Issuu on Google+

JNEPHROL 2010 ; 23 ( 02 ) : 216 - 223

ORIGINAL ARTICLE

www.sin-italy.org/jnonline – www.jnephrol.com

Sodium bicarbonate in preventing contrast nephropathy in patients at risk for volume overload: a randomized controlled trial Ali Vasheghani-Farahani1, Gelareh Sadigh1, Seyed Ebrahim Kassaian1, Seyed Mohammad Reza Khatami2, Akbar Fotouhi3, Seyed Amirhossein Razavi1, Mohammad Ali Mansournia3, Ali Kazemisaeid1, Abbas Soleimani1, Hamid Reza Pourhosseini1, Mohammad Alidoosti1, Ali Mohammad Hajizeinali1, Kianoush Hoseini1, Ebrahim Nematipour1

Abstract

Introduction

Background: Sodium bicarbonate has been recently proposed as a prophylactic measure for the prevention of contrast-induced nephropathy (CIN). We aimed to compare the efficacy of the combination of sodium bicarbonate with half saline, and half saline alone in preventing CIN in patients having uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema. Methods: Seventy-two patients undergoing elective coronary angiography with a serum creatinine level ≥1.5 mg/dL who had uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema were prospectively enrolled in a single-center, double-blind, randomized, controlled trial from August 2007 to July 2008 and were assigned to either an infusion of sodium bicarbonate plus half saline (n=36) or half saline alone (n=36). The primary end point was an absolute (≥0.5 mg/dL) or relative (≥25%) increase in serum creatinine 48 hours after the procedure (CIN). Results: There were no significant differences between the groups regarding their baseline demographic and biochemical characteristics, as well as the underlying disease. A total of 6.1% of the patients receiving sodium bicarbonate plus half saline developed CIN as opposed to 6.3% of the patients in the half saline group, which was not statistically different (odds ratio = 0.97; 95% confidence interval, 0.13-7.3; p=1.0). Conclusion: The combination therapy of sodium bicarbonate plus half saline does not offer additional benefits over hydration with half saline alone in the prevention of CIN. Key words: Angiography, Complications, Contrast media, Kidney, Prevention 216

Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran - Iran 2 Department of Nephrology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran - Iran 3 Department of Epidemiology, Tehran University of Medical Sciences, Tehran - Iran 1

Contrast-induced nephropathy (CIN) is the third leading cause of hospital-acquired acute renal failure (1-6) which leads to prolonged hospitalization, acceleration toward end-stage renal disease (2, 6-12) and an inpatient mortality rate of 34% (13). Its reported incidence is less than 10% in patients with normal renal function, but it may be as high as 25% in patients with preexisting renal impairment or certain risk factors such as diabetes mellitus, congestive heart failure, advanced age or concurrent administration of nephrotoxic drugs (6, 14). A number of preventive measures have been proposed for CIN. It is clear that hydration is an effective preventive measure (1, 8, 14-16). Other prophylactic measures include dopamine, fenoldopam, mannitol, N-acetylcysteine, theophilline, sodium bicarbonate, hemofiltration, hemodialysis and use of low- or iso-osmolar contrast agents (1, 2-4, 6, 7, 1422). However, the results were often disappointing or inconclusive. Recently, urine alkalinization by sodium bicarbonate has been regarded as resulting in an impressive reduction of CIN when compared with isotonic saline in several randomized controlled trials (7, 8, 23-25); however, newer studies with larger sample sizes have not found sodium bicarbonate to be superior to saline hydration (9, 26-28). Most of these studies exclude patients with uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema due to the risk of volume overload. In the present single-center, double-blind, randomized, controlled trial, we attempted to investigate these patients who are at risk for volume overload, and compared the combination of sodium bicarbonate with half saline, and hydration with half saline for the prophylaxis of CIN after elective coronary angiography.

© 2010 Società Italiana di Nefrologia - ISSN 1121-8428


JNEPHROL 2010 ; 23 ( 02 ) : 216 - 223

Fig. 1 - Study flow chart. eGFR = estimated glomerular filtration rate (measured in ml/min per 1.73 m2); PCI = percutaneous coronary intervention.

