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Three Part Question

In [adult patients receiving intravenous radiographic contrast] is [sodium bicarbonate better than hydration alone] in [reducing the incidence of contrast induced nephropathy, avoiding hemodialysis]?

Clinical Scenario

You wish to investigate the cause of severe abdominal pain in an elderly diabetic female in the emergency department. You determine she needs a C.T. scan of her her abdomen/pelvis. You would like to use I.V. contrast to evaluate for mesenteric ischemia or diverticulitis, but her baseline creatinine is 1.7.
Not using I.V. contrast could cause you to miss the diagnosis, yet using I.V. contrast could be devistating to her kidney function. You wonder if anything other than hydration could prevent contrast associated renal failure.

Search Strategy

I searched my topic on PubMed's clinical query section using MeSH terms of sodium bicarbonate therapy and nephropathy.
("Sodium Bicarbonate/therapeutic use"[MAJR] AND "Kidney Diseases"[MAJR]) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract]))

Search Outcome

Only the first article, Merten et al, deals specifically with I.V. contrast-induced nephropathy and sodium bicarbonate therapy in adult patients.
1:
Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonton CA 3rd, Rittase RA, Norton HJ, Kennedy TP.
Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial.
JAMA. 2004 May 19;291(19):2328-34.
PMID: 15150204 [PubMed - indexed for MEDLINE]
The other four articles listed are irrelevant in this specific clinical query.
2:
Ngugi NN, McLigeyo SO, Kayima JK.
Related Articles, Links
Treatment of hyperkalaemia by altering the transcellular gradient in patients with renal failure: effect of various therapeutic approaches.
East Afr Med J. 1997 Aug;74(8):503-9.
PMID: 9487416 [PubMed - indexed for MEDLINE]
3:
Passfall J, Pai J, Spies KP, Haller H, Luft FC.
Related Articles, Links
Effect of water and bicarbonate loading in patients with chronic renal failure.
Clin Nephrol. 1997 Feb;47(2):92-8.
PMID: 9049456 [PubMed - indexed for MEDLINE]
4:
Kalhoff H, Diekmann L, Kunz C, Stock GJ, Manz F.
Related Articles, Links
Alkali therapy versus sodium chloride supplement in low birthweight infants with incipient late metabolic acidosis.
Acta Paediatr. 1997 Jan;86(1):96-101.
PMID: 9116434 [PubMed - indexed for MEDLINE]
5:
Wakabayashi Y, Ohwada T, Kikawada R.
Related Articles, Links
Haemo-dialysis/-filtration using sodium bicarbonate depresses cardiac function in critically ill patients with acute renal failure.
Jpn Circ J. 1994 Feb;58(2):81-6.
PMID: 8196158 [PubMed - indexed for MEDLINE]

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

For this study an increase of serum creatinine level of at least 25% was defined as contrast induced renal failure. These were measured consecutively on the two mornings following I.V. contrast administration. Of the 119 patients completing the study, only 1.7% (1 of 60 patients) in those receivng sodium bicarbonate developed contrast induced renal failure compared with 13.6% (8 of 59 patients) receiving only sodium chloride hydration. The sodium bicarbonate solution used in this study is easy to mix, readily available, inexpensive, and can be infused over the hour prior to I.V. contrast administration. This study was not performed in the emergency department setting but may be adaptable to this patient population due to its ease of administration. All nine randomized patients who developed contrast induced renal failure were noted to have "prolonged" hospital stays as a consequence of their complication. The number of hospital days was not quantified in the paper. However, none of these nine patients required hemodialysis. More data is needed to determine the cost benefit of sodium bicarbonate prophylaxis. With an absolute risk reduction of 11.9%, the number needed to treat to prevent one case of renal failure is 8.4.

Clinical Bottom Line

The administration of sodium bicarbonate is more effective than hydration alone in the prevention of contrast induced renal failure as measured by serum creatinine levels. The sodium bicarbonate solution is easy to mix, inexpensive, and can be infused during the normal time a patient waits to have a C.T. scan performed in the emergency department. More data are needed to determine the practicality and benefit in the emergency department setting and to delineate cost savings from shorter hospitalization time and prevention of hemodialysis.

References

1. Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonto Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate: A Randomized Trial JAMA May 19, 2004; 2328-34