title: N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography.
abstract: OBJECTIVE
  We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy.
  
  
  METHODS
  The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.
  
  
  RESULTS
  The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.
  
  
  CONCLUSIONS
  We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; Mayo Clinic College of Medicine, Rochester, MN; Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ. Electronic address: traub.stephen@mayo.edu.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Traub
authors.affiliation: Indiana University School of Medicine, Indianapolis, IN.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Mitchell
authors.affiliation: University of Mississippi Medical Center, Jackson, MS.
authors.forename: Alan E
authors.initials: AE
authors.lastname: Jones
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Aimee
authors.initials: A
authors.lastname: Tang
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: O'Connor
authors.affiliation: Center for Vascular Biology, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Teresa
authors.initials: T
authors.lastname: Nelson
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: John
authors.initials: J
authors.lastname: Kellum
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Technomics Research, Minneapolis, Minnesota; Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA; Harvard Medical School, Boston, MA.
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
mesh_terms: D000111:Acetylcysteine / Q000627:therapeutic use*; D000328:Adult; D003287:Contrast Media / Q000009:adverse effects*; D000077324:Crystalloid Solutions; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D007552:Isotonic Solutions / Q000008:administration & dosage; D007674:Kidney Diseases / Q000139:chemically induced / Q000517:prevention & control*; D008297:Male; D017693:Sodium Bicarbonate / Q000008:administration & dosage; D012965:Sodium Chloride / Q000008:administration & dosage / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D003287:Contrast Media; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D012965:Sodium Chloride; D017693:Sodium Bicarbonate; D000111:Acetylcysteine