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Fluid administration strategies for the prevention of contrast-associated acute kidney injury. Curr Opin Nephrol Hypertens 2022; 31:414-424. [PMID: 35894275 DOI: 10.1097/mnh.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The known timing of contrast media exposure in patients identified as high-risk for contrast-associated acute kidney injury (CA-AKI) enables the use of strategies to prevent this complication of intravascular contrast media exposure. Although multiple preventive strategies have been proposed, periprocedural fluid administration remains as the primary preventive strategy. This is a critical review of the current evidence evaluating a variety of fluid administration strategies in CA-AKI. RECENT FINDINGS Fluid administration strategies to prevent CA-AKI include comparisons of intravenous (i.v.) to no fluid administration, different fluid solutions, duration of fluid administration, oral hydration, left ventricular end diastolic-pressure guided fluid administration and forced diuresis techniques. SUMMARY Despite an abundance of fluid administration trials, it is difficult to make definitive recommendations about preventive fluid administration strategies due to low scientific quality of published studies. The literature supports use of i.v. compared with no fluid administration, especially in high-risk patients undergoing intra-arterial contrast media exposure. Use of isotonic saline is recommended over 0.45% saline or isotonic sodium bicarbonate. Logistical considerations support shortened over longer i.v. fluid administration strategies, despite an absence of evidence of equivalent efficacy. Current literature does not support oral hydration for high-risk patients. The use of tailored fluid administration in heart failure patients and forced diuresis with matching fluid administration are promising new fluid administration strategies.
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Kendrick J, Chonchol M, You Z, Jovanovich A. Lower serum bicarbonate is associated with an increased risk of acute kidney injury. J Nephrol 2020; 34:433-439. [PMID: 32436182 DOI: 10.1007/s40620-020-00747-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lower serum bicarbonate levels are associated with an increased risk of kidney disease progression. Whether lower serum bicarbonate levels are associated with an increased risk of developing acute kidney injury (AKI) is unclear. METHODS We included 8393 patients from the Systolic Blood Pressure Intervention Trial (SPRINT) that had baseline serum bicarbonate levels and complete data available. AKI was a predetermined adjudicated adverse event that was determined by hospital admission and discharge records with AKI as a recorded diagnosis. Serum bicarbonate was examined in clinically significant cutoffs ≤ 24, 25-28 and > 28 mEq/L, with 25-28 mEq/L as the reference group. Cox proportional hazard models were used to examine the association between serum bicarbonate and development of AKI. RESULTS The mean (SD) age, estimated glomerular filtration rate (eGFR), and serum bicarbonate level at baseline were 68 (9) years, 77 (23) ml/min/1.73m2 and 26.3 (2.6) mEq/L, respectively. Participants with serum bicarbonate levels ≤ 24 mEq/L were more likely to be male and to have lower baseline eGFR. After a median follow-up time of 3.3 years, 293 participants developed AKI. More patients in the lower bicarbonate group developed AKI (6.1% vs 2.8% in the 25-28 mEq/L and 2.1% in the > 28 mEq/L). A bicarbonate level ≤ 24 mEq/L was associated with a significantly increased risk of AKI compared to those with a bicarbonate level of 25-28 mEq/L after full adjustment (HR 1.42, 95% CI 1.1-1.8). CONCLUSION Lower serum bicarbonate levels are an independent risk factor for the development of AKI.
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Affiliation(s)
- Jessica Kendrick
- Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA. .,Division of Renal Diseases and Hypertension, University of Colorado Denver, 12700 E. 19th Ave, C281, Aurora, CO, 80045, USA.
| | - Michel Chonchol
- Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Zhiying You
- Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Anna Jovanovich
- Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA.,VA Eastern Colorado Healthcare System, Aurora, CO, USA
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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[Vitamin C+sodium bicarbonate versus sodium bicarbonate alone in preventing contrast-induced nephropathy]. Ann Cardiol Angeiol (Paris) 2017; 66:190-196. [PMID: 28551197 DOI: 10.1016/j.ancard.2017.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/26/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Contrast-induced nephropathy (CIN) is a common and severe complication in interventional cardiology. OBJECTIVE The aim of our study was to compare the incidence of contrast-induced nephropathy in two accelerated hydration protocols: the first one by the serum bicarbonate and the second combining the serum bicarbonate and oral vitamin C. METHODS This is a multicenter prospective, randomized study conducted between October 2012 and May 2013, including 160 patients. RESULTS The mean age of our study population was 60.8±9.3 years (36-83 years). The two study groups were comparable in terms of cardiovascular risk factors, concomitant medication, and baseline serum creatinine. The CIN incidence was 6.3% in the vitamin C group and 10% in the control group (P=0.38). No significant difference was observed in terms of CIN incidence between the different subgroups analyzed. CONCLUSION According to our study, ascorbic acid administered orally as part of an accelerated hydration protocol does not reduce the incidence of CIN.
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Park JT. Postoperative acute kidney injury. Korean J Anesthesiol 2017; 70:258-266. [PMID: 28580076 PMCID: PMC5453887 DOI: 10.4097/kjae.2017.70.3.258] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 01/07/2023] Open
Abstract
Acute kidney injury (AKI) after cardiac surgery is a common and serious complication. Several definitions of AKI have been proposed recently, and include both increases in serum creatinine levels and decreases in urine output as diagnostic criteria. The pathophysiology of postoperative AKI is complex and involves both ischemic injury and systemic inflammation. Identifying risk factors, such as old age, underlying diabetes, heart failure, and obesity, may aid in the application of preventative methods for postoperative AKI. Additionally, recognizing different risks after different types of surgical procedures would be valuable. Novel biomarkers that could detect AKI more precisely at an earlier time point are being investigated. Several new biomarkers have been assessed in large multi-center studies and are believed to accommodate conventional clinical findings in diagnosing postoperative AKI. In high-risk patients, preventative measures, such as the maintenance of adequate hemodynamics and sufficient fluid resuscitation, could lower the incidence of postoperative AKI. Avoiding nephrotoxic agents and optimizing preoperative hemoglobin levels to avoid excessive transfusions would also be beneficial. In situations in which medical management fails to maintain sufficient urine output and acid-base and electrolyte homeostasis, early initiation of renal replacement therapy should be considered.
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Affiliation(s)
- Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Korea
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Cho JS, Soh S, Shim JK, Kang S, Choi H, Kwak YL. Effect of perioperative sodium bicarbonate administration on renal function following cardiac surgery for infective endocarditis: a randomized, placebo-controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:3. [PMID: 28057030 PMCID: PMC5217446 DOI: 10.1186/s13054-016-1591-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/12/2016] [Indexed: 12/18/2022]
Abstract
Background Patients with infective endocarditis (IE) have an elevated risk of renal dysfunction because of extensive systemic inflammation and use of nephrotoxic antibiotics. In this randomized, placebo-controlled trial, we investigated whether perioperative sodium bicarbonate administration could attenuate postoperative renal dysfunction in patients with IE undergoing cardiac surgery. Methods Seventy patients randomly received sodium chloride (n = 35) or sodium bicarbonate (n = 35). Sodium bicarbonate was administered as a 0.5 mmol/kg loading dose for 1 h commencing with anesthetic induction, followed by a 0.15 mmol/kg/h infusion for 23 h. The primary outcome was peak serum creatinine (SCr) level during the first 48 h postoperatively. The incidence of acute kidney injury, SCr level, estimated glomerular filtration rate, and major morbidity endpoints were assessed postoperatively. Results The peak SCr during the first 48 h postoperatively (bicarbonate vs. control: 1.01 (0.74, 1.37) mg/dl vs. 0.88 (0.76, 1.27) mg/dl, P = 0.474) and the incidence of acute kidney injury (bicarbonate vs. control: 29% vs. 23%, P = 0.584) were similar in both groups. The postoperative increase in SCr above baseline was greater in the bicarbonate group than in the control group on postoperative day 2 (0.21 (0.07, 0.33) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.028) and postoperative day 5 (0.23 (0.08, 0.36) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.017). Conclusions Perioperative sodium bicarbonate administration had no favorable impact on postoperative renal function and outcomes in patients with IE undergoing cardiac surgery. Instead, it was associated with possibly harmful renal effects, illustrated by a greater increase in SCr postoperatively, compared to control. Trial registration ClinicalTrials.gov, NCT01920126. Registered on 31 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1591-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jin Sun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sanghwa Kang
- Department of Anesthesiology and Pain Medicine, National Health Insurance Corporation Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Haegi Choi
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea. .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Soh S, Song JW, Shim JK, Kim JH, Kwak YL. Sodium bicarbonate does not prevent postoperative acute kidney injury after off-pump coronary revascularization: a double-blinded randomized controlled trial. Br J Anaesth 2016; 117:450-457. [PMID: 28077531 DOI: 10.1093/bja/aew256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common morbidity after off-pump coronary revascularization. We investigated whether perioperative administration of sodium bicarbonate, which might reduce renal injury by alleviating oxidative stress in renal tubules, prevents postoperative AKI in off-pump coronary revascularization patients having renal risk factors. METHODS Patients (n=162) having at least one of the following AKI risk factors were enrolled: (i) age >70 yr; (ii) diabetes mellitus; (iii) chronic renal disease; (iv) congestive heart failure or left ventricular ejection fraction <35%; and (v) reoperation or emergency. Patients were evenly randomized to receive either sodium bicarbonate (0.5 mmol kg-1 for 1 h upon induction of anaesthesia followed by 0.15 mmol kg-1 h-1 for 23 h) or 0.9% saline. Acute kidney injury within 48 h after surgery was assessed using the Acute Kidney Injury Network criteria. RESULTS The incidences of AKI were 21 and 26% in the bicarbonate and control groups, respectively (P=0.458). Serially measured serum creatinine concentrations and perioperative fluid balance were also comparable between the groups. The length of postoperative hospitalization and incidence of morbidity end points were similar between the groups, whereas significantly more patients in the bicarbonate group required prolonged mechanical ventilation (>24 h) relative to the control group (20 vs 6, P=0.003). CONCLUSIONS Perioperative sodium bicarbonate administration did not decrease the incidence of AKI after off-pump coronary revascularization in high-risk patients and might even be associated with a need for prolonged ventilatory care. CLINICAL TRIAL REGISTRATION NCT01840241.
