N-Acetylcysteine Plus Intravenous Fluids Versus Intravenous Fluids Alone to Prevent Contrast-Induced Nephropathy in Emergency Computed Tomography

• Published in: Annals of emergency medicine 2013-11, Vol.62 (5), p.511-520.e25
• Main Authors: Traub, Stephen J., MD, Mitchell, Alice M., MD, MS, Jones, Alan E., MD, Tang, Aimee, MD, O'Connor, Jennifer, BS, Nelson, Teresa, MS, Kellum, John, MD, Shapiro, Nathan I., MD, MPH
• Format: Article
• Language: English
• Subjects: Acetylcysteine - therapeutic use; Adult; Contrast Media - adverse effects; Double-Blind Method; Emergency; Female; Humans; Infusions, Intravenous; Isotonic Solutions - administration & dosage; Kidney Diseases - chemically induced; Kidney Diseases - prevention & control; Male; Sodium Bicarbonate - administration & dosage; Sodium Chloride - administration & dosage; Sodium Chloride - therapeutic use; Tomography, X-Ray Computed; Treatment Outcome
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2013.04.012

Study objective We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy. Methods The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT. Results The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval −4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids. Conclusion We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.