Prevention of Contrast-Induced Nephropathy.

•  Mainstay treatment is hydration.
•  Some experts suggest that simple intravenous hydration with 0.9% saline is adequate therapy for prevention of CIN due to the expansion of intravascular volume limiting renalvasoconstriction and hypoperfusion. Therefore, less contact time of contrast material with the renal tubules.Disadvantage is the length time required to administer the fluid and the risk for volume overload.
• Several randomized control trials have indicated that sodium bicarbonate is modestly better than 0.9% saline for hydration but contradicted with other results which showed no effect.
•  Largest meta-analysis indicated that N-acetylcysteine was efficacious and better than both saline and sodium bicarbonate. However the supporting evidence is conflicting.

Treatment:

0.9% saline:

• Pre-contrast: Infusion of 0.9% saline at 1mL/kg per hour 12 hours before procedure
• Post contrast: same dosage 12 hours after procedure

Sodium bicarbonate 8.4%:

• Pre-contrast: Infusion of 150mEq of sodium bicarbonate in 1L of 5% dextrose at a rate of 3mL/kg per hour for 1 hour before procedure
• Post-contrast:  1mL/kg per hour for 6 hours

NAC:
Oral Dose

• Pre contrast: 600-1200mgPO X 2 doses
• Post contrast: 600-1200mg PO  X 2 doses
• Feeding tube or NG access: 600-1200mg (3mLof 20% solution) liquid NG BD X 4 doses

IV Dose

• Pre-contrast: 600-1200mg X 1 dose 2 hours before the procedure
• Post-contrast: PO 600-1200mg BD X 4 doses

Additional information: 

• Use of N-acetylcysteine at higher dose was not stated in the guidelines for the prevention of contrast induced nephropathy. However, it was indicated for the treatment paracetamol poisoning.

References:

1.      https://www.hosp.uky.edu/pharmacy/formulary/criteria/ContrastNephropathyGuidelines.pdf
2.       http://www.aacn.org/wd/Cetests/media/C126.pdf
3.      http://www.car.ca/uploads/standards%20guidelines/20110617_en_prevention_cin.pdf
4.       http://www.ncbi.nlm.nih.gov/pubmed/2598989
5.       http://www.emdocs.net/nac-prevention-contrast-induced-nephropathy/