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Affiliation(s)
- S Soh
- Department of Anaesthesiology and Pain Medicine and
| | - J W Song
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - J K Shim
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - J H Kim
- Department of Anaesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang City, Gyeonggi-do 410-719, Republic of Korea
| | - Y L Kwak
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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Jung SY, Park JT, Kwon YE, Kim HW, Ryu GW, Lee SA, Park S, Jhee JH, Oh HJ, Han SH, Yoo TH, Kang SW. Preoperative Low Serum Bicarbonate Levels Predict Acute Kidney Injury After Cardiac Surgery. Medicine (Baltimore) 2016; 95:e3216. [PMID: 27043687 PMCID: PMC4998548 DOI: 10.1097/md.0000000000003216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Acute kidney injury (AKI) after cardiac surgery is a common and serious complication. Although lower than normal serum bicarbonate levels are known to be associated with consecutive renal function deterioration in patients with chronic kidney injury, it is not well-known whether preoperative low serum bicarbonate levels are associated with the development of AKI in patients who undergo cardiac surgery. Therefore, the clinical implication of preoperative serum bicarbonate levels on AKI occurrence after cardiac surgery was investigated. Patients who underwent coronary artery bypass or valve surgery at Yonsei University Health System from January 2013 to December 2014 were enrolled. The patients were divided into 3 groups based on preoperative serum bicarbonate levels, which represented group 1 (below normal levels) <23 mEq/L; group 2 (normal levels) 23 to 24 mEq/L; and group 3 (elevated levels) >24 mEq/L. The primary outcome was the predicated incidence of AKI 48 hours after cardiac surgery. AKI was defined according to Acute Kidney Injury Network criteria. Among 875 patients, 228 (26.1%) developed AKI within 48 hours after cardiac surgery. The incidence of AKI was higher in group 1 (40.9%) than in group 2 (26.5%) and group 3 (19.5%) (P < 0.001). In addition, the duration of postoperative stay in a hospital intensive care unit (ICU) was longer for AKI patients and for those in the low-preoperative-serum-bicarbonate-level groups. A multivariate logistic regression analysis showed that low preoperative serum bicarbonate levels were significantly associated with AKI even after adjustment for age, sex, hypertension, diabetes mellitus, operation type, preoperative hemoglobin, and estimated glomerular filtration rate. In conclusion, low serum bicarbonate levels were associated with higher incidence of AKI and prolonged ICU stay. Further studies are needed to clarify whether strict correction of bicarbonate levels close to normal limits may have a protective role in preventing further AKI development.
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Affiliation(s)
- Su-Young Jung
- From the Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Brain Korea 21 PLUS, Yonsei University, Seoul, South Korea
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de Caestecker M, Humphreys BD, Liu KD, Fissell WH, Cerda J, Nolin TD, Askenazi D, Mour G, Harrell FE, Pullen N, Okusa MD, Faubel S. Bridging Translation by Improving Preclinical Study Design in AKI. J Am Soc Nephrol 2015; 26:2905-16. [PMID: 26538634 DOI: 10.1681/asn.2015070832] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Despite extensive research, no therapeutic interventions have been shown to prevent AKI, accelerate recovery of AKI, or reduce progression of AKI to CKD in patients. This failure in translation has led investigators to speculate that the animal models being used do not predict therapeutic responses in humans. Although this issue continues to be debated, an important concern that has not been addressed is whether improvements in preclinical study design can be identified that might also increase the likelihood of translating basic AKI research into clinical practice using the current models. In this review, we have taken an evidence-based approach to identify common weaknesses in study design and reporting in preclinical AKI research that may contribute to the poor translatability of the findings. We focused on use of N-acetylcysteine or sodium bicarbonate for the prevention of contrast-induced AKI and use of erythropoietin for the prevention of AKI, two therapeutic approaches that have been extensively studied in clinical trials. On the basis of our findings, we identified five areas for improvement in preclinical study design and reporting. These suggested and preliminary guidelines may help improve the quality of preclinical research for AKI drug development.
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Affiliation(s)
- Mark de Caestecker
- Division of Nephology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Ben D Humphreys
- Division of Renal Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Kathleen D Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - William H Fissell
- Division of Nephology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jorge Cerda
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | - Thomas D Nolin
- Renal-Electrolyte Division, Department of Medicine and Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama, Birmingham, Alabama
| | - Girish Mour
- Renal-Electrolyte Division, Department of Medicine and Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nick Pullen
- Pfizer Global Research and Development, Inflammation & Immunology Research Unit, Cambridge, Massachusetts
| | - Mark D Okusa
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California; Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Sarah Faubel
- Renal Division, University of Colorado Denver and Denver Veterans Affairs Medical Center, Aurora, Colorado
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Kim JH, Kim HJ, Kim JY, sik Ahn H, Ahn IM, Choe WJ, Lim CH. Meta-Analysis of Sodium Bicarbonate Therapy for Prevention of Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2015; 29:1248-56. [DOI: 10.1053/j.jvca.2015.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Indexed: 12/25/2022]
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Current status of sodium bicarbonate in coronary angiography: an updated comprehensive meta-analysis and systematic review. Cardiol Res Pract 2015; 2015:690308. [PMID: 25973282 PMCID: PMC4417980 DOI: 10.1155/2015/690308] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/25/2015] [Indexed: 11/18/2022] Open
Abstract
This systematic review with meta-analysis sought to determine comparison of efficacy and safety of hydration with sodium bicarbonate versus sodium chloride on contrast induced nephropathy and clinical outcomes. We searched major electronic databases for studies in randomized controlled trials. A value of P < 0.1 for Q test or I2 > 50% indicated significant heterogeneity between the studies. Literature search of all databases retrieved 650 studies. 29 studies enrolled in meta-analysis. Pooled analysis indicated about the incidence of CIN (OR of 0.718; 95% CI: 0.60 to 0.85; P = 0.000), requirement of hemodialysis (OR of 1.00; 95% CI: 0.49 to 2.01; P = 0.9), mean changes of serum creatinine (WMD of 2.321; 95% CI: 1.995 to 2.648; P = 0.000), length of hospital stays (WMD of −0.774; 95% CI: −1.65 to 0.10; P = 0.08), major adverse cardiovascular events (OR = 1.075, 95% CI: 0.59 to 1.95; P = 0.8), and mortality (OR of 0.73; 95% CI: 0.42 to 1.26; P = 0.2). Overall, hydration with sodium bicarbonate could significantly reduce CIN and the length of hospital stay compared to sodium chloride. In addition NAC added as a supplement to sodium bicarbonate could increase prophylactic effects against nephropathy.
