Allopurinol Administration for the Prevention of Contrast-Induced Nephropathy: A Network Meta-analysis With Trial Sequential Analysis

Abstract

Contrast-induced nephropathy represents a major source of morbidity in patients undergoing coronary angiography. Various preventive measures have been proposed, although the optimal one remains still unknown. The aim of the present meta-analysis is to accumulate current literature knowledge and evaluate the renoprotective effects of allopurinol administration before contrast medium exposure. To achieve this, MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Google Scholar databases were searched from inception to November 8, 2018. Statistical meta-analysis was conducted with Review Manager 5.3, TSA 0.9.5.5 and R-3.4.3. Six studies were included with a total of 918 patients. Quantitative synthesis revealed that allopurinol leads to significantly reduced incidence of contrast-induced nephropathy compared with hydration alone [odds ratio: 0.29, 95% confidence interval: (0.09–0.90)]. Trial sequential analysis suggested that Z-curve crossed the O'Brien–Fleming significance boundaries, although required information size was not reached. Network meta-analysis indicated that allopurinol had the highest probability (81.2%) to rank as the most effective intervention compared with hydration and N-acetyl cysteine; however, significant overlap with the rest treatments was noted. In conclusion, the present meta-analysis suggests that allopurinol may represent a promising measure for the prevention of acute kidney injury after coronary angiography. Future large-scale randomized controlled trials should verify this finding, while combinations of allopurinol with other novel interventions should be evaluated to define the most effective strategy to be implemented in the clinical setting.

Consenso de la Asociación Colombiana de Nefrología e Hipertensión Arterial (Asocolnef) y la Asociación Colombiana de Radiología (ACR) sobre recomendaciones basadas en la evidencia de la injuria renal aguda asociada al uso de medios de contraste yodados (IRA-ACI)

“…A menos de que se desarrollen ECA que incluyan muestras representativas y demuestren algún beneficio clínico, el uso de estos agentes para la prevención de la IRA-ACI no tendrán un nivel de evidencia sólida que permitan recomendarlos para su uso rutinario en los escenarios clínicos. Dentro de estas moléculas podríamos mencionar: teofilina [113], ácido ascórbico [114], trimetazidina [115], alopurinol [116], prostaglandina E1 [117], fenoldopam [118], alfa-tocoferol [119], nicorandil [120], péptidos natriuréticos [109], manitol o diuréticos [94,121] o dopamina [122].…”

Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury

“…Several other pharmaceutical agents have been tried for prevention of PC-AKI, including theophylline, 46 prostaglandin E1, 47 nicorandil, 48 ascorbic acid, 49 allopurinol, 50 alpha-tocopherol, 51 fenoldopam, natriuretic peptides, 44 and trimetazidine. 52 Though some of these trials report a small benefit, these trials are small, and with unclear benefit in clinical outcomes, like the initial NAC trials.…”

Canadian Association of Radiologists Guidance on Contrast-Associated Acute Kidney Injury

“…Several other pharmaceutical agents have been tried for prevention of PC-AKI, including theophylline, 48 prostaglandin E1, 49 nicorandil, 50 ascorbic acid, 51 allopurinol, 52 alpha-tocopherol, 53 fenoldopam, natriuretic peptides, 46 and trimetazidine. 54 Though some of these trials report a small benefit, these trials are small, and with unclear benefit in clinical outcomes, like the initial NAC trials.…”