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Zhu R, Zheng R, Deng B, Liu P, Wang Y. Association of N-acetylcysteine use with contrast-induced nephropathy: an umbrella review of meta-analyses of randomized clinical trials. Front Med (Lausanne) 2023; 10:1235023. [PMID: 37790125 PMCID: PMC10543416 DOI: 10.3389/fmed.2023.1235023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background The effectiveness of N-acetylcysteine (NAC) in treating contrast-induced nephropathy (CIN) has been the subject of conflicting meta-analyses, but the strength of the evidence for these correlations between NAC use and CIN has not been measured overall. Objective To evaluate the data from randomized clinical studies (RCTs) that examined the relationships between NAC use and CIN in meta-analyses. Methods Between the creation of the database and April 2023, searches were made in PubMed, Cochrane Library, EMBASE, and Web of Science. N-acetylcysteine, contrast-induced nephropathy, or contrast-induced renal disease were among the search keywords used, along with terms including systematic review and meta-analysis. The Assessment of Multiple Systematic Reviews, version 2, which assigned grades of extremely low, low, moderate, or high quality to each meta-analysis's scientific quality, was used to evaluate each meta-analysis. The confidence of the evidence in meta-analyses of RCTs was evaluated using the Grading of Recommendation, Assessment, Development and Evaluations method, with evidence being rated as very low, low, moderate, or high. Results In total, 493 records were screened; of those, 46 full-text articles were assessed for eligibility, and 12 articles were selected for evidence synthesis as a result of the screening process. Based on the pooled data, which was graded as moderate-quality evidence, it can be concluded that NAC can decrease CIN (OR 0.72, 95% CI 0.65-0.79, p < 0.00001) and blood levels of serum creatinine (MD -0.09, 95% CI -0.17 to -0.01, p = 0.03). In spite of this, there were no associations between NAC and dialysis requirement or mortality in these studies. Conclusion The results of this umbrella review supported that the renal results were enhanced by NAC. The association was supported by moderate-quality evidence. Systematic review registration [https://clinicaltrials.gov/], identifier [CRD42022367811].
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Affiliation(s)
| | | | | | - Ping Liu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiru Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Panova IG, Tatikolov AS. Endogenous and Exogenous Antioxidants as Agents Preventing the Negative Effects of Contrast Media (Contrast-Induced Nephropathy). Pharmaceuticals (Basel) 2023; 16:1077. [PMID: 37630992 PMCID: PMC10458090 DOI: 10.3390/ph16081077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
The use of conventional contrast media for diagnostic purposes (in particular, Gd-containing and iodinated agents) causes a large number of complications, the most common of which is contrast-induced nephropathy. It has been shown that after exposure to contrast agents, oxidative stress often occurs in patients, especially in people suffering from various diseases. Antioxidants in the human body can diminish the pathological consequences of the use of contrast media by suppressing oxidative stress. This review considers the research studies on the role of antioxidants in preventing the negative consequences of the use of contrast agents in diagnostics (mainly contrast-induced nephropathy) and the clinical trials of different antioxidant drugs against contrast-induced nephropathy. Composite antioxidant/contrast systems as theranostic agents are also considered.
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Affiliation(s)
- Ina G. Panova
- International Scientific and Practical Center of Tissue Proliferation, 29/14 Prechistenka Str., 119034 Moscow, Russia;
| | - Alexander S. Tatikolov
- N.M. Emanuel Institute of Biochemical Physics, Russian Academy of Sciences, 4 Kosygin Str., 119334 Moscow, Russia
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Heshmatzadeh Behzadi A, Amoozgar B, Jain S, Velasco N, Zahid U, Abbasi H, Alasadi L, Prince MR. Trimetazidine reduces contrast-induced nephropathy in patients with renal insufficiency undergoing coronary angiography and angioplasty: A systematic review and meta-analysis (PRISMA). Medicine (Baltimore) 2021; 100:e24603. [PMID: 33725824 PMCID: PMC7969219 DOI: 10.1097/md.0000000000024603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/26/2020] [Accepted: 01/12/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES This systematic review and meta-analysis assesses the utility of trimetazidine (TMZ) to prevent contrast induced nephropathy (CIN) in patients with renal insufficiency undergoing coronary angiography and angioplasty. MATERIALS AND METHODS This meta-analysis was formulated and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of databases was conducted by 2 researchers independently for clinical trials, comparing hydration plus TMZ vs conventional hydration alone for prevention of CIN through January 2020. All patients had renal insufficiency (defined as GFR < 89 ml/minute/1.73 m2) and the outcome of interest was the incidence of contrast induced acute kidney injury. The odds ratio (OR) was estimated with 95% confidence interval (CI). Heterogeneity was reported with the I2 statistic, using a fixed-effects model, and >50% of I2 was considered to be statistically significant. RESULTS Eleven studies, 1611 patients, met the inclusion/exclusion criteria: 797 patients comprised the TMZ plus hydration group and the remaining 814 patients comprised the control (hydration only) group. Heterogeneity was low I2 = 0%, P = .84, and the heterogeneity of each study was also low. The incidence of CIN in the TMZ plus hydration group was 6.6% (53/797), while the incidence of CIN in the control (hydration only) group was 20% (165/814). Pooled analysis of all studies showed TMZ reduced incidence of CIN compared to saline hydration alone (OR risk 0.30, 95% CI 0.21, 0.42, P < .0001). CONCLUSION TMZ added to hydration reduces CIN in renal insufficiency patients undergoing coronary angiography.
