Role of N-Acetylcysteine to Prevent Contrast-Induced Nephropathy: A Meta-analysis

2Advocate Illinois Masonic Medical Center, Chicago, IL
American journal of therapeutics (Impact Factor: 1.13). 08/2013; Publish Ahead of Print(1). DOI: 10.1097/MJT.0b013e31829dbc1c
Source: PubMed


It is unclear whether N-acetylcysteine is useful in preventing contrast-induced nephropathy in patients undergoing coronary angiography. Because of different inclusion and exclusion criteria and different definitions of studied parameters, various studies have reported different outcomes. A systematic search was done using PubMed, Ovid, and the Cochrane library, and studies were pooled after strict inclusion and exclusion criteria. Separate analysis was conducted for all endpoints including only studies that used an N-acetylcysteine (NAC) dose of 600 mg, and another separate analysis was conducted for all endpoints including only studies that used oral route NAC to study how the dose and route of administration of NAC affect the outcomes. The results of the pooled analysis significantly favored the use of NAC to prevent contrast-induced nephropathy in patients undergoing coronary angiography but failed to show any significant benefit in terms of creatinine levels preangiography and postangiography, need for dialysis, and all-cause mortality. The effects of route and dose of NAC did not show any significant difference except in respect to incidence of postcatheterization nephropathy. This study shows that NAC may not have any impact on clinical outcomes after peripheral or coronary artery catheterization and that dose and route do not seem to have any effect on these outcomes.

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    ABSTRACT: Contrast-induced nephropathy (CIN) represents an important adverse effect of contrast media (CM) administration. Contrast-induced nephropathy is associated with prolonged hospitalization as well as increased cardiovascular morbidity, renal morbidity, and all-cause mortality. Several risk factors may predict CIN incidence, and various scores and ratios have been proposed to identify high-risk patients. Novel biomarkers may provide an earlier diagnosis of CIN. A multifactorial approach is required for CIN prevention including hydration, administration of low- or iso-osmolar CM, minimizing CM volume, and statin administration. Renal function may deteriorate after CM administration, even in the absence of CIN. Therefore, this deterioration may not be an "all or none" phenomenon; it may well occur in many patients receiving CM, with/without CIN, and may prove to be an underestimated risk factor. Patients should be followed up for longer periods as outpatients after CM exposure to assess kidney function and predict subsequent increased morbidity and mortality.
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    ABSTRACT: This systematic review with meta-analysis sought to determine the strength of evidence for effects of antioxidants (AO) such as N-acetyl cysteine (NAC), vitamin C, vitamin E, and alpha-lipoic acid on the incidence of CIN, requirement for hemodialysis, level of serum creatinine, and mortality after coronary angiography. After Medline, Embase, Elsevier, Sciences online database and Google scholar literature search, studies with randomized controlled design were selected for the meta-analysis. The effect sizes measured were odds ratio (OR) for categorical variable and standard mean difference (SMD) with 95% confidence interval for calculating differences between mean changes of serum creatinine in intervention and control groups. A value of P< 0.1 for Q test or I2 >50% indicated significant heterogeneity between the studies. Literature search of all major databases retrieved 2350 studies. After screening, a total of 49 trials were identified that reported outcomes. Pooled treatment effect analysis revealed that NAC (OR of 0.79; 95% CI: 0.69-0.9; P=0.000), vitamin C (0.63 (95% CI: 0.45-0.89; P=0.000), and vitamin E (OR of 0.5; 95% CI: 0.27-0.92; P=0.026) could significantly reduce the incidence of CIN. NAC (SMD of -0.119; 95% CI: -0.191 to -0.046; P=0.000), but not vitamin C (SMD of -0.08; 95% CI: -0.22 to 0.04; P=0.1) and vitamin E (-0.25; 95% CI: -0.46 to -0.05; P=0.1) could significantly reduce mean level of serum creatinine Nevetheless, AO could not reduce the incidence of mortality with an OR of 0.94 (95% CI: 0.69-1.28; P=0.7). Overall, antioxidants such as NAC, vitamin C, and vitamin E may reduce the incidence of CIN, while only NAC might be able to significantly lower serum creatinine levels. There is no impact of of anti-oxidant supplementation on mortality.
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