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Zhang B, Liang L, Chen W, Liang C, Zhang S. The efficacy of sodium bicarbonate in preventing contrast-induced nephropathy in patients with pre-existing renal insufficiency: a meta-analysis. BMJ Open 2015; 5:e006989. [PMID: 25783425 PMCID: PMC4368906 DOI: 10.1136/bmjopen-2014-006989] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The aim of this meta-analysis was to explore the efficacy of sodium bicarbonate in preventing contrast-induced nephropathy (CIN). METHODS We searched PubMed, Medline and the Cochrane Library from 1 January 2004 to 1 August 2014. The effect estimate was expressed as a pooled OR with 95% CI, using the fixed-effects or random-effects model. RESULTS 20 randomised controlled trials (n=4280) were identified. Hydration with sodium bicarbonate was associated with a significant decrease in CIN among patients with pre-existing renal insufficiency (OR 0.67, 95% CI 0.47 to 0.96; p=0.027). However, moderate heterogeneity was noted across trials (I(2)=48%; p=0.008). Subgroup analyses indicated a better effect of sodium bicarbonate in studies using low-osmolar (OR 0.59, 95% CI 0.37 to 0.93; p=0.024) compared with iso-osmolar contrast agents (OR 0.76, 95% CI 0.43 to 1.34; p=0.351). The odds of CIN with sodium bicarbonate were lower in studies including only patients undergoing emergency (OR 0.16, 95% CI 0.05 to 0.51; p=0.002) compared with elective procedures (OR 0.76, 95% CI 0.54 to 1.06; p=0.105). Sodium bicarbonate was more beneficial in patients given a bolus injection before procedures (OR 0.15, 95% CI 0.04 to 0.54; p=0.004) compared with continuous infusion (OR 0.75, 95% CI 0.53 to 1.05; p=0.091). Sodium bicarbonate plus N-acetylcysteine (OR 0.17, 95% CI 0.04 to 0.79; p=0.024) was better than sodium bicarbonate alone (OR 0.71, 95% CI 0.48 to 1.03; p=0.071). The effect of sodium bicarbonate was considered greater in papers published before (OR 0.19, 95% CI 0.09 to 0.41; p=0.000) compared with after 2008 (OR 0.85, 95% CI 0.62 to 1.16; p=0.302). However, no significant differences were found in mortality (OR 0.69, 95% CI 0.36 to 1.32; p=0.263) or requirement for dialysis (OR 1.08, 95% CI 0.52 to 2.25; p=0.841). CONCLUSIONS Sodium bicarbonate is effective in preventing CIN among patients with pre-existing renal insufficiency. However, it fails to lower the risks of dialysis and mortality and therefore cannot improve the clinical prognosis of patients with CIN.
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Affiliation(s)
- Bin Zhang
- Department of Radiology, Guangdong Academy of Medical Sciences/Guangdong General Hospital, Graduate College, Guangzhou, Guangdong Province, China
- Southern Medical University, Guangzhou, Guangdong Province, China
| | - Long Liang
- Department of Radiology, Guangdong Academy of Medical Sciences/Guangdong General Hospital, Graduate College, Guangzhou, Guangdong Province, China
- Southern Medical University, Guangzhou, Guangdong Province, China
| | - Wenbo Chen
- Department of Radiology, Guangdong Academy of Medical Sciences/Guangdong General Hospital, Graduate College, Guangzhou, Guangdong Province, China
| | - Changhong Liang
- Department of Radiology, Guangdong Academy of Medical Sciences/Guangdong General Hospital, Graduate College, Guangzhou, Guangdong Province, China
| | - Shuixing Zhang
- Department of Radiology, Guangdong Academy of Medical Sciences/Guangdong General Hospital, Graduate College, Guangzhou, Guangdong Province, China
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Abstract
Abstract
Background:
The effect of urinary alkalinization in cardiac surgery patients at risk of acute kidney injury (AKI) is controversial and trial findings conflicting. Accordingly, the authors performed a prospectively planned individual patient data meta-analysis of the double-blind randomized trials in this field.
Methods:
The authors studied 877 patients from three double-blind, randomized controlled trials enrolled to receive either 24 h of intravenous infusion of sodium bicarbonate or sodium chloride. The primary outcome measure was a postoperative increase in serum creatinine concentration of greater than 25% or 0.5 mg/dl (> 44 μm/L) within the first five postoperative days. Secondary outcomes included the raw change in serum creatinine, greater than 50% and greater than 100% rises in serum creatinine, developing AKI (Acute Kidney Injury Network criteria), initiation of renal replacement therapy, morbidity, and mortality.
Results:
Patients were similar in demographics, comorbidities, and cardiac procedures. Sodium bicarbonate increased plasma bicarbonate (P < 0.001) and urine pH (P < 0.001). There were no differences in the development of the primary outcome (Bicarbonate 45% [39–51%] vs. Saline 42% [36–48%], P = 0.29). This result remained unchanged when controlling for study and covariates (odds ratio [OR], 99% confidence interval [CI]: Bicarbonate vs. Control, 1.11 [0.77–1.60], P = 0.45). There was, however, a significant study-adjusted benefit in elective coronary artery bypass surgery patients in terms of renal replacement therapy (Bicarbonate vs. Control, OR: 0.38 [99% CI: 0.25–0.58], P < 0.0001) and the development of an Acute Kidney Injury Network grade = 3 (Bicarbonate vs. Control, OR: 0.45 [99% CI: 0.43–0.48], P < 0.0001).
Conclusions:
Urinary alkalinization using sodium bicarbonate infusion is not associated with an overall lower incidence of AKI; however, it reduces severe AKI and need for renal replacement therapy in elective coronary artery bypass patients.
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Yang JQ, Ran P, Chen JY, He YT, Li LW, Tan N, Li G, Sun S, Liu Y, Zhan JX, Zheng JY, Zhou YL. Development of contrast-induced acute kidney injury after elective contrast media exposure in patients with type 2 diabetes mellitus: effect of albuminuria. PLoS One 2014; 9:e106454. [PMID: 25192238 PMCID: PMC4156370 DOI: 10.1371/journal.pone.0106454] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 08/07/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The influence of albuminuria and urinary pH on the development of contrast-induced acute kidney disease (CI-AKI) in patients with type 2 diabetes mellitus (T2DM) after elective coronary angiography (CAG) or percutaneous coronary intervention (PCI) is unknown. METHODS CI-AKI was defined as an increase in serum creatinine >26.4 µmol/L or ≥50% of baseline value within 48 hours after contrast media exposure. Demographics, traditional risk factors, clinical outcomes and CI-AKI incidence were compared between groups. Univariate analysis and multivariate logistic regression were performed to assess risk factors of CI-AKI. RESULTS We observed 597 patients with T2DM after CAG or PCI. Patients were divided into 3 groups based on early morning urinary albumin: negative group (urine dipstick negative, n = 483), trace group (urine dipstick trace, n = 60), and positive group (urine dipstick ≥1+, n = 54). CI-AKI occurred in 33 (5.5%) patients, including 19 (3.9%) in the negativealbuminuria group, 4 (6.7%) in the trace group, and 10 (18.5%) in the positive group (p< 0.001), respectively. After adjusting for potential confounding risk factors, positive albuminuria (OR = 3.8, 95% CI: 1.5 to 9.2, p = 0.004) and urinary pH<6 (OR = 2.4, 95% CI: 1.1 to 5.1, p = 0.020) remained significantly associated with CI-AKI. CONCLUSION Preprocedural albuminuria and urinary pH <6 are independent risk factors of CI-AKI in patients with T2DM undergoing elective cardiac catheterization, and may be used to identify patients at high risk of post-procedural CI-AKI.
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Affiliation(s)
- Jun-qing Yang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Peng Ran
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ji-yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- * E-mail: (JYC); (YLZ)
| | - Yi-ting He
- Department of Cardiology, Shunde first hospital, Foshan, Guangdong, China
| | - Li-wen Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Guang Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Shuo Sun
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yong Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jia-xin Zhan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jian-yi Zheng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ying-ling Zhou
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- * E-mail: (JYC); (YLZ)
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Schiffl H. Sodium bicarbonate infusion for prevention of acute kidney injury: No evidence for superior benefit, but risk for harm? Int Urol Nephrol 2014; 47:321-6. [DOI: 10.1007/s11255-014-0820-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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16
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Turner KR, Fisher EC, Hade EM, Houle TT, Rocco MV. The role of perioperative sodium bicarbonate infusion affecting renal function after cardiothoracic surgery. Front Pharmacol 2014; 5:127. [PMID: 24917818 PMCID: PMC4040918 DOI: 10.3389/fphar.2014.00127] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 05/12/2014] [Indexed: 01/11/2023] Open
Abstract
Cardiac surgery associated acute kidney injury (CSA-AKI) is associated with poor outcomes including increased mortality, length of hospital stay (LOS) and cost. The incidence of acute kidney injury (AKI) is reported to be between 3 and 30% depending on the definition of AKI. We designed a multicenter randomized controlled trial to test our hypothesis that a perioperative infusion of sodium bicarbonate (SB) during cardiac surgery will attenuate the post-operative rise in creatinine indicating renal injury when compared to a perioperative infusion with normal saline. An interim analysis was performed after data was available on the first 120 participants. A similar number of patients in the two treatment groups developed AKI, defined as an increase in serum creatinine the first 48 h after surgery of 0.3 mg/dl or more. Specifically 14 patients (24%) who received sodium chloride (SC) and 17 patients (27%) who received SB were observed to develop AKI post-surgery, resulting in a relative risk of AKI of 1.1 (95% CI: 0.6–2.1, chi-square p-value = 0.68) for patients receiving SB compared to those who received SC. The data safety monitoring board for the trial recommended closing the study early as there was only a 12% probability that the null hypothesis would be rejected. We therefore concluded that a perioperative infusion of SB failed to attenuate the risk of CSA-AKI.
