Prevention of contrast-induced nephropathy: a critical review.
OBJECTIVE
Although contrast-induced nephropathy (CIN) is common and portends a significant morbidity and mortality, only few large and well designed trials have assessed the available prophylactic measures and there are no clear evidence-based guidelines that can easily be adopted by the clinician. We critically discuss the evidence for periprocedural hydration, pharmacological agents, periprocedural withdrawal of medication, application of renal replacement therapy and the use of contrast media.


RESULTS
Pending confirmation of the superiority of sodium bicarbonate, NaCl 0.9% remains the fluid of choice for periprocedural hydration. A recent trial found a dose-dependent beneficial effect of acetylcysteine on CIN and mortality, adding to the controversy on the prophylactic use of this agent. Publication bias of acetylcysteine trials may have confounded the results of the meta-analyses, since negative results were more likely to be published as an abstract only. Periprocedural haemofiltration protected against CIN in a high-risk population, but the results require confirmation before the technique can be recommended.


CONCLUSIONS
Pending randomized controlled trials with rigorous scientific design, we propose practical mixed evidence-based and opinion-based guidelines for the prevention of CIN, using a stratification of patients into three risk groups, based on their renal function and a risk-prediction model.
Van Praet
Jens T
JT
Department of Internal Medicine, University of Gent, Gent, Belgium.
De Vriese
An S
AS
D000111:Acetylcysteine / Q000627:therapeutic use; D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000517:prevention & control*; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage; D000959:Antihypertensive Agents / Q000008:administration & dosage; D003287:Contrast Media / Q000008:administration & dosage / Q000009:adverse effects*; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage; D019317:Evidence-Based Medicine; D005440:Fluid Therapy / Q000379:methods; D006801:Humans; D008353:Mannitol / Q000008:administration & dosage; D008687:Metformin / Q000008:administration & dosage; D009994:Osmolar Concentration; D016032:Randomized Controlled Trials as Topic; D017582:Renal Replacement Therapy; D012307:Risk Factors; D013806:Theophylline / Q000627:therapeutic use; D014783:Viscosity
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000959:Antihypertensive Agents; D003287:Contrast Media; D004232:Diuretics; D008353:Mannitol; D008687:Metformin; D003404:Creatinine; D013806:Theophylline; D000111:Acetylcysteine