Sodium Bicarbonate for the Prevention of Contrast Induced-Acute Kidney Injury: A Systematic Review and Meta-analysis
Brar SS, Hiremath S, Dangas G, Mehran R, Brar SK, Leon MB. Clin J Am Soc Nephrol. 2009 Oct;4(10):1584-92
This meta-analysis examined the use of sodium bicarbonate vs sodium chloride for the prevention of contrast induced nephropathy. The authors detected significant heterogeneity that was largely explained by trial size and publication status. Among the large randomized trials, there was no benefit for hydration with sodium bicarbonate. Studies suggesting a benefit of sodium bicarbonate was limited to small trials of lower methodological quality.
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Abstract:
BACKGROUND AND OBJECTIVES: Infusion of sodium bicarbonate has been suggested as a preventative strategy but reports are conflicting on its efficacy. The aim of this study was to assess the effectiveness of hydration with sodium bicarbonate for the prevention of contrast-induced acute kidney injury (CI-AKI). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Medline, EMBASE, Cochrane library, and the Internet were searched for randomized controlled trials comparing hydration between sodium bicarbonate and chloride for the prevention of CI-AKI between 1966 and November 2008. Fourteen trials that included 2290 patients were identified. There was significant heterogeneity between studies (P heterogeneity = 0.02; I(2) = 47.8%), which was largely accounted for by trial size (P = 0.016). Trials were therefore classified by size. RESULTS: Three trials were categorized as large (n = 1145) and 12 as small (n = 1145). Among the large trials, the incidence of CI-AKI for sodium bicarbonate and sodium chloride was 10.7 and 12.5%, respectively; the relative risk (RR) [95% confidence interval (CI)] was 0.85 (0.63 to 1.16) without evidence of heterogeneity (P = 0.89, I(2) = 0%). The pooled RR (95% CI) among the 12 small trials was 0.50 (0.27 to 0.93) with significant between-trial heterogeneity (P = 0.01; I(2) = 56%). The small trials were more likely to be of lower methodological quality. CONCLUSIONS: A significant clinical and statistical heterogeneity was observed that was largely explained by trial size and published status. Among the large randomized trials there was no evidence of benefit for hydration with sodium bicarbonate compared with sodium chloride for the prevention of CI-AKI. The benefit of sodium bicarbonate was limited to small trials of lower methodological quality.
October 25th, 2009 at 11:33 am
Based on this paper (and other evidence), I think the Nephrology community can focus on ensuring high risk patients are volume expanded prior to contrast exposure, without worrying too much about whether to use isotonic NaHCO3 solution or saline. Since saline is much simpler to use, this should be our default solution of choice.
I think we need to remember that using isotonic NaHCO3 requires nursing or pharmacy to specially prepare the solution, which increases costs, delays initiation of treatment and runs the risk of medical error.