|Year : 2017 | Volume
| Issue : 3 | Page : 837-841
Oral versus intravenous hydration in protection against contrast-induced nephropathy in patients undergoing coronary angiography
Mahmoud A Mahmoud Soliman, Awny G Shalaby, Mona E Mansour MBBCH
Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||14-Jul-2016|
|Date of Acceptance||16-Oct-2016|
|Date of Web Publication||15-Nov-2017|
Mona E Mansour
Menoufia University, Faculty of Medicine, Shebin Elkom, Menoufia, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the efficacy of oral hydration for prevention of contrast-induced nephropathy (CIN).
CIN is related to increased long-term morbidity and mortality. Adequate intravenous hydration has been demonstrated to lessen its occurrence. Oral hydration with water is inexpensive and readily available. However, its role in CIN prevention is yet to be determined.
Patients and methods
This study included 200 patients (age 55 ± 7.55 years, 98 female/102 male) scheduled for diagnostic coronary angiography, who were divided into two groups. Eligible patients in group I (100 patients) were hydrated orally with 500 ml of water given 4 h before contrast; consumption of water was stopped 2 h before performing coronary angiography and was resumed with 600 ml after the procedure. Group II (100 patients) received intravenous hydration in the form of isotonic saline 0.9% at 3 ml/kg over 1-h before coronary angiography and 1 ml/kg over 6 h after the procedure. During the procedure all patients received contrast medium (Telebrix). The primary endpoint of the study was the evaluation of renal function before and 72 h after contrast medium administration.
A total of 200 patients were included in the analysis, who were divided into two groups: group I comprised 100 patients who received per-os oral water. Group II comprised 100 patients who received intravenous saline. The incidence of CIN was statistically similar in the oral and intravenous arms (6 and 7%, respectively; P = 0.774). There was no significant difference between the two groups regarding serum creatinine elevation 48–72 h after contrast exposure (as P = 0.410).
Oral hydration with water is as effective as intravenous hydration with saline in preventing CIN. Oral hydration is cheaper and more easily administered than intravenous hydration.
Keywords: coronary angiography, contrast-induced nephropathy, hydration methods
|How to cite this article:|
Mahmoud Soliman MA, Shalaby AG, Mansour ME. Oral versus intravenous hydration in protection against contrast-induced nephropathy in patients undergoing coronary angiography. Menoufia Med J 2017;30:837-41
|How to cite this URL:|
Mahmoud Soliman MA, Shalaby AG, Mansour ME. Oral versus intravenous hydration in protection against contrast-induced nephropathy in patients undergoing coronary angiography. Menoufia Med J [serial online] 2017 [cited 2018 Dec 11];30:837-41. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/837/218273
| Introduction|| |
Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury (AKI) and can constitute up to 10% of hospital-acquired AKI. .
CIN is defined as impairment of renal function measured as increase of 25% in serum creatinine from baseline or 0.5 mg/dl increase in absolute value within 48–72 h after intravenous contrast .
Severe AKI requires dialysis and results in increased morbidity and mortality, prolonged hospitalization, and overall increased healthcare resource utilization ,,,.
Hydration is the cornerstone for protection against CIN. Renal perfusion is decreased for up to 20 h following contrast media; hence, intravascular volume expansion maintains the renal blood flow, which preserves nitric oxide production and thus prevents medullary hypoxemia and enhances contrast elimination.
Intravenous fluid administration has therapeutic benefit for the prevention of CIN but requires nursing time, hospital stay, and increased healthcare resource utilization ,,.
Oral hydration for volume expansion is an alternative to intravenous fluid and has advantages of logistical ease and lower healthcare resource utilization.
| Patients and Methods|| |
This study was designed as a cross-sectional observational study.
The study population included 200 patients, who were divided into two groups. Group I (100 patients) were hydrated orally with 500 ml of water given 4 h before administration of contrast. Consumption of water through the oral route was stopped 2 h before coronary angiography and was resumed with 600 ml after the procedure. Group II (100 patients) received intravenous hydration in the form of isotonic saline 0.9% at 3 ml/kg over one hour before coronary angiography and 1 ml/kg over 6 h after coronary angiography . The patients included in this study were from the catheterization unit of Menoufia University Hospital and Mahalla Cardiac Center who were undergoing coronary angiography for evaluation of coronary anatomy between May 2015 and November 2015. Their creatinine levels before the elective coronary diagnostic angiography was not more than 1.1 mg/dl and the ejection fraction% was more than 50%. Exclusion criteria were pregnancy, heart failure, recent myocardial infarction, pulmonary edema, and allergy to contrast. Further, patients with impaired kidney function or who were admitted for emergency angiography were also excluded.
