Sodium bicarbonate plus N-acetylcysteine prophylaxis: a meta-analysis

Abstract

Objectives: We sought to conduct a meta-analysis to compare N-acetylcysteine (NAC) in combination with sodium bicarbonate (NaHCO(3)) for the prevention of contrast-induced acute kidney injury (AKI).

Background: Contrast-induced AKI is a serious consequence of cardiac catheterizations and percutaneous coronary interventions (PCI). Despite recent supporting evidence for combination therapy, not enough has been done to prevent the occurrence of contrast-induced AKI prophylactically.

Methods: Published randomized controlled trial data were collected from OVID/PubMed, Web of Science, and conference abstracts. The outcome of interest was contrast-induced AKI, defined as a >or=25% or >or=0.5 mg/dl increase in serum creatinine from baseline. Secondary outcome was renal failure requiring dialysis.

Results: Ten randomized controlled trials met our criteria. Combination treatment of NAC with intravenous NaHCO(3) reduced contrast-induced AKI by 35% (relative risk: 0.65; 95% confidence interval: 0.40 to 1.05). However, the combination of N-acetylcysteine plus NaHCO(3) did not significantly reduce renal failure requiring dialysis (relative risk: 0.47; 95% confidence interval: 0.16 to 1.41).

Conclusions: Combination prophylaxis with NAC and NaHCO(3) substantially reduced the occurrence of contrast-induced AKI overall but not dialysis-dependent renal failure. Combination prophylaxis should be incorporated for all high-risk patients (emergent cases or patients with chronic kidney disease) and should be strongly considered for all interventional radio-contrast procedures.

Figure 1:. Study Selection.

Figure 2:. Contrast-Induced AKI.

Individual randomized controlled trials are listed in order by year of publication. Outcome is contrast-induced AKI. Figure 2A: contrast-induced AKI (25% relative increase in serum creatinine from baseline). Figure 2B: contrast-induced AKI (≥0.5 mg/dL increase in serum creatinine from baseline). Figure 2C: contrast-induced AKI (≥25% or ≥0.5 mg/dL increase in serum creatinine from baseline). CI: 95 percent confidence interval. The size of each square denotes the weight of each trial’s relative risk in calculating the combined relative risk. The diamond represents the combined relative risk at the center; opposing points of the diamond represent the 95% confidence intervals. Treatment: N-acetylcysteine plus sodium bicarbondate. AA: N-acetylcysteine plus ascorbic acid.

Figure 3:. Renal Failure Requiring Dialysis.

Individual randomized controlled trials are listed in order by year of publication. Outcome is dialysis. CI: 95 percent confidence interval. The size of each square denotes the weight of each trial’s relative risk in calculating the combined relative risk. The diamond represents the combined relative risk at the center; opposing points of the diamond represent the 95% confidence intervals. Treatment: N-acetylcysteine plus sodium bicarbondate. AA: N-acetylcysteine plus ascorbic acid.