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Sodium Bicarbonate Plus N-Acetylcysteine Prophylaxis

A Meta-Analysis

Jeremiah R. Brown, PhD^_*,,_*, Clay A. Block, MD, David J. Malenka, MD, Gerald T. O'Connor, PhD, ScD^_*, Anton C. Schoolwerth, MD, MSHA, Craig A. Thompson, MD, MMSc

^_* The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
Section of Nephrology and Hypertension, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
Section of Cardiology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
Department of Invasive Cardiology and Vascular Medicine, Yale University School of Medicine, New Haven, Connecticut

^_* Reprint requests and correspondence: Dr. Jeremiah R. Brown, Clinical Research Section, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756 (Email: jbrown{at}Dartmouth.edu).

Objectives: We sought to conduct a meta-analysis to compare N-acetylcysteine (NAC) in combination with sodium bicarbonate (NaHCO₃) 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 25% 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 NaHCO₃ 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 NaHCO₃ 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 NaHCO₃ 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.

Key Words: acute kidney injury • contrast • epidemiology • meta-analysis • renal pharmacology

Abbreviations and Acronyms   AKI = acute kidney injury   CI = confidence interval   NAC = N-acetylcysteine   NaHCO3 = sodium bicarbonate   PCI = percutaneous coronary interventions   RCT = randomized controlled trial   RR = relative risk   Cr = increase in serum creatinine

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