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Affiliation(s)
- Katja R Turner
- Department of Anesthesiology, Wexner Medical Center at the Ohio State University Columbus, OH, USA
| | | | - Erinn M Hade
- Center for Biostatistics, The Ohio State University Columbus, OH, USA
| | - Timothy T Houle
- Department of Anesthesia, Wake Forest School of Medicine Winston-Salem, NC, USA
| | - Michael V Rocco
- Section on Nephrology, Department of Medicine, Wake Forest School of Medicine Winston-Salem, NC, USA
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Sodium Bicarbonate Infusion to Reduce Cardiac Surgery–Associated Acute Kidney Injury. Crit Care Med 2013; 41:1599-607. [DOI: 10.1097/ccm.0b013e31828a3f99] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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18
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Tehrani S, Laing C, Yellon DM, Hausenloy DJ. Contrast-induced acute kidney injury following PCI. Eur J Clin Invest 2013; 43:483-90. [PMID: 23441924 DOI: 10.1111/eci.12061] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/03/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coronary revascularization using percutaneous coronary intervention (PCI) is one of the major treatments for patients with stable coronary artery disease, with approximately 1.5 million patients undergoing PCI in the United States and Europe every year. An important neglected complication of PCI is contrast-induced acute kidney injury (CI-AKI). DESIGN In this article, we review the definition, pathogenesis and management of CI-AKI and highlight potential therapeutic options for preventing CI-AKI in post-PCI patients. RESULTS CI-AKI is an important but underdiagnosed complication of PCI that is associated with increased in-hospital morbidity and mortality. Patients with pre-existing renal impairment and diabetes are particularly susceptible to this complication post-PCI. Optimization of the patients' circulating volume remains the mainstay for preventing CI-AKI, although the best strategy for achieving this is still controversial. CONCLUSION Following PCI, CI-AKI is an overlooked complication which is associated with significant morbidity and mortality. In this article, we review the pathophysiology of CI-AKI in patients undergoing PCI and discuss the potential therapeutic options for preventing it.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, University College London, London, UK
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19
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Hougardy JM, De Backer D. Sodium bicarbonate to prevent cardiac surgery-associated kidney injury: the end of a dream? Crit Care 2012; 16:186. [PMID: 23234469 PMCID: PMC3672585 DOI: 10.1186/cc11837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The rationale of urine alkalinization through intravenous sodium bicarbonate to prevent cardiac surgery-associated acute kidney injury relies on several pathophysiological arguments. Urine alkalinization is easily feasible in the ICU setting and is often considered to be associated with few side effects. In a previous issue of Critical Care, a retrospective study evaluates the effect of routine intravenous bicarbonate use to prevent cardiac surgery-associated acute kidney injury with cardiopulmonary bypass. This commentary discusses recent data on the use of bicarbonate to prevent cardiac surgery-associated acute kidney injury.
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Affiliation(s)
- Jean-Michel Hougardy
- Department of Nephrology and Erasme University Hospital, Université Libre de Bruxelles, B-1070 Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, B-1070 Brussels, Belgium
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20
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Etezadi F, Pourfakhr P, Mojtahedzade M, Najafi A, Moharari RS, Yarandi KK, Khajavi MR. Effects of tight versus non tight control of metabolic acidosis on early renal function after kidney transplantation. ACTA ACUST UNITED AC 2012; 20:36. [PMID: 23351673 PMCID: PMC3555784 DOI: 10.1186/2008-2231-20-36] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 08/29/2012] [Indexed: 11/12/2022]
Abstract
Background Recently, several studies have been conducted to determine the optimal strategy for intra-operative fluid replacement therapy in renal transplantation surgery. Since infusion of sodium bicarbonate as a buffer seems to be safer than other buffer compounds (lactate, gluconate, acetate)that indirectly convert into it within the liver, We hypothesized tight control of metabolic acidosis by infusion of sodium bicarbonate may improve early post-operative renal function in renal transplant recipients. Methods 120 patients were randomly divided into two equal groups. In group A, bicarbonate was infused intra-operatively according to Base Excess (BE) measurements to achieve the normal values of BE (−5 to +5 mEq/L). In group B, infusion of bicarbonate was allowed only in case of severe metabolic acidosis (BE ≤ −15 mEq/L or bicarbonate ≤ 10 mEq/L or PH ≤ 7.15). Minute ventilation was adjusted to keep PaCO2 within the normal range. Primary end-point was sampling of serum creatinine level in first, second, third and seventh post-operative days for statistical comparison between groups. Secondary objectives were comparison of cumulative urine volumes in the first 24 h of post-operative period and serum BUN levels which were obtained in first, second, third and seventh post-operative days. Results In group A, all of consecutive serum creatinine levels were significantly lower in comparison with group B. With regard to secondary outcomes, no significant difference between groups was observed. Conclusion Intra-operative tight control of metabolic acidosis by infusion of Sodium Bicarbonate in renal transplant recipients may improve early post-operative renal function.
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Affiliation(s)
- Farhad Etezadi
- Sina Hospital, Tehran University of Medical Sciences, Hassan Abad sq, Tehran, Iran.
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21
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Hung YM, Lin SL, Hung SY, Huang WC, Wang PYP. Preventing radiocontrast-induced nephropathy in chronic kidney disease patients undergoing coronary angiography. World J Cardiol 2012; 4:157-72. [PMID: 22655164 PMCID: PMC3364502 DOI: 10.4330/wjc.v4.i5.157] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 03/16/2012] [Accepted: 03/23/2012] [Indexed: 02/06/2023] Open
Abstract
Radiocontrast-induced nephropathy (RCIN) is an acute and severe complication after coronary angiography, particularly for patients with pre-existing chronic kidney disease (CKD). It has been associated with both short- and long-term adverse outcomes, including the need for renal replacement therapy, increased length of hospital stay, major cardiac adverse events, and mortality. RCIN is generally defined as an increase in serum creatinine concentration of 0.5 mg/dL or 25% above baseline within 48 h after contrast administration. There is no effective therapy once injury has occurred, therefore, prevention is the cornerstone for all patients at risk for acute kidney injury (AKI). There is a small but growing body of evidence that prevention of AKI is associated with a reduction in later adverse outcomes. The optimal strategy for preventing RCIN has not yet been established. This review discusses the principal risk factors for RCIN, evaluates and summarizes the evidence for RCIN prophylaxis, and proposes recommendations for preventing RCIN in CKD patients undergoing coronary angiography.
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Affiliation(s)
- Yao-Min Hung
- Yao-Min Hung, Division of Nephrology, Jiannren Hospital, Kaohsiung 813, Taiwan, China
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22
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Hafiz AM, Jan MF, Mori N, Shaikh F, Wallach J, Bajwa T, Allaqaband S. Prevention of contrast-induced acute kidney injury in patients with stable chronic renal disease undergoing elective percutaneous coronary and peripheral interventions: Randomized comparison of two preventive strategies. Catheter Cardiovasc Interv 2011; 79:929-37. [DOI: 10.1002/ccd.23148] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/02/2011] [Accepted: 03/19/2011] [Indexed: 01/05/2023]
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de Bie MK, van Rees JB, Herzog CA, Rabelink TJ, Schalij MJ, Jukema JW. How to reduce the incidence of contrast induced acute kidney injury after cardiac invasive procedures, a review and practical recommendations. Curr Med Res Opin 2011; 27:1347-57. [PMID: 21561396 DOI: 10.1185/03007995.2011.580732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Contrast induced acute kidney injury is an important complication after cardiac (invasive) procedures and is associated with substantial morbidity and mortality. The aim of the current article is to provide a comprehensive overview of the current knowledge regarding contrast induced acute kidney injury. METHODS Current literature was reviewed and relevant articles were selected. Articles were identified through MEDLINE and Pubmed selecting articles, limited between 1980 and 2010. RESULTS The pathophysiological process resulting in contrast induced acute kidney injury is not completely understood, nevertheless several mechanisms involved have been proposed. However, the risk factors for contrast induced acute kidney injury and its timing are well known, making it amenable for preventive strategies. In the past decade various preventive strategies have been investigated with different results. CONCLUSIONS Currently, only adequate hydration, with saline, is uniformly accepted as a beneficial prophylactic strategy. Furthermore promising results have also been reported for several other prophylactic strategies. These results, however, need to be confirmed in future trials.
