Nephopathy Prevention after Coronaty Angiography

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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creatinine is an inaccurate estimate of creatinine clearance, which is calculated according to the formula of Cockcroft and Gault (19) or the modification of diet in renal disease (MDRD) (20). The most commonly used definition in clinical trials is a rise in serum creatinine of 0.5 mg/dl or a 25% increase from baseline value, assessed at 48 hours after the procedure. The European Society of Urogenital Radiology defines impairment in renal function as an increase in Scr >0.5 mg/dl or >25% creatinine clearance within 3 days after intravascular administration of contrast medium, without an alternative etiology (21). The Acute Kidney Injury Network definition is a rise in serum creatinine ≥ 0.3 mg/dl with oligulia.

The frequency of CIN has decreased over the past decade from a general incidence of 15% to 7% of patients (22). Risk of death is increased in patients developing CIN (1; 4, 23-25). Risk of death during hospitalization in patients that developed CIN was 34% compared to 7% in patients that did not develop CIN. After adjusting for comorbid disease, CIN has a 5.5 fold increase in risk of death (26), and a higher mortality especially in patients requiring dialysis (4). Dialysis after CIN varies depending on the patients underlying risks at the time of contrast administration, but is generally less than 1% (4, 27-28).

The development of CIN has also been associated with increased hospital stays, regardless of baseline renal function (29).

The most important risk factor for CIN is preexisting renal dysfunction (2-4), with the degree of preexisting renal impairment being the most powerful predictor.

Preprocedural creatinine of 2 - 2.9 mg/dl has an Odds ratio of CIN 7.37 compared to 12.82 when preprocedural creatinine is ≥ 3 mg/dl2. Diabetes mellitus has a significant impact on the incidence of CIN in patients with mild to moderate renal insufficiency (creatinine < 2.0 mg/dl), whereas, in advanced renal insufficiency (creatinine ≥ 2.0 mg/dl), the incidence of CIN in patients with diabetic and nondiabetic nephropathy did not differ2. CIN is rare in patients with normal renal function in the absence of diabetes mellitus. There is a 2% incidence of nondiabetic patients with a baseline creatinine ≤ 1.1 mg/dl2 and 50% of patients with diabetic nephropathy and a mean serum creatinine of 5.9 mg/dl have a > 25% increase after

coronary angiography (30). Atherosclerosis and reduced effective circulating arterial volume (31) are particular risks.

Procedures with coronary angiography and intervention may be associated with a higher complexity, longer duration and limited success, thus indicating an unstable postprocedural period with impaired cardiac output. In addition other factors may affect CIN such as older age (>75 years) (32-33), repeat exposure to contrast medium (34) and nephrotoxic medication as well as drugs impairing renovascular autoregulation such as nonsteroidal anti inflammatory drugs (NSAID ) and angiotensin converting enzyme inhibitors (ACEI).

Methods

Study population This study was approved by the Ethics committee of Vajira Hospital. This single center, prospective randomized controlled trial compared the infusion of isotonic saline versus sodium bicarbonate plus isotonic saline as the hydration fluid to prevent CIN in patients undergoing coronary angiogram or percutaneous coronary interventions. In this randomized study, consecutive eligible patients scheduled for exposure to the nonionic radiographic contrast agent were considered for enrollment. Eligible patients included individuals aged 18 years or older that were scheduled to undergo cardiac catherization. Exclusion criteria included those 75 years or older, end stage renal disease, creatinine clearance ≤ 15 ml/mim, cirrhosis , sepsis, congestive heart failure, left ventricular ejection fraction ≤ 40%, recent exposure to contrast media within 2 days of the study, allergy to contrast media, pregnancy, body mass index ≥ 30 and administration of N-acetylcysteine during the study.

Protocol Patients were identified as study candidates based on elective coronary angiogram or percutaneous coronary intervention. Qualified patients who agreed to enter the study were sequentially assigned to 1 of 2 treatment groups by the pharmacy based on a randomization schedule.

Patients were allocated to the isotonic saline or sodium bicarbonate plus isotonic saline (154 mEq/L) study group.

