View source for Contrast-induced nephropathy

{{subpages}}
In [[medicine]], '''contrast-induced nephropathy''' is [[acute kidney injury]] from [[radiocontrast]]. It is defined as either a greater than 25% increase of serum creatinine or an absolute increase in serum creatinine of 0.5 mg/dL.<ref name="pmid16436769">{{cite journal |author=Barrett BJ, Parfrey PS |title=Clinical practice. Preventing nephropathy induced by contrast medium |journal=N. Engl. J. Med. |volume=354 |issue=4 |pages=379–86 |year=2006 |pmid=16436769 |doi=10.1056/NEJMcp050801}}</ref>

==Who is at risk?==
Factors associated with an increased risk of contrast-induced nephropathy are:<ref name="pmid9375704">{{cite journal | author=McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW | title=Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality | journal=Am J Med | year=1997 | pages=368-75 | volume=103 | issue=5  | id=PMID 9375704}}</ref><ref name="pmid10334456">{{cite journal | author=Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell RO Jr, Ryan TJ, Smith SC Jr | title=ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions | journal=J Am Coll Cardiol | year=1999 | pages=1756-824 | volume=33 | issue=6  | id=PMID 10334456}}</ref>
* dose of [[radiocontrast]] more than 5 x body weight [kg])/serum creatinine<ref>{{Cite journal | volume = 150 | issue = 3 | pages = 170-177 | last = Marenzi | first = Giancarlo | coauthors = Emilio Assanelli, Jeness Campodonico, Gianfranco Lauri, Ivana Marana, Monica De Metrio, Marco Moltrasio, Marco Grazi, Mara Rubino, Fabrizio Veglia, Franco Fabbiocchi, Antonio L. Bartorelli
| title = Contrast Volume During Primary Percutaneous Coronary Intervention and Subsequent Contrast-Induced Nephropathy and Mortality
| journal = Ann Intern Med | accessdate = 2009-02-03 | date = 2009-02-03
| url = http://www.annals.org/cgi/content/abstract/150/3/170 }}</ref>
* preexisting [[renal insufficiency]] (such as [[Creatinine clearance]] < 60 mL/min [1.00 mL/s] - [http://www.intmed.mcw.edu/clincalc/creatinine.html online calculator])
* preexisting [[diabetes]]
* reduced intravascular volume

A [[clinical prediction rule]] is available to estimate probability of nephropathy (increase =25% and/or =0.5 mg/dl in serum creatinine at 48 h)<ref name="pmid15464318">{{cite journal |author=Mehran R, Aymong ED, Nikolsky E, ''et al'' |title=A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation |journal=J. Am. Coll. Cardiol. |volume=44 |issue=7 |pages=1393–9 |year=2004 |pmid=15464318 |doi=10.1016/j.jacc.2004.06.068}}</ref>:

Risk Factors:
* Systolic blood pressure <80 mm Hg - 5 points
* Intraarterial balloon pump - 5 points
* Congestive [[heart failure]] (Class III-IV or history of pulmonary edema)  - 5 points
* Age >75 y - 4 points
* Hematocrit level <39% for men and <35% for women - 3 points
* Diabetes - 3 points
* [[Radiocontrast]] media volume - 1 point for each 100 mL
* Renal insufficiency:
** Serum creatinine level >1.5 g/dL - 4 points
:: or
:* Estimated [[Glomerular filtration rate]] ([http://www.intmed.mcw.edu/clincalc/creatinine.html online calculator])
::* 2 for 40–60 mL/min/1.73 m2
::* 4 for 20–40 mL/min/1.73 m2
::* 6 for < 20 mL/min/1.73 m2

Scoring:<br>
5 or less points
*Risk of CIN - 7.5
*Risk of Dialysis - 0.04%
6–10 points
*Risk of CIN - 14.0
*Risk of Dialysis - 0.12%
11–16 points
*Risk of CIN - 26.1*
*Risk of Dialysis - 1.09%
>16 points
*Risk of CIN -  57.3
*Risk of Dialysis -  12.8%