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Affiliation(s)
- Mihály K de Bie
- Department of Cardiology, Leiden University Medical Center, the Netherlands
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Motohiro M, Kamihata H, Tsujimoto S, Seno T, Manabe K, Isono T, Sutani Y, Yuasa F, Iwasaka T. A new protocol using sodium bicarbonate for the prevention of contrast-induced nephropathy in patients undergoing coronary angiography. Am J Cardiol 2011; 107:1604-8. [PMID: 21420053 DOI: 10.1016/j.amjcard.2011.01.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/22/2011] [Accepted: 01/22/2011] [Indexed: 11/26/2022]
Abstract
Contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality rates. Although a previous study reported that pretreatment with sodium bicarbonate is more effective than sodium chloride for prophylaxis of CIN, this has not been a universal finding. We performed a prospective randomized trial to investigate whether CIN can be avoided using sodium bicarbonate. In total 155 patients with a glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) who were undergoing coronary angiography were enrolled. We assigned patients to sodium chloride plus sodium bicarbonate (bicarbonate group, n = 78) or sodium chloride alone (chloride group, n = 77). Infusion of sodium bicarbonate at 1 ml/kg/hour continued from 3 hours before to 6 hours after coronary angiography. CIN was defined as a 25% increase in serum creatinine from baseline value or an absolute increase of ≥0.5 mg/dl, which appeared within 2 days of contrast. Baseline GFR was not significantly different between the 2 groups. Patients in the bicarbonate group had a higher GFR than those in the chloride group on day 2 (45.8 ± 13.4 vs 40.9 ± 14.6 ml/min/1.73 m(2), p = 0.031) and at 1 month (49.5 ± 14.7 vs 43.7 ± 15.5 ml/min/1.73 m(2), p = 0.019). CIN occurred in 10 patients (13%) in the chloride group but in only 2 patients (2.6%) in the bicarbonate group (p = 0.012). Sodium chloride plus sodium bicarbonate is more effective than sodium chloride alone for prophylaxis of CIN and can lead to retention of better long-term renal function.
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25
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Ueda H, Yamada T, Masuda M, Okuyama Y, Morita T, Furukawa Y, Koji T, Iwasaki Y, Okada T, Kawasaki M, Kuramoto Y, Naito T, Fujimoto T, Komuro I, Fukunami M. Prevention of contrast-induced nephropathy by bolus injection of sodium bicarbonate in patients with chronic kidney disease undergoing emergent coronary procedures. Am J Cardiol 2011; 107:1163-7. [PMID: 21349483 DOI: 10.1016/j.amjcard.2010.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 12/10/2010] [Accepted: 12/10/2010] [Indexed: 01/14/2023]
Abstract
We conducted a prospective study to determine whether a bolus injection of sodium bicarbonate before emergent coronary procedures in patients with chronic kidney disease (CKD) might prevent contrast-induced nephropathy (CIN). We enrolled 59 patients with CKD, defined by a serum creatinine concentration of >1.1 mg/dl or an estimated glomerular filtration rate of <60 ml/min, who were scheduled at admission to undergo an emergent coronary procedure. The patients were randomized to receive a bolus intravenous injection of 154 mEq/L of sodium bicarbonate (n = 30) or sodium chloride (n = 29) at the dose of 0.5 ml/kg, before contrast administration, followed by infusion of 154 mEq/L sodium bicarbonate at 1 ml/kg/hour for 6 hours in both groups. The primary end point was the occurrence of CIN, defined as an increase by > 25% or > 0.5 mg/dl of the serum creatinine level within 2 days after the procedure. In the sodium bicarbonate group, the serum creatinine concentration remained unchanged within 2 days of contrast administration (from 1.32 ± 0.46 to 1.38 ± 0.60 mg/dl, p = 0.33). In contrast, it had increased in the sodium chloride group (1.51 ± 0.59 to 1.91 ± 1.19 mg/dl, p = 0.006). The incidence of CIN was significantly lower in the sodium bicarbonate group than in the sodium chloride group (3.3% vs 27.6%, p = 0.01). In conclusion, rapid alkalization by bolus injection of sodium bicarbonate was effective for the prevention of CIN in patients with CKD undergoing emergent procedures.
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26
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Abstract
Experimental findings in vitro and in vivo illustrate enhanced hypoxia and the formation of reactive oxygen species (ROS) within the kidney following the administration of iodinated contrast media, which may play a role in the development of contrast media-induced nephropathy. Clinical studies indeed support this possibility, suggesting a protective effect of ROS scavenging or reduced ROS formation with the administration of N-acetyl cysteine and bicarbonate infusion, respectively. Furthermore, most risk factors, predisposing to contrast-induced nephropathy are prone to enhanced renal parenchymal hypoxia and ROS formation. In this review, the association of renal hypoxia and ROS-mediated injury is outlined. Generated during contrast-induced renal parenchymal hypoxia, ROS may exert direct tubular and vascular endothelial injury and might further intensify renal parenchymal hypoxia by virtue of endothelial dysfunction and dysregulation of tubular transport. Preventive strategies conceivably should include inhibition of ROS generation or ROS scavenging.
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27
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Haase M, Bellomo R, Haase-Fielitz A. Novel Biomarkers, Oxidative Stress, and the Role of Labile Iron Toxicity in Cardiopulmonary Bypass-Associated Acute Kidney Injury. J Am Coll Cardiol 2010; 55:2024-33. [DOI: 10.1016/j.jacc.2009.12.046] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/30/2009] [Accepted: 12/07/2009] [Indexed: 12/15/2022]
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Sodium bicarbonate plus N-acetylcysteine prophylaxis: a meta-analysis. JACC Cardiovasc Interv 2010; 2:1116-24. [PMID: 19926054 DOI: 10.1016/j.jcin.2009.07.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 07/25/2009] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We sought to conduct a meta-analysis to compare N-acetylcysteine (NAC) in combination with sodium bicarbonate (NaHCO(3)) for the prevention of contrast-induced acute kidney injury (AKI). BACKGROUND Contrast-induced AKI is a serious consequence of cardiac catheterizations and percutaneous coronary interventions (PCI). Despite recent supporting evidence for combination therapy, not enough has been done to prevent the occurrence of contrast-induced AKI prophylactically. METHODS Published randomized controlled trial data were collected from OVID/PubMed, Web of Science, and conference abstracts. The outcome of interest was contrast-induced AKI, defined as a >or=25% or >or=0.5 mg/dl increase in serum creatinine from baseline. Secondary outcome was renal failure requiring dialysis. RESULTS Ten randomized controlled trials met our criteria. Combination treatment of NAC with intravenous NaHCO(3) reduced contrast-induced AKI by 35% (relative risk: 0.65; 95% confidence interval: 0.40 to 1.05). However, the combination of N-acetylcysteine plus NaHCO(3) did not significantly reduce renal failure requiring dialysis (relative risk: 0.47; 95% confidence interval: 0.16 to 1.41). CONCLUSIONS Combination prophylaxis with NAC and NaHCO(3) substantially reduced the occurrence of contrast-induced AKI overall but not dialysis-dependent renal failure. Combination prophylaxis should be incorporated for all high-risk patients (emergent cases or patients with chronic kidney disease) and should be strongly considered for all interventional radio-contrast procedures.
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29
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Kunadian V, Zaman A, Spyridopoulos I, Qiu W. Sodium bicarbonate for the prevention of contrast induced nephropathy: a meta-analysis of published clinical trials. Eur J Radiol 2010; 79:48-55. [PMID: 20074886 DOI: 10.1016/j.ejrad.2009.12.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Revised: 12/11/2009] [Accepted: 12/11/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND Contrast induced nephropathy (CIN) is a serious but rare complication following contrast based procedures. Sodium bicarbonate (NaHCO(3)) has been postulated to prevent CIN by various mechanisms. However, the outcomes following sodium bicarbonate administration to prevent CIN have been inconsistent. METHODS A meta-analysis of published randomized clinical trials to determine if the administration of sodium bicarbonate is superior to sodium chloride among patients with chronic renal failure undergoing catheterization and interventional procedures in preventing CIN was performed. RESULTS Data were combined across seven published clinical trials consisting of 1734 patients. There were no significant differences in the baseline characteristics between the NaHCO(3) and NaCl groups except patients in the bicarbonate group were heavier (P=0.04). The odds ratio (OR) for the development of contrast nephropathy for NaHCO(3) versus NaCl was 0.33 (95% confidence interval [CI] 0.16-0.69; P=0.003). Heterogeneity and publication bias were detectable with P-values 0.01 and 0.0005 respectively. There was no difference between the NaHCO(3) group and the NaCl group in the occurrence of death [OR 0.6; 95% CI (0.26-1.41); P=0.24], congestive heart failure [OR 0.85; 95% CI (0.32-2.24); P=0.74] and the requirement for renal replacement therapy [OR 0.56; 95% CI (0.22-1.41); P=0.22]. CONCLUSION This meta-analysis demonstrates that based on currently available randomized trials, the administration of NaHCO(3) is superior to the administration of NaCl alone in the prevention of CIN among patients with moderate to severe chronic kidney disease. However, further controlled clinical trials are needed due to significant study heterogeneity and publication bias.