After appropriate evaluation and initial measurement of blood pressure and weight, the preprocedural fluid was administered at the same rate. The initial intravenous bolus THAI HEART JOURNAL Vol. 23 No.2 April 2010

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Short Course Sodium Bicarbonate versus Isotonic Saline for Contrast Induced Nephropathy Prevention after Coronary Angiography

was 3 ml/kg/hr for 1 hour before the coronary angiogram then 1 ml/kg/hr during and 6 hours after the procedure.

Basic serum chemistries and urine examination were obtained 1 week before admission in outpatients or 1 day for hospitalized patients and on postprocedural days 1 and 2 and until any increase of serum creatinine resolved.

Data Collection and Management Study End points and Statistical Analysis The primary end point was contrast induced nephropathy that was defined as a decrease of ≥ 25% in creatinine clearance or an increase ≥ 0.5 mg/dl 48 hours after the procedure. Secondary end points were change in serum creatinine, creatinine clearance, urine pH postcontrast day 1 and day 2 and complications such as inhospital death, congestive heart failure and acute renal failure.

The sample size was calculated by using the rate of CIN in 30% of the isotonic saline group and 1.7% of the sodium bicarbonate group. The analysis indicated that a sample size of 60 patients would be required to detect a statistical significance with a power of 80% (α = 0.05).

The test for significance was conducted using the student ’s t test for continuous variables. Data are expressed as percentage or mean (± SD). All tests were 2 tailed, with differences reported as significant if p < 0.05.

Results

Between September 2008 and November 2008, 86 patients were randomized to receive sodium bicarbonate (n = 46) or isotonic saline (n = 40). The characteristics of the 86 patients completing the study are shown in Table 1.

There were no statistically significant differences between the groups in age, sex, and underlying disease. The mean age in the isotonic saline group was 65.4 years and 61.5 years for the sodium bicarbonate group (p = 0.085). 47% had diabetes mellitus which was similar in both groups (p = 0.976). The mean serum creatinine baseline was 1.27 ± 0.49 mg/dl in the isotonic saline group whereas it was 1.26 ± 0.26 mg/dl in the sodium bicarbonate group. There was no difference between both groups (p = 0.848) .The mean creatinine clearance baseline was slightly but not statistically lower 50.70 ± 19.81 ml/min/1.73m2 in the isotonic saline group compared to the 53.26 ± 16.65 ml/min/1.73 m2 in THAI HEART JOURNAL Vol. 23 No.2 April 2010

the sodium bicarbonate group(p = 0.517). Percutaneous coronary intervention treatment had 70 % of the isotonic saline treatment group and 65 % of the sodium bicarbonate group (p = 0.637). Most of the patients had CIN risk scores ≤ 5, which account for 72.5% of the isotonic saline and 69.6% of the sodium bicarbonate group. The proportion of CIN risk scores in both groups are shown in Figure 1.

Postcontrast serum creatinine in the isotonic saline and sodium bicarbonate group was not different at both day 1 (p = 0.49) and day 2 (p = 0.52). Creatinine clearance showed a trend to be lower in the isotonic saline group (49.13 ± 18.69 ml/min/1.73 m2) compared to sodium bicarbonate group (55.00 ± 19.84 ml/min/1.73 m2) (p = 0.16) at postcontrast day 1 and at postcontrast day 2 it was 48.55 ± 17.60 ml/min/1.73 m2 in the isotonic saline group compared to 53.74 ± 19.81 ml/min/1.73 m2 in the sodium bicarbonate group (p = 0.20). The increase in mean urine pH was not statistically significant for both day 1 (p = 0.16) and day 2 (p = 0.92). The incidence of CIN was Figure 1. Proportion of CIN risk score in isotonic saline and sodium bicarbonate group. (Color code: blue color represent CIN risk scores ≤ 5, red color represent CIN risk scores 5-10, yellow color represent CIN risk scores 11-15, green color represent CIN risk scores ≥ 16)

