Pharmacological interventions for the prevention of contrast-induced acute kidney injury in high-risk adult patients undergoing coronary angiography: A systematic review and meta-analysis of randomised controlled trials

Objective
Quantify the efficacy of strategies to prevent contrast-induced acute kidney injury (CI-AKI) in high-risk patients undergoing coronary angiography(CAG) with or without percutaneous coronary intervention (PCI).
Background
CI-AKI remains a common problem. The renoprotective efficacy of existing pharmacological agents remains uncertain in high-risk populations.
Methods
Systematic review and meta-analysis of randomized controlled trials(RCTs) to compare different strategies versus hydration in patients with chronic kidney disease (CKD) undergoing CAG+/-PCI. Primary outcome was incident CI-AKI. Fixed-effects meta-analyses estimated odds ratios(OR), 95% confidence intervals (CI), and heterogeneity.
Results
Forty-eight RCTs were included. Seven pharmacological strategies wereevaluated by multiple RCTs and 10 by one RCT each. These had varyingrisk of bias; >25% of trials were at high risk of performance bias. Five strategies significantly reduced the odds of CI-AKI: N-acetylcysteine (27trials, 5694 participants; OR=0.77, 95% CI 0.65-0.91, p=0.002,I2=36%), ascorbic acid (4 trials, 759 participants; OR=0.59, 95% CI0.39-0.89, p=0.01, I2=0%), statin (2 trials, 3234 participants; OR=0.59, 95% CI 0.39-0.89, p=0.75, I2=0%), trimetazidine (2 trials, 214participants; OR=0.27, 95% CI 0.10-0.71, p=0.01, I2=0%) and nicorandil(2 trials, 389 participants; OR=0.47, 95% CI 0.23-0.94, p=0.03,I2=52%). Theophylline had a similar, but non-significant, effect. A subgroup analysis found that the benefit of NAC was highest in patients requiring a high contrast dose.
Conclusions
Several drugs are renoprotective in CKD patients undergoing CAG+/-PCI. The evidence is strongest for NAC. We recommend that NAC should be used when a high dose of contrast is anticipated.