Hariprasad Trivedi

High-dose N-acetylcysteine for the Prevention of Contrast-induced Nephropathy

BACKGROUND Whether N-acetylcysteine is beneficial for the prevention of contrast-induced nephropathy is uncertain. METHODS We conducted a meta-analysis to evaluate the efficacy of high-dose N-acetylcysteine for the prevention of contrast-induced nephropathy. Our prespecified inclusion criteria were as follows: adult subjects; English language literature; administration of high-dose N-acetylcysteine a priori defined as a daily dose greater than 1200 mg or a single periprocedural dose (within 4 hours of contrast exposure) greater than 600 mg; prospective trials of individuals randomized to N-acetylcysteine, administered orally or intravenously, versus a control group; and trials that included the end point of the incidence of contrast-induced nephropathy. Trials that compared N-acetylcysteine with another active treatment were excluded. RESULTS Sixteen comparisons of patients randomized to high-dose N-acetylcysteine versus controls met our prespecified inclusion criteria with a total sample size of 1677 subjects (842 assigned to high-dose N-acetylcysteine and 835 assigned to the control arm). The average population age was 68 years, 38.7% were diabetic, and the majority was male (67.8% of reported instances). The weighted mean baseline creatinine of the overall population was 1.58 mg/dL. No significant heterogeneity was detected (P = .09; I(2) = 34%). The overall effect size assuming a common odds ratio revealed an odds ratio of 0.46 (95% confidence interval [CI], 0.33-0.63) for the occurrence of contrast-induced nephropathy with the use of high-dose N-acetylcysteine. The results of the more conservative random effects approach were similar (odds ratio = 0.52; 95% CI, 0.34-0.78). There was no evidence of publication bias (P = .34). CONCLUSION Our results suggest that high-dose N-acetylcysteine decreases the incidence of contrast-induced nephropathy.

Cost implications of caring for chronic kidney disease: are interventions cost-effective?

Recent data suggest a large, rising burden of chronic kidney disease (CKD) in the general population and rising expenses associated with it. In 2007, CKD contributed 27.6% of costs and CKD subjects constituted 9.8% of the population. Between 1993 and 2007, overall Medicare costs nearly doubled and CKD-associated costs increased about 5-fold. The Medicare cost of end-stage renal disease has risen from

Hydration with sodium bicarbonate for the prevention of contrast-induced nephropathy: a meta-analysis of randomized controlled trials

12.2 in 2000 to

Contrast-induced nephropathy after a second contrast exposure

20.8 billion in 2007. This review examines cost-effectiveness of prevention and treatment of CKD. Mathematical derivation of savings associated with prevention of CKD is not feasible because of dearth of data. However, examination of various factors that would affect such a hypothetical derivation indicates that prevention of CKD is cost-effective. Better data enable modeling of gross savings of slowing the progression of CKD. Data suggest that if at the beginning of the current decade, the rate of decline in GFR decreased by 10% and 30% in every patient with GFR of 60 mL/min/1.73 m(2) or less the gross direct cumulative health care savings over the next 10 years amount to

Circadian rhythm of salivary cortisol, plasma cortisol, and plasma ACTH in end-stage renal disease

18.56 and

Readability and comprehensibility of over-the-counter medication labels

60.61 billion, respectively. Additional benefits accrue as a result of diminishing disability and gain in productivity. The analysis suggests that prevention and slowing progression of CKD is cost-effective.

Declining Rates of Deceased Donor Renal Transplantation in the United States Over Successive Years of Listing

BACKGROUND Whether hydration with sodium bicarbonate is beneficial for the prevention of contrast-induced nephropathy is uncertain. METHODS We conducted a meta-analysis of trials to evaluate the benefit of sodium bicarbonate solutions for the prevention of contrast-induced nephropathy. Our pre-specified criteria were; 1) adult subjects; 2) English literature 3) randomized trials of individuals assigned to a bicarbonate-containing intravenous solution versus an alternate solution; 4) an end-point that included the incidence of contrast-induced nephropathy 5) a uniform contrast agent. Trials in which certain additional prophylactic agents were allowed or administered in a non-standardized, non-stratified manner were ineligible. RESULTS Ten randomized comparisons of sodium bicarbonate versus sodium chloride satisfied study criteria (total n = 1,090). The majority of studies involved subjects undergoing cardiac angiography and a nonionic low osmolar contrast agent was used in most instances. Woolfs test showed no evidence of heterogeneity (p = 0.10; I2 = 39%) and there was no publication bias (p = 0.34). The effect size using the exact Mantel-Haenszel-test revealed an odds ratio (OR) of 0.57 (95% CI: 0.38 - 0.85) for the occurrence of contrast-induced nephropathy with the use of sodium bicarbonate. An analysis restricted to studies that employed hydration without additional prophylactic agents favored sodium bicarbonate to a greater extent (OR 0.33:95% CI: 0.17 - 0.62). However, many trials in this arena may not be considered high-quality studies. CONCLUSION Though inference should be tempered by trial quality issues, given lack of heterogeneity or publication bias the summary effect of randomized trials balanced in important characteristics favors hydration with sodium bicarbonate for the prevention of contrast-induced nephropathy.