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Table 1. Baseline clinical, biochemical, and procedural characteristics of study patients Characteristics Age , mean (yrs) Male gender (%) Body mass index (kg/m2) Smoking history (%) Coronary artery disease (%) Diabetes mellitus (%) Hypertension (%) Dyslipidemia (%) Angiotensin converting enzyme inhibitor Angiotensin II receptor blocker Calcium channel blocker Diuretic Beta-blocker HMG coA reductase inhibitor Basal serum creatinine, mean (mg/dl) Basal creatinine clearance, mean (ml/min) Urine pH, mean Procedure type - Coronary angiography (%) - Percutaneous coronary intervention (%) Contrast volume (≥ 100 cc)

Isotonic saline (n = 40) 65.4 ± 10.8 26 ( 65 ) 22.0 ± 2.0 16 (40) 27 (67.5) 19 (47) 30 (75) 24 (60) 16 (40) 11 (27.5) 7 (17.5) 9 (22.5) 33 (82.5) 36 (90) 1.27 ± 0.49 50.70 ± 19.81 6.13 ± 0.69

Sodium bicarbonate (n = 46) 61.5 ± 9.8 27 ( 59) 24.1 ± 3.0 17 (40) 33 (71) 22 (47) 38 (82) 22 (47) 17 (40) 10 (21.7) 10 (21.7) 6 (13) 39 (84.7) 43 (93) 1.26 ± 0.26 53.26 ± 16.65 6.29 ± 0.34

12 (30) 28 (70) 19 (47.5)

16 (34.7) 30 (65) 21 (45.6)

p value 0.085 0.554 <0.001* 0.554 0.669 0.976 0.387 0.259 0.772 0.535 0.989 O.249 0.775 0.556 0.848 0.517 0.325 0.637 0.89

* statistical significance p ≤ 0.05

higher in the isotonic saline group (7.5%) compared to the 4.3 % in the sodium bicarbonate group, however the difference was not statistically significant between the groups (p = 0.16), as shown in Table 2.

On post contrast day 1 there was no difference (p = 0.117) in the mean change in serum creatinine. The difference in the mean creatinine clearance decrease in the isotonic saline group of 1.57 ml/min/1.73 m2 was in contrast to the increase of 1.73 ml/min/1.73m2 for the sodium bicarbonate group and was statistically significant (p = 0.024). The mean urine pH Increase in both groups showed no difference (p = 0.711), as shown in Table 3.

The mean change in serum creatinine on post contrast day 2 was not different (p = 0.293). The difference of the decrease in mean creatinine clearance 2.15 ml/min/

1.73m2 in the isotonic saline group compared to the decrease of 0.478 ml/min/1.73m2 in the sodium bicarbonate group was not statistically significant (p = 0.135). The increase in mean urine pH change in both groups were not statistically different (p = 0.432), as shown in Table 4.

No patient developed clinical congestive heart failure, acute renal failure that required dialysis, or an in hospital death.

Discussion

The results of the short course sodium bicarbonate treatment in this study do not suggest a superiority to hydration with isotonic saline for the prevention of contrast induced nephropathy after coronary angiography. The incidence of CIN of 7.5% with isotonic saline was higher THAI HEART JOURNAL Vol. 23 No.2 April 2010

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Short Course Sodium Bicarbonate versus Isotonic Saline for Contrast Induced Nephropathy Prevention after Coronary Angiography

Table 2. Baseline and follow up biochemical characteristics of study Characteristics Serum creatinine mean (mg/dl) D0 D1 D2 CCr mean (ml/min/1.73m2) D0 D1 D2 Urine pH mean D0 D1 D2 Result Contrast induced nephropathy (%)

Isotonic saline (n = 40)

Sodium bicarbonate (n = 46)

p value

1.27 ± 0.49 1.30 ± 0.49 1.31 ± 0.48

1.26 ± 0.26 1.24 ± 0.27 1.43 ± 1.18

0.85 0.49 0.52

50.70 ± 19.81 49.13 ± 18.69 48.55 ± 17.60

53.26 ± 16.65 55.00 ± 19.84 53.74 ± 19.81

0.52 0.16 0.20

6.13 ± 0.69 6.54 ± 0.69 6.46 ± 0.68

6.29 ± 0.94 6.78 ± 0.90 6.48 ± 0.80

0.34 0.16 0.92

3 (7.5)

2 (4.3)

