 595 mL in the treatment group (n = 79) and 1,178 ± 788 mL in the control group (n = 106), P = .040. Blood loss between groups at 48 (366 ± 318 mL versus 412 ± 363 mL, P = .382) and 72 (194 ± 300 mL versus 176 ± 224 mL, P = .643) hours was not significantly different. There were no significant differences in postoperative transfusions or other bleeding parameters. Conclusions. Preoperative exposure to NAC did not increase postoperative blood loss or negatively affect other bleeding parameters.

N-acetylcysteine does not prevent contrast-induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease: a randomized clinical trial

Background

Patients with diabetes mellitus (DM) and chronic kidney disease (CKD) constitute to be a high-risk population for the development of contrast-induced nephropathy (CIN), in which the incidence of CIN is estimated to be as high as 50%. We performed this trial to assess the efficacy of N-acetylcysteine (NAC) in the prevention of this complication.

Methods

In a prospective, double-blind, placebo controlled, randomized clinical trial, we studied 90 patients undergoing elective diagnostic coronary angiography with DM and CKD (serum creatinine ≥ 1.5 mg/dL for men and ≥ 1.4 mg/dL for women). The patients were randomly assigned to receive either oral NAC (600 mg BID, starting 24 h before the procedure) or placebo, in adjunct to hydration. Serum creatinine was measured prior to and 48 h after coronary angiography. The primary end-point was the occurrence of CIN, defined as an increase in serum creatinine ≥ 0.5 mg/dL (44.2 μmol/L) or ≥ 25% above baseline at 48 h after exposure to contrast medium.

Results

Complete data on the outcomes were available on 87 patients, 45 of whom had received NAC. There were no significant differences between the NAC and placebo groups in baseline characteristics, amount of hydration, or type and volume of contrast used, except in gender (male/female, 20/25 and 34/11, respectively; P = 0.005) and the use of statins (62.2% and 37.8%, respectively; P = 0.034). CIN occurred in 5 out of 45 (11.1%) patients in the NAC group and 6 out of 42 (14.3%) patients in the placebo group (P = 0.656).

Conclusion

There was no detectable benefit for the prophylactic administration of oral NAC over an aggressive hydration protocol in patients with DM and CKD.

Trial registration

NCT00808795

Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution

BACKGROUND

In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography.

METHODS

Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality).

RESULTS

During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced.

CONCLUSIONS

Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.