Subjects and methods Study population Between August 2007 and July 2008, 2,392 candidates for coronary angiography at Tehran Heart Center were evaluated for eligibility to be included in the study. The eligible patients comprised individuals aged â&#x2030;Ľ18 years, with serum creatinine levels of at least 1.5 mg/dL within 2 weeks prior to the commencement of the study, having at least 1 of the following conditions: uncontrolled hypertension (treated systolic blood pressure >160 mm Hg, or diastolic blood pressure >100 mm Hg), compensated severe heart failure (ejection fraction <30% or New York Heart Association grades III-IV) or a previous history of pulmonary edema. The exclusion criteria included unstable serum creatinine (change in creatinine concentration of at least 0.5 mg/dL or 25% from creatinine measured prior to the study to that of the day of angiography [baseline creatinine]); previous history of dialysis; estimated glomerular filtration rate (eGFR)

<20 ml/min per 1.73 m2 (calculated with the 4-variable Modification of Diet and Renal Disease Study equation) (15); emergency catheterization; recent exposure to radiographic contrast agents (within 2 days prior to the study); allergy to contrast agent; pregnancy; administration of dopamine, mannitol, fenoldopam or N-acetylcysteine during the intended time of the study; need for continuous hydration therapy (e.g., sepsis); and multiple myeloma.

Randomization and intervention A total of 72 eligible patients (Fig. 1), who signed an informed consent for participation in the trial, were randomly divided into 1 of the 2 treatment groups via the balanced block randomization protocol. Prior to the study; 8 blocks, each containing 10 case numbers, were randomized through computerized randomization, so that half of the cases in each block constituted group 1 and the other half were group 2. The case numbers were given to the patients according to their entry time. The patients, physicians, laboratory staff and the epidemiologist who analyzed the data 217


Vasheghani-Farahani et al: Bicarbonate and contrast-induced nephropathy

were not aware of the intervention for each group. The patients assigned to group 1 received the solution containing 1,075 mL of 0.45% sodium chloride, and the patients in group 2 received the solution prepared by adding 75 mL of 8.4% sodium bicarbonate to 1 L of 0.45% sodium chloride. The solutions for each group were prepared by 1 of our nursing staff not involved in this study. The initial intravenous bolus was given at the rate of 3 ml/kg for 1 hour immediately before contrast injection, followed by an infusion of 1 ml/kg per hour for 6 hours after the procedure. For patients weighing more than 110 kg, the initial fluid bolus and drip was limited to doses administered to a patient weighing 110 kg. All types of diuretics were routinely withheld on the day of the procedure. The low-osmolar contrast agent iohexol (Omnipaque 350 mg I/mL; Amersham Health, Ireland), was used for all patients. Serum creatinine concentration was assessed on the day of angiography prior to hydration protocol (baseline creatinine) as well as on days 2 and 5 after the procedure. Urine pH measurement was performed before the procedure and after the angiography when the patients voided spontaneously. The Mehran risk score for predicting CIN was calculated with respect to several risk factors including the dose of contrast media, baseline eGFR, older age, hypotension, congestive heart failure, anemia, diabetes mellitus and the use of intra-aortic balloon pump (8, 29). This study was reviewed and approved by the review board and ethics committee of Tehran University of Medical Sciences, and was in adherence with the Declaration of Helsinki.

Outcomes and follow-up The primary outcome measure was the development of CIN, defined as an absolute (≥0.5 mg/dL) or relative (≥25%) increase over baseline creatinine 48 hours after the exposure to a contrast agent. The secondary outcome measures were duration of hospitalization and urine pH after the initial bolus. Since serum creatinine tends to peak 3-5 days after the exposure to a contrast agent (2, 17), the development of CIN on day 5 was additionally assessed.

Statistical analysis The continuous variables were summarized by either mean and standard deviation or median and quartile deviation, depending on the distribution of the data. The categorical variables were expressed as frequencies and percentages. The continuous variables were compared using Student’s independent t-test, and the categorical data were com218

pared using the chi-square test. Where needed, the MannWhitney U-test and Fisher exact test were employed instead. Odds ratios for the development of CIN, with 95% confidence intervals (95% CI), were calculated. Analysis of covariance was performed to examine the effects of potential confounding factors on the incidence of CIN. Before beginning the study, the sample size for the primary end point of CIN was calculated, assuming the development of CIN in 15% of the saline group and 5% of the sodium bicarbonate group on the basis of the previous data. Chisquare analysis showed that a sample size of 280 patients would be required to detect a statistically significant difference at the 5% level with a power of 80%. However, the study was terminated early with 72 patients mainly due to a slower than expected enrollment process.