The study was approved by the local Ethics Committee, and informed consent was obtained from each patient.
Baseline demographic, clinical, and laboratory data were obtained from patients' charts and were recorded. All patients underwent creatinine evaluation before angiography as well as evaluation of hemoglobin and fasting and postprandial blood sugar. Creatinine was measured 48–72 h after angiography using 60 μm (hematology analyzer).
Estimated glomerular filteration rate (eGFR) was calculated before and 48–72 h after coronary angiography using the MDRD equation (Modification of Diet in Renal Disease Study): 186 × (creatinine/88.4)−1.154 × (age)−0.203 × (0.742 if female) × (1.210 if Black).
The collected data were organized, tabulated, and statistically analyzed using statistical package for the social studies, version 19 (IBM, Illinois, Chicago, USA). For numerical values the range, mean and SD were calculated. Differences between two mean values were analyzed using Student's t-test . Differences in mean values before and after intervention were tested using the paired t-test. For categorical variables the number and percentage were calculated and differences between subcategories were tested by means of the c2-test. The risk for nephropathy before and after intervention was tested by the Wilcoxon singed rank test (Z). Odds ratio was estimated to quantify the risk factors affecting the incidence of CIN, and 95% confidence interval (CI) was calculated for each affecting variable. Logistic regression analysis was performed to study the independent effect of each variable. The level of significance was considered as P value less than 0.05.
| Results|| |
The baseline characteristics of the groups are presented in [Table 1] and [Table 2] [Figure 1]a and [Figure 1]b. The mean age in group I was 54.46 ± 7.55 years, and the mean age in group II was 55.02 ± 6.80 years. There was no statistically significant difference between the two groups as regards age (P > 0.05). A total of 102 patients were male, representing 51% of the study population, and the remaining 98 patients were female, representing 49% of the study population. Group I included 57 (57%) male and 43 (43%) female patients. Group II included 55 (55%) male and 45 (45%) female patients; therefore, there was no significant difference in sex (P = 0.776).
|Figure 1: Comparison between group I and group II as regards demographic data.|
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There was no significant difference between the number of diabetes mellitus (DM) patients in group 1 and those in group II: 53 DM patients in group I and 50 DM patients in group II (P = 0.671). There was no significant difference between the number of hypertension (HTN) patients in group 1 and those in group II: 60 HTN patients in group I and 51 HTN patients in group II (P = 0.200).
There was no significant difference between the number of anemic patients in group I and those in group II: 46 patients were anemic in group I and 35 patients were anemic in group II (P = 0.113) [Table 2] and [Figure 2]).
|Figure 2: Comparison between group 1 and group 2 as regards DM and HTN and anemia. DM, diabetes mellitus; HTN, hypertension.|
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There was no significant difference between the two groups in the incidence of CIN: six patients in group I and seven patients in group II (P = 0.774) [Table 3] and [Figure 3]).
|Figure 3: Comparison of contrast-induced nephropathy. (CIN) between the studied groups.|
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There was no significant difference in creatinine levels 48 h after intervention in group I when compared with group II: mean ± SD creatinine in group I was 1.09 ± 0.30 and that in group II was 1.15 ± 0.61 (P = 0.410) [Table 4] and [Figure 4]).
|Table 4: Comparison of mean creatinine before and after intervention in the studied groups|
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|Figure 4: Comparison of creatinine before and 48 h after intervention between the studied groups.|
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There was no significant difference between the two groups as regards postcontrast eGFR: in group I the mean ± SD eGFR was 70.10 ± 16.79 and that in group II was 72.28 ± 21.76 (P = 0.430) [Table 5].
|Table 5: Comparison of mean eGFR before and after intervention in the studied groups|
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There was no significant difference between the protective powers of oral hydration and that of intravenous hydration. There was no significance difference between the two groups in terms of the number of CIN patients who had DM: five patients developed CIN in group I versus seven patients in group II (P = 0.674). There was no significance difference between the two groups in terms of the number of CIN patients who had HTN: in group I six patients developed CIN versus four patients in group II (P = 0.943). There was no significance difference between the two groups in terms of the number of CIN patients who had anemia: four patients developed CIN in group I versus five patients in group II (P = 0.943) [Table 6].
|Table 6: Relationship between CIN, diabetes, HTN, and anemia in the studied groups|
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| Discussion|| |
CIN may be due to contrast-mediated renal vasoconstriction, reperfusion injury from free radical formation, or tubular toxicity from direct cytotoxic effects of radiocontrast on the renal tubular epithelium ,,.
