Prevention Of Radiocontrast-induced Nephropathy Research Articles

Prevention of Radiocontrast-Induced Nephropathy after Coronary Angiography: N-Acetylcysteine plus Saline Hydration versus Saline Hydration

Purpose: To compare the incidence of radiocontrast-induced nephropathy ( RCIN) in patients undergoing coronary angiography pretreated with N-acetylcysteine NAC plus saline hydration or saline hydration alone and to determine the association between various risk factors and RCIN. Methods: Patients were retrospectively evaluated over a one-year period. RCIN was defined as an acute rise in serum creatinine of at least 0.5 mg/dl or more than 25 % from baseline value. SPSS software, version 13 was used for data analysis. Results: Overall, 299 patients were studied. Thirteen patients (4.3%) developed RCIN. RCIN was 3.3 % in patients treated with hydration, and 8.3 % in patients treated with NAC plus hydration (p = 0.09) . In patients with RCIN, the changes in creatinine and % change in creatinine after 24 h were significantly lower in the NAC plus hydration group (p = 0.039 and p = 0.042, respectively). RCIN was significantly associated with male gender (p = 0.017), history of renal failure (p = 0.006), ischemic heart disease (p = 0.003), and diuretic treatment (p = 0.013). Conclusion: NAC plus saline hydration may not be more effective than saline hydration alone in decreasing RCIN after coronary angiography. Additional efforts to find an ideal preventive treatment are

Cystatin C and Creatinine as Markers for Radiocontrast-Induced Nephropathy in Patients Treated with N-Acetylcysteine

The beneficial effect of N-acetylcysteine (NAC) in the prevention of radiocontrast-induced nephropathy (RCIN) as well as the definition of an adequate surrogate parameter for the evaluation of the incidence of RCIN remain points of controversial discussion. Nearly all clinical studies used an increase in serum creatinine to define renal injury, although cystatin C is suggested to be superior to creatinine in estimating glomerular filtration rate (GFR). Furthermore, a recent study showed that in healthy volunteers, NAC leads to a decrease in serum creatinine without influencing serum cystatin C concentrations, implicating a possible overestimation of the protective effect of NAC on the incidence of RCIN. We compared serum creatinine and cystatin C levels in patients with chronic kidney disease undergoing coronary angiography, as these patients are to be considered at highest risk for the development of RCIN. A total of three doses of NAC was given orally, and patients received isotonic saline intravenously. Serum levels at baseline and 24 hours after angiography were not significantly different for serum creatinine (1.72 ± 0.08 mg/dl and 1.72 ± 0.08 mg/dl) and for cystatin C (1.72 ± 0.09 mg/dl and 1.76 ±0.10 mg/dl). There was a significant positive correlation between creatinine and cystatin C serum levels before and after exposure to radiocontrast medium (p < 0.05) in all patients, including subgroup analyses. We conclude that serum creatinine and cystatin C are equivalent surrogate parameters for the evaluation of NAC in the prevention of RCIN. Furthermore, we present a prophylactic treatment regime easily applicable even in an outpatient setting, which seems to protect very effectively against RCIN in a high-risk group of patients.

The Role of Extracorporeal Blood Purification Therapies in the Prevention of Radiocontrast-Induced Nephropathy

Radiocontrast-induced nephropathy (RCIN) is a common and potentially serious complication following diagnostic and therapeutic cardiology procedures using radiocontrast media. The first and most important step in reducing the likelihood of RCIN is to identify patients at risk, by medical history and measurement of serum creatinine concentration to allow calculation of estimated glomerular filtration rate (GFR). Extracorporeal blood purification effectively removes radiocontrast media from the circulation. Periprocedural extracorporeal blood purification (hemodialysis or continuous renal replacement therapy) does not reduce the incidence of RCIN compared with standard medical therapy, and cannot be recommended at this time. The potential benefit of continuous venovenous hemofiltration published by a single center should be confirmed with further studies before it can be recommended or disregarded, and higher doses of continuous renal replacement therapy may also merit further investigation.

