Дозозависимый протективный эффект ацетилцистеина от радиоконтраст-индуцированной нефропатии после первичной ангиопластики:
RCIN occurred in 66/352 patients (19%) overall: 17/115 (15%) who received standard-dose (3,000 mg) acetylcysteine; 10/118 (8%) who received high-dose (6,000 mg) acetylcysteine; and 39/119 (33%) who were given placebo (P < 0.001). Multivariate logistic regression, with adjustment for factors including age, baseline serum creatinine level and contrast volume, revealed that placebo was associated with a significantly higher risk of RCIN than standard-dose acetylcysteine (odds ratio 2.60; 95% CI 1.30-5.18; P = 0.007) or high-dose acetylcysteine (odds ratio 5.78; 95% CI 2.56-13.16; P < 0.001). In-hospital mortality rate was significantly higher among patients on placebo (11%) than among patients who received standard-dose acetylcysteine (4%) or high-dose acetylcysteine (3%; P = 0.02). Patients on placebo also showed a significantly higher incidence of a composite endpoint comprising death, acute renal failure, or need for mechanical ventilation (18%) than those in the standard-dose or high-dose acetylcysteine groups (7% and 5%, respectively; P = 0.002).
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Еще вариант:
The researchers assigned 56 to an infusion of sodium bicarbonate plus high-dose N-acetylcysteine (N-AC) just prior to contrast injection, which was continued for 12 hours after PCI, and 55 to standard hydration with intravenous isotonic saline for 12 hours after PCI. Both groups received two doses of oral N-AC the following day.
According to the team, only one patient (1.8%) in the sodium bicarbonate plus N-AC arm developed contrast-induced nephropathy, defined as a serum creatinine of 0.5 mg/dL or greater, compared with 12 (21.8%) in the control arm (p < 0.001).
The absolute risk reduction of contrast-induced nephropathy with sodium bicarbonate plus N-AC versus standard hydration was 20%, resulting in the number required to treat of five patients to prevent one case of contrast-induced nephropathy.
Acute anuric renal failure occurred in one patient in the sodium bicarbonate plus N-AC group versus seven in the control group (1.8% vs 12.7%). Four patients required renal replacement therapy (one in the sodium bicarbonate group and three in the saline group).
The overall incidence of acute pulmonary edema was 2.7% and did not differ between the two groups. This rate is similar to that seen in three previous studies.
During a 7-day monitoring period, one patient in the sodium bicarbonate plus N-AC hydration group died of cardiogenic shock (1.8%). There were four deaths (7.3%) in the saline group (two from cardiogenic shock and two from multiorgan failure).
J Am Coll Cardiol 2007;49:1283-1288.
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birdname
22.03.2007, 20:00
Спасибо большое, Вадим Валерьевич. Честно говоря, я не в первый раз натыкаюсь на эту информацию, но так и не поняла: для этого годится только венный ацетилцистеин, или пероральный тоже?
Уважаемая Ольга,
приведу фрагмент еще одной недавней публикации, где подробно описывается протокол назначения (похоже в/в введение соды оказывает доп. протекцию):
Protocol
After enrollment, patients were randomly assigned to 1 of the 3 following treatments: intravenous saline plus NAC administration (saline plus NAC group), intravenous sodium bicarbonate plus NAC administration (bicarbonate plus NAC group), or intravenous saline plus intravenous ascorbic acid plus NAC (saline plus ascorbic acid plus NAC group). All 3 therapies were instituted both before and after administration of the contrast agent. Isotonic saline (0.90%) was given intravenously at a rate of 1 mL/kg body weight per hour (0.5 mL/kg for patients with left ventricular ejection fraction <40%) for 12 hours before and 12 hours after administration of the contrast agent. Patients allocated to the bicarbonate plus NAC group received 154 mEq/L sodium bicarbonate in dextrose and H2O, according to the protocol reported by Merten et al. The initial intravenous bolus was 3 mL · kg–1 · h–1 for 1 hour immediately before contrast injection. After this, patients received the same fluid at a rate of 1 mL · kg–1 · h–1 during contrast exposure and for 6 hours after the procedure. Patients allocated to the saline plus ascorbic acid plus NAC group received 3 g ascorbic acid intravenously 2 hours before followed by 2 g the night and the morning after the procedure. We used the intravenous infusion of ascorbic acid because of the low bioavailability after oral administration.
All patients received NAC (Fluimucil, Zambon Group SpA, Milan, Italy) orally at a dose of 1200 mg twice daily on the day before and the day of administration of the contrast agent (total of 2 days). Diuretics were routinely withheld on the day of contrast injection.
Из Briguori C, Airoldi F, D'Andrea D, Bonizzoni E, Morici N, Focaccio A, Michev I, Montorfano M, Carlino M, Cosgrave J, Ricciardelli B, Colombo A.
Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies.
Circulation. 2007 Mar 13;115(10):1211-7.
Three hundred twenty-six consecutive patients with chronic kidney disease, referred to our institutions for coronary and/or peripheral procedures, were randomly assigned to prophylactic administration of 0.9% saline infusion plus NAC (n=111), sodium bicarbonate infusion plus NAC (n=108), and 0.9% saline plus ascorbic acid plus NAC (n=107). All enrolled patients had serum creatinine 2.0 mg/dL and/or estimated glomerular filtration rate <40 mL · min–1 · 1.73 m–2. Contrast nephropathy risk score was calculated in each patient. In all cases, iodixanol (an iso-osmolar, nonionic contrast agent) was administered. The primary end point was an increase of 25% in the creatinine concentration 48 hours after the procedure (CIN). The amount of contrast media administered (179±102, 169±92, and 169±94 mL, respectively; P=0.69) and risk scores (9.1±3.4, 9.5±3.6, and 9.3±3.6; P=0.21) were similar in the 3 groups. CIN occurred in 11 of 111 patients (9.9%) in the saline plus NAC group, in 2 of 108 (1.9%) in the bicarbonate plus NAC group (P=0.019 by Fisher exact test versus saline plus NAC group), and in 11 of 107 (10.3%) in the saline plus ascorbic acid plus NAC group (P=1.00 versus saline plus NAC group).
PS.
Предыдущий опыт освещен в этой доступной публикации (после бесплатной регистрации):
Pannu N, Wiebe N, Tonelli M; Alberta Kidney Disease Network.
Prophylaxis strategies for contrast-induced nephropathy.
JAMA. 2006 Jun 21;295(23):2765-79.
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van den Berk G, Tonino S, de Fijter C, Smit W, Schultz MJ.
Bench-to-bedside review: preventive measures for contrast-induced nephropathy in critically ill patients.
Crit Care. 2005 Aug;9(4):361-70.
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