Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?

1 Answer

Mednet Member

Nephrology · Thomas Jefferson University Hospital Nephrology

Answered on · Updated on

There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weisbord et al., PMID 29130810).

Contrast-associated AKI was similar (9.1 versus 8.7 percent [OR 1.06, 95% CI 0.87-1.28]), need for dialysis at 90 days (1.2 versus 1.2 [OR 0.97, 95% CI 0.58- 1.60]), and death (2.7 versus 2.4 [OR 1.10, 95% CI 0.78-1.57]) were seen in the acetylcysteine and placebo treatment groups.

In this same trial, they hydrated the patients with either normal saline (0.9 %) or sodium bicarb (1.26%) based solution with the following regimen (which offered flexibility to providers at trial sites):

Pre-procedure : 1-3 cc/kg/hr x 1-12 hrs
During procedure: 1-1.5 cc/kg/hr x 1-12 hrs
Post-procedure : 1-3 cc/kg/hr x 2-12 hrs

Again, contrast-associated AKI (9.5 versus 8.3 percent [odds ratio (OR) 1.16, 95% CI 0.96-1.41]), need for dialysis at 90 days (1.3 versus 1.2 [OR 1.09, 95% CI 0.65-1.81]), and death (2.4 versus 2.7 [OR 0.87, 95% CI 0.61-1.24]) were seen in the bicarbonate and saline treatment groups.

With no benefit of either IV fluid, normal saline is a better choice as it is cheaper and will not need preparation in pharmacy.

It is at the provider’s discretion to determine the need for hydration in any patient with suspected mild hypervolemia prior to contrast study.

As for patients on a diuretic, holding these drugs on the day of procedure is preferable as long as it is safe from the patient's cardiovascular/volume status at the day of procedure.