0.53

than the 4.3% observed in the sodium bicarbonate group, however, this difference was not statistically significant (p = 0.16). In high risk groups such as renal impairment, diabetes mellitus, congestive heart failure and older age, the incidence has been calculated to be > 20-30%. In our study the mean age was 65.4 years in the isotonic saline group and 61.5 years in the sodium bicarbonate group (p = 0.085). An average of half the patients in our study had a high risk characteristic to develop CIN. 47% had diabetes mellitus and a mean serum creatinine baseline of 1.27 ± 0.49 mg/dl in the isotonic saline group whereas it was 1.26 ± 0.26 mg/dl in the sodium bicarbonate group.

Independent predictors for the development of contrast induced nephropathy are diabetes mellitus and serum creatinine 1.2-1.9 mg/dl Odds ratio 2.42 (95% CI 1.543.79)2. Most of the patients in this study had moderate renal impairment (creatinine clearance = 30 - 59 ml/min/ 1.73 m2). A large contrast volume (≥ 100 cc) was used in 47.5 % of the isotonic saline and 45.6% of the sodium bicarbonate group. Most of the patients had CIN risk scores ≤ 5 that estimate the risk of CIN to be 7.5% and risk of dialysis 0.04% (35). Even the results of this short course of sodium bicarbonate does not suggest superiority to THAI HEART JOURNAL Vol. 23 No.2 April 2010

hydration with isotonic saline for prevention of contrast induce nephropathy after coronary angiography, incidence of a higher CIN 7.5% in isotonic saline compared to 4.3% in the sodium bicarbonate course.

An hypothesis that contrast injury from free radicals (36-38) generated within an acid environment of the renal medulla has been postulated. Contrast induced nephropathy appears to be caused by the hyperosmolar nature of most contrast agents. This might be compounded in the renal medulla, which is normally deficient in oxygen, with PaO2 of 10 to 20 mmHg (39). Radiocontrast causes vasoconstriction (36-37, 40), decrease in renal blood flow and a further increase in renal medulla hypoxemia (41) that is exacerbated by a compromised renal circulation in diabetes and preexisting renal disease. Paradoxically, decreased oxygen tension promotes mitochrondial generation of reactive oxygen species (42-43). The superoxide driven Haber-Weiss reaction can account for free radical production in many oxidant mediated human diseases (44). The reaction is catalyzed by minute amounts of iron in the biologic environment and is most active at an acid pH (pKa = 4.9). By increasing the medullary pH, bicarbonate might protect from oxidant injury by slowing

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Table 3. Difference change in serum creatinine, creatinine clearance, urine pH day 0 and day 1

Serum creatinine, mean (mg/dl) CCr, mean (ml/min/1.73m2) Urine pH mean

Isotonic saline (n = 40) D0 D1 1.27 ± 0.49 1.30 ± 0.49

Diff -0.02

50.70 ± 19.81 49.13 ± 18.69 -1.57 6.13 ± 0.69

6.54 ± 0.69

0.482

Sodium bicarbonate (n = 46) D0 D1 1.26 ± 0.26 1.24 ± 0.27 53.26 ± 16.65 6.29 ± 0.94

p value Diff 0.02

0.117

55.00 ± 19.84 1.73

0.024*

6.78 ± 0.90

0.489

0.711

Sodium bicarbonate (n = 46) D0 D2 Diff 1.26 ± 0.26 1.43 ± 1.18 -0.006

p value

* statistical significance p ≤ 0.05 CCr = creatinine clearance

Table 4. Difference change in serum creatinine, creatinine clearance, urine pH day 0 and day 2

