Is treatment with N-acetylcysteine to prevent contrast-induced nephropathy when using bicarbonate hydration out of date?

Comparative Effectiveness of 12 Treatment Strategies for Preventing Contrast-Induced Acute Kidney Injury: A Systematic Review and Bayesian Network Meta-analysis

“…15 16 17 Our study has several limitations. First, the trial network could not include some 18 19 20 treatment agents, such as Na/K citrate, 57 allopurinol, 58 statin plus alsprostadil, 59 that 21 22 23 may be efficacious but were evaluated in only one or two small trials without a 24 25 connection with other commonly used treatments. For many specific treatments, the 26 27 28 number of patients and events in the available trials may not be sufficient to form a 29 30 31 well-connected network for meta-analysis.…”

Prevention of acute kidney injury and protection of renal function in the intensive care unit

“…However, no benefit was observed in studies using NAC in vascular patients [233,234] nor in diabetic patients when compared with hydration alone [235]. Several recent studies have employed the use of NAC with other agents such as bicarbonate [236,237], hydration, and theophylline, with mixed results [70,151,[237][238][239][240].…”

Contrast-Induced Nephropathy: Pathophysiology and Preventive Strategies

“…Patients who undergo coronary angiography are at highest risk for CIN. 17,24 Often the procedure is done under emergent conditions, and patients may be volume depleted, and their hemodynamic status may be less than optimal. 17,24 An increased incidence of CIN is predicted because of more frequent use of contrast media in radiology departments, an increase in the incidence of chronic kidney disease, and an aging population.…”

“…3 Studies have been done on the use of sodium bicarbonate infusions, and guidelines suggest use of this agent; however, confirmatory trials are still needed. 1,4,13,15,17,24 N-acetylcysteine increases production of nitric oxide, which has vasodilatory capabilities, and the concentration of gluta thione, which acts as a free radical scavenger. 3,20,22,27 Compared with infusion of normal saline alone, administration of Nacetylcysteine in conjunction with infusions of normal saline significantly decreased the risk for CIN.…”

“…flushing, itching, angioedema, hypotension, bronchospasm 27 Determine whether contrast media were administered recently Obtain complete history of recent procedures and diagnostic tests Notify physician if contrast medium was administered within the previous 10 days 30 Avoid administration of contrast media within 3-10 days of procedure 1,18,30 Choose contrast agent Notify appropriate personel (physician, procedure nurses) of patient's risk and need to limit amount of contrast medium to less than 100 mL 11,22,24 Low-osmolarity or iso-osmolar agents are preferred 1,3,15,23,24,30 Obtain medication history Continue current dose of statin 1,32 Give ascorbic acid, 3 g per day before the procedure and 2 g twice daily after the procedure 17,30 Obtain a complete list of medications, including over-the-counter medications Notify physician of nephrotoxic medications Withhold medications as ordered by physician; minimal time to withhold is 48 hours or several days before the procedure 1,9,30 ; preferable time frame is weeks before the procedure, when feasible 20 Maintain optimal fluid balance Continue infusion of isotonic saline (12 hours after procedure) or sodium bicarbonate (6 hours after procedure) 4,5,9,13,15,17,18,30 Monitor for symptoms of fluid overload in patients with left ventricular dysfunction; urine output may be matched with infusion volume 30 Resume administration of diuretics on physician's orders, preferably 24 hours after administration of contrast media 30 Assess serum laboratory values Serum creatinine and electrolyte levels should be monitored daily during the hospital stay 1,17 Reassess glomerular filtration rate ...…”