No Saline Before Contrast – No Problem
March 24, 2017
Short Attention Span Summary
That’s AMACING! No contrast prophylaxis? No problem.
This RCT compared high risk patients with GFR 30-59: no treatment prior to CT contrast vs. IV normal saline (NS) prior to contrast. They found no difference in contrast-induced nephropathy (just under 3% for each group), defined as a creatinine increase of 25% at 2-6 days. Follow up at 2-6 days was over 90% for each group. There were also no patients in either group who needed dialysis at 35-day follow up.
Spoon Feed
In patients with eGFR 30-59, there was no benefit to giving NS prior to IV contrast for CT. Total EM has an excellent deep dive on this paper.
Abstract
Lancet. 2017 Feb 20. pii: S0140-6736(17)30057-0. doi: 10.1016/S0140-6736(17)30057-0. [Epub ahead of print]
Nijssen EC1, Rennenberg RJ2, Nelemans PJ3, Essers BA4, Janssen MM5, Vermeeren MA6, Ommen VV6, Wildberger JE5.
Author information:
1Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands. Electronic address: estelle.nijssen@mumc.nl.
2Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.
3Department of Epidemiology, Maastricht University Medical Centre, Maastricht, Netherlands.
4Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, Netherlands.
5Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.
6Department of Cardiology, Maastricht University Medical Centre, Maastricht, Netherlands.
Abstract
BACKGROUND:
Intravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. However, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. This was the aim of the AMACING trial.
METHODS:
AMACING is a prospective, randomised, phase 3, parallel-group, open-label, non-inferiority trial of patients at risk of contrast-induced nephropathy according to current guidelines. High-risk patients (with an estimated glomerular filtration rate [eGFR] of 30-59 mL per min/1·73 m2) aged 18 years and older, undergoing an elective procedure requiring iodinated contrast material administration at Maastricht University Medical Centre, the Netherlands, were randomly assigned (1:1) to receive intravenous 0·9% NaCl or no prophylaxis. We excluded patients with eGFR lower than 30 mL per min/1·73 m2, previous dialysis, or no referral for intravenous hydration. Randomisation was stratified by predefined risk factors. The primary outcome was incidence of contrast-induced nephropathy, defined as an increase in serum creatinine from baseline of more than 25% or 44 μmol/L within 2-6 days of contrast exposure, and cost-effectiveness of no prophylaxis compared with intravenous hydration in the prevention of contrast-induced nephropathy. We measured serum creatinine immediately before, 2-6 days, and 26-35 days after contrast-material exposure. Laboratory personnel were masked to treatment allocation. Adverse events and use of resources were systematically recorded. The non-inferiority margin was set at 2·1%. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT02106234.
FINDINGS:
Between June 17, 2014, and July 17, 2016, 660 consecutive patients were randomly assigned to receive no prophylaxis (n=332) or intravenous hydration (n=328). 2-6 day serum creatinine was available for 307 (92%) of 332 patients in the no prophylaxis group and 296 (90%) of 328 patients in the intravenous hydration group. Contrast-induced nephropathy was recorded in eight (2·6%) of 307 non-hydrated patients and in eight (2·7%) of 296 hydrated patients. The absolute difference (no hydration vs hydration) was -0·10% (one-sided 95% CI -2·25 to 2·06; one-tailed p=0·4710). No hydration was cost-saving relative to hydration. No haemodialysis or related deaths occurred within 35 days. 18 (5·5%) of 328 patients had complications associated with intravenous hydration.
INTERPRETATION:
We found no prophylaxis to be non-inferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration according to current clinical practice guidelines.
FUNDING:
Stichting de Weijerhorst.
Copyright © 2017 Elsevier Ltd. All rights reserved.
PMID: 28233565 [PubMed – as supplied by publisher]