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Affiliation(s)
| | - Behzad Amoozgar
- Department of Medicine, Jersey Shore University Medical Center, Perth Amboy Divisions, New Jersey
| | - Shalini Jain
- CHI Health Creighton University Medical Center, Omaha
| | - Noel Velasco
- Department of Radiology, Yale New Haven, Bridgeport Hospital, Connecticut
| | - Umar Zahid
- Brookdale University Hospital Medical Center, New York
| | - Hamidreza Abbasi
- Hackensack Meridian Health and JFK Neuroscience Institute, Edison, NJ
| | - Lutfi Alasadi
- Brookdale University Hospital Medical Center, New York
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medicine
- Department of Radiology, Columbia College of Physicians and Surgeons, New York
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Lakhal K, Ehrmann S, Robert-Edan V. Iodinated contrast medium: Is there a re(n)al problem? A clinical vignette-based review. Crit Care 2020; 24:641. [PMID: 33168006 PMCID: PMC7653744 DOI: 10.1186/s13054-020-03365-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
As we were taught, for decades, that iodinated contrast-induced acute kidney injury should be dreaded, considerable efforts were made to find out effective measures in mitigating the renal risk of iodinated contrast media. Imaging procedures were frequently either downgraded (unenhanced imaging) or deferred as clinicians felt that the renal risk pertaining to contrast administration outweighed the benefits of an enhanced imaging. However, could we have missed the point? Among the abundant literature about iodinated contrast-associated acute kidney injury, recent meaningful advances may help sort out facts from false beliefs. Hence, there is increasing evidence that the nephrotoxicity directly attributable to modern iodinated CM has been exaggerated. Failure to demonstrate a clear benefit from most of the tested prophylactic measures might be an indirect consequence. However, the toxic potential of iodinated contrast media is well established experimentally and should not be overlooked completely when making clinical decisions. We herein review these advances in disease and pathophysiologic understanding and the associated clinical crossroads through a typical case vignette in the critical care setting.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France.
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, CHRU Tours, Tours France and Centre d'étude des Pathologies Respiratoires INSERM U1100, Université de Tours, Tours, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France
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Xie W, Liang X, Lin Z, Liu M, Ling Z. Latest Clinical Evidence About Effect of Acetylcysteine on Preventing Contrast-Induced Nephropathy in Patients Undergoing Angiography: A Meta-Analysis. Angiology 2020; 72:105-121. [PMID: 32830526 DOI: 10.1177/0003319720950162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Contrast-induced nephropathy (CIN) is a serious complication of angiographic procedures. It is the third most common cause of hospital acquired acute renal injury. As there are currently no approved therapies for CIN, prevention could be the best strategy to address this issue. Acetylcysteine may indirectly play an antioxidant role by inducing the synthesis of glutathione. Acetylcysteine can also reduce renal vasoconstriction induced by contrast medium stimulation by stabilizing nitric oxide and acting directly or indirectly on renal cortex and medulla microcirculation. To evaluate the effect of acetylcysteine on the prevention of CIN in patients after angiography, we systematically searched and analyzed the clinical data of patients including the incidence of CIN and change in serum creatinine (SCr) at 48 hours after angiography from selected articles. The result showed that acetylcysteine significantly reduces the incidence of CIN (risk ratios: 0.78, 95% CI: 0.68-0.90, I 2 = 37.3%) and the level of SCr (standardized mean difference: -0.53, 95% CI: -0.93 to -0.12, I 2 = 91.5%) after angiography compared with the control group. Overall, the use of acetylcysteine in patients after angiography was associated with a significant reduction of CIN and the level of SCr.
