Use and efficacy of saline hydration and N-acetyl cysteine to prevent contrast-induced nephropathy in low-risk populations undergoing coronary artery angiography

Abstract

Contrast-induced nephropathy (CIN) is most commonly defined as acute renal failure occurring within 48-72 h of exposure to an intravascular radiographic contrast medium that is not attributable to other causes. In the international literature, a 25% increase in serum creatinine levels or an increase in absolute values of 0.5 mg/dl from baseline has been suggested to define CIN. The reported incidence of CIN varies widely, ranging from 2 to 50%. This variability results from differences in the presence or absence of risk factors. With a retrospective analysis we evaluated the use of saline hydration plus N-acetyl cysteine (NAC) to prevent CIN in a low-risk population of patients undergoing coronary artery angiography compared with an historic low risk group not treated. From January 2009 to December 2009, 152 consecutive patients who underwent coronary artery angiography with a low osmolarity contrast agent were enrolled in our study, and compared with an historic control group consisting of 172 low-risk patients. Nephrotoxic drugs such as diuretics, ACE-I and ARBs were stopped at least 24 h before the procedure. Inclusion criteria to define low-risk population were the absence of: diabetes, age >65 years, or baseline creatinine >1.4 mg/dl. We have treated group A (152 patients, 47.3%) with a saline hydration (1 ml/kg/h) plus N-acetyl cysteine 600 mg 12 h before and 12 h after the procedure; group B (group control of 170 patients, 52.7%) were not treated. The overall incidence of CIN was 7.1% (23 patients). In particular, the incidence of CIN was 2.6% (4 patients) in the group A and 11.2% (19 patients) in the group B (p = 0.002). In the multivariate analysis, including risk factor such as age, hypertension, hypercholesterolemia, current smoking habit baseline creatinine level, contrast index and hydration, the last variable was the only one inversely correlated independently with the incidence of CIN (p = 0.001). In conclusion, intravenous hydration with saline and NAC is an effective and low cost tool in preventing CIN in patients undergoing coronary artery angiography, and, according to the current guidelines, should be used in all high-risk patients for CIN. Our results show that even in patients at low risk, hydration with saline 0.9% plus NAC is useful and significantly reduces the incidence of CIN.

Are we still wondering or wandering in the dark?

“…In the current study of Calabro et al [13], investigators found a reduction in the incidence of CIN, confirming previous results of a high risk population [14] in the low risk patients (no diabetes, age \65 and no creatinine greater than 1.4 mg/dL).…”

Contrast-induced nephropathy

“…Promising approaches include minimizing the volume of contrast, peri-procedural intravenous hydration, sodium bicarbonate, particularly during emergency and urgent coronary angiography, and high-dose N-acetylcysteine [15][16][17][18]. Peri-procedural haemofiltration in patients with severe CKD and associated left ventricular dysfunction, who cannot tolerate adequate intravenous hydration, have been shown to be effective [19,20].…”

Carotid stenting with low-dose contrast medium for patients with moderate-to-severe chronic renal insufficiency: Keyhole carotid stenting

“…Some different approaches, including volume expansion with a saline solution, use of dilutedcontrast agent, and reduction of the contrast agent dose [7], may be beneficial to prevent CIN in high-risk patients. It is noteworthy that although controversies and little evidence exist regarding the beneficial effect of N-acetylcysteine on nephrotoxicity [8,9], the combination of hydration and N-acetylcysteine treatment might help to reduce the incidence of CIN in high-risk patients, as demonstrated by the randomized study of Chen et al [9].…”

“…This approach requires a very small quantity of contrast medium; thus, no change is observed between the pre-procedural and post-procedural serum creatinine value using pre-procedural hydration and possibly N-acetylcysteine treatment [8,9]. This procedure allows digital cerebral angiography and endovascular carotid stenting to be performed in the same session using minimal contrast medium for patients with renal insufficiency and critical carotid stenosis.…”