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Efficacy and safety of N-acetylcysteine for preventing post-intravenous contrast acute kidney injury in patients with kidney impairment: a systematic review and meta-analysis

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Abstract

Objectives

N-Acetylcysteine (NAC) may confer protection against post-contrast acute kidney injury (PC-AKI), although evidence is sparse and conflicting. The objective was to analyse the evidence on the efficacy and safety of NAC vs no administration of NAC in preventing PC-AKI in patients with pre-existing kidney impairment undergoing a non-interventional radiological examination requiring intravenous (IV) contrast media (CM) administration.

Methods

We carried out a systematic review including randomised controlled trials (RCTs) published in MEDLINE, EMBASE, and Clinicaltrials.gov up to May 2022. The primary outcome was PC-AKI. Secondary outcomes included the requirement of renal replacement therapy, all-cause mortality, serious adverse events, and length of hospital stay. We conducted the meta-analyses using the Mantel–Haenszel method and following a random-effects model.

Results

NAC was not associated with a significant reduction in PC-AKI (RR 0.47, 95%CI 0.20 to 1.11; 8 studies; 545 participants; I2: 56%; low certainty), all-cause mortality (RR 0.67, 95%CI 0.29 to 1.54; 2 studies; 129 participants; very low certainty), or length of hospital stay (mean difference 9.2 days, 95%CI − 20.08 to 38.48; 1 study; 42 participants; very low certainty). The impact on other outcomes could not be determined.

Conclusions

NAC may not reduce the risk of PC-AKI or all-cause mortality in people with kidney impairment who receive an IV CM prior to radiological imaging, although the certainty of the evidence is very low or low.

Clinical relevance statement

Our review concludes that prophylactic administration of N-acetylcysteine may not significantly reduce the risk of acute kidney injury in patients with kidney impairment receiving an intravenous contrast media prior to non-interventional radiological imaging, which may support decision making in this common clinical scenario.

Key Points

• N-Acetylcysteine may not significantly reduce the risk of acute kidney injury in patients with kidney impairment receiving an intravenous contrast media prior to non-interventional radiological imaging.

• All-cause mortality and length of hospital stay would not be decreased with the administration of N-Acetylcysteine in this setting.

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Abbreviations

95%CI:

95% Confidence interval

AKI:

Acute kidney injury

CKD:

Chronic kidney disease

CM:

Contrast media

CrCl:

Creatinine clearance

CT:

Computed tomography

eGFR:

Estimated glomerular filtration rate

IV:

Intravenous

LOS:

Length of hospital stay

MD:

Mean difference

NAC:

N-Acetylcysteine

PC-AKI:

Post-contrast acute kidney injury

PCI:

Percutaneous coronary intervention

RCT:

Randomised controlled trial

RoB:

Risk of bias

RR:

Risk ratio

RRT:

Renal replacement therapy

SAEs:

Serious adverse events

sCr:

Serum creatinine

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Acknowledgements

The authors acknowledge Mª del Mar Ubeda and Eukene Ansuategui from Osakidetza (Spain) for carrying out the literature searches.

Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Autonomous University of Barcelona (UAB), Barcelona, Spain

    Claudia Maestro

  2. Unit of Innovation and Organization, Navarre Health Service, Tudela Street 20, first floor, 31003, Pamplona, Navarre, Spain

    Leire Leache, Marta Gutiérrez-Valencia, Luis Carlos Saiz & Juan Erviti

  3. Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain

    Leire Leache, Marta Gutiérrez-Valencia, Luis Carlos Saiz & Juan Erviti

  4. Radiology Service, University Hospital of Navarre, Navarre Health Service, Pamplona, Navarre, Spain

    Helena Gómez & Maria Carmen Bacaicoa

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  1. Claudia Maestro
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Correspondence to Leire Leache.

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Maestro, C., Leache, L., Gutiérrez-Valencia, M. et al. Efficacy and safety of N-acetylcysteine for preventing post-intravenous contrast acute kidney injury in patients with kidney impairment: a systematic review and meta-analysis. Eur Radiol 33, 6569–6581 (2023). https://doi.org/10.1007/s00330-023-09577-1

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