Results Clinical characteristics Between August 2007 and July 2008, 72 patients were randomized to receive either half saline (n=36) or sodium bicarbonate plus half saline (n=36) (Fig. 1). There were protocol deviations: 3 patients with eGFR <20 ml/min per 1.73 m2 were enrolled in the study by mistake, and a total of 8 patients had an unstable serum creatinine. The overall follow-up rates were 97.2% and 94.4% in the half saline and bicarbonate groups, respectively. All of the patients were included in the analysis based on the intention-totreat principle. After the analysis, the 8 patients with unstable creatinine were excluded, and the analysis for the study end points was conducted. The clinical and biochemical characteristics of the patients in the 2 groups are given in Tables І and II. There was no significant difference between the 2 groups in the baseline characteristics. The mean volume of the contrast media was 123 ± 31 mL in the half saline group and 113 ± 33 mL in the bicarbonate group. The mean Mehran risk score was 8.2 ± 3.5 in the half saline group and 9.0 ± 4.7 in the bicarbonate group. The postcontrast data in the 2 groups are listed in Table III. Comparing urine pH before and after the procedure confirmed urinary alkalinization in both half saline (mean difference in pH -0.5; 95% CI, -0.8 to -0.2; p=0.001) and bicarbonate (mean difference in pH -0.8; 95% CI, -1.2 to -0.4; p=0.001) groups. Although the amount of urinary alkalinization was higher in the bicarbonate group, it was not significantly different from that of half saline group (mean difference in pH -0.27; 95% CI, -0.76 to +0.23; p=0.28).


JNEPHROL 2010 ; 23 ( 02 ) : 216 - 223

Contrast-induced nephropathy The percentage changes in creatinine concentration from the baseline to days 2 and 5 after contrast administration were not significantly different between the 2 groups (Tab. III). After the 2 groups were adjusted for baseline creatinine, the difference in creatinine concentration between the 2 groups on day 2 was -0.02 (95% CI, -0.2 to +0.1; p=0.816). Similarly, this difference was 0.23 (95% CI, -0.1 to +0.6, p=0.179) on day 5. The primary end point (CIN on day 2) occurred in 4 patients

(6.2%), 2 patients (6.3%) of whom were in the half saline group, and 2 (6.1%) were in the bicarbonate group; the difference was not statistically significant (odds ratio [OR] = 0.97; 95% CI, 0.13-7.32; p=1). Additionally, the incidence of CIN on day 5 as well as the total CIN on days 2 and 5 were not significantly different between the 2 groups (Tab. IV). No significant difference was observed in the incidence of CIN between the 2 groups, even after excluding the 8 patients with unstable creatinine from the primary analysis. The primary end point of CIN occurred in 3 patients: 2 (7.1%) in the half saline group and 1 (3.3%) in the sodium

TABLE I CLINICAL AND PROCEDURAL BASELINE CHARACTERISTICS OF THE PATIENTS Characteristics

Half saline (n=36)

Sodium bicarbonate plus half saline (n=36)

Age, mean (SD), years Age >75 years, no. (%) Women, no. (%) Weight, mean (SD), kg Systolic blood pressure, mean (SD), mm Hg Diastolic blood pressure, mean (SD), mm Hg Hypertension, no. (%) Ejection fraction, mean (SD), % Ejection fraction <45, no. (%) Compensated severe heart failure*, no. (%) History of pulmonary edema, no. (%) Uncontrolled hypertensionâ&#x20AC; , no. (%) Diabetes mellitus, no. (%) Acute coronary syndrome, n (%) Drugs, no. (%) Diuretics Loop diuretic Aspirin Calcium channel blocker Angiotensin-converting enzyme inhibitor Angiotensin II receptor blocker Aminoglycoside Volume of contrast media, mean (SD), mL Contrast >100 mL Contrast >200 mL

