Evidence-based emergency medicine review. Prevention of contrast-induced nephropathy in the emergency department.

STUDY OBJECTIVE

Contrast-induced nephropathy is the third leading cause of hospital-acquired acute renal failure. Expanded use of contrast-enhanced imaging exposes an ever-widening number of patients to this renal toxin. We perform an evidence-based emergency medicine review comparing different therapies to prevent contrast-induced nephropathy. We limit our review to prophylactic therapies that are practical for an emergency department setting.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for randomized trials comparing a wide range of medications to prevent contrast-induced nephropathy. We defined contrast-induced nephropathy by a commonly used surrogate measure of renal failure: a 25% or 0.5 mg/dL absolute increase in serum creatinine level from baseline 48 to 72 hours postcontrast. We limited our review to only trials for patients with baseline renal insufficiency, who are most at risk for contrast-induced nephropathy. We excluded prophylactic protocols requiring more than 2 hours precontrast to initiate and any trials of experimental medications or those that required invasive monitoring. We used standard criteria to appraise the quality of published trials.

RESULTS

We found 7 randomized trials; 3 using N-acetylcysteine, 2 using theophylline, and 1 each using bicarbonate and ascorbic acid. Although many of these trials showed statistically significant reductions in the risk for contrast-induced nephropathy, none were sufficiently powered to detect reductions in mortality rate or the need for dialytic therapy.

CONCLUSION

Evidence from randomized trials shows that these interventions (theophylline, bicarbonate, and ascorbic acid) under review were appropriate to an ED setting and decreased the risk of contrast-induced nephropathy. The case for the effectiveness (N-acetylcysteine) was less certain.