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Affiliation(s)
- Vijayalakshmi Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals, NHS Foundation Trust/Newcastle University, Newcastle upon Tyne, United Kingdom.
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Abu Jawdeh BG, Kanso AA, Schelling JR. Evidence-based approach for prevention of radiocontrast-induced nephropathy. J Hosp Med 2009; 4:500-6. [PMID: 19824094 DOI: 10.1002/jhm.477] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The frequency of radiocontrast administration is dramatically increasing, with over 80 million doses delivered annually worldwide. Although recently developed radiocontrast agents are relatively safe in most patients, contrast nephropathy (CN) is still a major source of in-hospital and long-term morbidity and mortality, particularly in patients with preexisting kidney disease. Multiple protocols for CN prevention have been studied; however, strict guidelines have not been established, in part because of conflicting efficacy data for most prevention approaches. In this work, we critically review the major trials that have addressed common CN prophylaxis strategies, including type of radiocontrast media, N-acetylcysteine administration, extracellular fluid volume expansion, and hemofiltration/hemodialysis. We conclude with evidence-based recommendations for CN prevention, which emphasize concurrent NaHCO3 infusion and N-acetylcysteine administration. These guidelines should be helpful to hospitalists, who frequently order radiocontrast studies, and could therefore have a significant impact on prevention of CN.
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Affiliation(s)
- Bassam G Abu Jawdeh
- Department of Medicine, Case Western Reserve University School of Medicine, Rammelkamp Center for Research, Cleveland, Ohio 44109-1998, USA.
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Tamura A, Goto Y, Miyamoto K, Naono S, Kawano Y, Kotoku M, Watanabe T, Kadota J. Efficacy of single-bolus administration of sodium bicarbonate to prevent contrast-induced nephropathy in patients with mild renal insufficiency undergoing an elective coronary procedure. Am J Cardiol 2009; 104:921-5. [PMID: 19766757 DOI: 10.1016/j.amjcard.2009.05.034] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 05/10/2009] [Accepted: 05/10/2009] [Indexed: 01/12/2023]
Abstract
We sought to clarify whether a single-bolus intravenous administration of sodium bicarbonate in addition to hydration with sodium chloride prevents contrast-induced nephropathy (CIN). One hundred forty-four patients with mild renal insufficiency (serum creatinine >1.1 to <2.0 mg/dl) undergoing an elective coronary procedure were randomly assigned to the following 2 groups: standard hydration with sodium chloride plus single-bolus intravenous administration of sodium bicarbonate (20 mEq) immediately before contrast exposure (group A, n = 72) and standard hydration alone (group B, n = 72). The primary end point was development of CIN, defined as an increase >25% or >0.5 mg/dl in serum creatinine within 3 days after the procedure. Incidence of the primary end point was lower in group A than in group B (1.4% vs 12.5%, p = 0.017). Incidence of adverse clinical events (acute pulmonary edema, acute renal failure requiring dialysis, and death within 7 days of procedure) did not differ between the 2 groups (0% vs 1.4%). In conclusion, single-bolus intravenous administration of sodium bicarbonate in addition to standard hydration can more effectively prevent CIN than standard hydration alone in patients with mild renal insufficiency undergoing an elective coronary procedure.
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Affiliation(s)
- Akira Tamura
- Internal Medicine 2, Oita University, Yufu, Japan.
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Meier P, Ko DT, Tamura A, Tamhane U, Gurm HS. Sodium bicarbonate-based hydration prevents contrast-induced nephropathy: a meta-analysis. BMC Med 2009; 7:23. [PMID: 19439062 PMCID: PMC2693108 DOI: 10.1186/1741-7015-7-23] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 05/13/2009] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Contrast-induced nephropathy is the leading cause of in-hospital acute renal failure. This side effect of contrast agents leads to increased morbidity, mortality, and health costs. Ensuring adequate hydration prior to contrast exposure is highly effective at preventing this complication, although the optimal hydration strategy to prevent contrast-induced nephropathy still remains an unresolved issue. Former meta-analyses and several recent studies have shown conflicting results regarding the protective effect of sodium bicarbonate. The objective of this study was to assess the effectiveness of normal saline versus sodium bicarbonate for prevention of contrast-induced nephropathy. METHODS The study searched MEDLINE, EMBASE, Cochrane databases, International Pharmaceutical Abstracts database, ISI Web of Science (until 15 December 2008), and conference proceedings for randomized controlled trials that compared normal saline with sodium bicarbonate-based hydration regimen regarding contrast-induced nephropathy. Random-effects models were used to calculate summary odds ratios. RESULTS A total of 17 trials including 2,633 subjects were pooled. Pre-procedural hydration with sodium bicarbonate was associated with a significant decrease in the rate of contrast-induced nephropathy (odds ratios 0.52; 95% confidence interval 0.34-0.80, P = 0.003). Number needed to treat to prevent one case of contrast-induced nephropathy was 16 (95% confidence interval 10-34). No significant differences in the rates of post-procedure hemodialysis (P = 0.20) or death (P = 0.53) was observed. CONCLUSION Sodium bicarbonate-based hydration was found to be superior to normal saline in prevention of contrast-induced nephropathy in this updated meta-analysis.
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Affiliation(s)
- Pascal Meier
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
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Navaneethan SD, Singh S, Appasamy S, Wing RE, Sehgal AR. Sodium Bicarbonate Therapy for Prevention of Contrast-Induced Nephropathy: A Systematic Review and Meta-analysis. Am J Kidney Dis 2009; 53:617-27. [PMID: 19027212 DOI: 10.1053/j.ajkd.2008.08.033] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 08/27/2008] [Indexed: 02/05/2023]
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Prevention of contrast media-induced nephropathy by isotonic sodium bicarbonate: a meta-analysis. Wien Klin Wochenschr 2009; 120:742-8. [PMID: 19122985 DOI: 10.1007/s00508-008-1117-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2008] [Indexed: 01/07/2023]
Abstract
BACKGROUND The clinical value of hydration therapy using sodium bicarbonate in the prevention of contrast media-induced nephropathy is subject of controversy. OBJECTIVE This meta-analysis of randomized clinical trials was performed to determine whether hydration therapy using sodium bicarbonate consistently differs from control hydration regimens with normal saline in its preventive effects upon radiocontrast media-induced renal dysfunction. METHODS Randomized clinical trials comparing sodium bicarbonate with a control regimen for prevention of contrast media-induced nephropathy were selected by multiple methods, including computer searches of bibliographic databases, perusal of reference lists, and manual searching. Major findings were qualitatively summarized. In addition, a quantitative meta-analysis was performed on renal dysfunction data. RESULTS Altogether, 9 randomized clinical trials with a total of 2,043 patients were included. The pooled odds ratio was 0.45 (confidence interval, 0.26-0.79), indicating a significant treatment benefit of sodium bicarbonate compared to normal saline. Heterogeneity was detectable (p=0.016) and evidence of publication bias was present (p=0.012). After adjustment for presumed unpublished trials after trim-and-fill analysis, the estimated pooled odds ratio was 0.65 (confidence interval, 0.36-1.20). CONCLUSION This meta-analysis confirms that, based on currently available randomized trials, bicarbonate therapy is effective in preventing contrast media-induced nephropathy. However, study heterogeneity and publication bias are substantial, and therefore further controlled clinical trials are needed.
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Sodium bicarbonate to prevent increases in serum creatinine after cardiac surgery: a pilot double-blind, randomized controlled trial. Crit Care Med 2009; 37:39-47. [PMID: 19112278 DOI: 10.1097/ccm.0b013e318193216f] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To test whether perioperative sodium bicarbonate infusion can attenuate postoperative increases in serum creatinine in cardiac surgical patients. DESIGN Double-blind, randomized controlled trial. SETTING Operating rooms and intensive care unit at a tertiary hospital. PATIENTS Cohort of 100 cardiac surgical patients at increased risk of postoperative acute renal dysfunction. INTERVENTION Patients were randomized to either 24 hrs of intravenous infusion of sodium bicarbonate (4 mmol/kg) or sodium chloride (4 mmol/kg). MEASUREMENTS AND MAIN RESULTS The primary outcome measure was the proportion of patients developing acute renal dysfunction defined as a postoperative increase in plasma creatinine concentration >25% of baseline within the first five postoperative days. Secondary outcomes included changes in plasma creatinine, plasma urea, urinary neutrophil gelatinase-associated lipocalin, and urinary neutrophil gelatinase-associated lipocalin/urinary creatinine ratio. Patients were well balanced for baseline characteristics. Sodium bicarbonate infusion increased plasma bicarbonate concentration (p < 0.001), base excess (p < 0.001), plasma pH (p < 0.001), and urine pH (p < 0.001). Fewer patients in the sodium bicarbonate group (16 of 50) developed a postoperative increase in serum creatinine compared with control (26 of 50) (odds ratio 0.43 [95% confidence interval 0.19-0.98]), (p = 0.043). The increase in plasma creatinine, plasma urea, urinary neutrophil gelatinase-associated lipocalin, and urinary neutrophil gelatinase-associated lipocalin/urinary creatinine ratio was less in patients receiving sodium bicarbonate, (p = 0.014; p = 0.047; p = 0.009; p = 0.004). There were no significant side effects. CONCLUSIONS Sodium bicarbonate loading and continuous infusion was associated with a lower incidence of acute renal dysfunction in cardiac surgical patients undergoing cardiopulmonary bypass. The findings of this pilot study justify further investigation. (ClinicalTrials.gov, NCT00334191).
