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The role of sodium bicarbonate in preventing contrast nephropathy needs to be evaluated in clinical settings.
We performed a retrospective cohort study at Mayo Clinic in Rochester, Minnesota, to assess the risk of contrast nephropathy associated with the use of sodium bicarbonate, N-acetylcysteine, and the combination of sodium bicarbonate with N-a...
Contexts in source publication
Context 1
... GFR ranges corresponding to stages of chronic kidney disease were based on previously published guidelines (29). The distribution of cases in each stage of chronic kidney disease is shown in Table 2. ...Context 2
... to recent reports, we assessed the difference in CN incidence between treatment groups on the basis of whether the patient had reduced GFR defined as GFR 60 ml/min per 1.73 m 2 (6). The associations with CN on the basis of stages of chronic kidney disease and reduced GFR classification were consistent with our a priori analysis ( Table 2). ...Citations
... The quest for treatment options for CIN has been longing since forever. Previous reports have demonstrated questionable efficacies and equivocal results for acetylcysteine, sodium bicarbonate, dopamine, anti-oxidants, and calcium channel blockers 8,[10][11][12][13][14][15] . Similarly, research into atrial natriuretic peptide, brain natriuretic peptide, and statins has also demonstrated conflicting results for their renoprotective effects [16][17][18][19][20][21] . ...
Introduction: Contrast-induced nephropathy (CIN) is a common post-procedural complication of percutaneous coronary intervention for acute myocardial infarction (AMI). Anisodamine hydrobromide is an alkaloid that has demonstrated efficacy in improving microcirculation. This meta-analysis aims to evaluate the reno-protective effects of Anisodamine in patients undergoing percutaneous coronary intervention (PCI) for AMI. Methods: PubMed, Embase, Cochrane Library, Scopus, and clinicaltrials.gov were searched from inception to January 2024 for randomized controlled trials (RCTs) comparing the efficacy of Anisodamine in preventing the development of CIN. Outcomes of interest included the incidence of CIN, serum creatinine levels, and estimated glomerular filtration rate (eGFR). A random-effects model was used for pooling standard mean differences (SMDs) and odds ratios (ORs) with a 95% confidence interval (CI). Statistical significance was considered at a P<0.05. Results: 3 RCTs involving 563 patients were included. Anisodamine was associated with a reduction in the incidence of CIN [OR: 0.44; 95% CI: 0.28, 0.69; P=0.0003], a reduction in serum creatinine levels at 48 [SMD: −6.78; 95% CI: −10.54,−3.02; P=0.0004] and 72 hours [SMD: −6.74; 95% CI: −13.33,−0.15; P=0.03], and a higher eGFR at 24 [SMD: 5.77; 95% CI: 0.39, 11.14; P=0.03], and 48 hours [SMD: 4.70; 95% CI: 2.03,7.38; P=0.0006]. The levels of serum creatinine at 24 hours and eGFR value at 72 hours were comparable between both groups. Conclusions:
Anisodamine has demonstrated clinical efficacy in ameliorating the development of CIN post-PCI in AMI patients. Large, multi-centric RCTs are warranted to evaluate the robustness of these findings.
... A meta-analysis of these trials also revealed a lower incidence of CI-AKI with sodium bicarbonate-based hydration than with normal saline-based hydration [8]. However, a retrospective cohort study that included 7,977 patients found that the incidence of CI-AKI was higher in those who received sodium bicarbonate than in those who did not, and remained higher after propensity score matching [9]. Finally, in 2018, the PRESERVE (Prevention of Serious Adverse Events Following Angiography) trial in high-risk patients found that intravenous administration of sodium bicarbonate was not superior to normal saline for the prevention of CI-AKI [10]. ...
... Contrast-induced nephropathy (CIN) is a common complication of procedures that foresee the use of contrast media and is known as the third leading cause of hospital-acquired acute kidney injury, accounting for 11% of all cases [4]. In the last decades several therapies for the prevention of CIN, such as different hydration and alkalinization measures [5,6], N-acetylcysteine (NAC) [7], Fenoldopam, dialysis and hemofiltration [8,9], have been explored in randomized clinical trial with conflicting results. Due to the important pleiotropic effects of statins, a large number of studies have assessed their role for the prevention of CIN. ...
