Elsevier

Heart & Lung

Volume 36, Issue 3, May–June 2007, Pages 195-204
Heart & Lung

Issues in cardiovascular nursing
Efficacy of N-acetylcysteine and hydration versus placebo and hydration in decreasing contrast-induced renal dysfunction in patients undergoing coronary angiography with or without concomitant percutaneous coronary intervention

https://doi.org/10.1016/j.hrtlng.2006.08.004Get rights and content

Objective

Contrast-induced renal dysfunction is an iatrogenic complication that occurs more frequently in patients with preexisting renal dysfunction. A prospective, double-blind, randomized, placebo, controlled trial was completed to assess the efficacy of N-acetylcysteine in decreasing the incidence of contrast-induced renal dysfunction in patients with an acute coronary syndrome and renal insufficiency who underwent coronary angiography with or without percutaneous coronary intervention.

Methods

With similar intravenous hydration protocols, 20 patients received N-acetylcysteine (treatment group) and 20 patients received placebo (control group) in a twice per day dosing regimen with one dose before and three doses after contrast media exposure.

Results

The two groups were similar at baseline on demographic and clinical characteristics, and preexisting renal insufficiency. Contrast-induced renal dysfunction, defined as an increase in serum creatinine greater than 44 μmol/L (.5 mg/dL) and/or 25% above baseline within 48 hours, occurred in 7.5% of the cohort, with 2.5% in the treatment group, and 5% in the control group, for an absolute difference of 2.5%. There was no difference in serum creatinine or creatinine clearance at 24 hours or at 48 hours between the treatment and control groups.

Conclusion

These results suggest that this cohort gained no added protection to renal function with the use of N-acetylcysteine.

Section snippets

Background

The toxic effects of contrast media have been known for more than half a century. Many studies have looked at the use of different treatment modalities to reduce the incidence or degree of renal impairment incurred with the use of contrast media in coronary angiography, including hydration, furosemide, dopamine, mannitol, calcium channel blockers, and atrial natriuretic peptide, as well as low and high osmolar contrast agents.8, 10, 11, 12, 13, 14, 15, 16, 17, 18 To date, no treatment modality

Purpose

The purpose of this study was to examine the efficacy of N-acetylcysteine and hydration in decreasing the incidence of CIRD in patients who present with an ACS. The hypotheses were that N-acetylcysteine and intravenous hydration would decrease the incidence of CIRD, attenuate the change in serum creatinine, and maintain or improve the level of creatinine clearance after contrast media exposure.

Design

A prospective, double-blind, randomized, placebo, controlled trial was used to assess the efficacy of oral N-acetylcysteine and intravenous hydration in decreasing the incidence of CIRD in patients admitted with an ACS and renal dysfunction who underwent risk stratification with coronary angiography with or without concomitant percutaneous coronary intervention (PCI). Patients received similar intravenous hydration of .45% normal saline at 1 mL/kg/h 4 to 6 hours before and 12 hours after

Screening and final study cohort

There were 132 patients screened for possible enrollment into the study. Of the patients screened, 19 were excluded on the basis of heart failure, 19 were risk stratified using methods other than coronary angiography, 18 declined participation, 17 underwent primary angiography, 5 were enrolled in another investigation at the time of screening, and 5 had a diagnosis of either dementia, inebriation, or encephalopathy, and were unable to give informed consent, 4 were unable to read or write

Discussion

The incidence of CIRD is typically 10% to 40% in patients who undergo coronary angiography with evidence of renal dysfunction.2, 3 On the basis of two definitions of CIRD, the incidence observed was 7.5% in this study cohort. The lower incidence of CIRD found at this institution can be attributed to the practices currently implemented for identified patients with renal dysfunction (alternative imaging techniques, use of third-generation contrast agents, and minimizing contrast volume during

Conclusion

The use of N-acetylcysteine in ACS was conducted over a 10-month period in patients with biochemical evidence of renal dysfunction undergoing coronary angiography with or without concomitant PCI. The use of N-acetylcysteine and intravenous hydration with .45% normal saline showed a trend toward decreasing the incidence of CIRD in this patient cohort. From the results of this study and a review of the current literature, several cohorts have been identified who require further investigations

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