Pilot study of B-natriuretic peptide for the prevention of radiocontrast-induced nephropathy after cardiac catheterization

Pilot study of B-natriuretic peptide for the prevention of radiocontrast-induced nephropathy after cardiac catheterization

Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial

Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial

Prevention of Radiocontrast-induced Nephropathy with N-acetylcysteine after Cardiac Angiography in Diabetic Patients with Renal Dysfunction

Purpose. To examine the effects of N-acetylcysteine (NAC) in a homogeneous high-risk population. Methods. This is a prospective randomized single-blinded placebo-controlled clinical study. Diabetic patients with pre-existing renal insufficiency (serum creatinine concentration (SCC) above 1.6mg/dL, or estimated creatinine clearance (CCR) less than 40mL/min) who had received moderate to large amounts of non-ionic low osmolar contrast medium, Omnipaque (iohexol), during a diagnostic or interventional procedure were eligible to participate. All patients were adequately hydrated with half-saline (1mL/(kg•h) from 12 hours before to 12 hours after the procedure). They were randomized into one of two groups. Patients in the NAC group were given NAC 600mg orally twice a day, 4 doses in total; the first dose was given one day before the procedure. Patients in the control group were given placebo orally twice a day, 4 doses in total; the first dose was given one day before the procedure. SCC was assessed before hydration, 2 days after the procedure, and 5 days after the procedure. Radiocontrast-induced nephropathy (RCIN) was defined as a 25% rise from baseline or an absolute increase of 0.5mg/dL in SCC after the procedure. The primary end-point was risk of developing RCIN. Results. Twenty patients completed the study. There were no significant differences in age, sex, body mass index, blood pressure, duration of angiography, or mean volume of dye infused between the two groups. CCR did not change significantly in either group 2 days after angiography (NAC group 24.5±10.3 vs 29.6±10.6mL/min, N=11, p=0.34; control group 27.4±10.3 vs 29.6±10.6mL/min, N=9, p=0.57), or 5 days after angiography (NAC group 24.5±10.3 vs 27.4±11.8mL/min, N=11, p=0.40; control group 27.4±10.3 vs 24.2±8.8mL/min, N=9, p=0.43). None of the patients in the NAC group and five patients in the control group developed RCIN. The incidence of RCIN was lower in the NAC group (0% vs 56%, p=0.006, N=20). The average length of hospitalization was shorter in the NAC group (5.2 vs 8.1 days, p=0.04, N=20). None of the patients who developed RCIN required dialysis. Conclusion. NAC protects diabetic patients with renal dysfunction from iohexol-related RCIN after cardiac angiographic procedures.

Subtle renal dysfunction after radiocontrast administration in prospective renal donors: Does N-acetylcysteine have a role in its prevention?

<b>Background: </b> Radiographic contrast media (RCM) can cause a reduction in the renal function by multiple mechanisms; reactive oxygen species is one of them. Whether the reduction can be prevented by the administration of antioxidants is still debatable. <i> N</i> -acetylcysteine (NAC) has shown some benefit in patients with renal dysfunction in the prevention of radiocontrast-induced nephropathy (RCIN). <b> Materials and</b> <b> Methods</b> : We prospectively studied 95 healthy kidney donors, who were undergoing intravenous urography (IVU) followed by digital subtraction renal angiography (DSRA) with ionic, high-osmolar contrast agent for pretransplant evaluation. Patients were randomly assigned either to receive the <i> N</i> -acetylcysteine 600 mg orally twice daily (acetylcysteine group) or placebo (control group) on the day before and that of RCM administration in addition to the intravenous 0.45% saline (1 ml/kg body weight per hour) on the day and following day of the procedure. Serum creatinine, urinary enzymes <i> N</i>-acetyl β glucosaminidase (NAG), γ glutamyl-1-transferase (GGT), alanine amino peptidase (AAP), fractional excretion of sodium (FeNa) and 24-h urinary creatinine clearance were performed before and 48 h after the procedure. The levels of urinary enzymes measured after 96 h of DSRA were available in only 57 donors. Radiocontrast-induced nephropathy was defined as an increase in the baseline serum creatinine of at least 0.5 mg/dl within 48 h after injection of radiocontrast media (RCM). <b> Results: </b> Increase in the urinary enzymes (NAG, GGT and AAP) and reduction in creatinine clearance was observed in both groups after receiving the contrast media. However, the number of patients with significant increase in enzymuria (at least >50% increase above the baseline value) and mean drop in creatinine clearance was statistically not different between the acetylcysteine and control groups. <b> Conclusion:</b> Renal damage in the form of reduction in creatinine clearance and increase in urinary enzymes has been observed after administration of radiocontrast. However, clinically significant RCM-induced acute kidney injury is uncommon in patients with normal renal function. Prophylactic oral administration of the antioxidant <i> N</i> -acetylcysteine at a dose of 600 mg twice daily before and on the day of contrast administration is probably not required in patients with normal renal function.