Background:
The identification of preventive strategies, such as statin therapy, is crucial for the management of contrast-induced nephropathy (CIN). Several studies showed the association between KIF6 polymorphism (replacement of Trp719 with Arg) and an increased cardiovascular risk, while others showed a correlation between 'pleiotropic' effects of statins and a reduction in cardiovascular events in the population with the risk allele due to the documented modulation of response to statin by KIF6 polymorphism. Aim of this study is to assess the impact of KIF6 polymorphism on the development of CIN.
Methods:
We analysed 1253 consecutive patients undergoing coronary angiography/PCI. Serum creatinine was collected at baseline, 24 and 48 hours after contrast exposure. We identified the different allelic patterns and assessed the incidence of CIN (absolute increase of 0.5mg/dL or relative >25% in creatinine at 24 and 48h).
Results:
KIF6 Arg mutation was found in 669 patients (heterozygotes n = 525, homozygotes n = 144). The total prevalence of CIN was 12.5% and we did not find any association between KIF6 polymorphism and CIN development (11.3%, 13.7%, 13.2% p = 0.30). At subgroups analysis among statin 'naïve' patients we found a higher prevalence of CIN in homozygous patients as compared to wild-type (20.7% vs 11.3%, p = 0.05), while opposite results were observed among patients with statin therapy (8.6% vs 13.2%, p = 0.28).
Conclusion:
KIF6 homozygous Arg was associated with a significant increase in the risk of CIN only among statin naive patients. Future studies are needed to evaluate the beneficial effects of statin especially in this subset of patients.
... Despite the proposed theoretical advantage of these strategies, until now, there has been no agreement on their relative effectiveness in clinical practice (3,5,12). Therefore, alternative prevention strategies are being employed in various clinical settings to reduce CIN (7,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Specifically, the theory of prevention of nephropathy by continuous IV hydration either with sodium bicarbonate or normal saline was based on the concept of neutralizing free radicals generated by CM (23). ...
... In the context of clinical studies, however, the impact of preventive hydration with sodium bicarbonate has been shown to be controversial and inconsistent (7,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Furthermore, a meta-analysis that included 22 randomized clinical trials revealed that sodium bicarbonate administration is not superior to the use of saline solution for preventing CIN, and neither sodium bicarbonate nor saline improved the mortality rate or the need for renal replacement in patients with risk factors (3). ...
... Several international studies have been conducted to explore the prevention of CIN after cardiac catherization using alternative prophylactic therapies (13)(14)(15)(16)(17)(18)(19)(20)(21)(22). However, only one local randomized trial was conducted to examine the relative efficacy of three preventive measures (excluding sodium bicarbonate) among patients undergoing coronary angiography (7). ...
... This finding is also supported by two large meta-analyses, where a total of 19,000 patients were examined, and the incidence of PC-AKI was estimated to be 5.0-6.4%, which is significantly lower than previously thought [12,13]. In these two papers, first of all, serum creatinine was measured in the vast majority after 2-3 days [12][13][14], while we did measure creatinine immediately after the CT, i.e., within 1-2 days, and thus several cases could have been missed in the studies included in the meta-analysis [12]. In addition, some of the studies were small, with 19 or 20 patients. ...
Post-contrast acute kidney injury (PC-AKI) is one of the side effects of iodinated contrast media, including those used in computed tomography. Its incidence seems exaggerated, and thus we decided to try estimate that number and investigate its significance in our clinical practice. We analyzed all computed tomographies performed in our clinic in 2019, including data about the patient and the procedure. In each case, we recorded the parameters of kidney function (serum creatinine concentration and eGFR) in four time intervals: before the test, immediately after the test, 14–28 days after the test, and over 28 days after the test. Patients who did not have a follow-up after computed tomography were excluded. After reviewing 706 CT scans performed in 2019, we included 284 patients undergoing contrast-enhanced CT and 67 non-enhanced CT in the final analysis. On this basis, we created two comparable groups in terms of age, gender, the severity of chronic kidney disease, and the number of comorbidities. We found that AKI was more common in the non-enhanced CT population (25.4% vs. 17.9%). In terms of our experience, it seems that PC-AKI is not a great risk for patients, even those with chronic kidney disease. Consequently, the fear of using contrast agents is not justified.