Lack of nephrotoxicity of gadodiamide in unselected hospitalized patients.

Background: The risk of contrast-induced nephropathy (CIN) after repeated contrast exposure has not been evaluated. Methods: We prospectively evaluated the effects of two contrast exposures during an investigational study of a new computerized tomography (CT) scanner. Adult subjects who underwent a variety of contrast-enhanced imaging procedures with conventional apparatus, as part of routine care, were invited to undergo a second contrast-enhanced research scan. Subjects were required to have an estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2 and a serum creatinine (sCr) value measured immediately prior to the second contrast exposure that was <125% of that measured prior to the first imaging study. Results: Twenty-eight subjects underwent a second contrast exposure after a mean interval of 20 ± 13 days (75% males, 89% Caucasians, 21% diabetics, mean age 60.6 ± 6 years, mean contrast volume 130 ± 42 mL). There was a significant increase in mean sCr and decline in eGFR after the second contrast exposure (sCr 0.93 ± 0.14 vs. 0.86 ± 0.15 mg/dL prior, p = 0.027; eGFR 83.9 ± 13.5 vs. 89.8 ± 13 mL/min/1.73 m2 prior, p = 0.028). Four subjects (14.3% of the population) developed CIN. Conclusion: Even in subjects with relatively preserved renal function there is a notable risk of CIN after repeated contrast exposure. This conclusion was unaltered by several sensitivity analyses.

Acute Effect of Furosemide on Glomerular Filtration Rate in Diastolic Dysfunction

Objective Patients with end-stage renal disease (ESRD) can display the features of endogenous hypercortisolism but are difficult to evaluate for Cushings syndrome. We evaluated the circadian rhythm of plasma compared with salivary cortisol in subjects with ESRD. Design Plasma and salivary cortisol and plasma ACTH samples were drawn frequently over 24 h in an inpatient research unit in stable ESRD subjects on daytime chronic hemodialysis (n=16) vs controls (n=8). Methods Plasma cortisol was measured every 2 h from 0800 to 0600 h the following day. Salivary cortisol was measured every 2 h, except between 2400 and 0400 h (sleep time). Plasma ACTH measured in a subset of samples and C-reactive protein (CRP) was measured as a marker of a subclinical inflammatory state in all subjects. Results ESRD subjects had a discernable circadian rhythm in plasma and salivary cortisol, but with a significantly higher nadir (1800–2400 h) compared with the controls (P=0.016–<0.001). After excluding four ESRD subjects without a normal circadian rhythm, the ESRD subjects still had higher nadir plasma and salivary cortisol and plasma ACTH compared with controls. There was no difference in the correlation of salivary and plasma cortisol in control vs ESRD subjects. ESRD subjects had higher CRP levels compared with controls. Conclusions ESRD subjects had increased late-night plasma and salivary cortisol and plasma ACTH levels. Late-night salivary cortisol is a reliable index of plasma cortisol in ESRD patients.

Outcomes in Patients with Chronic Kidney Disease Referred Late to Nephrologists: A Meta-analysis

Abstract Nonprescription medications are relatively safe, but not risk-free and can lead to serious adverse events, particularly if used contrary to directions or without attention to depicted warnings. The question arises whether the information presented on the product label is readable and comprehensible to the average lay person. We examined the product labels of nonprescription medications for readability and comprehensibility characteristics using the Flesch–Kincaid method. The Flesch–Kincaid reading ease scores and grade level scores were derived. We further validated the grade level scores using the Gunning–Fog method. Qualitative assessment of select labels found severe deficiencies such as poor organization and inundation with technical terms. By quantitative assessment the average reading ease score of 40 nonprescription medication labels (including nonsteroidal anti-inflammatory agents, antacids, laxative preparations, anti-allergy medications, H-2 blockers, proton pump inhibitors, sleep aids, an antiasthmatic, and cough and cold remedies) was 38 ± 12. The average Flesch–Kincaid grade level score was 16 ± 5. All labels except one were at reading grade level greater than the eighth grade. The average grade level of education necessary to understand the material according to the Gunning–Fog method was 17 ± 5 and all labels were above the eighth grade reading level. Nonprescription medication labels are written in a language that is not comprehensible to the average member of the general public. There is a need for considerable improvement in the readability of these labels.