Is radiocontrast-induced nephropathy avoidable? The scientific evidence in 2006

Abstract Due to the wide use of radiocontrast agents (RCA) in modern radiology and interventional cardiology, the incidence of radiocontrast-induced nephropathy (RCIN) is increasing. The risk factors for RCIN are primarily pre-existing (even mild) renal dysfunction, diabetes mellitus, absolute or relative hypovolemia, nephrotoxic drugs, etc., particularly in elderly patients. The presence of these risk factors seems to be more important than the type of contrast agent used. To date, there are several certainties and controversies in the prevention of RCIN. Hydration with normal saline and/or bicarbonate administration pre-and post-intervention is certainly useful. Though controversial, N-Acetylcysteine administration may be still advisable. Recent investigations showed the benefits of aminophylline/theophylline administration in RCA-induced renal tubular toxicity. Conventional hemodialysis cannot prevent RCIN, but may potentially aggravate renal dysfunction through hemodynamic instability. “High-flux” hemodialysis and hemodiafiltration may contribute efficiently to RCIN prevention, but systematic use of these modern dialysis techniques is limited by high costs and availability. The authors review — in a systematic manner, and in the perspective of evidence-based medicine — the most important data from literature concerning the prevention of RCIN.

Contrast-induced nephropathy: Pharmacological prophylaxis

Contrast media-associated acute renal failure represents the third most common cause of in-hospital renal function deterioration after decreased renal perfusion and post-operative renal insufficiency. Although generally benign, this complication is associated with a mortality rate ranging from 3.8 to 64%, depending on the increase of creatinine concentration. Multiple drugs have been tested in an attempt to prevent this complication. Central to the pathophysiology of contrast-induced nephrotoxicity (CIN) is an alteration in renal hemodynamics. In an effort to reverse these hemodynamic changes, vasodilators and diuretics have been tested as prophylactic drugs. However, their effectiveness has not been confirmed. Recently, considerable interest has resulted from the initial positive data on the effectiveness of prophylactic administration of antioxidant compounds, such as acetylcysteine and ascorbic acid. In this review, we focus on the effectiveness of pharmacologic therapies for preventing CIN.

Recent advances in the prevention of radiocontrast-induced nephropathy

Radiocontrast nephropathy is a serious clinical problem associated with increased morbidity and mortality, particularly in patients with chronic renal failure. The optimal strategy to prevent radiocontrast nephropathy has not been established. This article reviews recent clinical researches concerning new developments in the prevention of radiocontrast nephropathy and analyzes unresolved issues. Among all prophylactic measures that have been proposed, periprocedural hydration with isotonic saline has demonstrated effectiveness in the prevention of radiocontrast nephropathy. Thus, it remains the most frequently applied measure in clinical practice. Recently, additional benefit has been shown to derive from the infusion of isotonic alkalizing (sodium bicarbonate), instead of isotonic (sodium chloride) solutions. The use of nonionic low-osmolar and, more recently, nonionic iso-osmolar contrast agents has been demonstrated to significantly reduce the risk of radiocontrast nephropathy in patients with renal impairment, in comparison with hyperosmolar contrast media. Recently, periprocedural hemofiltration has emerged as a safe and very effective strategy to prevent radiocontrast nephropathy and to reduce its associated poor outcome in patients with severe chronic renal failure. In the past few years, several trials with acetylcysteine have shown conflicting results. Nevertheless, most of them indicated that acetylcysteine, particularly when associated with adequate hydration, might be useful in preventing radiocontrast nephropathy in patients with renal impairment. A possible dose-dependent protective effect has been suggested by more recent trials that included patients undergoing coronary interventional procedures requiring large contrast volume. Adequate prophylaxis is needed to reduce the high morbidity and mortality associated with radiocontrast nephropathy in high-risk patients. By reviewing the available evidence from clinical trials, this article provides an overview of current strategies and unresolved issues concerning the prevention of radiocontrast nephropathy.