Several hydration protocols have been investigated in previous studies. Hydration with oral fluid has been shown to be as effective as intravenous hydration in patients with chronic kidney disease ,, and in high-risk patients with diabetes.
The oral route of volume expansion has been used successfully in other clinical settings, such as in the correction and prevention of hypovolemia from gastrointestinal losses as well as with physical activity in hot and dry environments ,,.
The oral route also has considerable advantages over the intravenous route. It can easily be prescribed for outpatient procedures and it does not require nursing and day-care resources ,. Because of these logistical benefits it is likely to be implemented more frequently than intravenous volume expansion .
Lastly, it would likely result in a net saving in terms of healthcare resources. However, compliance with oral volume expansion would be harder to measure, especially in a real-world setting outside clinical research.
In this study we found no significant difference between preprocedural intravenous volume expansion and oral volume expansion in the prevention of CIN. The study was conducted on 200 patients, 100 patients in group I (oral hydration) and 100 patients in group II (intravenous hydration). There was no statistically significant difference in patients' demographics or clinical data between the two groups. There was no statistically significant difference in the number of patients who had CIN 48 h after angiography in group I (six patients, 6%) when compared with that in group II (seven patients, 7%). Thus, there was no significant difference in the protective power of oral hydration versus intravenous hydration in the prevention of CIN. In contrast to our results, in the study by Trivedi et al. .the incidence of CIN was 3.7 and 34.6% with intravenous hydration and oral hydration, respectively (P = 0.005). The limitations of the study by Trivedi and colleagues included a small sample size of 53 patients and absence of a specific regimen in the oral hydration group. In contrast, Wrobel et al.  reported similar findings to ours. In their study, creatinine clearance was 65.3 ± 23.39 ml/min in group 1 and 73.5 ± 21.94 ml/min in group 2 (NS) after 48 h.
Further, Cho et al.  recommended at least 1100 ml of regular water, with 500 ml 4 h before and 600 ml after the procedure. They found no statistically significant difference between pretreatment with intravenous normal saline compared with pretreatment with oral hydration alone (P = 0.617).
Kong et al.  recommended 2000 or 2500 ml of water with at least 2000 ml of hydration after the procedure. Seven (5.8%) patients developed CIN within the first 48 h following the coronary procedures. The number of CIN patients in group A (intravenous group), group B, and group C (oral group) was two (5.0%), three (7.5%), and two (5.0%), respectively (P = 0.86).
Hiremath et al.  reported that oral hydration was as effective as intravenous hydration in preventing CIM in six trials that included 513 patients. The summary odds ratio was 1.19 (95% CI 0.46, 3.10, P = 0.73), suggesting no difference between the two routes of volume expansion.
Also Cheungpasitporn et al.  reported no significantly increased risk for CIN in the oral fluid regimen group compared with the intravenous fluid regimen group (risk ratio = 0.94, 95% CI = 0.38–2.31).
| Conclusion|| |
The oral route of volume expansion may be as effective as the intravenous route. However, the relative effectiveness of oral volume expansion versus intravenous volume expansion in the prevention of CIN cannot be firmly stated. Given the potential advantages of oral volume expansion (e.g. reduced patient burden and cost) over intravenous volume expansion, adequately powered trials comparing these strategies with clinically important outcomes need to be conducted.
Hydration with oral fluids before and after coronary angiography may be as effective as intravenous saline infusion in preventing CIN.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA 2003; 289
Harjai KJ, Raizada A, Shenoy C, Sattur S, Orshaw P, Yaeger K, et al.
A comparison of contemporary definitions of contrast nephropathy in patients undergoing percutaneous coronary intervention and a proposal for a novel nephropathy grading system. Am J Cardiol 2008; 101
Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002; 39
Gruberg L, Mehran R, Dangas G, Mintz GS, Waksman R, Kenneth MK et al.