Serum creatinine mean (mg/dl) CCr, mean (ml/min/1.73 m2) Urine pH, mean

Isotonic saline (n = 40) D0 D2 1.27 ± 0.49 1.31 ± 0.48

Diff 0.03

50.70 ± 19.81 48.55 ± 17.60 -2.15 6.13 ± 0.69

6.46 ± 0.68

0.33

53.26 ± 16.65 6.29 ± 0.94

53.74 ± 19.81 0.478 6.48 ± 0.80

0.184

0.293 0.135 0.432

CCr = creatinine clearance

the Haber-Weiss radical production. Superoxide also generated by ischemia might react with medullary nitric oxide to form the potent oxidant peroxinitrite (45). At physiologic concentrations, bicarbonate scavenges peroxynitrite and other reactive oxygen species generated from nitric oxide (46). The potential effect of sodium bicarbonate on these events may occur in light of the pH conditions within the nephron. The end of the proximal tubule in the medulla, as a consequence of active reabsorption, the tubular bicarbonate concentration has declined to about 6 mEq/L, and the tubular fluid pH is approximately 6.5 (47). In the descending Loop of Henle, water and chloride are passively reabsorbed (47), and the urine pH increases to about 7.4 at the tip of the papilla,

which is spared from contrast nephropathy (48), suggesting that a higher pH is protective.

Our results on the urine pH measurement after procedure day 1 and day 2 did not achieve the increase near 7.4 which is spared from CIN and did not increase urine pH significantly between baseline preprocedure and postprocedure. Mean urine pH 6.54 ± 0.69 in the isotonic saline group more acidified the urine compared to the 6.78 ± 0.90 in the sodium bicarbonate group. Even though the difference was not statistically significant the result of the mean creatinine clearance decrease of 1.57 ml/min/1.73 m2 from isotonic saline compared to the increase of 1.73 ml/min/1.73m2 from sodium bicarbonate was statistically significant The day 2 results where the mean of 6.46 ± THAI HEART JOURNAL Vol. 23 No.2 April 2010

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Short Course Sodium Bicarbonate versus Isotonic Saline for Contrast Induced Nephropathy Prevention after Coronary Angiography

0.68 from the isotonic saline compared to 6.48 ± 0.80 from the sodium bicarbonate showed no differences between groups is compatible with a decrease in mean creatinine clearance 2.15 ml/min/1.73m2 with isotonic saline compared to a decrease 0.478 ml/min/1.73m2 with sodium bicarbonate (p = 0.135). Our study indicated that patients receiving sodium bicarbonate experienced urine alkalinization. Merten et al measured mean urine pH after an initial bolus of 5.6 in isotonic saline compared to 6.5 in sodium bicarbonate. Although it did not increase to 7.4 there was a significant increase in urine pH (p = 0.002)(49) and the incidence of CIN decreased from 17%with the isotonic saline to 2% with the sodium bicarbonate (49).

The study has several limitations. The results are from a single institution, sample sizes are small although adequately powered.

Conflict of Interest None

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Short Course Sodium Bicarbonate versus Isotonic Saline for Contrast Induced Nephropathy Prevention after Coronary Angiography

การศึกษาเปรียบเทียบ การปองกันภาวะไตวายจากสารทึบรังสี หลังการสวนหัวใจ ดวยการใช โซเดียมไบคารบอเนตและสารน้ำระยะสัน้ กอนการสวนหัวใจ พรทิพย นิม่ ขุนทด,ไพบูลย โชตินพรัตนภัทร, อนวัช เสริมสวรรค หนวยโรคหัวใจและหลอดเลือด งานอายุรกรรม วิทยาลัยแพทยศาสตรกรุงเทพมหานครและวชิรพยาบาล