N-acetylcysteine in the prevention of radiocontrast-induced nephropathy.

N-acetylcysteine is a remarkably active agent shown to be useful in a variety of clinical settings. The drug has actions relevant to radiocontrast-induced nephropathy (RCIN) that include vasodilatation, enhancement of renal medullary blood flow, and antioxidant properties. The drug's pharmacokinetics are remarkable for almost complete first pass metabolism after oral administration, resulting in no free drug reaching the circulation. After intravenous administration, extensive reaction with tissue and plasma proteins greatly limits the amount of circulating free drug. Given the difficulty achieving free drug in the systemic circulation, it is highly likely that the drug works via its metabolites. The primary mechanism may be through L-cysteine as a cellular source for glutathione production. Clinical studies of N-acetylcysteine in the prevention of RCIN have yielded highly mixed results; five were dramatically positive, and eight others had no demonstrable efficacy at all. The following will review the individual studies, attempt to reconcile the divergent results, and propose future research needs.

N-Acetylcysteine in the Prevention of Radiocontrast-Induced Nephropathy: Clinical Trials and End Points

N-acetylcysteine (NAC) has been suggested to prevent radiocontrast-induced nephropathy (RCIN) in patients with a reduced renal function. However, clinical studies have not been demonstrating this effect consistently. Also, reviews and meta-analyses dealing with the question of prevention of RCIN by NAC have been controversial. Nearly all investigators used serum creatinine as surrogate end point of their trials, and changes in serum creatinine concentrations are thought to reflect the extent of renal injury as primary outcome. In a recent study, an effect of NAC on creatinine values and estimated glomerular filtration rate without any effect on cystatin C levels has been shown in volunteers with a normal renal function. Therefore, before renal protective effects of NAC in RCIN are proposed, any direct effects of NAC on creatinine, urea, and estimated glomerular filtration rate should be addressed. In future trials, the glomerular filtration rate should preferentially be measured directly, or at least additional markers of the renal function (e.g., serum cystatin C) have to be assessed. Furthermore, additional ‘hard’ end points, i.e., hospital morbidity, mortality, or dialysis dependency, should be considered in the design of future studies of RCIN.

Prevention of radiocontrast-induced nephropathy.

Prevention of radiocontrast-induced nephropathy.

Role of N-acetylcysteine in the prevention of radiocontrast-induced nephropathy.

To examine the role of N-acetylcysteine (NAC) in the prevention of radiocontrast-induced nephropathy (RIN). A literature search of MEDLINE (1966-December 2001) was performed using the following search terms: N-acetylcysteine, nephropathy, acute renal failure, and radiocontrast. Pertinent English-language animal and human studies were reviewed. Few small animal trials have demonstrated that NAC significantly prevents the development or reduces the severity of acute renal failure. Two human studies demonstrated NAC significantly reduces the occurrence of RIN. NAC may reduce the occurrence of RIN in high-risk patients. Further large-scale studies are needed to corroborate findings from earlier trials.

Role of N-Acetylcysteine in the Prevention of Radiocontrast-Induced Nephropathy

OBJECTIVE:To examine the role of N-acetylcysteine (NAC) in the prevention of radiocontrast—induced nephropathy (RIN).DATA SOURCES:A literature search of MEDLINE (1966–December 2001) was performed using the following search terms: N-acetylcysteine, nephropathy, acute renal failure, and radiocontrast.STUDY SELECTION:Pertinent English-language animal and human studies were reviewed.DATA SYNTHESIS:Few small animal trials have demonstrated that NAC significantly prevents the development or reduces the severity of acute renal failure. Two human studies demonstrated NAC significantly reduces the occurrence of RIN.CONCLUSIONS:NAC may reduce the occurrence of RIN in high-risk patients. Further large-scale studies are needed to corroborate findings from earlier trials.

