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High-dose N-acetylcysteine decreases incidence of contrast-induced nephropathy

Clinical Question:
Does high-dose N-acetylcysteine prevent contrast-induced nephropathy?

Bottom Line:
Administering high-dose N-acetylcysteine (NAC) prior to and after contrast exposure reduces the incidence of contrast-induced nephropathy (CIN). Although the optimal dosage remains uncertain from this meta-analysis, data from previous trials support the use of 1200 mg orally twice daily (Eur Heart J. 2004; 25(3):206-211). (LOE = 1a)

Reference:
Trivedi H, Daram S, Szabo A, Bartorelli AL, Marenzi G. High-dose N-acetylcysteine for the prevention of contrast-induced nephropathy. Am J Med 2009;122(9):874.e9-15.  [PMID:19699385]

Study Design:
Meta-analysis (randomized controlled trials)

Allocation:
Uncertain

Setting:
Various (meta-analysis)

Synopsis:
Existing meta-analyses of the benefit of standard-dose NAC (600 mg twice daily) for preventing CIN are inconclusive because of significant heterogeneity of treatment effect among trials. These investigators searched MEDLINE, the Cochrane Registry of Controlled Trials, and abstracts from major scientific meetings for randomized trials -- limited to English-language literature -- evaluating the efficacy of high-dose NAC compared with placebos in the prevention of CIN. High-dose NAC was defined as a daily dose greater than 1200 mg or a single preprocedural dose of more than 600 mg given either orally or intravenously. Two reviewers independently assessed study eligibility and data extraction, and discrepancies were resolved by consensus. Quality criteria for the 16 eligible studies (N = 1677) were assessed using the Delphi list and the Jadad scale. Study participants were an average age of 68 years and had a weighted mean serum creatinine level of 1.58 mg/dL (140 umol/L). Almost 40% were diabetic. Overall, the use of high-dose NAC decreased the occurrence of CIN (odds ratio [OR] = 0.46; 95% CI, 0.33-0.64). Restricting the analysis to the 9 studies with a Jadad score of 3 or more, indicating higher quality studies, demonstrated an even lower incidence of CIN with the use of high-dose NAC (OR = 0.34; 0.22-0.52). Formal assessment found no significant heterogeneity among the individual studies and no evidence of publication bias.

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