Are the UK NICE AKI guidelines dead on arrival?

The UK NICE AKI guidelines were just published amid much publicity. The guidelines are worth reading because they provide insight into how easily a guideline committee can get something wrong with the management of a potentially preventable problem. How so?

Well lets take one sliver of the guideline - the question of whether 0.9% saline plus N-acetyl cysteine (NAC) is  clinically more effective than 0.9% saline alone in patients at high risk of contrast induced acute kidney injury (CI-AKI).

Essentially the guideline analysis concedes that the evidence supports 0.9% saline plus NAC over 0.9% saline both clinically in preventing CI-AKI and from a cost-benefit perspective.

But in the summary guideline statement, which incidentally, is all that doctors are going to have time to read, NAC is not recommended - only either sodium chloride or sodium bicarbonate.

And yet the press release issued along with the guidelines says that more needs to be done to prevent AKI and AKI-associated deaths.

What do I think about the UK NICE guidelines - a definite thumbs down.
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NICE AKI Guidelines....

Preventing acute kidney injury in adults having iodinated contrast agents

7. 1.2.7  Offer intravenous volume expansion to adults having iodinated contrast agents if:
   they are at increased risk of contrast-induced acute kidney injury because of risk factors in recommendation 1.1.6, or they have an acute illness.
   
   Offer either isotonic sodium bicarbonate or 0.9% sodium chloride.
   
8. 
   1.2.8  Consider temporarily stopping ACE inhibitors and ARBs in adults having iodinated contrast agents if they have chronic kidney disease with an eGFR less than 40 ml/min/1.73 m2.
   
9. 
   1.2.9  Discuss care with a nephrology team before offering iodinated contrast agent to adults with contraindications to intravenous fluids if:
   they are at increased risk of contrast-induced acute kidney injury, or they have an acute illness, or they are on renal replacement therapy. 
   

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From the NICE full guideline....

6.2.11.3

Evidence statements
Clinical

•   There was a clear clinical benefit for NAC and sodium chloride 0.45% over sodium chloride 0.45% alone in reducing CI-AKI.
•   Low to very low quality evidence suggested that there may be advantages for NAC and sodium chloride 0.45% over sodium chloride 0.45% for reducing: in hospital mortality, mortality at 30 days and 1 year, and number of patients needing RRT. However the uncertainty of these effects was too large to make clear conclusions about clinical benefit. There was no clinical benefit between the regimen for length of hospital stay.
  
•   Only one study (N=180) reported mortality at 6 months. There seemed to be a disadvantage for NAC and sodium chloride 0.45% over sodium chloride 0.45%, however again the uncertainty of these effects was too large to make clear conclusions about clinical harm.
  Economic
  

 An original cost-effectiveness analysis developed for this guideline showed that NAC + sodium chloride 0.45% is less costly than sodium chloride 0.45% (£3,726 vs. £3,800) and also more effective (2.531 vs. 2.518 QALYs). Therefore NAC + sodium chloride 0.45% is the preferred strategies among the two considered. However when the strategies compared in the model are considered altogether (sodium bicarbonate + sodium chloride 0.9%, NAC + sodium bicarbonate, NAC + sodium chloride 0.9%, sodium bicarbonate, sodium chloride 0.9%, NAC + sodium chloride 0.45%, sodium chloride 0.45%, oral fluids) sodium bicarbonate and sodium chloride 0.9% with or without NAC have similar costs and effectiveness and are the optimal strategies.