62.7 (11) 4 (11.4) 7 (19.4) 75.2 (8) 147.7 (17) 80 (8) 24 (70.6) 38.3 (13) 5 (15.2) 15 (42.9) 5 (13.9) 15 (45.5) 13 (38.2) 38 (53.5)

61.4 (9) 2 (5.6) 8 (22.2) 69.1 (16) 143.4 (30) 78.6 (10) 23 (65.7) 33.9 (10) 8 (29.6) 18 (58.1) 9 (25) 14 (43.8) 12 (33.3) 33 (46.5)

4 (23.5) 2 (11.8) 13 (76.5) 3 (17.6) 8 (47.1) 1 (5.9) 0 (0) 123 (31) 17 (48.6) 0 (0)

8 (47.1) 7 (41.2) 15 (88.2) 0 (0) 9 (52.9) 5 (29.4) 0 (0) 112 (33) 11 (30.6) 1 (2.8)

*Ejection fraction <30%, or New York Heart Association grade III-IV. â&#x20AC;  Treated systolic blood pressure >160 mm Hg, or diastolic blood pressure >100 mm Hg. 219


Vasheghani-Farahani et al: Bicarbonate and contrast-induced nephropathy

TABLE II BIOCHEMICAL BASELINE CHARACTERISTICS OF THE PATIENTS Characteristics

Half saline (n=36)

Sodium bicarbonate plus half saline (n=36)

Baseline creatinine, mean (SD), mg/dL

1.71 (0.45)

1.77 (0.52)

Baseline creatinine >2 mg/dL, no. (%)

5 (13.8)

5 (13.9)

Baseline creatinine >2.5 mg/dL, no. (%)

2 (5.5)

4 (11.1)

Baseline eGFR, mean (SD), ml/min per 1.73m²

44.2 (13)

42.7 (13)

Baseline serum sodium, mean (SD), mEq/L

135.1 (23)

138.9 (4)

Baseline serum potassium, mean (SD), mEq/L

4.6 (0.5)

4.5 (0.5)

Baseline serum BUN, mean (SD), mg/dL

59.7 (22)

61.3 (32)

8.1 (1)

7.9 (1)

Baseline urine pH, mean (SD)

5.31 (0.5)

5.40 (0.6)

Mehran risk score, mean (SD)

8.2 (3)

9 (5)

Score ≤5, no. (%)

7 (23.3)

7 (24.1)

Score 6 to 10, no. (%)

15 (50)

11 (37.9)

Score 11 to 16, no. (%)

7 (23.3)

7 (24.1)

Score ≥16, no. (%)

1 (3.3)

4 (13.8)

Baseline serum uric acid, mean (SD), mg/dL

BUN = blood urea nitrogen; eGFR = estimated glomerular filtration rate.

TABLE III POSTPROCEDURAL DATA OF THE PATIENTS Half saline (n=36)

Sodium bicarbonate plus half saline (n=36)

Mean difference (95% CI)

p Value

5.81 (0.9) 0.51 (0.8) 4.5 (3)

6.12 (1) 0.78 (1.2) 1.5 (5)

-0.31 (-0.77 to 0.14) -0.27 (-0.76 to 0.23) --

0.17 0.28 0.90

Percentage change in creatinine concentration from baseline To day 2 after contrast, mean (SD), % -0.68 (18) To day 5 after contrast, mean (SD), % -0.01 (26)

-2.06 (18) 6.2 (29)

+1.9 (-6.9 to 10.8) -6.2 (-19.5 to 7)

0.66 0.35

Percentage change in eGFR from baseline To day 2 after contrast, mean (SD), % To day 5 after contrast, mean (SD), %

8.8 (34) 0.01 (29)

-3.8 (-18.4 to 10.8) 7 (-7.9 to 21.9)

0.60 0.35

Urine PH after initial bolus, mean (SD) Change in urine PH, mean (SD) Duration of hospitalization, median (quartile deviation)

5.04 (24) 6.09 (33)

95% CI = 95% confidence interval; eGFR = estimated glomerular filtration rate. 220


JNEPHROL 2010 ; 23 ( 02 ) : 216 - 223

TABLE IV INCIDENCE OF CIN IN STUDY PATIENTS Half saline (n=36) Serum creatinine, â&#x2030;Ľ0.5 mg/dL or â&#x2030;Ľ25% increase On day 2 after angiography, no. (%) On day 5 after angiography, no. (%) On days 2 and 5 after angiography, no. (%)

