Clinical ResearchPrevention of Contrast-Induced Nephropathy in Vascular Surgery Patients
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.
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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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Cited by (0)
Presented at the Twenty-seventh Annual Meeting of the Canadian Society for Vascular Surgery, Toronto, Ontario, Canada, September 9–10, 2005.