... Infusion of sodium bicarbonate instead of sodium chloride was ever advocated for urinary alkalization and reducing the generation of free radicals [3]. Some studies found administration of sodium bicarbonate was effective in preventing CA-AKI [4,5], but some others drew different conclusions [6,7], even harmful [8]. ...
... Due to various factors including hemodynamic instability, insufficient hydration and cardiac dysfunction, the risk of CA-AKI was higher in patients undergoing emergency PCI than those undergoing elective PCI [15]. In addition to hydration and contrast agent dose reduction, pharmacological strategies such as furosemide [8], N-acetylcysteine [9], statin [10], ascorbic acid [11] and sodium bicarbonate [4,12] were also evaluated. However, no effective treatment for CA-AKI in high-risk patients has been defined. ...
... However, some later trials showed different results [7,19,20], and even suggested that bicarbonate may increase the risk of CA-AKI. A retrospective cohort study at Mayo Clinic [8] showed that urine alkalinization by bicarbonate alone was associated with increased risk of CA-AKI compared with placebo, and a prospective randomized trial conducted by Theresia Klima et al. [21] drew similar conclusion in patients with renal insufficiency. The inconsistency of the results may be associated with following factors: (1) urine alkalization was not (3) Some studies included lowrisk patients with intact baseline kidney function but some included patients with moderate-to-severe renal dysfunction [20,22,23]. ...
Aim
We investigated whether perioperative urine pH was associated with contrast-associated acute kidney injury (CA-AKI) in patients undergoing emergency percutaneous coronary intervention (PCI).
Methods
The study enrolled 1109 consecutive patients undergoing emergency PCI. Patients were divided into three groups based on perioperative urine pH (5.0–6.0, 6.5– 7.0, 7.5–8.5). The primary endpoint was the development of CA-AKI, defined as an absolute increase ≥ 0.3 mg/dL or a relative increase ≥ 50% from baseline serum creatinine within 48 h after contrast medium exposure.
Results
Overall, 181 patients (16.3%) developed contrast-associated acute kidney injury. The incidences of CA-AKI in patients with urine pH 5.0–6.0, 6.5–7.0, and 7.5–8.5 were 19.7%, 9.8%, and 23.3%, respectively. After adjustment for potential confounding factors, perioperative urine pH 5.0–6.0 and 7.5–8.5 remained independently associated with CA-AKI [odds ratio (OR)1.86, 95% confidence interval (CI) 1.25–2.82, P = 0.003; OR 2.70, 95% CI 1.5–4.68, P < 0.001, respectively]. The association was consistent in subgroups of patients stratified by several CA-AKI risk predictors. However, the risk of CA-AKI associated with urine pH 7.5–8.5 was stronger in patients with worse renal function (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m ² ) (HR 5.587, 95% CI 1.178–30.599 vs. HR 2.487, 95% CI 1.331–4.579; overall interaction P < 0.05).
Conclusion
The urine pH and CA-AKI may underlie the V-shape relationship.
... Studies on bicarbonate, however, have been controversial, spanning from beneficial, [29][30][31][32][33][34][35] to neutral 36,37 or toxic effects. 38,39 Nevertheless, favorable results of prevention protocols using bicarbonate have been noted in studies also documenting a significant alkalinization of urines, 30,32,35,40 while a similar protocol did not prove effective when the dose of bicarbonate was insufficient to such aim. 41 Markota et al., 42 in a study on patients with eGFR more than 15 ml/ min/1.73 ...
Intravascular administration of iodinated contrast media is an essential tool for the imaging of blood vessels and cardiac chambers, as well as for percutaneous coronary and structural interventions. Along with the spreading of diagnostic and interventional procedures, the increasing incidence of contrast-induced nephropathy (CIN) has become an important and prognostically relevant problem. CIN is thought to be largely dependent on oxidative damage, and is a considerable cause of renal failure, being associated with prolonged hospitalization and significant morbidity/mortality. The most effective treatment strategy of this serious complication remains prevention, and several preventive measures have been extensively investigated in the last few years.
Preprocedural hydration is the best-known and mostly accepted strategy. The administration of sodium bicarbonate has controversial effects, and is likely to be ineffective when the infused dose is unable to achieve adequate urine alkalinization. Since alkaline pH suppresses the production of free radicals, increasing urine pH would be an attractive goal for CIN prevention.