Prevention of radiocontrast-induced nephropathy by adenosine antagonists in rats with chronic nitric oxide deficiency.

To evaluate therapeutic options for the prevention of radiocontrast media (RCM)-induced nephropathy, a model was developed in which rats received NG-nitro-L-arginine methyl ester (L-NAME) for 10 wk in order to inhibit nitric oxide (NO) synthetase. This study tests the hypothesis that infusion of an adenosine antagonist before RCM application may avoid the vasoconstrictive response in NO-depleted rats. Rats received L-NAME for 10 wk orally (50 mg/L drinking water) to achieve NO depletion. Renal function was determined by [3H]inulin clearance for analysis of the GFR and by flowmetry for assessing renal blood flow (RBF). After a control clearance period (baseline clearance period), the renal response to RCM application (sodium diatrizoate, 2 ml/kg body wt) was measured two times every 30 min starting 30 min after RCM application (clearance periods 1 and 2). L-NAME rats and control rats received two adenosine antagonists. The nonselective adenosine antagonist theophylline was given as an initial bolus of 50 mumol/kg body wt within 10 min, followed by continuous infusion of 100 mumol/kg body wt per h, and the specific adenosine A1-receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine (DPCPX) was given as a bolus of 100 micrograms/kg body wt before RCM application. Results were compared with vehicle infusion. In the control group, no significant change of GFR or RBF could be detected after application of RCM with or without prior infusion of DPCPX or theophylline. In L-NAME rats, RBF decreased significantly after RCM application (baseline, 5.6 +/- 0.2 ml/min; first clearance period, 4.6 +/- 0.3 ml/min [P < 0.05]; second clearance period, 4.3 +/- 0.3 [P < 0.01]). GFR was also reduced in L-NAME rats without previous infusion of theophylline or DPCPX (baseline, 0.95 +/- 0.1 ml/min; first clearance period, 0.83 +/- 0.1 ml/min; second clearance period, 0.69 +/- 0.1 ml/min [P = 0.058]). Prior treatment with either theophylline or DPCPX resulted in complete protection against a decline of RBF and GFR induced by RCM in L-NAME rats. Rats with chronic NO blockade showed a significant increase of the renal vasoconstrictive effect of contrast media. Application of L-NAME in rats seems to constitute a suitable animal model to study the pathophysiology of radiocontrast media-induced nephropathy. In this animal model, administration of adenosine antagonists prevented the decline of GFR and RBF.

Induction and prevention of radiocontrast-induced nephropathy in dogs with heart failure

Radiocontrast-induced nephropathy (RCIN) is a clinically important cause of acute renal failure with no effective treatment. Recognizing the high incidence of RCIN in humans with severe congestive heart failure (CHF), this study was designed to test the hypotheses that dogs with experimental CHF are at increased risk for RCIN and that pharmacologic renal levels of atrial natriuretic factor (ANF) can prevent RCIN in this model. In chronic experiments, three groups of five conscious dogs received intravenous radiocontrast (7 ml/kg). One group consisted of normal controls, while the two other groups had experimental CHF induced by eight days of ventricular pacing at 250 beats per minute. One of the CHF groups received an infusion of ANF (30 ng/kg/min) into the suprarenal aorta for one hour before, during and after the infusion of radiocontrast to achieve pharmacologic renal plasma levels. Renal function remained stable in the normal controls in contrast to the consistent decreases in daily creatinine clearance during the five days following radiocontrast in experimental CHF. In addition, ANF prevented radiocontrast-induced reductions in creatinine clearance in dogs with experimental CHF. Additional studies performed in two groups of anesthetized dogs with experimental CHF demonstrated that, in this model of RCIN, the reduction in renal function appears biphasic, and the action of ANF may be to increase glomerular filtration rate prior to radiocontrast, thus allowing a maintenance of renal function during and after radiocontrast.