==Prevention==
To minimize the risk for contrast-induced nephropathy, various actions can be taken if the patient has predisposing conditions. A [[meta-analysis]] suggests "High-dose [[statin]]s plus hydration with or without [[N-acetylcysteine|NAC]] might be the preferred treatment strategy to prevent contrast-induced". <ref name="pmid27707552">{{cite journal| author=Su X, Xie X, Liu L, Lv J, Song F, Perkovic V et al.| title=Comparative Effectiveness of 12 Treatment Strategies for Preventing Contrast-Induced Acute Kidney Injury: A Systematic Review and Bayesian Network Meta-analysis. | journal=Am J Kidney Dis | year= 2016 | volume=  | issue=  | pages=  | pmid=27707552 | doi=10.1053/j.ajkd.2016.07.033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27707552  }} </ref> A separate [[meta-analysis]] addresses interventions in for emergent patients with baseline renal insufficiency.<ref name="pmid17512638">{{cite journal |author=Sinert R, Doty CI |title=Evidence-based emergency medicine review. Prevention of contrast-induced nephropathy in the emergency department |journal=Annals of emergency medicine |volume=50 |issue=3 |pages=335-45, 345.e1-2 |year=2007 |pmid=17512638 |doi=10.1016/j.annemergmed.2007.01.023}}</ref>

====Choice of radiocontrast agent====
Iso-osmolar, nonionic [[radiocontrast]] media may be the best according to a [[randomized controlled trial]].<ref name="pmid12571256">{{cite journal |author=Aspelin P, Aubry P, Fransson S, Strasser R, Willenbrock R, Berg K |title=Nephrotoxic effects in high-risk patients undergoing angiography |journal=N Engl J Med |volume=348 |issue=6 |pages=491-9 |year=2003 |pmid=12571256}}</ref>

Hypo-osmolar, non-ionic [[radiocontrast]] agents are beneficial if iso-osmolar, nonionic contrast media is not available due to costs.<ref name="pmid2643042">{{cite journal |author=Schwab S, Hlatky M, Pieper K, Davidson C, Morris K, Skelton T, Bashore T |title=Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic radiographic contrast agent |journal=N Engl J Med |volume=320 |issue=3 |pages=149-53 |year=1989 |pmid=2643042}}</ref>

====Hydration with or without bicarbonate====
The roles of sodium bicarbonate administration to prevent acute kidney injury is not clear according to a [[systematic revie]]ws of [[randomized controlled trial]]s.<ref name="pmid19884624">{{cite journal| author=Zoungas S, Ninomiya T, Huxley R, Cass A, Jardine M, Gallagher M et al.| title=Systematic review: sodium bicarbonate treatment regimens for the prevention of contrast-induced nephropathy. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 9 | pages= 631-8 | pmid=19884624 
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19884624 | doi=10.1059/0003-4819-151-9-200911030-00008 }}</ref><ref name="pmid19713291">{{cite journal| author=Brar SS, Hiremath S, Dangas G, Mehran R, Brar SK, Leon MB| title=Sodium bicarbonate for the prevention of contrast induced-acute kidney injury: a systematic review and meta-analysis. | journal=Clin J Am Soc Nephrol | year= 2009 | volume= 4 | issue= 10 | pages= 1584-92 | pmid=19713291 
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19713291 | doi=10.2215/CJN.03120509 | pmc=PMC2758263 }}</ref> Heterogeneous, conflicting trial results may be due to publication bias with the smaller, less rigorous trials showing benefit.<ref name="pmid19884624"/><ref name="pmid19713291"/>

A common regimen is three 50 ml ampules of bicarbonate in 850 ml of water with 5% dextrose. The renoprotective effects of bicarbonate are thought to be due to urinary alkalinization, which creates an environment less amenable to the formation of harmful [[free radicals]].<ref name="pmid11822926">{{cite journal |author=Mueller C, Buerkle G, Buettner H, Petersen J, Perruchoud A, Eriksson U, Marsch S, Roskamm H |title=Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty |journal=Arch Intern Med |volume=162 |issue=3 |pages=329-36 |year=2002 |pmid=11822926}}</ref>.

