Contrast Induced Nephropathy
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CIN
CONTRAST INDUCED NEPHROPATHY
SUUB
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PATOGENEZA PREVENTIE
EPIDEMIOLOGIE
CIN
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PATOGENEZA
Studii pe animale
Second hit injury
Context clinic
Context interventional
Dose dependent
Agent dependent
Cumulativ
Non linear
Marker si inductor de
prognostic negativ
mecanisme descrise in special in studii cu compusi “vechi”-generatie I
care este impactul real uman?
concluzii contradictorii si nerepetabile intre studii
CIN vs CAN
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Probleme…
Un diagnostic de excludere chiar acolo unde este mai putin probabil sa il excluzi (ex. angio-ateroembolie).
Definitie heterogena cu impact heterogen asupra concluziilor de prognostic si preventie.
Efect nociv prezent teoretic (generatia I) dar neclar dpdv practic (generatiile noi).
Greu de cuantificat patogenetic (uman) cel putin din cauza comorbiditatilor asociate; dovezi indirecte; lot martor - ?
CIN este inlocuit cu CAN din cauza acestor neajunsuri.
Cat de real este CIN/CAN ? http://ccforum.com/content/16/2/R67
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AKIN reflecta cel mai bine prognosticul pe termen scurt si lung.
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DEFINITIA CREEAZA INCIDENTA
AKIN reflecta cel mai bine prognosticul pe termen scurt si lung.
3 intervale de timp
3 valori cut-off de Cr
9 definitii
Lakhal, Ehrmann J Crit Care 2011
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CONTEXTUL CREEAZA INCIDENTA
Incidenta creste cu gradul de afectare renala
Lakhal, Ehrmann J Crit Care 2011
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AKIN 1
∆Cr/Cri>50% ∆Cr>0.3mg/dl
Masa musculara ▼ Crs ▼
Afectare renala Crs ▲
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monomeri ionici inel benzen cu 3 I 1400-1800mosm/kg
dimeri nonionici 2 inele de benzen “unite” 290 mosm/kg
monomeri nonionici 500-850mosm/kg !ioxaglate este ionic
GENERATII
3
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Agenti de contrast
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►Boala renala cronica-GFR<60ml/min ► Nefropatie diabetica ► examen efectuat in urgenta ► abord arterial versus venos ► balon de contrapulsatie ► ICC NYHA ¾ ► varsta>75ani ► Mielom
RISC
► Sepsis ► Ciroza ► Sdr. Nefrotic ► anemie ► hipovolemie ► instabilitate hemodinamica ► Sdr.coronarian acut cu Fej scazuta ► Alte nefrotoxine
Cantitate agent de contrast Tip agent de contrast Repetarea in < 2 saptamani
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Calculator…
Calculator de risc
2004
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Calculator imperfect
Contextul interventional-arterial vs venos(cut off ClCr diferit – 60 vs 45)
Tipul de agent (generatie 1,2 sau 3)
Intervalul de repetare
Asociere de nefrotoxine(ex. AG)
Ce risc calculeaza?
CI-AKI AKI
APASA Daca ai net
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6 7
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MUCH ADO ABOUT NOTHING? 2%
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PREVENTIE
TRATAMENT
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ANTIOXIDANTI
REPLETIE VOLEMICA
VASODILATATORI RENALI
HEMODIAFILTRARE
PREVENTIE
MODIFICAREA FACTORILOR DE RISC ATUNCI CAND E POSIBIL.
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VOLUM
NS 1-1.5ml/kg/h pentru 6h inainte si dupa contrast
Bicarbonat izoosmolar 3ml/kg/h cu o ora inainte si 1ml/kg/h pentru 6 ore dupa SC( efect antioxidant – ROS dependent de pH prin r. Haber-Weiss)
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NACC
600-1200 mg oral de 2 ori pe zi cu o zi inainte si in ziua adm. SC
Administrarea iv. este descurajata
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Hemodiafiltrare
Imediat dupa adm. SC o poate inlatura dar nu previne CIN/CAN
Nu este recomandata profilactic de cei mai multi autori
Rol profilactic la CKD 5(ClCr< 15ml/min/1.73m2)
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Nu au rol, cel putin in prezent
Fenoldopam
Dopamine
Bloc.can Ca
Furosemide
Manitol
PG.
Ac. ascorbic
ANP
ATP
L arginina
IECA
Nebivolol
Aminofilina
Statine
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METFORMIN SI CIN
Update ESUR 2011
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Concluzii
Este un diagnostic de excludere
Patogeneza ce implica toxicitate directa si VC
Incidenta dependenta de agent,context clinic si interventional
Epidemiologie neclara si extrem de heterogena
Greu de separat de comorbiditati
Preventia implica repletie volemica, +/- NACC si influentarea cator mai multi factori de risc(ex. cantitatea de SC, agentul, raport risc/beneficiu).
ASIGURAREA VOLEMIEI
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