Elsevier

Annals of Vascular Surgery

Volume 21, Issue 5, September–October 2007, Pages 593-597
Annals of Vascular Surgery

Clinical Research
Prevention of Contrast-Induced Nephropathy in Vascular Surgery Patients

https://doi.org/10.1016/j.avsg.2007.07.006Get rights and content

Presently, only hydration and N-acetylcysteine have been shown to be effective in decreasing the incidence of radiographic contrast-induced nephropathy. We investigated the role of N-acetylcysteine and various hydration protocols in vascular surgery patients undergoing angiography. A single-center, randomized, placebo-controlled trial was conducted in patients with stable, preexisting renal dysfunction undergoing elective, outpatient angiography. Patients were randomized to outpatient oral hydration and N-acetylcysteine, inpatient hydration plus N-acetylcysteine, or our standard therapy of inpatient intravenous hydration alone. Two of twenty-eight (7%) patients who received outpatient oral hydration and N-acetylcysteine developed contrast-induced nephropathy, while two of 25 (8%) who recieved inpatient hydration plus N-acetylcysteine developed contrast-induced nephropathy and two of 25 (8%) who received standard therapy of inpatient intravenous hydration alone developed contrast-induced nephropathy. There was no statistical difference in incidence of contrast-induced nephropathy between the groups. No statistically significant independent risk factors were identified among the patients who developed contrast-induced nephropathy. N-Acetylcysteine did not confer additional benefit to patients treated with inpatient intravenous hydration. Outpatient oral hydration plus N-acetylcysteine was as effective at preventing contrast-induced nephropathy as inpatient therapies and avoided costly hospital admission.

Introduction

Radiographic contrast-induced nephropathy (CIN) is an established cause of iatrogenic acute renal dysfunction, and some degree of residual renal impairment is reported in up to 30% of those with CIN.1 Preventative measures to reduce the incidence of CIN are of great interest, and several randomized trials have demonstrated significant benefit of N-acetylcysteine (NAC) administration in reducing the incidence of CIN.2, 3 A trial in patients undergoing coronary angiography (approximately 180 mL contrast) revealed an 8% incidence of CIN in patients receiving NAC plus hydration versus a 45% incidence in patients receiving hydration alone.3 Since this publication the benefit of NAC has been debated, and two recent meta-analyses have been published which appear to support its use in patients with more severe renal dysfunction or when a complete hydration protocol is not possible.4, 5 The purpose of this study was to compare the incidence of CIN in vascular surgery patients who received outpatient oral hydration plus NAC with inpatient hydration plus NAC and our current standard therapy of inpatient intravenous (IV) hydration alone in patients with an element of chronic renal failure requiring catheter-based angiography.

Section snippets

Inclusion Criteria

Patients with preexisting renal impairment undergoing angiography for peripheral vascular disease and aneurysmal disease were prospectively randomized. This study received local ethics approval from the University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects. Patients with serum creatinine concentrations greater than 140 μmol/L or estimated creatinine clearance < 50 mL/min were eligible. Creatinine clearance (CrCl) was estimated on the basis of

Results

Patient demographics and baseline characteristics were similar between groups (Table I). CIN occurred in six of 78 patients for an overall incidence of 8%. CIN occurred in two of 25 patients (8%) who received NAC and IV hydration, two of 25 patients (8%) who received placebo plus IV hydration, and two of 28 patients (7%) who received NAC and oral hydration (Table II, Fig. 1). There were no significant differences between the groups. The mean creatinine concentration increased from 167 ± 46 to

Discussion

Acetylcysteine is a thiol-containing antioxidant that has been used to treat pulmonary disease and acute acetaminophen toxicity. It is well tolerated, may be administered orally or IV, and has very limited side effects (occasional gastrointestinal upset and urticaria). Its activity is thought to be related to its role as a free radical scavenger or as a reactive sulfhydryl compound that increases the reducing capacity of the cell.6 CIN is thought to occur because of the vulnerability of the

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Presented at the Twenty-seventh Annual Meeting of the Canadian Society for Vascular Surgery, Toronto, Ontario, Canada, September 9–10, 2005.

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