Clinical question: In patients undergoing coronary and peripheral angiography, does acetylcysteine before and after the procedure protect the kidneys?
Background: Contrast-induced acute kidney injury is a serious complication of procedures that use iodinated contrast material and can lead to the need for dialysis, prolonged hospital stay, and increased cost and mortality. Acetylcysteine is thought to prevent this, but previous results from more than 40 trials conflict regarding its effectiveness.
Study design: Double-blinded randomized trial.
Setting: Forty-six centers in Brazil.
Synopsis: The study enrolled 2,308 patients with at least one risk factor for contrast-induced kidney injury and undergoing coronary or peripheral arterial diagnostic intravascular angiography or percutaneous intervention. Participants received two doses of acetylcysteine or placebo before and after contrast administration. End points included contrast-induced acute kidney injury, mortality, and the need for dialysis at 30 days.
Disappointingly, acetylcysteine did not significantly reduce the incidence of the end points in any patients, including the high-risk subgroups of those with diabetes mellitus and chronic renal failure, and those receiving the largest amounts of contrast. Limitations of the study include only a small number of events, as a larger number of events may help more accurately assess mortality and the need for dialysis. Additionally, creatinine may not be as good a marker for contrast-induced acute kidney injury as newer markers like cystatin C. The median volume of contrast used was low compared with previous studies, and cointerventions, such as hydration, were at the discretion of the attending physician.
Bottom line: Acetylcysteine use did not result in a lower incidence of contrast-induced acute kidney injury or other renal outcomes, and routine use prior to angiography is not recommended.
Citation: Berwange O, Cavalcanti AB, Sousa AG, et al. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized acetylcysteine for contrast-induced nephropathy trial (ACT). Circulation. 2011;124:1250-1259.