Bicarbonate or saline to prevent contrast-induced nephropathy?

For patients with chronic renal insufficiency (gfr<60) undergoing coronary angiography, previous small RCTs showed bicarbonate to be superior to saline (abstract) (abstract) (abstract) in preventing CIN, but in a subsequent larger RCT, it was not found to be superior (when combined with N-acetylcysteine) (abstract). A recent meta-analysis found bicarbonate to be superior to saline, but noted signficant study heterogeneity and likely publication bias, calling for a larger RCT (meta-analysis). Now we have a larger RCT, in which 353 high risk patients (gfr <60 with DM, CHF, HTN, or age >75) were randomized to saline or bicarbonate infusions, and N-acetylcysteine was given at the discretion of the treating physician (in about half of patients). There was no difference in incidence of CIN between the groups (even when stratified by DM or receipt of N-acetylcysteine). In summary, it is unlikely that bicarbonate infusions are more beneficial than saline in preventing CIN (abstract)

Danielle Scheurer

Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

1 Comment

  1. Titilola Britto on January 31, 2009 at 3:24 pm

    Standard saline protocols require 4 hours of infusion prior to test, while bicarbonate protocols only need one hour. In an ED, an urgent cardiac cath or an outpatient who does not want to spend nine+ hours at the facility. the bicarbonate protocol is effective and much more convenient.
    The other important point is that Clinicians assessment of and correction of volume depletion is still one of the most important preventive strategies in avoiding CIN (contrast induced nephropathy). acetylcysteine is probably voodoo and volume expabnsion in CKD patients at risk is still the most effective preventive strategy

Leave a Comment