Nephopathy Prevention after Coronaty Angiography

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Short Course Sodium Bicarbonate versus Isotonic Saline for Contrast Induced Nephropathy Prevention after Coronary Angiography Porntip Nimkuntod MD1, Paiboon Chotinoparatpat MD2, and Anawat Sermswan MD2 1 2

Fellowship, Cardiovascular Medicine, BMA Medical College and Vajira Hospital, Bangkok Department of Medicine, BMA Medical College and Vajira Hospital, Bangkok.

Abstract

Background: Saline infusion is an effective strategy for prevention of contrast induced nephropathy (CIN). Sodium bicarbonate may be effective as well but a recent study did not suggest that sodium bicarbonate is superior to saline in CIN. Objective: To examine the efficacy of a short course of sodium bicarbonate compared to isotonic saline for prevention of CIN. Methods: This was a randomized, controlled double blind single center prospective study. 86 patients who were undergoing coronary angiography from September 2008 to November 2008 were enrolled. We excluded patients with end stage renal disease and impaired left ventricular ejection fraction. Contrast nephropathy risk scores were calculated in each patient. Isotonic saline (n = 40) and sodium bicarbonate plus isotonic saline (n = 46) were given at the same rate (3 ml/kg for 1hour before, 1 ml/kg/hr for 6 hours during and after the completion of the procedure). The primary end point was CIN (decrease of ≼ 25% in creatinine clearance or increase of serum creatinine ≼ 0.5 mg/dl 48 hour after the procedure). The secondary end points were change in serum creatinine, creatinine clearance, urine pH and in hospital death, congestive heart failure and acute renal failure. Results: The mean age of patients was 63.3 years and 47.7% had diabetes mellitus. The groups were well matched for baseline characteristics. Most patients had CIN risk scores < 5 (72.5%, 69.6% p = NS) and were similar in both groups. CIN was 7.5 % of the isotonic saline group and 4.3% of the sodium bicarbornate group (p = 0.53). Mean creatinine clearance at 24 hours decreased 1.57 ml/min/1.73m2 in the isotonic saline group and increased 1.73 ml/min/1.73m2 in the sodium bicarbonate group (p = 0.024) but there was no difference in the change of creatinine clearance and serum creatinine at 48 hours post procedure in either group. Urine pH increased in the sodium bicarbonate group more than the isotonic saline group. There was no death, congestive heart failure and acute renal failure in the hospital. Conclusion: The results of the short course sodium bicarbonate regimen did not have an advantage over isotonic saline for the prevention of contrast induced nephropathy after coronary angiography. Keywords: Sodium bicarbonate, Isotonic saline, Contrast induced nephropathy, Coronary angiography Thai Heart J 2010; 23 : 56-64 E-Journal : http://www.thaiheartjournal.org

Introduction

Contrast induced nephropathy (CIN) is the third leading course of hospital acquired acute renal failure accounting for 10% of all cases (1) and contributing to prolonged hospital stays and increased medical costs (1-2).

Correspondence: Porntip Nimkuntod, MD Cardiovascular Medicine, BMA Medical College and Vajira Hospital, Bangkok E mail address: m_stent@hotmail.com THAI HEART JOURNAL Vol. 23 No.2 April 2010

Renal failure after contrast administration requiring inhospital dialysis is associated with poor outcome, including 36% in- hospital and 19% with two years survival (3-4). The incidence of CIN varies widely across studies depending on the patient population and baseline risk factors. CIN is defined in the recent literature as an increase in serum creatinine (Scr) occurring within the first 24 (5), 48 (2, 6-18), or rarely 72 (17), 96 (18), or 120 (4) hours after contrast exposure and peaking up to 5 days. The rise in serum creatinine is expressed either in an absolute term (0.5 to1.0 mg/dl) or as a proportional rise in serum creatinine of 25% to 50% above the baseline value. Serum


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Nephopathy Prevention after Coronaty Angiography by suwan samrit - Issuu