Prevent contrast induced nephropathy

1. Contrast Induced
Nephropathy

2. The Kidney Disease: Improving Global Outcomes (KDIGO) definition of contrast-induced acute kidney
injury (CI-AKI)
• Serum creatinine rise by 0.3 mg/dl
within 48 hours or
• Serum creatinine rise 150% from
baseline value within one week or
• Urine output < 0.5ml/kg/hr for > 6
consecutive hours
1. KDIGO clinical practice guideline for
acute kidney injury. Kidney Int Suppl
2012;2:8e12.
2. Michael TT, Karmpaliotis D, Brilakis
ES, Alomar M, Abdullah SM,Kirkland
BL, Mishoe KL, Lembo N, Kalynych
A, Carlson H, Banerjee S, Luna M,
Lombardi W, Kandzari DE. Temporal
trends of fluoroscopy time and
contrast utilization in coronary
chronic total occlusion
revascularization: insights from a
multicenter united states
registry.Catheter Cardiovasc Interv
2014.

3. Risk factors for development of contrast induced acute kidney injury
Patient related
1. LV Dysfunction
2. Volume depletion
3. Nephrotoxic medication (diuretics,NSAID)
4. Anaemia
5. Low serum albumin (< 35 g/L)
6. CHF
7. Female
8. 75 years+
9. Renal transplant
10. EGFR<60ML/MIN
Procedure related
1. More contrast volume
2. Multiple or long procedure
3. IABP
4. Hypotension

4. Pre-procedure
1. Patient selection and risk assessment
2. Calculation of maximum allowable contrast dose
3. Intravenous hydration
4. N-acetylcysteine
5. Sodium bicarbonate
6. Hemodialysis or hemofiltration
7. Statins
8. Antioxidants
9. Theophylline
10. Removal of nephrotoxins
11. Computed tomography coronary angiography

5. Intra-procedure
1. Limitation of contrast volume
2. Iso-osmolar contrast
3. Maintain haemodynamic stability
4. Hybrid CTO strategy
5. Stage procedures for other lesions or multiple CTOs
6. Intravascular ultrasound (IVUS)
7. Tip injections
8. Reverse controlled antegrade and retrograde tracking (Reverse CART)
9. Small size retrograde catheter
10. Forced diuresis (Renal Guard)
11. Coronary sinus contrast media extraction
12. Contrast conservation system

6. Proposed algorithm for prevention of
contrast-induced acute kidney injury
All patients eGFR <60 ml/min eGFR <30ml/min
Pre-procedure Mehran score
MCAD
IV Hydration
Avoid nephrotoxin
D/W Nephrology
Renal transplant
IV Bicarbonate
Intra-procedure Iso osmolar contrast
Limit contrast
IVUS
Tip injections
Staging
Use Renal guard
Post procedure Serum creatinine F/U till 72 hours

7. Calculation of maximum allowable contrast dose(MCAD)
• MACD= 5 mlx weight in
kg/baseline serum creatinine
mg/dl
• The use of contrast beyond the
MACD was later correlated to an
increased risk of CI-AKI.A ratio of
<3.7 for the volume of contrast
media to creatinine clearance
has also been proposed as a
stricter limit.
1. Cigarroa RG, Lange RA, Williams RH, Hillis LD.
Dosing of contrast material to prevent contrast
nephropathy in patients with renal disease.Am J
Med 1989;86:649.
2. Brown JR, Robb JF, Block CA, Schoolwerth AC,
Kaplan AV,O’Connor GT, Solomon RJ, Malenka DJ.
Does safe dosing of iodinated contrast prevent
contrast-induced acute kidney injury? Circ
Cardiovasc Interv 010;3:34.
3. Laskey WK, Jenkins C, Selzer F, Marroquin OC,
Wilensky RL, Glaser R, Cohen HA, Holmes DR Jr;
NHLBI Dynamic Registry. Volume-tocreatinine
clearance ratio: a pharmacokinetically based risk
factor for prediction of early creatinine increase
after percutaneous coronary intervention. J Am
Coll Cardiol 2007;50:584.

8. Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M,Mintz GS, Lansky AJ, Moses JW, Stone
GW, Leon MB, Dangas G. A simple risk score for prediction of contrast-induced nephropathy after
percutaneous coronary intervention: development and initial validation.J Am Coll Cardiol 2004;44

9. Contemporary evidence based practice

10. For better care of your patient