N-acetylcysteine does not prevent contrast-induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease: a randomized clinical trial

<p>Abstract</p> <p>Background</p> <p>Patients with diabetes mellitus (DM) and chronic kidney disease (CKD) constitute to be a high-risk population for the development of contrast-induced nephropathy (CIN), in which the incidence of CIN is estimated to be as high as 50%. We performed this trial to assess the efficacy of <it>N</it>-acetylcysteine (NAC) in the prevention of this complication.</p> <p>Methods</p> <p>In a prospective, double-blind, placebo controlled, randomized clinical trial, we studied 90 patients undergoing elective diagnostic coronary angiography with DM and CKD (serum creatinine ≥ 1.5 mg/dL for men and ≥ 1.4 mg/dL for women). The patients were randomly assigned to receive either oral NAC (600 mg BID, starting 24 h before the procedure) or placebo, in adjunct to hydration. Serum creatinine was measured prior to and 48 h after coronary angiography. The primary end-point was the occurrence of CIN, defined as an increase in serum creatinine ≥ 0.5 mg/dL (44.2 μmol/L) or ≥ 25% above baseline at 48 h after exposure to contrast medium.</p> <p>Results</p> <p>Complete data on the outcomes were available on 87 patients, 45 of whom had received NAC. There were no significant differences between the NAC and placebo groups in baseline characteristics, amount of hydration, or type and volume of contrast used, except in gender (male/female, 20/25 and 34/11, respectively; P = 0.005) and the use of statins (62.2% and 37.8%, respectively; P = 0.034). CIN occurred in 5 out of 45 (11.1%) patients in the NAC group and 6 out of 42 (14.3%) patients in the placebo group (P = 0.656).</p> <p>Conclusion</p> <p>There was no detectable benefit for the prophylactic administration of oral NAC over an aggressive hydration protocol in patients with DM and CKD.</p> <p>Trial registration</p> <p>NCT00808795</p

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Prevention of acute kidney injury and protection of renal function in the intensive care unit

Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention

Myocardial Perfusion Imaging. Dual-Energy Approaches

The evaluation of patients presenting with symptoms sug- gestive of myocardial ischemia is one of the most common and challenging scenarios clinicians face. Despite consider- able advances in treatment, more than 50% of acute myocar- dial infarctions (AMI) resulting in death occur in patients before undergoing cardiac catheterization. Thus, risk stratifi- cation plays a central role in averting major adverse cardiac events [1]. The current WHO rating attributes more than 25% of deaths worldwide to cardiovascular disease (CVD). Despite a decreasing trend in the last decade, CVD is the leading cause of death in the United States and worldwide. On average there is approximately one CVD-related death every 40 s, resulting in the death of over 2000 Americans each day. The estimated direct and indirect cost of CVD in 2015 was $320.1 billion and is projected to be$918 billion by 2030. According to the current appropriate use criteria, coro- nary CT angiography (CCTA) is a robust imaging technique that provides a noninvasive, morphological assessment of the coronary arteries which can accurately depict coronary anatomy and atherosclerotic plaque burden. Thanks to its power to exclude significant coronary artery stenosis in patients with low and intermediate coronary artery disease (CAD) risk profiles, CCTA has become an integral part of the noninvasive diagnostic workup for the anatomic evaluation of the coronary arteries in patients with suspected CAD. A growing body of evidence has validated CCTA as the noninvasive imaging technique with the high- est sensitivity and specificity in detecting CAD, with a pooled sensitivity and specificity of 98% and 89%, respectively. These results compare favorably with alterna- tive noninvasive imaging tests, where SPECT reaches sensitivities and specificities of 88% and 61%, PET of 84% and 81%, and cardiac magnetic resonance imaging (CMR) of 89% and 76%, respectively. Although CCTA remains a morphological technique that can accurately depict coronary anatomy and atherosclerotic plaque burden, it is hampered by several limitations in the assessment of the hemodynamic significant coronary stenosis. The FAME and COURAGE trials, two major studies validating the impact of functional tests in coronary revascu- larization, have shown that the hemodynamic relevance of coronary stenosis is not adequately predicted by purely ana- tomical tests. Additionally, without functional data, ICA and CCTA can only provide limited correlation with myocardial perfusion defects. As revascularization should be guided by information on the state of myocardial perfusion, increasing efforts aim at determining the functional relevance of lesions by CCTA. Thus, noninvasive evaluation of patients with suspected CAD has started to shift focus from morphological CAD assessment to a complex, comprehensive mor- phological and functional evaluation. Furthermore, patient evaluation, management, and prognostication are more reli- able and effective when morphological and functional assess- ments are used in concert. Multiple CT techniques have the potential to provide a functional analysis. Some of these techniques are based on post-processing analysis of CCTA dataset and are focused on the direct assessment of coronary stenosis significance, such as CCTA-derived fractional flow reserve (CT-FFR) and transluminal attenuation gradient (TAG). CT-FFR relies on principles of computational fluid dynamics to calculate the ratio between the maximum coronary flow in the presence of a coronary stenosis and the hypothetical maximum coronary flow in absence of stenosis. Despite excellent results in terms of diagnostic accuracy, the only CT-FFR software that has been granted FDA approval to date requires complex offsite analysis. TAG represents the contrast attenuation gradient along the course of a coronary artery. The reliability of this technique is often hampered by extensive coronary cal- cifications or temporal inhomogeneity due to the acquisition window covering multiple heartbeats. The correlation between coronary density and the corresponding aortic attenuation at the same axial slice, formally known as CCO (corrected coronary opacification), has been proposed as a method to achieve more robust results. However, TAG and CCO have inferior diagnostic performance when compared to other functional tests. Other techniques based on CT data are focused on direct assessment of myocardial ischemia. Due to recent advance- ments in CT technology, in fact, in addition to its role in assessing coronary morphology and left ventricular function, CCTA has been utilized in the evaluation of a third aspect in the diagnostic algorithm of ischemic heart disease – myocardial perfusion. Computed tomography myocardial perfusion imaging (CTMPI) offers the possibility to directly detect the presence of perfusion defects in the myocardium following the administration of pharmacological stressing agent. Providing diagnostic information for each of these three cor- nerstones of ischemic heart disease workup, this emerging technology has the potential to become the stand-alone method for the evaluation of patients with suspected CAD using a single imaging modality and within a single imaging session