In patients with stage 3 chronic kidney disease (CKD) undergoing nonemergent computed tomography (CT) with iodine-based contrast media, withholding prehydration with sodium bicarbonate does not lead to worse renal outcomes, according to study results published online ahead of print in JAMA Internal Medicine.

In the Kompas trial, investigators randomly assigned 262 patients to receive no prehydration and 261 to receive prehydration with 250 mL of 1.4% sodium bicarbonate infused for 1 hour before elective contrast-enhanced CT. Mean serum creatinine level rose similarly and significantly in both groups (median age 74 years; 64% male) at 2 to 5 days after contrast administration: 3.0% in the no prehydration group vs 3.5% in the prehydration group. Acute kidney injury (defined as an increase in creatinine level greater than 25% or more than 0.5 mg/dL) at 2 to 5 days occurred in more patients without prehydration: 2.7% vs 1.5%, respectively — a relative risk increase of 70% but a small absolute difference, Menno Huisman, MD, PhD, of Leiden University Medical Center in the Netherlands, and colleagues reported. None of the patients required dialysis or experienced acute heart failure. Results also did not differ significantly in analyses of high-risk subgroups.

With respect to costs, withholding prehydration saved $143.94 per patient.

“Strategies to prevent PC-AKI [post-contrast acute kidney injury], including discontinuing nephrotoxic agents, preventing patients from being in a hypovolemic state by means of volume expansion, and alkalinizing urine by means of infusion of sodium bicarbonate, have become the standard care for years,” Dr Huisman’s team wrote. “The risk of renal failure induced by ICM [iodine-based contrast media] may be overstated in the literature and overestimated by clinicians.”

The investigators highlighted that their results pertain to contrast-enhanced CT in an elective setting. The study findings should not be extrapolated to emergent CT, angiography with intraarterial iodine-based contrast media administration or to acute interventions, such as percutaneous transluminal coronary interventions.

The reduced volume of fluid administration (250 mL of sodium bicarbonate vs 2 L of saline) was also an important advantage, the researchers explained, because volume overload is possible, especially in patients with congestive heart failure. In a previous trial, the team demonstrated that sodium bicarbonate was noninferior to saline.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Reference

Timal RJ, Kooiman J, Sijpkens YJ, et al. Effect of no prehydration vs sodium bicarbonate prehydration prior to contrast-enhanced computed tomography in the prevention of postcontrast acute kidney injury in adults with chronic kidney disease: The Kompas randomized clinical trial [published online February 17, 2020]. JAMA Intern Med. doi: 10.1001/jamainternmed.2019.7428