2 (6.3) 4 (11.4) 4 (13.9)

Sodium bicarbonate plus half saline (n=36)

Odds ratio (95% CI)

p Value

2 (6.1) 4 (11.8) 5 (14.3)

0.97 (0.13-7.3) 1.03 (0.24-4.5) 1.03 (0.27-3.94)

1 1 1

95% CI = 95% confidence interval; CIN = contrast-induced nephropathy.

bicarbonate group (OR=0.45; 95% CI, 0.04-5.24; p=0.605). Furthermore, an assessment of CIN based on creatinine on day 5 demonstrated no significant difference between the 2 groups (6.7% half saline vs. 12.9% bicarbonate, OR=2.0; 95% CI, 0.3-12.2; p=0.671).

Discussion To our knowledge, this is the first randomized controlled trial to investigate the preventive strategies for CIN in a group of patients who were at risk for volume overload. Additionally, in the present study we compared the additive effect of the 2 strategies of CIN prevention (urine alkalinization and saline hydration) in 1 arm, and hydration alone with saline in another arm, in patients undergoing elective coronary angiography. The results of the present study suggest no significant difference in the development of CIN as defined by 2 end points, between the treatment groups. The primary end point (CIN on day 2) occurred in 6.3% of the patients randomized to receive half saline and in 6.1% of those randomized to receive sodium bicarbonate plus half saline. CIN pathogenesis is not well understood. In a recent study, Merten et al suggested that alkalizing renal tubular fluid with sodium bicarbonate might reduce the injury, given the fact that free radical formation was prompted by an acidic environment (7). Although 4 other studies on patients undergoing elective or emergency coronary procedures supported this alkalizing hypothesis (8, 23-25), the 4 recently published large trials (9, 26-28) demonstrated no benefit of sodium bicarbonate over saline. In most of these trials a 154 mEq/L infusion of sodium bicarbonate was administered in the bicarbonate group as a bolus of 3 ml/kg 1 hour before contrast, followed by an infusion of 1 ml/kg per hour for 6 hours after the procedure (protocol of Merten et al)

(7). Moreover, a cohort study in 7,977 patients at the Mayo Clinic showed an increasing risk of developing CIN in patients who received bicarbonate alone compared with the no-treatment group (10). Among all of the patients who undergo coronary angiography, patients with uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema are at high risk of volume overload; therefore, hydration with saline as well as sodium bicarbonate should be used with caution (30). On the other hand, more potent intravascular volume expansion and inhibition of the renin-angiotensin pathway may be achieved by higher sodium concentration with isotonic sodium chloride solution (12). As a result, nearly all of the previous trials have excluded this group of patients. Only an evidence-based study by Merten et al has suggested an infusion of 0.6 ml/kg from an injectable ampule of NaHCO3 (50 mEq/50 mL) 10 to 20 minutes before the procedure followed by postprocedure urinary alkalinization as in the protocol of Merten et al in patients who are volume overloaded (31). Although Mueller et al in a trial in 1,620 patients found a superiority of isotonic saline hydration over half saline in preventing CIN (12), no subgroup analysis was performed in patients with volume overload. Based on a general consensus, hypotonic solutions are used as a hydration therapy for patients with volume overload. In the current study, we postulated that an isotonic solution of sodium bicarbonate with sodium chloride would have a greater benefit than either hypotonic sodium chloride or sodium bicarbonate alone. We used half saline as baseline hydration regimen. Moreover, the sodium content of sodium bicarbonate was halved in the present study compared with that in the protocol of Merten et al. As a result, the bicarbonate solution had a higher sodium concentration and tonicity apart from 221


