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my personal edition > cardiology other > news
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DGReview
Pre-treatment With Acetylcysteine For Cardiac Catheterisation Reduces Contrast-Induced Nephropathy
A DGReview of :"Prophylaxis of contrast-induced nephropathy in patients undergoing coronary angiography"
Catheterization and Cardiovascular Interventions
12/05/2003
By Mohammad Ahmad, MD
Prophylactic administration of acetylcysteine reduces the development of contrast-induced nephropathy in patients with mild to moderate renal dysfunction prior to coronary angiography, say American researchers.
Contrast-induced nephropathy (CIN) is an important cause of acute renal failure in patients undergoing cardiac catheterisation. Prehydration and the use of low-osmolality contrast agents may prevent CIN. Evidence suggests that the use of acetylcysteine reduces the incidence of CIN in patients undergoing computed tomography (CT).
In a randomised, double blind trial, Briain D. MacNeill, MD, and colleagues from the Cardiology Division, Massachusetts General Hospital and Harvard Medical School in Boston, United States, examined the prophylactic efficacy of acetylcysteine in decreasing the incidence of CIN in elderly patients with mild to moderate renal insufficiency.
Researchers defined mild to moderate renal dysfunction as a serum creatinine (Cr) >/= 1.5 mg/dL while CIN was defined as a rise in serum creatinine of > 25% from baseline. Prior to cardiac catheterisation, all patients were treated with 0.45% saline at a rate of 1 mL/kg/hr for 12 hr for in-patients and 2 mL/kg/hr for 4 hr for day-case patients. Serum creatinine and urea were measured before and at 24, 48, and 72 hours after the procedure.
Twenty-one patients were randomised to 600 mg of acetylcysteine, and 22 patients to placebo. Each group received 2 doses - first at the time of randomisation, followed by the second dose 4 hours later. Catheterisation was carried out with non-ionic contrast agents (iopromide or ioxilan). The patients received 3 additional doses of acetylcysteine 600 mg or placebo at 12-hr intervals after the catheterisation. All patients received post catheterisation hydration with 0.45% saline at 75 mL/hr for 12 hr.
The results show no significant difference in baseline renal function between patients receiving acetylcysteine, or placebo. The serum creatinine levels remained unchanged in the acetylcysteine group (1.89 ± 0.38 at baseline to 1.90 ± 0.36 mg/dL at 72 hr) compared to the placebo (1.90 ± 0.36 at baseline to 2.38 ± 1.19 mg/dL at 72 hr).
By the 72 hours, CIN occurred in 1 out of 21 patients put on acetylcysteine compared to 7 of 22) patients in the placebo group (P = .046).
No adverse effect was observed in patients receiving acetylcysteine treatment. Serum creatinine levels at 48 and 72 hours remained constant in the acetylcysteine group but continued to rise at 48 and 72 hours in the placebo group.
The authors noted that CIN is a significant iatrogenic complication with profound effects on patient morbidity and mortality. Pre-existing renal dysfunction, particularly diabetic nephropathy, and advanced age may predispose to CIN.
The researchers concluded that the cumulative effect of the data from the present and earlier studies along with the safe pharmacological profile and relatively low cost of acetylcysteine tilts the balance further towards the uses of acetylcysteine in mild to moderate renal dysfunction patients undergoing cardiac catheterisation.
Cathet Cardiovasc Intervent 2003;60:4:458-461.
"Prophylaxis of contrast-induced nephropathy in patients undergoing coronary angiography"
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