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Affiliation(s)
- Wenchao Xie
- Department of Cardiology, the First People's Hospital of Yulin, the Sixth Affiliated Hospital of Guangxi Medical University, Yulin, Guangxi, China
| | - Xiangwen Liang
- Department of Cardiology, the First People's Hospital of Yulin, the Sixth Affiliated Hospital of Guangxi Medical University, Yulin, Guangxi, China
| | - Zhihai Lin
- Department of Cardiology, the First People's Hospital of Yulin, the Sixth Affiliated Hospital of Guangxi Medical University, Yulin, Guangxi, China
| | - Ming Liu
- Department of Cardiology, the First People's Hospital of Yulin, the Sixth Affiliated Hospital of Guangxi Medical University, Yulin, Guangxi, China
| | - Zheng Ling
- Department of Cardiology, the First People's Hospital of Yulin, the Sixth Affiliated Hospital of Guangxi Medical University, Yulin, Guangxi, China
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Radiological iodinated contrast-induced nephropathy. Rev Clin Esp 2019; 219:403-410. [PMID: 30318246 DOI: 10.1016/j.rce.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 11/20/2022]
Abstract
The use of iodinated contrast media can cause renal toxicity. Whether contrast media are exclusively responsible for kidney damage is currently the subject of debate, given that in most cases, other potential causes of the renal failure are present. With current low-osmolar and iso-osmolar contrast media, the incidence rate of contrast-induced nephropathy is estimated to be <1% in the low-risk population but can increase to 37% in patients who are administered contrast by an intra-arterial administration and/or who have renal failure with an estimated glomerular filtration rate (eGFR) <30mL/min/1.73m2. To minimize the risk of renal toxicity, the recommendation is to administer the least amount of contrast possible and ensure appropriate volume expansion by infusing 0.9% saline solution.
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Radiological iodinated contrast-induced nephropathy. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kalogirou TE, Meditskou S, Davidopoulou S, Savvas I, Pitoulias AG, Pitoulias GA. Investigating the Possible Protective Role of Direct Intra-arterial Administration of Mannitol and N-Acetylcysteine and Per Os Administration of Simvastatin Against Contrast-Induced Nephropathy: An Experimental Study in a Rabbit Model. Cardiovasc Intervent Radiol 2019; 42:1777-1785. [PMID: 31392490 DOI: 10.1007/s00270-019-02304-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Contrast-induced nephropathy (CIN) is one of the leading causes of hospital-acquired acute kidney injury due to the use of iodinated contrast media in various interventional procedures like endovascular aneurysm repair. Its pathophysiology remains mostly unclear. The purpose of the present study was to comparatively study the possible protective role of direct intra-arterial administration of mannitol and acetylcysteine and per os administration of simvastatin in a histopathological level. MATERIALS AND METHODS In the present study, we administered iopromide directly in the infrarenal aorta of 24 New Zealand white rabbits after laparotomy. Animals were divided in four groups of six: G1 received iopromide with no protection, G2 iopromide with mannitol, G3 iopromide with acetylcysteine, and G4 iopromide with simvastatin. Renal function blood parameters were assessed prior to the administration, and in 48 h; histopathological evaluation of the kidneys was performed. RESULTS CIN was evident only in the no protection group G1. Moreover, G1 demonstrated significantly more severe lesions than groups G2, G3, and G4 regarding histopathological findings in glomeruli, vacuolization of tubular epithelial cells, tubular proteinaceous casts, and tubular necrosis. According to our results, intra-arterial administration of mannitol seems to be effective in protection against tubular necrosis. CONCLUSION In general, all three agents demonstrated a protective role in preventing the development of CIN, although it seems that there are various pathways that remain to be investigated further.
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Affiliation(s)
- Thomas E Kalogirou
- Department of Vascular Surgery, 2nd Surgical Department, General Hospital of Thessaloniki "G.Gennimatas", Aristotle University of Thessaloniki, Eth. Aminis 41, 546 35, Thessaloniki, Greece.
