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J Am Coll Cardiol ; 33(2): 403-11, 1999 Feb.
Article in English | MEDLINE | ID: mdl-9973020

ABSTRACT

OBJECTIVES: This study was done to test the hypothesis that a forced diuresis with maintenance of intravascular volume after contrast exposure would reduce the rate of contrast-induced renal injury. BACKGROUND: We have previously shown a graded relationship with the degree of postprocedure renal failure and the probability of in-hospital death in patients undergoing percutaneous coronary intervention. Earlier studies of singular prevention strategies (atrial natriuretic factor, loop diuretics, dopamine, mannitol) have shown no clear benefit across a spectrum of patients at risk. METHODS: A prospective, randomized, controlled, single-blind trial was conducted where 98 participants were randomized to forced diuresis with intravenous crystalloid, furosemide, mannitol (if pulmonary capillary wedge pressure <20 mm Hg), and low-dose dopamine (n = 43) versus intravenous crystalloid and matching placebos (n = 55). RESULTS: The groups were similar with respect to baseline serum creatinine (2.44+/-0.80 and 2.55+/-0.91 mg/dl), age, weight, diabetic status, left ventricular function, degree of prehydration, contrast volume and ionicity, and extent of peripheral vascular disease. The forced diuresis resulted in higher urine flow rate (163.26+/-54.47 vs. 122.57+/-54.27 ml/h) over the 24 h after contrast exposure (p = 0.001). Two participants in the experimental arm versus five in the control arm required dialysis, with all seven cases having measured flow rates <145 ml/h in the 24 h after the procedure. The mean individual change in serum creatinine at 48 h, the primary end point, was 0.48+/-0.86 versus 0.51+/-0.87, in the experimental and control arms, respectively, p = 0.87. There were no differences in the rates of renal failure across six definitions of renal failure by intent-to-treat analysis. However, in all participants combined, the rise in serum creatinine was related to the degree of induced diuresis after controlling for baseline renal function, r = -0.36, p = 0.005. The rates of renal failure in those with urine flow rates greater than 150 ml/h in the postprocedure period were significantly lower, 8/37 (21.6%) versus 28/61 (45.9%), p = 0.03. CONCLUSIONS: Forced diuresis with intravenous crystalloid, furosemide, and mannitol if hemodynamics permit, beginning at the start of angiography provides a modest benefit against contrast-induced nephropathy provided a high urine flow rate can be achieved.


Subject(s)
Contrast Media/adverse effects , Diuretics/therapeutic use , Kidney Diseases/prevention & control , Aged , Cardiotonic Agents/administration & dosage , Cardiotonic Agents/therapeutic use , Coronary Angiography , Coronary Disease/diagnostic imaging , Creatinine/blood , Crystalloid Solutions , Diuresis , Diuretics/administration & dosage , Dopamine/administration & dosage , Dopamine/therapeutic use , Drug Therapy, Combination , Female , Follow-Up Studies , Furosemide/administration & dosage , Furosemide/therapeutic use , Humans , Isotonic Solutions , Kidney Diseases/blood , Kidney Diseases/chemically induced , Male , Mannitol/administration & dosage , Mannitol/therapeutic use , Plasma Substitutes/administration & dosage , Plasma Substitutes/therapeutic use , Prospective Studies , Pulmonary Wedge Pressure , Rehydration Solutions/administration & dosage , Rehydration Solutions/therapeutic use , Risk Factors , Single-Blind Method , Treatment Outcome
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