Coronary artery disease
A New Protocol Using Sodium Bicarbonate for the Prevention of Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography

https://doi.org/10.1016/j.amjcard.2011.01.045Get rights and content

Contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality rates. Although a previous study reported that pretreatment with sodium bicarbonate is more effective than sodium chloride for prophylaxis of CIN, this has not been a universal finding. We performed a prospective randomized trial to investigate whether CIN can be avoided using sodium bicarbonate. In total 155 patients with a glomerular filtration rate (GFR) <60 ml/min/1.73 m2 who were undergoing coronary angiography were enrolled. We assigned patients to sodium chloride plus sodium bicarbonate (bicarbonate group, n = 78) or sodium chloride alone (chloride group, n = 77). Infusion of sodium bicarbonate at 1 ml/kg/hour continued from 3 hours before to 6 hours after coronary angiography. CIN was defined as a 25% increase in serum creatinine from baseline value or an absolute increase of ≥0.5 mg/dl, which appeared within 2 days of contrast. Baseline GFR was not significantly different between the 2 groups. Patients in the bicarbonate group had a higher GFR than those in the chloride group on day 2 (45.8 ± 13.4 vs 40.9 ± 14.6 ml/min/1.73 m2, p = 0.031) and at 1 month (49.5 ± 14.7 vs 43.7 ± 15.5 ml/min/1.73 m2, p = 0.019). CIN occurred in 10 patients (13%) in the chloride group but in only 2 patients (2.6%) in the bicarbonate group (p = 0.012). Sodium chloride plus sodium bicarbonate is more effective than sodium chloride alone for prophylaxis of CIN and can lead to retention of better long-term renal function.

Section snippets

Methods

We prospectively enrolled patients undergoing coronary angiography or intervention at 2 Japanese hospitals from November 2004 through May 2007. Indications for coronary angiography or intervention for each patient were left to the discretion of each clinical cardiologist. All patients were ≥20 years old and had an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Exclusion criteria included serum creatinine levels >4 mg/dl, changes in serum creatinine levels of ≥0.5 mg/dl during

Results

In total 158 patients were randomized to receive sodium bicarbonate plus sodium chloride (n = 79) or sodium chloride (n = 79), with 155 patients completing the study. Of the 158 patients, 3 did not complete the study. Two patients in the chloride group had no follow-up laboratory test results. In the bicarbonate group, 1 patient had to interrupt the infusion of sodium bicarbonate because of angialgia.

Clinical characteristics of the 155 patients who completed the study are listed in Table 1.

Discussion

The major finding of this study is that treatment of patients with sodium bicarbonate plus sodium chloride before and after coronary angiography decreased the incidence of CIN compared to use of sodium chloride alone. In addition, eGFR was improved not only in the short term but also for the long term in patients treated with sodium bicarbonate plus sodium chloride.

The mechanism by which CIN occurs is not well understood. The 2 major theories are renal vasoconstriction and direct renal tubular

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