A [[meta-analysis]] is available, but does not include all the studies in the evidence table below.<ref name="pmid18926598">{{cite journal |author=Sinert R, Doty CI |title=Update: Prevention of contrast-induced nephropathy in the emergency department |journal=Ann Emerg Med |volume=54 |issue=1 |pages=e1–5 |year=2009 |month=July |pmid=18926598 |doi=10.1016/j.annemergmed.2008.08.014 |url=http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(08)01638-7 |issn=}}</ref>

{| class="wikitable"
|+ Randomized controlled trials of sodium bicarbonate<ref name="pmid15150204">{{cite journal |author=Merten G, Burgess W, Gray L, Holleman J, Roush T, Kowalchuk G, Bersin R, Van Moore A, Simonton C, Rittase R, Norton H, Kennedy T |title=Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial |journal=JAMA |volume=291 |issue=19 |pages=2328-34 |year=2004 |pmid=15150204}}</ref><ref name="pmid17309916">{{cite journal |author=Briguori C, Airoldi F, D'Andrea D, Bonizzoni E, Morici N, Focaccio A, Michev I, Montorfano M, Carlino M, Cosgrave J, Ricciardelli B, Colombo A |title=Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies |journal=Circulation |volume=115 |issue=10 |pages=1211-7 |year=2007 |pmid=17309916}}</ref><ref name="pmid17719320">{{cite journal |author=Masuda M, Yamada T, Mine T, ''et al.'' |title=Comparison of usefulness of sodium bicarbonate versus sodium chloride to prevent contrast-induced nephropathy in patients undergoing an emergent coronary procedure |journal=Am. J. Cardiol. |volume=100 |issue=5 |pages=781–6 |year=2007 |month=September |pmid=17719320 |doi=10.1016/j.amjcard.2007.03.098 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(07)01040-5 |issn=}}</ref><ref name="pmid18702961">{{cite journal |author=Maioli M, Toso A, Leoncini M, ''et al'' |title=Sodium bicarbonate versus saline for the prevention of contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention |journal=Journal of the American College of Cardiology |volume=52 |issue=8 |pages=599–604 |year=2008 |month=August |pmid=18702961 |doi=10.1016/j.jacc.2008.05.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(08)01941-4 |issn=}}</ref><ref name="pmid18768415">{{cite journal |author=Brar SS, Shen AY, Jorgensen MB, ''et al'' |title=Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial |journal=JAMA : the journal of the American Medical Association |volume=300 |issue=9 |pages=1038–46 |year=2008 |month=September |pmid=18768415 |doi=10.1001/jama.300.9.1038 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18768415 |issn=}}</ref><ref name="pmid21349483">{{cite journal| author=Ueda H, Yamada T, Masuda M, Okuyama Y, Morita T, Furukawa Y et al.| title=Prevention of contrast-induced nephropathy by bolus injection of sodium bicarbonate in patients with chronic kidney disease undergoing emergent coronary procedures. | journal=Am J Cardiol | year= 2011 | volume= 107 | issue= 8 | pages= 1163-7 | pmid=21349483 | doi=10.1016/j.amjcard.2010.12.012 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21349483  }} </ref>
! rowspan="2"| Study name or<br/>first author!!rowspan="2"| Patients!!rowspan="2"| Intervention!!colspan="3"|Primary outcomes!!rowspan="2"|Conclusion
|-
! Definition!!Rate in intervention group!!Rate in controlgroup
|-
| Merten (2004)<ref name="pmid15150204"/> || 119 patients with kidney disease (serum creatinine at least 1.1 mg/dL). Mean [[glomerular filtration rate|GFR]] was 41 mL/min per 1.73 m<sup>2</sup>||&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1 mL/kg per hour for 6 hours during and after contrast||<u>></u> 25% rise in serum creatinine within 2 days||1.7%||13.6%||Bicarb is beneficial
|-
| Masuda (2007)<ref name="pmid17719320"/>|| 59 patients undergoing emergent coronary angiography||&bull; 3 mL/kg per hour for 1 hour before  contrast<br/>&bull; 1 mL/kg per hour for 6 hours during and after contrast<br/>Controls received isotonic saline:<br/>&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1 mL/kg per hour for 6 hours during and after contrast||  >0.5 mg/dl or > 25% rise in serum creatinine within 2 days||7%||35%||Bicarb is beneficial
|-
| REMEDIAL (2007)<ref name="pmid17309916"/>|| 219 patients with kidney disease (serum creatinine at least 2.0 mg/dL or [[glomerular filtration rate|GFR]] 40 mL/min per 1.73 m<sup>2</sup> or less) undergoing coronary and/or peripheral procedures.<br />All patients received [[N-acetylcysteine|NAC]]||&bull; 3 mL/kg per hour for 1 hour before  contrast<br/>&bull; 1 mL/kg per hour for 6 hours during and after contrast<br/>Controls received isotonic saline:<br/>&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1 mL/kg per hour for 6 hours during and after contrast||<u>></u> 25% rise in serum creatinine within 2 days||1.9%||9.9%||Bicarb is beneficial
|-
| Maioli (2008)<ref name="pmid18702961"/>|| 502 patients with kidney disease ([[creatinine clearance]] 60 mL/min per 1.73 m<sup>2</sup> or less; mean [[glomerular filtration rate|GFR]] was 48 mL/min per 1.73 m<sup>2</sup>) undergoing coronary angiography<br />All patients received [[N-acetylcysteine|NAC]]||&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1 mL/kg per hour for 6 hours after contrast<br />Controls received:<br />&bull; isotonic saline 1 ml/kg/hr for 12 hours pre/post contrast||0.5 mg/dl rise in creatinine within 5 days||10%||11.5%||Bicarb is ''not'' beneficial
|-
| Brar (2008)<ref name="pmid18768415"/>|| 353 patients with kidney disease ([[glomerular filtration rate|GFR]] 60 mL/min per 1.73 m<sup>2</sup> or less; mean [[creatinine clearance]] was 36 - 39  mL/min) undergoing coronary angiography or intervention||&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1.5 mL/kg per hour for 4 hours during and after contrast<br />Controls received isotonic saline:<br />&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 1.5 mL/kg per hour for 4 hours during and after contrast||<u>></u> > 25% fall in [[glomerular filtration rate|GFR]] within 4 days||13.3%||14.6%||Bicarb is ''not'' beneficial
|-
| Ueda (2011)<ref name="pmid21349483"/>|| 59 patients with kidney disease ([[glomerular filtration rate|GFR]] 60 mL/min per 1.73 m<sup>2</sup> or less or creat > >1.1 mg/dl ; undergoing coronary angiography or intervention||&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 154 mEq/L of sodium bicarbonate 0.5 ml/kg before contrast<br />&bull; 3 mL/kg per hour for 1 hour before contrast<br/>&bull; 154 mEq/L sodium bicarbonate at 1 ml/kg/hour for 6 hours after contrast to both groups||<u>></u> > 25% fall in [[glomerular filtration rate|GFR]] or >0.5 mg/dl rise serum creatinine level within 2 days||3.3%||27.6%||Bicarb ''bolus is'' beneficial
|}

