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No benefit with use of periprocedural sodium bicarbonate or acetylcysteine in patients with CKD and angiography
Clinical Question
Does the use of sodium bicarbonate or acetylcysteine prevent death, need for dialysis, or worsening kidney function following angiography in patients with chronic kidney disease?
Bottom line
This study found no benefit of using periprocedural sodium bicarbonate or acetylcysteine to prevent death or worsening kidney function in patients with chronic kidney disease (CKD) who are undergoing angiography. Most of the patients in the trial underwent diagnostic angiography so the volume of contrast used was small and may have resulted in lower-than-predicted event rates. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
Patients with stage 3 or stage 4 CKD who were undergoing angiography were randomized, using concealed allocation and a 2-by-2 factorial design, to receive either intravenous 1.26% sodium bicarbonate or intravenous 0.9% sodium chloride in 1 liter bags and either oral acetylcysteine capsules or matched placebo. The fluid was administered for up to 12 hours prior to angiography, continued during angiography, and maintained for up to 12 hours following angiography. The acetylcysteine or matching placebo was given as 1200-mg capsules 1 hour before and 1 hour after angiography and then twice daily for 4 days after the procedure. Almost 5000 patients were included in the modified intention-to-treat analysis, which included all patients who received the trial interventions whether or not they underwent angiography. Enrollment in the trial was stopped early due to absence of difference in the groups at a pre-planned interim analysis. Baseline characteristics were fairly similar in the 4 treatment combination groups. Ninety percent of the patients in the trial received coronary angiography with only one third of those receiving further percutaneous intervention. Median volume of contrast received was 85 mL. For the primary endpoint of death, need for dialysis, or a persistent increase in baseline creatinine level by 50% at 90 days, there was no significant difference between the sodium bicarbonate and sodium chloride groups or between the acetylcysteine and placebo groups. Contrast-induced acute kidney injury occurred in similar frequencies in all groups with no differences between the specified comparisons.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
L’information est pratique mais les habitudes prennent du temps à changer surtout s’il l’habitude ne cause pas de mauvais effets.
so it is all due to the state of hydration?
Using of contrasts in patients with CKD is a major problom I beleave in most of cases can be avoided specially on spine MRI but I have a feeling if you give patients with normal kidney lot water to drink before and for one week after gadlenum they likely won't develop CKD I beleave same apply for iodine
The need for contrast and renal damage effects totally increases our need for more expedient access to MRI for our patients.
The axiom of do no harm.
This info is only relevant for radiologists.If they do not believe it,there is nothing the ordering physician can do about it.
finally evidence based re-assess guideline rather than following " traditional " guidelines without proper clinical scientific evidence : chapeau !
Good poem
Decision taken by Radiologists
It sounds as if fluid in general is what is important.
I think this is important as the cost of using the other agents is not negligible.
It is not clear what happens if we need to give a lot more that small doses of diagnostic contrast...ie. during bigger procedures?
The IVF used were significant and would need to be watched closely from what I can tell.
Excellent