N-acetylcysteine does not prevent contrast nephropathy in patients with renal impairment undergoing emergency CT: a randomized study

BMC Nephrology

Pierre-Yves Martin³  Patrick Saudan³  Thomas Perneger²  Christoph D Becker¹  François Sarasin⁴  Elise Dupuis-Lozeron²  Sophie De Seigneux³  Alexandra Platon¹  Pierre-Alexandre Poletti¹ 

[1] Department of Radiology, University Hospital of Geneva, Geneva, Switzerland;Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland;Service of Nephrology, Department of Internal Medicine specialties, University Hospital of Geneva, Geneva, Switzerland;Service of Emergency Medicine, University Hospital of Geneva, Geneva, Switzerland

关键词: Nephrotoxicity;    N-acetylcysteine;    Emergency medicine;    Contrast media;    Computerized Tomography;   

Others  :  1082920
DOI  :  10.1186/1471-2369-14-119

 received in 2012-11-06, accepted in 2013-05-09,  发布年份 2013

【 摘 要 】

Background

Patients admitted to the emergency room with renal impairment and undergoing a contrast computed tomography (CT) are at high risk of developing contrast nephropathy as emergency precludes sufficient hydration prior to contrast use. The value of an ultra-high dose of intravenous N-acetylcysteine in this setting is unknown.

Methods

From 2008 to 2010, we randomized 120 consecutive patients admitted to the emergency room with an estimated clearance lower than 60 ml/min/1.73 m² by MDRD (mean GFR 42 ml/min/1.73 m²) to either placebo or 6000 mg N-acetylcysteine iv one hour before contrast CT in addition to iv saline. Serum cystatin C and creatinine were measured one hour prior to and at day 2, 4 and 10 after contrast injection. Nephrotoxicity was defined either as 25% or 44 μmol/l increase in serum creatinine or cystatin C levels compared to baseline values.

Results

Contrast nephrotoxicity occurred in 22% of patients who received placebo (13/58) and 27% of patients who received N-acetylcysteine (14/52, p = 0.66). Ultra-high dose intravenous N-acetylcysteine did not alter creatinine or cystatin C levels. No secondary effects were noted within the 2 groups during follow-up.

Conclusions

An ultra-high dose of intravenous N-acetylcysteine is ineffective at preventing nephrotoxicity in patients with renal impairment undergoing emergency contrast CT.

Trial registration

The study was registered as Clinical trial (NCT01467154).