Alternatively, one [[randomized controlled trial]] of patients with a creatinine over 1.6 mg per deciliter (140 µmol per liter) or creatinine clearance below 60 ml per minute used 1 ml/kg of 0.45 percent saline per per hour for 6-12 hours before and after the contrast.<ref name="pmid7969280">{{cite journal |author=Solomon R, Werner C, Mann D, D'Elia J, Silva P |title=Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents |journal=N. Engl. J. Med. |volume=331 |issue=21 |pages=1416–20 |year=1994 |pmid=7969280 |doi=|url=http://content.nejm.org/cgi/content/full/331/21/1416}}</ref>

====Methylxanthines====
[[Adenosine]] antagonists such as the [[methylxanthine]]s [[theophylline]] and [[aminophylline]], may help<ref name="pmid17512638"/> although studies have conflicting results.<ref name="pmid15911721">{{cite journal |author=Bagshaw SM, Ghali WA |title=Theophylline for prevention of contrast-induced nephropathy: a systematic review and meta-analysis |journal=Arch. Intern. Med. |volume=165 |issue=10 |pages=1087-93 |year=2005 |pmid=15911721 |doi=10.1001/archinte.165.10.1087}}</ref> The best studied dose is 200 mg of theophylline given IV 30 minutes before contrast administration.<ref name="pmid12745095">{{cite journal |author=Huber W, Schipek C, Ilgmann K, ''et al'' |title=Effectiveness of theophylline prophylaxis of renal impairment after coronary angiography in patients with chronic renal insufficiency |journal=Am. J. Cardiol. |volume=91 |issue=10 |pages=1157–62 |year=2003 |pmid=12745095 |doi=10.1016/S0002-9149(03)00259-5 }}</ref><ref name="pmid12034949">{{cite journal |author=Huber W, Ilgmann K, Page M, ''et al'' |title=Effect of theophylline on contrast material-nephropathy in patients with chronic renal insufficiency: controlled, randomized, double-blinded study |journal=Radiology |volume=223 |issue=3 |pages=772–9 |year=2002 |pmid=12034949 |doi=}}</ref>