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Pakfetrat M, Nikoo MH, Malekmakan L, Tabandeh M, Roozbeh J, Nasab MH, Ostovan MA, Salari S, Kafi M, Vaziri NM, Adl F, Hosseini M, Khajehdehi P. A comparison of sodium bicarbonate infusion versus normal saline infusion and its combination with oral acetazolamide for prevention of contrast-induced nephropathy: a randomized, double-blind trial. Int Urol Nephrol 2009; 41:629-34. [PMID: 19137409 DOI: 10.1007/s11255-008-9520-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 12/23/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) is commonly encountered. Because the therapy of choice for prevention of CIN is controversial, in this study we compared the preventive efficacy of bicarbonate (Bi) infusion in dextrose water versus normal saline (NLS) infusion alone or in combination with oral acetazolamide (AZ). METHODS In a double-blind and randomized clinical trial, all patients undergoing coronary angiography or percutaneous coronary intervention received NLS (NLS group), its combination with AZ (AZ group) or infusion of Bi (Bi group) before the procedures. RIFLE (risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal disease) criteria were used to define CIN-associated acute kidney injury (AKI). RESULTS The risk of AKI in CIN was significantly lower in the Bi and AZ groups than in the NLS group (P <or= 0.04). Comparing pre-treatment and post-treatment values in each group the following results were obtained: serum creatinine (Scr) increased and eGFR decreased significantly in the NLS group (P = 0.04) and in all patients (P = 0.001, P = 0.02, respectively). In addition, serum potassium decreased significantly in the Bi and NLS groups (P <or= 0.02). Also, serum Bi increased significantly in the Bi group (P = 0.001) whereas it decreased significantly in the AZ group (P = 0.001). Urinary pH also increased in all groups (P <or= 0.04) except the NLS group (P > 0.05). CONCLUSIONS It seems that both Bi and AZ reduce the risk of CIN-related AKI, and close monitoring of serum potassium is needed during bicarbonate infusion.
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Affiliation(s)
- Maryam Pakfetrat
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Clinical significance and preventive strategies for contrast-induced nephropathy. Curr Opin Nephrol Hypertens 2008; 17:616-23. [PMID: 18941356 DOI: 10.1097/mnh.0b013e32830f45a3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Contrast-induced nephropathy continues to be a common cause of in-hospital acute kidney injury. Published studies on pathogenesis, clinical significance, diagnosis, and preventive measures have dramatically increased significantly in the past several years. This review will focus on new developments in contrast-induced nephropathy. RECENT FINDINGS Studies on the clinical significance of contrast-induced nephropathy are reviewed along with initial reports of biomarkers in diagnosing this complication of iodinated contrast administration. Emerging literature on the relative nephrotoxicity of iso-osmolar versus low-osmolar contrast media and the value of bicarbonate hydration are discussed. More recent preventive measures using prostacyclin, 'statins', and erythropoietin are also reviewed. SUMMARY Contrast-induced nephropathy is an increasing cause of acute kidney injury and is associated with significant mortality and morbidity. Future developments in this field will focus on refining the clinical significance of this complication, earlier diagnosis with biomarkers, clarifying the role for bicarbonate and iso-osmolar contrast agents as preventive strategies, and the introduction of new prophylactic techniques on the basis of an improved understanding of pathogenesis at the cellular level.
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Hogan SE, L'Allier P, Chetcuti S, Grossman PM, Nallamothu BK, Duvernoy C, Bates E, Moscucci M, Gurm HS. Current role of sodium bicarbonate-based preprocedural hydration for the prevention of contrast-induced acute kidney injury: a meta-analysis. Am Heart J 2008; 156:414-21. [PMID: 18760120 DOI: 10.1016/j.ahj.2008.05.014] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Accepted: 05/17/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal hydration strategy for prevention of contrast-induced acute kidney injury (AKI) remains unknown. The purpose of this meta-analysis is to compare the effectiveness of normal saline (NS) versus sodium bicarbonate hydration (NaHCO(3)) for prevention of contrast-induced AKI. METHODS We performed a meta-analysis of randomized controlled trials that compared saline-based hydration with sodium bicarbonate-based hydration regimen for prophylaxis of contrast-induced AKI. The literature search included MEDLINE, EMBASE, and Cochrane databases (2000 to October 2007); conference proceedings; and bibliographies of retrieved articles. Information was extracted on study design, sample characteristics, and interventions. Random-effects models were used to calculate summary risk ratios for contrast-induced AKI, need for hemodialysis, and death. RESULTS Seven trials with 1,307 subjects were included. Preprocedural hydration with sodium bicarbonate was associated with a significant decrease in the rate of contrast-induced AKI (5.96% in the NaHCO(3) arm versus 17.23% in the NS arm, summary risk ratio 0.37, 95% CI 0.18-0.714, P = .005). There was no difference in the rates of postprocedure hemodialysis or death. Formal testing revealed moderate heterogeneity and a strong likelihood of publication bias. CONCLUSIONS Although sodium bicarbonate hydration was found to be superior to NS in prevention of contrast-induced AKI, these results are in the context of study heterogeneity and, likely, publication bias. An adequately powered randomized controlled trial is warranted to define the optimal hydration strategy in patients at high risk of contrast-induced AKI who are scheduled to undergo contrast administration.
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Affiliation(s)
- Shea E Hogan
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI 48109-5853, USA
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Masuda M, Yamada T, Okuyama Y, Morita T, Sanada S, Furukawa Y, Tsukamoto Y, Okuda K, Iwasaki Y, Yasui T, Fukunami M. Sodium Bicarbonate Improves Long-Term Clinical Outcomes Compared With Sodium Chloride in Patients With Chronic Kidney Disease Undergoing an Emergent Coronary Procedure. Circ J 2008; 72:1610-4. [DOI: 10.1253/circj.cj-08-0368] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Yuji Okuyama
- Division of Cardiology, Osaka General Medical Center
| | | | - Shoji Sanada
- Division of Cardiology, Osaka General Medical Center
| | | | | | - Keiji Okuda
- Division of Cardiology, Osaka General Medical Center
| | | | - Taku Yasui
- Division of Cardiology, Osaka General Medical Center
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Ozcan EE, Guneri S, Akdeniz B, Akyildiz IZ, Senaslan O, Baris N, Aslan O, Badak O. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial. Am Heart J 2007; 154:539-44. [PMID: 17719303 DOI: 10.1016/j.ahj.2007.05.012] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 05/18/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several protective therapies have been developed to prevent contrast-induced nephropathy (CIN). We aimed to investigate the efficacy of sodium bicarbonate by comparing 2 other regimens, including combination of N-acetylcysteine (NAC) plus sodium chloride and sodium chloride alone, to prevent CIN in patients undergoing cardiovascular procedures. METHODS We prospectively enrolled 264 patients who were scheduled for cardiovascular procedures and had a baseline creatinine level >1.2 mg/dL. The patients were assigned 1 of 3 prophylactic regimens: infusion of sodium bicarbonate, sodium chloride, sodium chloride plus oral NAC (600 mg bid). Contrast-induced nephropathy was defined as an increase in serum creatinine level >25% or 0.5 mg/dL after 48 hours. RESULTS There were no significant differences among groups regarding baseline demographic properties and nephropathy risk factors. The change in creatinine clearance was significantly better in the sodium bicarbonate group than other 2 groups (P = .007). The incidence of CIN was significantly lower in the sodium bicarbonate group (4.5%) compared with sodium chloride alone (13.6%, P = .036) and tended to be lower than in the combination group (12.5%, P = .059). After adjusting the Mehran nephropathy risk score, the risk of CIN significantly reduced with sodium bicarbonate compared with sodium chloride alone (adjusted risk ratio 0.29, P = .043). CONCLUSIONS Hydration with sodium bicarbonate provides better protection against CIN than the sodium chloride infusion does alone. Combination therapy of NAC plus sodium chloride did not offer additional benefit over hydration with sodium chloride alone.
