(PART II of II) 7) Hemodialysis. Lehnert et al.,63 in a randomized study, assessed the prophylactic use of hemodialysis for 3 hours in patients with serum creatinine above 1.4 mg/dl who underwent both cardiac and non-cardiac procedures, beginning immediately after the radiographic examination, in an attempt to eliminate the contrast medium and minimize its deleterious effects on the kidneys. The results indicated that this strategy was not useful for preventing CIN. Continuous hemofiltration (10 hours before and 10 hours after the procedure) was also assessed in the prophylaxis of CIN in 54 high-risk patients (Cr > 2.0 mg/dl) undergoing PTCA.64 The results were extremely favorable to hemofiltration in regard to in-hospital mortality (2.4% versus 14.7%) and the need for hemodialysis (0% versus 39%). However, it is worth noting the invasive and extremely expensive nature of that procedure. 8) Theophylline. Theophylline, a nonselective antagonist of the adenosine receptors, was assessed for preventing CIN. The results, however, were inconclusive. In a placebo-controlled randomized study65 comprising 100 patients with previous renal function suppression, the incidence of CIN was significantly reduced from 16% in the group receiving placebo to 4% in the group receiving theophylline in 48 hours. In another prospective randomized study66 comprising 60 patients with the same characteristics, aminophylline + hydration was compared with hydration alone and dopamine + hydration. No significant difference was observed in the incidence of CIN in the 3 groups studied (35% versus 30% versus 50%, respectively). Erley et al.67 also assessed the use of theophylline in a double-blind randomized study comparing hydration in 80 patients with chronic renal failure. The use of theophylline showed no additional benefit to hydration. 9) Angiotensin-converting enzyme inhibitors (ACE inhibitors). The possible role of medullary ischemia mediated by the renin-angiotensin system raised the hypothesis that ACE inhibitors could be useful for preventing CIN. The prophylactic use of captopril was assessed in diabetic patients undergoing coronary angiography.68 The results showed that the drug was useful for preventing CIN in diabetic patients with a significant risk reduction of 79%. In that randomized study, however, only 71 patients were included. Therefore, larger clinical trials are required to confirm the beneficial effects of the ACE inhibitors in this subgroup of patients. 10) Dopamine. Low doses of dopamine have a renal vasodilating effect, causing an increase in the glomerular filtration rate and renal blood flow. Two randomized studies assessed the use of low doses of dopamine for preventing CIN. One of these studies66 compared the use of dopamine combined with hydration, aminophylline combined with hydration, and hydration alone in patients undergoing PTCA. Another study69 with dopamine comprised 66 patients who underwent coronary angiography and were randomized to receive dopamine at the dosage of 2 µg/kg/minute combined with 0.45% saline solution or 0.45% saline solution alone. The results of both studies did not confirm the potential benefit of dopamine in preventing CIN. In addition, in patients with peripheral vascular disease, the use of dopamine may significantly worsen renal function as compared with the use of placebo.69 11) Atrial natriuretic peptide. The atrial natriuretic peptide is an inhibitor of the synthesis of vasopressin, which is a potent vasoconstrictor. Therefore, by improving renal blood flow, the atrial natriuretic peptide could reduce the incidence of CIN. That drug was assessed in the prophylaxis of CIN in a prospective study comprising 247 patients at risk70 who were randomized to receive placebo or atrial natriuretic peptide at 3 different dosages. The results showed that none of the atrial natriuretic peptide dosages assessed were able to reduce the incidence of CIN as compared to placebo. 12) N-acetylcysteine. There is evidence that the production of free radicals in the kidney increases after the administration of contrast media.12 N-acetylcysteine, an antioxidant, also has vasodilating properties because it increases the expression of the nitric oxide synthetase enzyme71 and can prevent contrast-medium induced renal failure both by reducing direct oxidative injury and by improving renal hemodynamic conditions. Tepel et al.72 reported that in patients with previous renal function suppression undergoing contrast-enhanced computed tomography, the administration of N-acetylcysteine at a dosage of 600 mg twice daily for 2 days significantly reduced the incidence of renal dysfunction caused by contrast medium from 21% in the group receiving placebo to 2% in the group receiving the drug. This result was confirmed in another small clinical trial assessing the use of N-acetylcysteine in 54 patients at risk who were undergoing cardiac catheterization.73 Recently, in a placebo-controlled randomized study74 comprising 183 patients with previous renal function suppression undergoing coronary angiography, coronary angioplasty or peripheral angiography, N-acetylcysteine was not useful for preventing CIN in the population studied. A post hoc analysis showed that the drug had a beneficial effect only in the subgroup of patients receiving a small volume of contrast medium (
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