Acute renal failure requiring dialysis after percutaneous coronary interventions. Catheter Cardiovasc Interv 2001; 52
James MT, Ghali WA, Knudtson ML, Ravani P, Tonelli M, Farres P, et al.
Associations between acute kidney injury and cardiovascular and renal outcomes after coronary angiography. Circulation 2011; 123
McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997; 103
American College of Radiology. ACR manual on contrast media
Reston, VA: American College of Radiology; 2010;.
Klein LW, Sheldon MW, Brinker J, Mixon TA, Skelding K, Adam Strunk, et al.
The use of radiographic contrast media during PCI: a focused review: a position statement of the Society of Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2009; 74
McCullough PA, Stacul F, Becker CR, Adam A, Lameire N, Tumlin JA, et al.
Contrast-induced nephropathy (CIN) consensus working panel: executive summary. Rev Cardiovasc Med 2006; 7
Cho R, Javed N, Traub D, Kodali S, Atem F, Srinivasan V. Oral hydration and alkalinization is noninferior to intravenous therapy for prevention of contrast-induced nephropathy in patients with chronic kidney disease. J Interv Cardiol 2010; 23
Richard FM, Richard H, Robert JM. A study guide to epidemiology and biostatistics, statistical significance. McCarter. [electronic resource] - 3rd ed., Vol. 5.
USA: Rockville, Md Aspen Publishers; 2001. p. 71–74.
McCullough PA, Sandberg KR. Epidemiology of contrast-induced nephropathy. Rev Cardiovas Med 2003; 4S5
Bader BD, Berger ED, Heede MB, I Silberbaur, S Duda, T Risler, et al
. What is the best hydration regimen to prevent contrast media-induced nephrotoxicity. Clin Nephrol 2004; 62
Taylor AJ, Hotchkiss D, Morse RW, McCabe J. PREPARED: preparation for angiography in renal dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction. Chest 1998; 114
Dussol B, Morange S, Loundoun A, Auquier P, Berland Y. A randomized trial of saline hydration to prevent contrast nephropathy nephrol dial transplant. Nephrol Dial Transplant 2006; 21
Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy centers for disease control and prevention. MMWR Recomm Rep 1992; 41
Shikawa T, Tamura H, Ishiguro H, Yamaguchi K, Minami K. Effect of oral rehydration solution on fatigue during outdoor work in a hot environment randomized crossover study. J Occup Health 2010; 52
Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ 2000; Bull World Health Organ 2000; 78
Kim SM, Cha R, Lee JP, Kim DK, Oh KH, Joo WK, et al.
Incidence and outcomes of contrast-induced nephropathy after computed tomography in patients with CKD. A quality improvement report. Am J Kidney Dis 2010; 55
Weisbord SD, Mor MK, Kim S, Hartwig KC, Sonel AF, Paul M, et al.
Factors associated with the use of preventive care for contrast-induced acute kidney injury. J Gen Intern Med 2009; 24
Trivedi HS, Moore H, Nasr S, Agrawal A, Goel P, Hewelt J. A randomized prospective trial to assess the role of saline hydration on the develoment of contrast nephrotoxicity. Nephron Clin Pract 2003; 93:C29–C34.
Wrobel W, Sinkiewicz W, Gordon M, Wozniak – wisniewska A. Oral versus intravenous hydration and renal function in diabetic patients undergoing percutaneous coronary interventions. Kardiol Pol 2010; 68
Kong DG, Hou YF, Ma LL, Yao DK, Wang LX. Comparison of oral and intravenous hydration strategies for the prevention of contrast-induced nephropathy in patients undergoing coronary angiography or angioplasty: a randomized clinical trial. Acta Cardiol 2012; 67
Hiremath S, Akbar A, Shabana W, Fergusson AD, Knoll AG. Prevention of contrast-induced acute kidney injury: is simple oral hydration similar to intravenous? a systematic review of the evidence. PLoS One 2013; 8
Cheungpasitporn W, Thongprayoon C, Brabec BA, Edmonds PJ, O'Corragain OA, Erickson SB., Oral hydration for prevention of contrast-induced acute kidney injury in elective radiological procedures: a systematic review and meta-analysis of randomized controlled trials. N
Am J Med Sci 2014; 6
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]