The Australian and New Zealand Society of Nephrology
The Australian and New Zealand Society of Nephrology is a not-for profit organisation representing the interests of health professionals committed to the prevention and treatment of kidney disease. Through the ANZSN, members support a range of research, education and clinical care initiatives to promote evidenced based practice and quality outcomes for patients in Australia, New Zealand and our region.
2.
Do not use oral acetylcysteine before giving radiocontrast to patients at increased risk for contrast-induced acute kidney injury
Routine use of acetylcysteine for patients undergoing angiography is not recommended. The largest randomised trial to date of 5,177 patients at high risk of renal complications who underwent angiography showed there was no benefit of oral acetylcysteine over placebo for the prevention of contrast-induced acute kidney injury (CI-AKI) or for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days. Unlike in previous protocols, the study population excluded patients with preserved kidney function (it included patients with stage 3 or 4 chronic kidney disease; those with stage 3A were required to have diabetes mellitus which increases the risk of CI-AKI in patients with impaired kidney function). This enhanced the generalisability of the results among patients at higher risk for AKI and other adverse outcomes.
Supporting evidence
KHA-CARI Guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for Acute Kidney Injury. Langham RG1, Bellomo R, D’Intini V, Endre Z, Hickey BB, McGuinness S, Phoon RK, Salamon K, Wood J, Gallagher MP. Nephrology (Carlton). 2014 May; 19(5):261-5
Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine, Steven D. Weisbord, M.D., Martin Gallagher, M.D., Ph.D., Hani Jneid, M.D., et al. N Engl J Med 2018; 378:603-614 DOI: 10.1056/NEJMoa1710933
How this list was made
The Australian and New Zealand Society of Nephrology (ANZSN) Clinical Policy and Advisory Committee worked with the RACP, as part of the Evolve Program, to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting, the list was condensed to the top-5 recommendations for reducing low-value practices in nephrology. Dr David Tunnicliffe has been the Lead Fellow on the project.
The list of recommendations was then subject to an extensive review process that involved key College societies with an interest or professional engagement with nephrology as well as health equity. It was then further consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further research and finetuning of the list, which was then finalised and approved by the ANZSN.
- 1 Do not give multiple daily doses of aminoglycoside antibiotics to patients with normal and stable kidney function as the risk of toxicity is less with a single daily dose
- 2 Do not use oral acetylcysteine before giving radiocontrast to patients at increased risk for contrast-induced acute kidney injury
- 3 Do not give routine prophylactic antibiotics to a child after the first urinary tract infection if at low risk of recurrent urinary tract infections
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4
Do not intensively lower HbA1C<6.5% to <8.0% in patients with early (stage 1-3) chronic kidney disease as intense lowering increases the risk of hypoglycaemia and mortality, noting that the individual target depends on factors such as severity of CKD, macrovascular complications, comorbidities, life expectancy and others
- 5 Do not prescribe aspirin therapy for primary prevention of cardiovascular disease in patients with stage 1-3 chronic kidney disease as there is no proven benefit and it is associated with increased risk of impaired haemostasis