Vasheghani-Farahani et al: Bicarbonate and contrast-induced nephropathy

its alkalinization properties, when compared with the half saline solution; therefore, it was hypothesized to be more nephroprotective. Additionally, our study had the advantage of checking the incidence of CIN both on day 2 and 5. We utilized the Mehran risk score (29) to estimate the nephropathy risk. Most patients enrolled in our trial had a medium risk score. The mean risk score was 8.6 ± 4.1, with an expected 14% CIN risk. Although the change in urine pH shows more urine alkalinization in the sodium bicarbonate group, the amount of alkalinization in the bicarbonate group is not significantly different from that of half saline group (0.78 vs. 0.51; 95% CI, -0.76 to +0.23; p=0.28). This may be either the result of the small sample size of the present study or the lower dose of sodium bicarbonate administered compared that in previous studies. The predominance of the negative range of confidence intervals is in favor of the first hypothesis. Additionally, a previous study of the present authors (28) has shown significant urine alkalinization in the bicarbonate group after infusion of the same amount of bicarbonate; however, these patients were not suffering from an underlying disease, which causes volume overload. Comparing CIN incidence on day 2 in the present study (6.2%) with that expected from Mehran risk scores (14%), shows that less CIN has occurred in the present study. However, the total CIN incidence on days 2 and 5 was 14.1%. This was consistent with the incidence of CIN during a 4-day postprocedural period in a previous study by Brar et al in patients with moderate to severe chronic kidney disease having at least 1 risk factor (26). Our study shows that if assessments for detecting CIN are limited to the first 48 hours, some of the CIN-positive patients will be missed. Even though our study could not show urine alkalinization in the bicarbonate group, which according to our hypothesis is mainly due to the insufficient statistical power of the present study, it seems that the combination of so-

References 1.

2.

222

Habeb M, Ağaç MT, Aliyev F, Pehlivanoğlu S, Ongen Z. Contrast media-induced nephropathy: clinical burden and current attempts for prevention. Anadolu Kardiyol Derg. 2005;5:124-129. McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008;51:1419-1428.

dium bicarbonate and half saline has no superiority over routine hydration therapy. Therefore, considering sodium bicarbonate as a prophylactic treatment for the prevention of CIN is premature. The small sample size of patients participating in the present study is a major limitation of our study. Although our institution is a referral hospital, the number of patients meeting the inclusion criteria during the 1-year period of the study was only 80, of whom 8 refused to participate. Further studies with larger sample sizes in multiple patient groups are recommended to evaluate the advantages or disadvantages of sodium bicarbonate over saline and to determine the amount of alkalinization and best hydration protocol appropriate for preventing CIN.

Conclusion The addition of sodium bicarbonate to half saline did not show any advantage over hydration with half saline for the prevention of CIN in patients with uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema undergoing elective coronary angiography. However, this was the result of a small sample sized study. Further investigations are recommended.

Financial support: This research was supported by Tehran University of Medical Sciences grant number 85-02-30-3595(2). Conflict of interest statement: None declared.

Address for correspondence: Seyed Mohammad Reza Khatami, MD Department of Nephrology Tehran Heart Center North Kargar Ave. 14117-13138 Tehran, Iran khatamis@sina.tums.ac.ir

3.

4. 5.

Sanaei-Ardekani M, Movahed MR, Movafagh S, Ghahramani N. Contrast-induced nephropathy: a review. Cardiovasc Revasc Med. 2005;6:82-88. Lin J, Bonventre JV. Prevention of radiocontrast nephropathy. Curr Opin Nephrol Hypertens. 2005;14:105-110. Schmidt P, Pank D, Nykamp D, Knowlton G, Jia H. N-Acetylcysteine and sodium bicarbonate versus N-acetylcysteine


JNEPHROL 2010 ; 23 ( 02 ) : 216 - 223

6.

7.

8.

9.

10.

11.

12.

13. 14.

15.

16.

17.

18.

19.

20.

