Prevention of Serious Adverse Events Following Angiography (PRESERVE)

• Acute Renal Failure
• Kidney Disease
• Coronary Artery Disease

• Drug: IV isotonic saline
  The investigators will administer 3 ml/kg of isotonic saline over 1 hour at an infusion rate of not less than 1 mL/kg per hour and not more than 3 mL/kg per hour prior to the angiographic procedure, 1-1.5ml/kg per hour during angiography, and 6 ml/kg of isotonic saline over 4 hours following the procedure at an infusion rate of not less than 1 mL/kg per hour and not more than 1.5 mL/kg per hour. Providers will retain discretion to administer larger volumes of isotonic saline (up to a maximum of 12 mL/kg) over durations of up to 12 hours pre and 12 hours post-procedure.
• Drug: IV isotonic bicarbonate
  The investigators will administer 3 ml/kg of isotonic bicarbonate over 1 hour at an infusion rate of not less than 1 mL/kg per hour and not more than 3 mL/kg per hour prior to the angiographic procedure, 1-1.5ml/kg per hour during angiography, and 6 ml/kg of isotonic bicarbonate over 4 hours following the procedure at an infusion rate of not less than 1 mL/kg per hour and not more than 1.5 mL/kg per hour. Providers will retain discretion to administer larger volumes of isotonic bicarbonate (up to a maximum of 12 mL/kg) over durations of up to 12 hours pre and 12 hours post-procedure.
• Drug: N-acetylcysteine
  NAC will be administered at a dose of 1200mg orally 1 hour prior to angiography, 1 hour following the procedure, and then twice daily for the next 4 days.
  Other Name: NAC
• Drug: Placebo
  A placebo study drug capsule will be administered orally 1 hour prior to angiography, 1 hour following the procedure, and then twice daily for the next 4 days.

• Active Comparator: Arm 1
  IV isotonic saline and oral placebo drug capsule
  Interventions:

  • Drug: IV isotonic saline
  • Drug: Placebo
• Active Comparator: Arm 2
  IV isotonic saline and oral N-acetylcysteine drug capsule
  Interventions:

  • Drug: IV isotonic saline
  • Drug: N-acetylcysteine
• Active Comparator: Arm 3
  IV isotonic bicarbonate and oral placebo drug capsule
  Interventions:

  • Drug: IV isotonic bicarbonate
  • Drug: Placebo
• Active Comparator: Arm 4
  IV isotonic bicarbonate and oral N-acetylcysteine drug capsule
  Interventions:

  • Drug: IV isotonic bicarbonate
  • Drug: N-acetylcysteine

Inclusion Criteria:

• Planned elective or urgent coronary or non-coronary angiography with iodinated contrast media in which it is anticipated that there will be an interval of 3 hours between the identification of the indication for angiography and the time of the planned procedure.
• Pre-angiography eGFR <60 ml/min/1.73 m2 with diabetes mellitus or pre-angiography eGFR <45 ml/min/1.73 m2 with or without diabetes mellitus
• Ability to provide informed consent

Exclusion Criteria:

• Stage 5 CKD (eGFR <15 mL/min/1.73 m2)
• Currently receiving hemodialysis, peritoneal dialysis, continuous renal replacement therapy, or sustained low efficiency dialysis (SLED)
• Unstable baseline SCr (if known) at the time of angiography defined by an increase in SCr of 25% over the 3 days prior to angiography

• Decompensated heart failure requiring any of the following therapies at the time of angiography:

  • IV milrinone, amrinone, dobutamine, or nesiritide
  • Isolated ultrafiltration therapy
  • Intra-aortic balloon pump
• Emergent angiography procedures defined as an anticipated duration of <3 hours between the identification of the indication for angiography and the time of the planned procedure.
• Receipt of intravascular iodinated contrast within the 5 days preceding angiography
• Receipt of oral or IV NAC within the 48 hours preceding angiography
• Known allergy to N-acetylcysteine (NAC)
• Known anaphylactic allergy to iodinated contrast media
• Prisoner
• Age <18 years
• Pregnancy
• Ongoing participation in an unapproved concurrent interventional study