A MAstricht Contrast-Induced Nephropathy Guideline - AMACING
Contribution To Literature:
The AMACING trial showed that no prophylactic hydration was noninferior to hydration at preventing contrast-induced nephropathy.
The goal of the trial was to evaluate prophylactic intravenous hydration compared with no hydration among patients at risk for contrast-induced nephropathy.
Patients with chronic kidney disease undergoing intravascular iodinated contrast administration were randomized to prophylactic hydration (n = 328) versus no hydration (n = 332). Patients in the hydration group could receive either 0.9% sodium chloride (NaCl) 3-4 cc/kg 4 hours before and 4 hours after contrast administration or 0.9% NaCl 1 cc/kg 12 hours before and 12 hours after contrast administration. All patients received iopromide (low osmolar contrast).
- Total number of enrollees: 660
- Duration of follow-up: 35 days
- Mean patient age: 43% were >75 years
- Percentage female: 41%
- Percentage with diabetes: 32%
- Patients with chronic kidney disease undergoing intravascular iodinated contrast administration
- Estimated glomerular filtration rate (eGFR) 45-59 ml/min/1.73 m2, and diabetes or at least two risk factors (age >75 years; anemia; cardiovascular disease; current nonsteroidal anti-inflammatory drugs or diuretics), or eGFR 30-45 ml/min/1.73 m2, or multiple myeloma or lymphoplasmacytic lymphoma with small chain proteinuria
- eGFR <30 ml/min/1.73 m2
- Renal replacement therapy
- Emergency procedures or intensive care patients
- No referral for prophylactic hydration
- Participation in another randomized trial
- Isolation for an infectious disease
Other salient features/characteristics:
- Inpatient: 9%
- Mean eGFR: 47 ml/min/1.73 m2
- Intra-arterial contrast: 48%
- Mean contrast volume: 92 cc
- Total intravenous hydration (includes pre- and post-administration): 1637 cc
The primary outcome, incidence of contrast-induced nephropathy, occurred in 2.7% of the hydration group versus 2.6% in the no hydration group (p = 0.47). The outcomes were the same among various tested subgroups.
- No hydration was cost-effective vs. hydration
- Renal failure: 0 vs. 0, for hydration vs. no hydration
- All-cause mortality: 0 vs. 0.9%, for hydration vs. no hydration (p = 0.13)
- Symptomatic heart failure: 4.0% vs. 0, for hydration vs. no hydration (p = 0.0001)
Among patients with chronic kidney disease undergoing intravascular contrast administration, no hydration was noninferior to prophylactic hydration. Although not designed as a superiority trial, hydration did not appear to be effective at preventing contrast-induced nephropathy among high-risk patients. No hydration was cost-effective by preventing hospitalizations that otherwise would have occurred. Prophylactic hydration was associated with a higher frequency of symptomatic heart failure episodes versus no hydration. These findings apply to hemodynamically stable outpatients who received a relatively small amount of contrast (<100 cc). This important trial challenges current practice recommendations for such patients, but should not be extrapolated to unstable patients, emergency procedures, or administration of larger volumes of intravascular contrast (>100 cc).
Nijssen EC, Rennenberg RJ, Nelemans PJ, et al. Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomized, phase 3, controlled, open-label, non-inferiority trial. Lancet 2017;389:1312-22.
Keywords: Anemia, Contrast Media, Diabetes Mellitus, Diuretics, Glomerular Filtration Rate, Heart Failure, Kidney Failure, Chronic, Lymphoma, Multiple Myeloma, Proteinuria, Renal Insufficiency, Renal Insufficiency, Chronic, Primary Prevention, Risk Factors, Sodium Chloride
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