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Affiliation(s)
- Emin E Ozcan
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
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Masuda M, Yamada T, Mine T, Morita T, Tamaki S, Tsukamoto Y, Okuda K, Iwasaki Y, Hori M, Fukunami M. Comparison of usefulness of sodium bicarbonate versus sodium chloride to prevent contrast-induced nephropathy in patients undergoing an emergent coronary procedure. Am J Cardiol 2007; 100:781-6. [PMID: 17719320 DOI: 10.1016/j.amjcard.2007.03.098] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 03/22/2007] [Accepted: 03/22/2007] [Indexed: 12/25/2022]
Abstract
In the case of an emergency coronary procedure where the risk of contrast-induced nephropathy is especially high, there are few reliable methods to attenuate renal injury. We examined the efficacy of sodium bicarbonate for the prevention of contrast-induced nephropathy in patients undergoing an emergency coronary procedure. We enrolled 59 patients who were scheduled to undergo an emergency coronary angiography or intervention. These patients were randomized to receive a 154-mEq/L infusion of sodium bicarbonate (n = 30) or sodium chloride (n = 29), as a bolus of 3 ml/kg/hour for 1 hour before the administration of contrast, followed by an infusion of 1 ml/kg/hour for 6 hours during and after the procedure. In the sodium bicarbonate group, serum creatinine concentration remained unchanged within 2 days of contrast administration (1.31 +/- 0.52 to 1.31 +/- 0.59 mg/dl), whereas it increased in the sodium chloride group (1.32 +/- 0.65 to 1.52 +/- 0.92 mg/dl, p = 0.01). The incidence of contrast-induced nephropathy (an increase >0.5 mg/dl or >25% in serum creatinine concentration within 2 days of contrast) was significantly lower in the sodium bicarbonate group than in the sodium chloride group (7% vs 35%, p = 0.01, risk ratio 0.19, 95% confidence interval 0.046 to 0.80). In conclusion, hydration with sodium bicarbonate is more effective than with sodium chloride for the prevention of contrast-induced nephropathy in patients undergoing an emergency coronary procedure.
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Affiliation(s)
- Masaharu Masuda
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan.
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Briguori C, Airoldi F, D'Andrea D, Bonizzoni E, Morici N, Focaccio A, Michev I, Montorfano M, Carlino M, Cosgrave J, Ricciardelli B, Colombo A. Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies. Circulation 2007; 115:1211-7. [PMID: 17309916 DOI: 10.1161/circulationaha.106.687152] [Citation(s) in RCA: 358] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Volume supplementation by saline infusion combined with N-acetylcysteine (NAC) represents an effective strategy to prevent contrast agent-induced nephrotoxicity (CIN). Preliminary data support the concept that sodium bicarbonate and ascorbic acid also may be effective in preventing CIN. METHODS AND RESULTS Three hundred twenty-six consecutive patients with chronic kidney disease, referred to our institutions for coronary and/or peripheral procedures, were randomly assigned to prophylactic administration of 0.9% saline infusion plus NAC (n=111), sodium bicarbonate infusion plus NAC (n=108), and 0.9% saline plus ascorbic acid plus NAC (n=107). All enrolled patients had serum creatinine > or = 2.0 mg/dL and/or estimated glomerular filtration rate < 40 mL x min(-1) x 1.73 m(-2). Contrast nephropathy risk score was calculated in each patient. In all cases, iodixanol (an iso-osmolar, nonionic contrast agent) was administered. The primary end point was an increase of > or = 25% in the creatinine concentration 48 hours after the procedure (CIN). The amount of contrast media administered (179+/-102, 169+/-92, and 169+/-94 mL, respectively; P=0.69) and risk scores (9.1+/-3.4, 9.5+/-3.6, and 9.3+/-3.6; P=0.21) were similar in the 3 groups. CIN occurred in 11 of 111 patients (9.9%) in the saline plus NAC group, in 2 of 108 (1.9%) in the bicarbonate plus NAC group (P=0.019 by Fisher exact test versus saline plus NAC group), and in 11 of 107 (10.3%) in the saline plus ascorbic acid plus NAC group (P=1.00 versus saline plus NAC group). CONCLUSIONS The strategy of volume supplementation by sodium bicarbonate plus NAC seems to be superior to the combination of normal saline with NAC alone or with the addition of ascorbic acid in preventing CIN in patients at medium to high risk.
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Affiliation(s)
- Carlo Briguori
- Laboratory of Interventional Cardiology, Clinica Mediterranea, Via Orazio, 2, I-80121, Naples, Italy.
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Thomsen HS, Morcos SK. Contrast-medium-induced nephropathy: is there a new consensus? A review of published guidelines. Eur Radiol 2006; 16:1835-40. [PMID: 16673094 DOI: 10.1007/s00330-006-0223-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2005] [Revised: 02/17/2006] [Accepted: 02/23/2006] [Indexed: 01/01/2023]
Abstract
The interest in contrast-medium-induced nephropathy has increased considerably during the last few years. Various guidelines regarding identifying patients at risk and measures to reduce the incidence of this complication have been proposed. The aim of this review was to analyse whether there is some consistency amongst these guidelines. A Medline search for the keyword "contrast medium induced nephropathy" during the period from the beginning of 2003 through the end of September 2005 was carried out. Only papers in English were reviewed. Thirteen guidelines were identified. Inconsistency was observed regarding advise on the prophylactic use of drugs and the isoosmolar dimer to reduce the incidence of contrast-medium-induced nephropathy. Consistency was found in relation to the importance of hydration, cessation of intake of nephrotoxic drugs and administration of the lowest possible dose of contrast medium. No new consensus has been observed in comparison to the European Society for Urogenital Radiology (ESUR) guidelines, which were published in 1999.
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Affiliation(s)
- Henrik S Thomsen
- Department of Diagnostic Radiology 54E2, Copenhagen University Hospital at Herlev, Herlev Ringvej 75, DK-2730 Herlev, Denmark.
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Sanaei-Ardekani M, Movahed MR, Movafagh S, Ghahramani N. Contrast-induced nephropathy: a review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2005; 6:82-8. [PMID: 16263365 DOI: 10.1016/j.carrev.2005.07.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Revised: 07/25/2005] [Accepted: 07/25/2005] [Indexed: 01/20/2023]
Abstract
Contrast-induced nephropathy (CIN) is one of the leading causes of renal impairment in the United States and the third cause of hospital-acquired renal failure. Reduction in the incidence of CIN can lead to a decrease in the morbidity, mortality, and length of hospital stay. Although prophylactic hydration has been promising in decreasing the occurrence of CIN, other efforts such as diuretics, calcium channel blockers, theophylline, aminophylline, atrial natriuretic peptide, dopamine, and fenoldopam have been disappointing. The preventive effect of N-acetylcysteine on CIN has not been consistent in the literature. In a recent clinical trial, bicarbonate infusion was more effective than hydration in the prevention of CIN. Mechanical devices are in development to perfuse renal arteries with protective drugs during contrast exposure or for removal of contrast from coronary sinus during coronary angiography. In this article, we have reviewed available data in regards to CIN.
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Affiliation(s)
- Mohammad Sanaei-Ardekani
- Department of Internal Medicine, Washington Hospital Center, Georgetown University, Washington, DC 20010, USA.
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Abstract
Contrast medium-induced nephrotoxicity (ie, contrast nephrotoxicity [CN]) remains an important complication of angiographic procedures. If administration of iodinated contrast medium is deemed necessary in patients at high risk of CN, volume expansion should be offered and the lowest possible dose of nonionic isosmolar dimeric or nonionic low-osmolar monomeric contrast medium should be used. Prophylactic administration of fenoldopam or acetylcysteine has not offered consistent protection against CN. Intravenous acetylcysteine could be considered in emergency situations. Recently, sodium bicarbonate infusion has been shown to reduce the risk of CN. Hemofiltration for several hours before and after contrast medium injection may offer good protection against CN in patients with advanced renal disease. Prophylactic hemodialysis does not offer any protection against CN.
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Affiliation(s)
- Sameh K Morcos
- Department of Diagnostic Imaging, Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Herries Road, Sheffield S5 7AU, United Kingdom.
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Lennon GM, Ryan PC, Fitzpatrick JM. Ischaemia-reperfusion injury in the rat kidney: effect of a single dose of sodium bicarbonate. Br J Surg 1993; 80:112-4. [PMID: 8381326 DOI: 10.1002/bjs.1800800137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The protective effect of intravenous 8.4 per cent sodium bicarbonate on renal function after ischaemia was evaluated in rats subjected to 45 or 90 min warm unilateral renal ischaemia. Two groups of control animals received normal or 3 per cent saline. All solutions were given by bolus injection 3 h before ischaemia. Renal function was significantly protected in animals receiving bicarbonate. Vascular congestion of the inner stripe of the renal medulla was prevented. The survival rate in the group undergoing 90-min ischaemia was 70 per cent for animals receiving bicarbonate and nil in those given saline. Preoperative alkalinization confers significant functional and morphological protection in the ischaemic kidney.
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Affiliation(s)
- G M Lennon
- Department of Surgery, Mater Misericordiae Hospital, Dublin, Ireland
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