In a prospective randomized controlled, open-label clinical trial we will test the hypothesis that urine alkalinization with either oral or intravenous bicarbonate on top of hydration alone is the main determinant of CIN prevention (primary endpoint) in a population of patients with moderate or severe chronic kidney disease scheduled for coronary angiography and/or angioplasty. If we then demonstrate nonsignificant differences in urine alkalinization and incidence of CIN between the two bicarbonate groups (secondary endpoint), a practical implication will be that oral administration is preferable for practical reasons over the administration of intravenous bicarbonate.
... [20,21]. Moreover, nephrotoxic drugs (aminoglycoside antibiotics and nonsteroidal antiinflammatory agents), hypercalcemia, dehydration, and contrast agents contribute to the development of renal failure [5,22,23]. As a result, the excess LCs form casts and aggregates with uromodulin in the distal nephron, leading to tubular obstruction and concomitant inflammation [20,21,24]. ...
Autologous stem cell transplantation (ASCT) is a standard treatment for multiple myeloma (MM), but the clinical response and renal curative effect in MM patients with renal failure (RF) remain controversial. The myeloma kidney disease has different types, and most are due to the direct toxic effects of light chain. Although ASCT can effectively clear the light chain, the data of renal function improvement are still limited. We reviewed the published literatures, focusing on the prospective studies, the retrospective analysis studies, and the case reports. RF patients who received ASCT displayed a low survival rate (OS: HR 1.95, 95% CI 1.020 to 3.720; I2=64.9% , P=0.014 ) and a shorter EFS/PFS (EFS/PFS: HR 1.53, 95% CI 1.090 to 2.140; I2=0% , P=0.669 ). However, ASCT was feasible and could have the similar clinical response outcomes compared with the normal renal function (CR: OR 1.013, 95% CI 0.569 to 1.804; I2=48.5% , P=0.101 ; PR: OR 1.013, 95% CI 0.342 to 1.226; I2=46.3% , P=0.144 ). Moreover, MM with RF after ASCT had a good improvement of renal function and melphalan is still an important factor affecting the treatment of ASCT.
... Sin embargo, se postuló el bicarbonato de sodio (BS) como alternativa, pensando en el beneficio teórico por la alcalinización de la luz tubular que disminuye los ROS 52 . Por lo tanto, se han realizado varios estudios comparando el BS vs. SSN en los que los resultados son muy variados y su uso es controvertido [53][54][55][56] . ...
El uso de medios de contraste dentro del arsenal diagnóstico y terapéutico médico puede ocasionar efectos adversos como toxicidad renal e injuria renal aguda, conocida como nefropatía inducida por contraste. Se estima que en la población con función renal normal la incidencia es del 0-5%; sin embargo, en personas con alteración de la función renal basal puede llegar a un 12-27%. La nefropatía inducida por contraste se define como un aumento absoluto (≥ 0,5mg/dl) o relativo (≥ 25%) de la creatinina sérica en 24-72 h postexposición al medio de contraste. Es la tercera causa de injuria renal aguda intrahospitalaria y conlleva un aumento en la morbimortalidad de la población. No se dispone de un tratamiento específico para esta entidad. Por tanto, el énfasis se realiza en la prevención. Se han probado distintos agentes farmacológicos, sin embargo, hoy en día los únicos métodos que han logrado asegurar adecuada nefroprotección son el uso de agentes de contraste isoosmolares o de baja osmolaridad junto con hidratación continua del paciente antes, durante y después de la intervención.
... Their study was stopped early because of a significant reduction in the occurrence of CA-AKI from 13.6% to 1.7%. However, subsequent studies reported conflicting results (11,(16)(17)(18)(19)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34). In meta-analyses, a lower incidence of CA-AKI was found in patients receiving bicarbonate compared with saline (12,13,(35)(36)(37)(38). ...
Objectives:
To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients.
Design:
Prospective, double-blind, multicenter, randomized controlled study.
Setting:
Three French ICUs.
Patients:
Critically ill patients with stable renal function (n = 307) who received intravascular contrast media.
Interventions:
Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure.
Measurements and main results:
The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively.
Conclusions:
Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.