====N-acetylcysteine====
N-acetylcysteine (NAC) 600 mg orally twice a day, on the day before and of the procedure if creatinine clearance is estimated to be less than 60 mL/min [1.00 mL/s]) may reduce nephropathy.<ref name="pmid19699385">{{cite journal| author=Trivedi H, Daram S, Szabo A, Bartorelli AL, Marenzi G| title=High-dose N-acetylcysteine for the prevention of contrast-induced nephropathy. | journal=Am J Med | year= 2009 | volume= 122 | issue= 9 | pages= 874.e9-15 | pmid=19699385 
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19699385 | doi=10.1016/j.amjmed.2009.01.035 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid12578487">{{cite journal |author=Kay J, Chow W, Chan T, Lo S, Kwok O, Yip A, Fan K, Lee C, Lam W |title=Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention: a randomized controlled trial |journal=JAMA |volume=289 |issue=5 |pages=553-8 |year=2003 |pmid=12578487}}</ref>.  A [[randomized controlled trial]] found higher doses of NAC (1200-mg IV bolus and 1200 mg orally twice daily for 2 days) benefited ([[relative risk reduction]] of 74%) patients receiving coronary angioplasty with higher volumes of contrast<ref name="pmid16807414">{{cite journal |author=Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, De Metrio M, Galli S, Fabbiocchi F, Montorsi P, Veglia F, Bartorelli A |title=N-acetylcysteine and contrast-induced nephropathy in primary angioplasty |journal=N Engl J Med |volume=354 |issue=26 |pages=2773-82 |year=2006 |pmid=16807414}}</ref>. However, a more recent trial found no benefit.<ref name="pmid20466200">{{cite journal| author=Thiele H, Hildebrand L, Schirdewahn C, Eitel I, Adams V, Fuernau G et al.| title=Impact of high-dose N-acetylcysteine versus placebo on contrast-induced nephropathy and myocardial reperfusion injury in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. The LIPSIA-N-ACC (Prospective, Single-Blind, Placebo-Controlled, Randomized Leipzig Immediate PercutaneouS Coronary Intervention Acute Myocardial Infarction N-ACC) Trial. | journal=J Am Coll Cardiol | year= 2010 | volume= 55 | issue= 20 | pages= 2201-9 | pmid=20466200 
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20466200 | doi=10.1016/j.jacc.2009.08.091 }} </ref>

<!--Since publication of the meta-analyses, two small and underpowered negative studies, one of IV NAC<ref name="pmid17414730">{{cite journal |author=Haase M, Haase-Fielitz A, Bagshaw SM, ''et al'' |title=Phase II, randomized, controlled trial of high-dose N-acetylcysteine in high-risk cardiac surgery patients |journal=Crit. Care Med. |volume=35 |issue=5 |pages=1324–31 |year=2007 |pmid=17414730 |doi=10.1097/01.CCM.0000261887.69976.12}}</ref> and one of 600 mg give four times around coronary angiography<ref name="pmid17509426">{{cite journal |author=Seyon RA, Jensen LA, Ferguson IA, Williams RG |title=Efficacy of N-acetylcysteine and hydration versus placebo and hydration in decreasing contrast-induced renal dysfunction in patients undergoing coronary angiography with or without concomitant percutaneous coronary intervention |journal=Heart & lung : the journal of critical care |volume=36 |issue=3 |pages=195–204 |year=2007 |pmid=17509426 |doi=10.1016/j.hrtlng.2006.08.004}}</ref>, found [[statistical significance|statistically insignificant]] trends towards benefit.-->

