Contrast nephropahthy

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Contrast nephropahthy

  1. 1. • Definition• Prognosis• Pathology• Risk factor• Incidence• Prevention• Recommendation
  2. 2. 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?
  3. 3. 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?
  4. 4. 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 ?
  5. 5. 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?
  6. 6. 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)
  7. 7. Definition25% rise in serum creatinine during the first three days after the procedure is the most acceptable definition .
  8. 8. Prognosis• Peak in 1-3 days• Recovery 5-10• If creatinine >440 moslt likely progress to RF requiring HD.
  9. 9. PATHOGENESISThe 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.
  10. 10. INCIDENCE AND RISK FACTORSThe reported incidence of radiocontrast-induced nephropathy varies widely, rangingfrom 0- 50%.
  11. 11. 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
  12. 12. Normal kidney functionNegligible with normal renal function, even if the patient is diabetic
  13. 13. In PCIIn 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) .
  14. 14. PREVENTION
  15. 15. Which of the following modalities can prevent CIN?• Lasix• Manitol• Dobutamin• Theophyline• Ca blockers• ANP• UF• HD• Statin
  16. 16. Effective• Hydration• NAC• NaHCO3
  17. 17. 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 .
  18. 18. 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
  19. 19. 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 .
  20. 20. NaHCO3• A prospective, single-center, randomized trial showed overall benefit of NaHCO3 compared to NS .• Issues with this study
  21. 21. 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
  22. 22. HydrationProphylactic regimen is the intravenousadministration of NS at a rate of 1 mL/kg /h for 12hours before and 12 hours after the radiographicstudy .
  23. 23. NACPO: 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 .
  24. 24. 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.
  25. 25. ContrastBoth low osmolal and iso-osmolal nonionic agents appear to lower the risk of nephropathy .
  26. 26. HD and UF• Creatinine >440• Decrease UOP• Acidosis• Hyperkalemia
  27. 27. 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?
  28. 28. 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?
  29. 29. 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 ?
  30. 30. 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?
  31. 31. Cholesterol embolism• Low complement• Eosinophilia• Eosinophilurea• Systemic ischemia• Acute deterioration• Last upto 8 weeks• Livedo reticularis
  32. 32. THANKS

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