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Contrast nephropathy.ppt
 

Contrast nephropathy.ppt

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    Contrast nephropathy.ppt Contrast nephropathy.ppt Presentation Transcript

    • Contrast Nephropathy Intern 黃賢能
      • 1. Kandzari DE. Contrast nephropathy : an evidence-based approach to prevention. American Journal of Cardiovascular Drugs. 3(6):395-405, 2003.
      • 2. Murphy SW. Contrast nephropathy. Journal of the American Society of Nephrology. 11(1):177-82, 2000 Jan.
      • 3. Birck R. Acetylcysteine for prevention of contrast nephropathy: meta-analysis. Lancet. 362(9384):598-603, 2003 Aug 23. 805 cases
      • 4. Curhan GC. Prevention of contrast nephropathy. JAMA. 289(5):606-8, 2003 Feb 5.
      • 5. Guitterez NV. Determinants of serum creatinine trajectory in acute contrast nephropathy. Journal of Interventional Cardiology. 15(5):349-54, 2002 Oct. 95 cases
      • 6. Durham JD. A randomized controlled trial of N-acetylcysteine to prevent contrast nephropathy in cardiac angiography. Kidney International. 62(6):2202-7, 2002 Dec. 79 cases
      • 7. Kini AS. Changing trends in incidence and predictors of radiographic contrast nephropathy after percutaneous coronary intervention with use of fenoldopam. American Journal of Cardiology. 89(8):999-1002, 2002 Apr 15. 260 cases
      • 8. Kini AS. A protocol for prevention of radiographic contrast nephropathy during percutaneous coronary intervention: effect of selective dopamine receptor agonist fenoldopam. Catheterization & Cardiovascular Interventions. 55(2):169-73, 2002 Feb. 150 cases
      • 9. McCullough PA. Prediction and prevention of contrast nephropathy. Journal of Interventional Cardiology. 14(5):547-58, 2001 Oct. 150 cases
      • 10. Tepel M. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. New England Journal of Medicine. 343(3):180-4, 2000 Jul 20. 83 cases
      • 11. Stevens MA. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy. Journal of the American College of Cardiology. 33(2):403-11, 1999 Feb
    • Contrast
      • Oil-soluble:
      • Dionosil: bronchogram
      • Lipiodol: TAE, lymphangiography
      • Water-soluble:
      • Ionic high-osmolarity: 900 osmo/kg
      • Ionic low-osmolarity: 500 osmo/kg
      • Non-ionic: 300 osmo/kg
    • Contrast
      • Excretion: 100% from kidney
      • 80% by glomerular filtration
      • 20% by excretion from renal tubule
      • Half life: 20 min (Ccr > 70 ml/min)
    • Contrast Nephropathy
      • Diagnosis:
      • A rise in serum creatinine of at least 0.5 (1) mg/dL within 48 h of contrast administration
      • Other causes of acute renal failure must be excluded
    • Clinical Feature
      • Prerenal type acute renal failure
      • Onset: within 24 to 48 h
      • Peak: 3rd to 5th days
      • Resolution: within 7~14 days
      • Transient
    • Risk Factor
      • Advanced age (> 65 y/o 1,9 )
      • Preexisting renal disease (CRI: CT: 8%~28% 3 , Angio: 15~40% 8 )
      • DM (20~50% 7,10 )
      • Dehydration 2,9
      • High contrast dose (neg: 3 )
      • Ionic, high-osmolar contrast media 1,2,4
    • Pathophysiology
      • Vasoconstriction: Endothelin-1
      • Immune response
      • Nephrotoxicity: free radicle
    • Prevention
      • Calcium channel blocker 4
      • Atrial natiuretic peptide (ANP)
      • Furosemide 4,5,11
      • Mannitol 5,11
      • Dopamine 5
      • Endothelin-receptor antagonist
      • Dialysis 4
    • Prevention
      • 0.45% saline 3,9,11
      • N-Acetylcysteine (NAC) 3,10
      • Acetylcysteine + hydration in chronic renal insufficiency 10
    • 0.45% Saline
      • Slightly Volume-expanded
      • High urine output (>150 ml/hr 11 )
      • Mannitol, crystalloid 11
    • N-Acetylcysteine (NAC)
      • Anti-oxidant
      • NAC + NO ---> S-nitrothiol (a potent vasodilator)
      • Increase the expression of NO synthase
    • Fenoldopam (Corlopam)
      • Selective dopamine-1 (DA-1) receptor agonist Fenoldopam: Cr>2 (incidence<4% 7, 4.7% vs. 19% 8 )
      • 0.1 mcg/kg/minute 1~2 days
      • Vasodilation
      • Anti-hypertension
    • Conclusion
      • Risk of contrast nephropathy could be reduced by
      • Selection
      • Preparation
    • Selection
      • No! Wait!
      • Age > 65 y/o
      • Preexisting renal disease: Cr > 2.5
      • Uncontrolled DM
      • Dehydration
      • Previous contrast nephropathy
    • Selection
      • It depends
      • Heart failure, hypoalbuminemia, liver failure
      • Uncontrolled hypertension
      • Ongoing infection
      • Discuss with ---
      • Lower contrast dose
      • Nonionic, low-osmolar contrast media
    • Preparation 0.45% saline, 1ml/kg/hr N-Acetylcysteine,600mg bid po*2 days Fenodolpam,0.1 mcg/kg/min Mannitol, crystalloid 12~24 hr 12 hr
    • Preparation
      • Follow up BUN, Cr for 3~5 days
      • Control hypertension, infection
      • Dialysis: can NOT prevent contrast nephropathy
    • Thanks!