• Definition• Prognosis • Pathology• Risk factor• Incidence• Prevention• Recommendation

Case 1

• 69 y/o M with NSTEMI is going for PCI. Baseline Cr 65. 2 days post PCI Cr is 94 with good UOP .

• Are you concerned about what happened?

Case 2

• 42 y/o F in 5C3 with T2 DM with baseline Cr of 60 she is scheduled for CT abdomen for pancreatitis .

• What is her risk of developing CIN?

Case 3

• 78 y/o came with IWMI with hypotension required IABP and pressors is going for diagnostic angiogram after successful lytic therapy . Known DM with Cr 150 ,he is concerned about his kidneys .

• Is there a way to predict his risk ?

Case 4

• 65 y/o F smoker ,T2 DM with Cr 100,HTN and sever PVD underwent 1ry PCI for AWMI. Next day Cr 200 and you notice periphral cynosis with rash over Rt leg.

• What is happening with her?

Types of radiocontrast agents

• First generation agents are ionic hyperosmolal monomers( 1500)

• Second generation agents are nonionic monomers with a lower osmolality than the first generation (600)

• The nonionic contrast agents are dimers with an osmolality ( 350)

Definition

25% rise in serum creatinine during the first three days after the procedure is the most

acceptable definition .

Prognosis

• Peak in 1-3 days• Recovery 5-10• If creatinine >440 moslt likely progress to RF

requiring HD.

PATHOGENESIS

The exact mechanism is not well understood . The two major theories, based mainly on animal

studies: renal vasoconstriction(endothelin)

direct toxic effects of the contrast agents.

INCIDENCE AND RISK FACTORS

The reported incidence of radiocontrast-induced nephropathy varies widely, ranging from 0- 50%.

Who is in risk • Underlying renal insufficiency, with the plasma

creatinine exceeding 132 µmol/L(4-11%) and 50% if exceeding 350µmol/L.

• Diabetic nephropathy with renal insufficiency (9-30%)

• Multiple myeloma (1.5%) • Advanced heart failure or other cause of reduced

renal perfusion such as hypovolemia • High total dose of contrast agent and the type of

the contrast

Normal kidney function

Negligible with normal renal function, even if the patient is diabetic

In PCI

In a review of over 7500 patients undergoing a PCI for coronary heart disease, the incidence of CIN was 3.3 percent overall and approximately 25 percent in those with a baseline serum creatinine above (177 µmol/L) .

PREVENTION

Which of the following modalities can prevent CIN?

• Lasix • Manitol • Dobutamin• Theophyline• Ca blockers • ANP• UF• HD • Statin

Effective

• Hydration • NAC• NaHCO3

Oral hydration

• Few small trials have evaluated the effectiveness of oral hydration or an outpatient hydration protocol in preventing contrast nephropathy.

• The results have been conflicting, some suggested that oral hydration as effective others less effective .

Type of fluid

• Prospective randomized trial of 1620 patients . The incidence of contrast-induced nephropathy was significantly lower in patients received NS than 1/2NS

Acetylcysteine

• There is inconsistency in the results of clinical trials regarding the effectiveness of NAC in prevention of contrast nephropathy .

• The overall direction of the data is towards benefit .

NaHCO3

• A prospective, single-center, randomized trial showed overall benefit of NaHCO3 compared to NS .

• Issues with this study

SUMMARY AND RECOMMENDATIONS

• Indication of the procedure

• The use of lower doses of contrast and avoidance of repetitive studies that are closely spaced.

• Avoid of volume depletion

• Avoid NSAID

• Stop metformin 48h before

Hydration

Prophylactic regimen is the intravenous administration of NS at a rate of 1 mL/kg /h for 12 hours before and 12 hours after the radiographic study .

NAC

PO: 600 mg orally BID and administered the day before and the day of the procedure .

IV: 150 mg/kg in 500 mL NS over 30 minutes immediately before contrast exposure, then 50 mg/kg in 500 mL NS over four hours .

NaHCO3

• A bolus of 3 mL/kg of NaHCO3 one hour prior to the procedure, and continued at a rate of 1 mL/kg for six hours after the procedure.

Contrast

Both low osmolal and iso-osmolal nonionic agents appear to lower the risk of nephropathy .

HD and UF

• Creatinine >440• Decrease UOP • Acidosis • Hyperkalemia

Case 1

• 62 y/o M with NSTEMI is going for PCI. Baseline Cr 65. 2 days post PCI Cr is 94 with good UOP .

• Are you concerned about what happened?

Case 2

• 42 y/o F in 5C3 with T2 DM with baseline Cr of 60 she is scheduled for CT abdomen for pancreatitis .

• What is her risk of developing CIN?

Case 3

• 78 y/o came with IWMI with hypotension requiring IABP is going for diagnostic angiogram after successful lytic therapy . Known DM with Cr 150 is concerned about his kidney function.

• Is there a way to predict his risk ?

Case 4

• 65 y/o F smoker ,T2 DM with Cr 100,HTN and sever PVD underwent 1ry PCI for AWMI. Next day Cr 200 and you notice periphral cynosis with rash over Rt leg.

• What is happening with her?

Cholesterol embolism

• Low complement • Eosinophilia • Eosinophilurea • Systemic ischemia • Acute deterioration• Last upto 8 weeks • Livedo reticularis

THANKS