| | - Soultana Meditskou
- Laboratory of Histology- Embryology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotiria Davidopoulou
- Department of Vascular Surgery, 2nd Surgical Department, General Hospital of Thessaloniki "G.Gennimatas", Aristotle University of Thessaloniki, Eth. Aminis 41, 546 35, Thessaloniki, Greece
| | - Ioannis Savvas
- Veterinary Anaesthesia, Analgesia, and Intensive Care Unit of Anaesthesiology, and Intensive Care Companion Animal Clinic, Faculty of Veterinary Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos G Pitoulias
- Department of Vascular Surgery, 2nd Surgical Department, General Hospital of Thessaloniki "G.Gennimatas", Aristotle University of Thessaloniki, Eth. Aminis 41, 546 35, Thessaloniki, Greece
| | - Georgios A Pitoulias
- Department of Vascular Surgery, 2nd Surgical Department, General Hospital of Thessaloniki "G.Gennimatas", Aristotle University of Thessaloniki, Eth. Aminis 41, 546 35, Thessaloniki, Greece
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Contrast-Induced Nephropathy: Update on the Use of Crystalloids and Pharmacological Measures. Int J Nephrol 2018; 2018:5727309. [PMID: 29854458 PMCID: PMC5954945 DOI: 10.1155/2018/5727309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/21/2018] [Accepted: 03/14/2018] [Indexed: 01/04/2023] Open
Abstract
Contrast-induced nephropathy (CIN) is a frequent and severe complication in subjects receiving iodinated contrast media for diagnostic or therapeutic purposes. Several preventive strategies were evaluated in the past. Recent clinical studies and meta-analyses delivered some new aspects on preventive measures used in the past and present. We will discuss all pharmacological and nonpharmacological procedures. Finally, we will suggest individualized recommendations for CIN prevention.
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Prevention of Contrast and Radiation Injury During Coronary Angiography and Percutaneous Coronary Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:32. [DOI: 10.1007/s11936-018-0621-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Li JX, Li Y, Yan SJ, Han BH, Song ZY, Song W, Liu SH, Guo JW, Yin S, Chen YP, Xia DJ, Li X, Li XQ, Jin EZ. Optimal antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: A systemic review and meta-analysis. Biomed Rep 2018; 8:138-147. [PMID: 29435272 PMCID: PMC5778825 DOI: 10.3892/br.2017.1036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/17/2017] [Indexed: 01/11/2023] Open
Abstract
A challenge for antithrombotic treatment is patients who present with atrial fibrillation (AF) and acute coronary syndrome, particularly in patients who have undergone coronary percutaneous intervention with stenting (PCIS). In the present study, a total of nine observational trials published prior to July 2017 that investigated the effects of dual antiplatelet therapy (DAPT; aspirin + clopidogrel) and triple oral antithrombotic therapy (TOAT; DAPT + warfarin) among patients with AF concurrent to PCIS were collected from the Medline, Cochrane and Embase databases and conference proceedings of cardiology, gastroenterology and neurology meetings. A meta-analysis was performed using fixed- or random-effect models according to heterogeneity. The subgroups were also analyzed on the occurrence of major adverse cardiac events (MACE), stroke and bleeding events in the two treatment groups. Analysis of baseline characteristics indicated that there was no significant difference in the history of coexistent disease or conventional therapies between the DAPT and TOAT groups. The primary end point incidence was 2,588 patients in the DAPT group (n=13,773) and 871 patients in the TOAT group (n=5,262) following pooling of all nine trials. There was no statistically significant difference in the incidence of primary end points between the DAPT and TOAT groups. Odds ratio (OR)=0.96, 95% confidence interval (CI)=0.73-1.27, P=0.79, with heterogeneity between trials (I2=82%, P<0.00001). Subsequently, on subgroup analysis, the results indicated no increased risk of major bleeding or ischemic stroke in the DAPT or TOAT group. However, compared with the TOAT group, there was an apparent increased risk of MACE plus ischemic stroke in the DAPT group (OR=1.62, 95% CI=1.43-1.83, P<0.00001) with heterogeneity between trials (I2=70%, P=0.01). In conclusion, the present meta-analysis suggests that TOAT (aspirin + clopidogrel + warfarin) therapy for patients with AF concurrent to PCIS significantly reduced the risk of MACE and stroke compared with DAPT (aspirin + clopidogrel) therapy. Further randomized controlled clinical trials are required to confirm the efficacy of the optimal antithrombotic therapy in patients with AF following PCIS.
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Affiliation(s)
- Jing-Xiu Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yang Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shu-Jun Yan
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Bai-He Han
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Zhao-Yan Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Wei Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shi-Hao Liu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ji-Wei Guo
- Department of Cardiology, Harbin First Hospital, Harbin, Heilongjiang 150001, P.R. China
| | - Shuo Yin
- Department of Pharmacy, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ye-Ping Chen
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - De-Jun Xia
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xin Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xue-Qi Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - En-Ze Jin
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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