บทคัดยอ ทีม่ า: การใชสารน้ำ มีประสิทธิภาพปองกันภาวะไตวายจากสารทึบรังสี แมขนาดและระยะเวลามีความแตกตางกัน โซเดียม ไบคารบอเนต พบวาสามารถปองกันภาวะไตวายจากสารทึบรังสี แมวา การศึกษาลาสุดพบวามีผลไมความแตกตางกันกับกลมุ ใชสารน้ำ วัตถุประสงค: เปรียบเทียบการปองกันภาวะไตวายจากสารทึบรังสี หลังการสวนหัวใจ ดวยการใช โซเดียมไบคารบอเนตและ สารน้ำระยะสัน้ กอนการสวนหัวใจ วิธกี ารดำเนินการวิจยั : คัดเลือกผปู ว ยโรคหัวใจทีท่ ำหัตถการฉีดสีสวนหัวใจแบบไมเรงดวนทีศ่ นู ยโรคหัวใจ วิทยาลัยแพทย ศาสตรกรุงเทพมหานครและวชิรพยาบาล 86 คน เกณฑการคัดออก คือ ไตวายเรือ้ รัง การบีบตัวของกลามเนือ้ หัวใจไมดี แบง ออกเปน 2 กลมุ คือ กลมุ ควบคุม ไดรบั สารน้ำ 40 คนและกลมุ ศึกษา โซเดียมไบคารบอเนต 46 คน อัตราเร็วในการใหสารน้ำ เทากัน 3 มล./กก. 1 ชัว่ โมงกอน และ1 มล./กก. 6 ชัว่ โมง หลังทำหัตถการฉีดสีสวนหัวใจ วัตถุประสงคหลัก คือ การเกิดภาวะ ไตวายจากสารทึบรังสี (คาภาวะทีม่ คี า การขจัดของเสียของไตลดลง ≥ 25% หรือมีการเพิม่ ขึน้ ของผลเลือดการทำงานของไต ≥ 0.5 มล./ดล. ใน 48 ชัว ่ โมง) และ วัตถุประสงครอง คือ การเปลีย่ นแปลงของคาภาวะทีม่ คี า การขจัดของเสียของไต ผลเลือด การทำงานของไต คาความเปนกรด ดาง ของปสสาวะวันที่ 1 และ 2 หลังทำหัตถการฉีดสีสวนหัวใจ ผลขางเคียง น้ำทวมปอด ไตวายเฉียบพลันทีต่ อ งลางไต เสียชีวติ ขณะนอนโรงพยาบาล ผลการศึกษา: อายุเฉลีย่ 63.3 ป 47.7 % เปนเบาหวาน สวนใหญอตั ราเสีย่ งของการเกิดภาวะไตวายจากสารทึบรังสี ≤ 5 ในกลมุ สารน้ำ 72.5%และโซเดียมไบคารบอเนต 69.6% การเกิดภาวะไตวายจากสารทึบรังสีในกลมุ สารน้ำ 7.5%และโซเดียม ไบคารบอเนต 4.3% ไมมคี วามแตกตางกันอยางมีนยั สำคัญทางสถิติ (p = 0.53) การเปลีย่ นแปลงลดลงของคาเฉลีย่ ภาวะทีม่ ี คาการขจัดของเสียของไตในกลมุ สารน้ำ 1.57 มล./นาที/1.73 ตรม. และเพิม่ ขึน้ ลดของคาเฉลีย่ ภาวะทีม่ คี า การขจัดของเสียของ ไตในกลมุ โซเดียมไบคารบอเนต 1.73 มล./นาที/1.73 ตรม. แตกตางกันอยางมีนยั สำคัญทางสถิติ (p = 0.024 ) เมือ่ ติดตาม 24 ชัว่ โมงหลังทำหัตถการฉีดสีสวนหัวใจ แตไมพบความแตกตางกันของการเปลีย่ นแปลงของคาการขจัดของเสียของไตและ ผลเลือดการทำงานของไตเมือ่ ติดตาม 48 ชัว่ โมง คาความเปนกรด ดาง ของปสสาวะเพิม่ ขึน้ ใน24 ชัว่ โมงของกลมุ โซเดียม ไบคารบอเนตเมือ่ เทียบกับกลมุ สารน้ำ ไมมคี วามแตกตางกันอยางมีนยั สำคัญทางสถิติ (p = 0.16) แตไมพบความแตกตางกัน ของคาความเปนกรด ดาง ของปสสาวะเพิม่ ขึน้ ของทัง้ 2 กลมุ เมือ่ ติดตาม 48 ชัว่ โมง (p = 0.92) การศึกษาไมพบวา มีการเกิดน้ำ ทวมปอด ไตวายเฉียบพลันทีต่ อ งลางไต หรือเสียชีวติ ขณะนอนโรงพยาบาล สรุปผลการวิจยั : การใชโซเดียมไบคารบอเนต ไมเหนือกวาการใชสารน้ำระยะสัน้ กอนการสวนหัวใจ เพือ่ ปองกันภาวะไต วายจากสารทึบรังสี

THAI HEART JOURNAL Vol. 23 No.2 April 2010