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Saline hydration alone is sufficient. Urinary alkalinization and acetylcysteine have been proposed as possible ways to minimize contrast-induced nephropathy (CIN) in patients who receive intra-arterial injections of iodinated contrast. In this multicenter study, researchers randomized about 5000 patients scheduled for angiography (primarily coronary) to receive periprocedural administration of intravenous sodium bicarbonate or saline and, additionally, to receive acetylcysteine or placebo. All patients had estimated glomerular filtration rates (GFRs) between 15 and 59 mL/minute/1.73 m2, and all patients received iso-osmolar or low-osmolar agents. The primary endpoint (90-day incidence of death, need for dialysis, or persistent increase in serum creatinine of ≥50% from baseline) was about 4%, with no differences between patients who received saline only and those who received bicarbonate, acetylcysteine, or both agents. Similarly, researchers noted no differences between groups in the incidence of acute kidney injury within several days (≈9% in each group). |
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COMMENT
This study confirms that neither bicarbonate nor acetylcysteine is associated with better renal outcomes than is saline alone in patients who are undergoing coronary angiography. The study’s premise is that contrast-induced nephropathy is an important clinical entity, but that premise has been challenged recently — at least in studies of intravenous iso-osmolar and low-osmolar contrast used in computed tomographic (CT) scanning (NEJM JW Gen Med Dec 15 2017 and Radiology 2017; 285:414; NEJM JW Gen Med May 1 2014 and Radiology 2014; 271:65; NEJM JW Gen Med Apr 1 2017 and Ann Emerg Med 2017; 69:577). These studies suggest that most “bumps” in serum creatinine (seen in both intravenous contrast recipients and matched controls) likely represent background fluctuations that are observed commonly in hospitalized patients and likely are explained by varying states of hydration, nephrotoxic drugs, and day-to-day changes in cardiovascular status. Contrast injections for coronary angiography might be more nephrotoxic than intravenous injections for CT scanning, but I’m not aware of compelling evidence to support that assumption.