【 授权许可】

   
2013 Poletti et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Levy EM, Viscoli CM, Horwitz RI: The effect of acute renal failure on mortality. A cohort analysis. JAMA 1996, 275(19):1489-1494.
• [2]Thomsen HS: Guidelines for contrast media from the european society of urogenital radiology. AJR Am J Roentgenol 2003, 181(6):1463-1471.
• [3]Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A: Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007, 11(2):R31.
• [4]Barrantes F, Feng Y, Ivanov O, Yalamanchili HB, Patel J, Buenafe X, Cheng V, Dijeh S, Amoateng-Adjepong Y, Manthous CA: Acute kidney injury predicts outcomes of non-critically ill patients. Mayo Clin Proc 2009, 84(5):410-416.
• [5]Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong Y, Manthous CA: Acute kidney injury criteria predict outcomes of critically ill patients. Crit Care Med 2008, 36(5):1397-1403.
• [6]Tian J, Barrantes F, Amoateng-Adjepong Y, Manthous CA: Rapid reversal of acute kidney injury and hospital outcomes: a retrospective cohort study. Am J Kidney Dis 2009, 53(6):974-981.
• [7]Lakhal K, Ehrmann S, Chaari A, Laissy JP, Regnier B, Wolff M, Pajot O: Acute kidney injury network definition of contrast-induced nephropathy in the critically ill: incidence and outcome. J Crit Care 2011, 26(6):593-599.
• [8]Kwon SH, Hyun J, Jeon JS, Noh H, Han DC: Subtle change of cystatin C, with or without acute kidney injury, associated with increased mortality in the intensive care unit. J Crit Care 2011, 27(3):293-300.
• [9]Bartholomew BA, Harjai KJ, Dukkipati S, Boura JA, Yerkey MW, Glazier S, Grines CL, O’Neill WW: Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Am J Cardiol 2004, 93(12):1515-1519.
• [10]Lencioni R, Fattori R, Morana G, Stacul F: Contrast-induced nephropathy in patients undergoing computed tomography (CONNECT) - a clinical problem in daily practice? A multicenter observational study. Acta Radiol 2010, 51(7):741-750.
• [11]Parfrey P: The clinical epidemiology of contrast-induced nephropathy. Cardiovasc Intervent Radiol 2005, 28(Suppl 2):S3-S11.
• [12]Parfrey PS, Griffiths SM, Barrett BJ, Paul MD, Genge M, Withers J, Farid N, McManamon PJ: Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med 1989, 320(3):143-149.
• [13]Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W: Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med 2000, 343(3):180-184.
• [14]Eisenberg RL, Bank WO, Hedgock MW: Renal failure after major angiography can be avoided with hydration. AJR Am J Roentgenol 1981, 136(5):859-861.
• [15]Stacul F, Adam A, Becker CR, Davidson C, Lameire N, McCullough PA, Tumlin J: Strategies to reduce the risk of contrast-induced nephropathy. Am J Cardiol 2006, 98(6A):59K-77K.
• [16]Carbonell N, Blasco M, Sanjuan R, Perez-Sancho E, Sanchis J, Insa L, Bodi V, Nunez J, Garcia-Ramon R, Miguel A: Intravenous N-acetylcysteine for preventing contrast-induced nephropathy: a randomised trial. Int J Cardiol 2007, 115(1):57-62.
• [17]Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, De Metrio M, Galli S, Fabbiocchi F, Montorsi P, et al.: N-acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med 2006, 354(26):2773-2782.
• [18]Baker CS, Wragg A, Kumar S, De Palma R, Baker LR, Knight CJ: A rapid protocol for the prevention of contrast-induced renal dysfunction: the RAPPID study. J Am Coll Cardiol 2003, 41(12):2114-2118.
• [19]Shalansky SJ, Pate GE, Levin A, Webb JG: N-acetylcysteine for prevention of radiocontrast induced nephrotoxicity: the importance of dose and route of administration. Heart 2005, 91(8):997-999.
• [20]Poletti PA, Saudan P, Platon A, Mermillod B, Sautter AM, Vermeulen B, Sarasin FP, Becker CD, Martin PY: I.v. N-acetylcysteine and emergency CT: use of serum creatinine and cystatin C as markers of radiocontrast nephrotoxicity. AJR Am J Roentgenol 2007, 189(3):687-692.
• [21]Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D: A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med 1999, 130(6):461-470.
• [22]Molitoris BA, Levin A, Warnock DG, Joannidis M, Mehta RL, Kellum JA, Ronco C, Shah S: Improving outcomes from acute kidney injury. J Am Soc Nephrol 2007, 18(7):1992-1994.
• [23]Weisbord SD, Mor MK, Resnick AL, Hartwig KC, Palevsky PM, Fine MJ: Incidence and outcomes of contrast-induced AKI following computed tomography. Clin J Am Soc Nephrol 2008, 3(5):1274-1281.
• [24]Kelly AM, Dwamena B, Cronin P, Bernstein SJ, Carlos RC: Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy. Ann Intern Med 2008, 148(4):284-294.
• [25]Caixeta A, Mehran R: Evidence-based management of patients undergoing PCI: contrast-induced acute kidney injury. Catheter Cardiovasc Interv 2010, 75(Suppl 1):S15-S20.
• [26]Gonzales DA, Norsworthy KJ, Kern SJ, Banks S, Sieving PC, Star RA, Natanson C, Danner RL: A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med 2007, 5:32.
• [27]Anderson SM, Park ZH, Patel RV: Intravenous N-acetylcysteine in the prevention of contrast media-induced nephropathy. Ann Pharmacother 2011, 45(1):101-107.
• [28]ACT Investigators: Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized acetylcysteine for contrast-induced nephropathy trial (ACT). Circulation 2011, 124(11):1250-1259.
• [29]Bader BD, Berger ED, Heede MB, Silberbaur I, Duda S, Risler T, Erley CM: What is the best hydration regimen to prevent contrast media-induced nephrotoxicity? Clin Nephrol 2004, 62(1):1-7.
• [30]Solomon R, Werner C, Mann D, D’Elia J, Silva P: Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents. N Engl J Med 1994, 331(21):1416-1420.
• [31]Hoffmann U, Fischereder M, Kruger B, Drobnik W, Kramer BK: The value of N-acetylcysteine in the prevention of radiocontrast agent-induced nephropathy seems questionable. J Am Soc Nephrol 2004, 15(2):407-410.