Some authors believe the benefit is not overwhelming.<ref name="pmid15547209">{{cite journal | author=Gleeson TG, Bulugahapitiya S | title=Contrast-induced nephropathy | journal=AJR Am J Roentgenol | year=2004 | pages=1673-89 | volume=183 | issue=6  | id=PMID 15547209}}</ref> The strongest results were from an [[Blind experiment|unblinded]] [[randomized controlled trial]] that used NAC intravenously.<ref name="pmid12821233">{{cite journal |author=Baker CS, Wragg A, Kumar S, De Palma R, Baker LR, Knight CJ |title=A rapid protocol for the prevention of contrast-induced renal dysfunction: the RAPPID study |journal=J. Am. Coll. Cardiol. |volume=41 |issue=12 |pages=2114–8 |year=2003 |pmid=12821233 |doi=}}</ref> A [[systematic review]] by [http://clinicalevidence.com Clinical Evidence] concluded that NAC is "[http://clinicalevidence.bmj.com/ceweb/about/guide.jsp likely to beneficial]" but did not recommend a specific dose.<ref name="pmid16973048">{{cite journal |author=Kellum J, Leblanc M, Venkataraman R |title=Renal failure (acute) |journal=Clinical evidence |volume= |issue=15 |pages=1191–212 |year=2006 |pmid=16973048 |doi=|url=http://clinicalevidence.bmj.com/ceweb/conditions/knd/2001/2001.jsp}}</ref> One study found that the apparent benefits of NAC may be due to its interference with the creatinine laboratory test itself.<ref name="pmid14747387">{{cite journal | author=Hoffmann U, Fischereder M, Kruger B, Drobnik W, Kramer BK | title=The value of N-acetylcysteine in the prevention of radiocontrast agent-induced nephropathy seems questionable | journal=J Am Soc Nephrol | year=2004 | pages=407-10 | volume=15 | issue=2  | id=PMID 14747387}}</ref> This is supported by a lack of correlation between creatinine levels and [[cystatin C]] levels.

In one study 15% of patients receiving NAC intravenously had allergic reactions.<ref name="pmid12821233"/>

====Prophylactic hemodialysis====
[[Randomized controlled trial]]s found benefit from prophylactic [[hemodialysis]] for patients with [[chronic kidney disease]] and a creatinine over 309.4 µmol/L (3.5 mg.dl) who have elective [[coronary catheterization]].<ref name="pmid10356104">{{cite journal |author=Hart RG, Pearce LA, McBride R, Rothbart RM, Asinger RW |title=Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators |journal=Stroke |volume=30 |issue=6 |pages=1223–9 |year=1999 |pmid=10356104 |doi=}}</ref><ref name="pmid17825709">{{cite journal |author=Lee PT, Chou KJ, Liu CP, ''et al'' |title=Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial |journal=J. Am. Coll. Cardiol. |volume=50 |issue=11 |pages=1015–20 |year=2007 |pmid=17825709 |doi=10.1016/j.jacc.2007.05.033 |issn=}}</ref>


====Ascorbic acid==== 
[[Ascorbic acid]] may help according to a [[systematic review]] of [[randomized controlled trial]]s.<ref name="pmid23994417">{{cite journal| author=Sadat U, Usman A, Gillard JH, Boyle JR| title=Does ascorbic acid protect against contrast-induced acute kidney injury in patients undergoing coronary angiography: a systematic review with meta-analysis of randomized, controlled trials. | journal=J Am Coll Cardiol | year= 2013 | volume= 62 | issue= 23 | pages= 2167-75 | pmid=23994417 | doi=10.1016/j.jacc.2013.07.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23994417  }} </ref>

====Other interventions====
Other pharmacological agents, such as [[furosemide]], [[mannitol]], [[dopamine]], and [[atrial natriuretic peptide]] have been tried, but have either not had beneficial effects, or had detrimental effects.<ref name="pmid7969280"/><ref name="pmid10073832">{{cite journal | author=Abizaid AS, Clark CE, Mintz GS, Dosa S, Popma JJ, Pichard AD, Satler LF, Harvey M, Kent KM, Leon MB | title=Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency | journal=Am J Cardiol | year=1999 | pages=260-3, A5 | volume=83 | issue=2  | id=PMID 10073832}}</ref>

==References==
{{reflist|2}}[[Category:Suggestion Bot Tag]]