and standard hydration for the prevention of radiocontrastinduced nephropathy following coronary angiography. Ann Pharmacother. 2007;41:46-50. Kelly AM, Dwamena B, Cronin P, Bernstein SJ, Carlos RC. Meta-analysis: effectiveness of drugs for preventing contrastinduced nephropathy. Ann Intern Med. 2008;148:284-294. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291:2328-2334. Ozcan EE, Guneri S, Akdeniz B, et al. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrastinduced nephropathy: a comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures: a single-center prospective controlled trial. Am Heart J. 2007;154:539-544. Maioli M, Toso A, Leoncini M, et al. Sodium bicarbonate versus saline for the prevention of contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. J Am Coll Cardiol. 2008;52:599-604. From AM, Bartholmai BJ, Williams AW, Cha SS, Pflueger A, McDonald FS. Sodium bicarbonate is associated with an increased incidence of contrast nephropathy: a retrospective cohort study of 7977 patients at Mayo Clinic. Clin J Am Soc Nephrol. 2008;3:10-18. Pannu N, Wiebe N, Tonelli M; Alberta Kidney Disease Network. Prophylaxis strategies for contrast-induced nephropathy. JAMA. 2006;295:2765-2779. Mueller C, Buerkle G, Buettner HJ, et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002;162:329-336. Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality: a cohort analysis. JAMA. 1996;275:1489-1494. Marenzi G, Bartorelli AL. Recent advances in the prevention of radiocontrast-induced nephropathy. Curr Opin Crit Care. 2004;10:505-509. Fauci AS, Braunwald E, Kasper DL, et al. Harrisonâ&#x20AC;&#x2122;s principles of internal medicine. 17th ed. New York: McGraw-Hill; 2008:260-270, 1759. Barreto R. Prevention of contrast-induced nephropathy: the rational use of sodium bicarbonate. Nephrol Nurs J. 2007;34:417-421. Asif A, Garces G, Preston RA, Roth D. Current trials of interventions to prevent radiocontrast-induced nephropathy. Am J Ther. 2005;12:127-132. Assadi F. Acetazolamide for prevention of contrast-induced nephropathy: a new use for an old drug. Pediatr Cardiol. 2006;27:238-242. Maeder M, Klein M, Fehr T, Rickli H. Contrast nephropathy: review focusing on prevention. J Am Coll Cardiol. 2004;44:1763-1771. Cavusoglu E, Chhabra S, Marmur JD, Kini A, Sharma SK. The prevention of contrast-induced nephropathy in patients

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

undergoing percutaneous coronary intervention. Minerva Cardioangiol. 2004;52:419-432. Morcos SK. Prevention of contrast media-induced nephrotoxicity after angiographic procedures. J Vasc Interv Radiol. 2005;16:13-23. Iyisoy A, Celik T, Yuksel UC, Bugan B, Isik E. The value of hydration and acetylcysteine in the prevention of contrastinduced nephropathy: a potentially catastrophic complication of the percutaneous coronary interventions. Int J Cardiol. 2009;134:431-433. Briguori C, Airoldi F, Dâ&#x20AC;&#x2122;Andrea D, et al. Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies. Circulation. 2007;115:1211-1217. Masuda M, Yamada T, Mine T, et al. Comparison of usefulness of sodium bicarbonate versus sodium chloride to prevent contrast-induced nephropathy in patients undergoing an emergent coronary procedure. Am J Cardiol. 2007;100:781-786. Recio-Mayoral A, Chaparro M, Prado B, et al. The renoprotective effect of hydration with sodium bicarbonate plus N-acetylcysteine in patients undergoing emergency percutaneous coronary intervention: the RENO Study. J Am Coll Cardiol. 2007;49:1283-1288. Brar SS, Shen AY, Jorgensen MB, et al. Sodium bicarbonate vs sodium chloride for the prevention of contrast mediuminduced nephropathy in patients undergoing coronary angiography: a randomized trial. JAMA. 2008;300:1038-1046. Adolph E, Holdt-Lehmann B, Chatterjee T, et al. Renal Insufficiency Following Radiocontrast Exposure Trial (REINFORCE): a randomized comparison of sodium bicarbonate versus sodium chloride hydration for the prevention of contrast-induced nephropathy. Coron Artery Dis. 2008;19:413-419. Vasheghani-Farahani A, Sadigh G, Kassaian SE, et al. Sodium bicarbonate plus isotonic saline versus saline for prevention of contrast-induced nephropathy in patients undergoing coronary angiography: a randomized controlled trial. Am J Kidney Dis. 2009;54:610-618. Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44:1393-1399. Barreto R. Prevention of contrast-induced nephropathy: the rational use of sodium bicarbonate. Nephrol Nurs J. 2007;34:417-421. Merten GJ, Burgess WP, Rittase RA, Kennedy TP. Prevention of contrast-induced nephropathy with sodium bicarbonate: an evidence-based protocol. Crit Pathw Cardiol. 2004;3:138-143.

Received: April 09, 2009 Revised: June 26, 2009 Accepted: July 24, 2009

223


Edema pulmonar iii