Contrast nephropathy.ppt

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Contrast nephropathy.ppt

  1. 1. Contrast Nephropathy Intern 黃賢能
  2. 2. <ul><li>1. Kandzari DE. Contrast nephropathy : an evidence-based approach to prevention. American Journal of Cardiovascular Drugs. 3(6):395-405, 2003. </li></ul><ul><li>2. Murphy SW. Contrast nephropathy. Journal of the American Society of Nephrology. 11(1):177-82, 2000 Jan. </li></ul><ul><li>3. Birck R. Acetylcysteine for prevention of contrast nephropathy: meta-analysis. Lancet. 362(9384):598-603, 2003 Aug 23. 805 cases </li></ul><ul><li>4. Curhan GC. Prevention of contrast nephropathy. JAMA. 289(5):606-8, 2003 Feb 5. </li></ul>
  3. 3. <ul><li>5. Guitterez NV. Determinants of serum creatinine trajectory in acute contrast nephropathy. Journal of Interventional Cardiology. 15(5):349-54, 2002 Oct. 95 cases </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  4. 4. <ul><li>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 </li></ul><ul><li>9. McCullough PA. Prediction and prevention of contrast nephropathy. Journal of Interventional Cardiology. 14(5):547-58, 2001 Oct. 150 cases </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  5. 5. Contrast <ul><li>Oil-soluble: </li></ul><ul><li>Dionosil: bronchogram </li></ul><ul><li>Lipiodol: TAE, lymphangiography </li></ul><ul><li>Water-soluble: </li></ul><ul><li>Ionic high-osmolarity: 900 osmo/kg </li></ul><ul><li>Ionic low-osmolarity: 500 osmo/kg </li></ul><ul><li>Non-ionic: 300 osmo/kg </li></ul>
  6. 6. Contrast <ul><li>Excretion: 100% from kidney </li></ul><ul><li>80% by glomerular filtration </li></ul><ul><li>20% by excretion from renal tubule </li></ul><ul><li>Half life: 20 min (Ccr > 70 ml/min) </li></ul>
  7. 7. Contrast Nephropathy <ul><li>Diagnosis: </li></ul><ul><li>A rise in serum creatinine of at least 0.5 (1) mg/dL within 48 h of contrast administration </li></ul><ul><li>Other causes of acute renal failure must be excluded </li></ul>
  8. 8. Clinical Feature <ul><li>Prerenal type acute renal failure </li></ul><ul><li>Onset: within 24 to 48 h </li></ul><ul><li>Peak: 3rd to 5th days </li></ul><ul><li>Resolution: within 7~14 days </li></ul><ul><li>Transient </li></ul>
  9. 9. Risk Factor <ul><li>Advanced age (> 65 y/o 1,9 ) </li></ul><ul><li>Preexisting renal disease (CRI: CT: 8%~28% 3 , Angio: 15~40% 8 ) </li></ul><ul><li>DM (20~50% 7,10 ) </li></ul><ul><li>Dehydration 2,9 </li></ul><ul><li>High contrast dose (neg: 3 ) </li></ul><ul><li>Ionic, high-osmolar contrast media 1,2,4 </li></ul>
  10. 10. Pathophysiology <ul><li>Vasoconstriction: Endothelin-1 </li></ul><ul><li>Immune response </li></ul><ul><li>Nephrotoxicity: free radicle </li></ul>
  11. 11. Prevention <ul><li>Calcium channel blocker 4 </li></ul><ul><li>Atrial natiuretic peptide (ANP) </li></ul><ul><li>Furosemide 4,5,11 </li></ul><ul><li>Mannitol 5,11 </li></ul><ul><li>Dopamine 5 </li></ul><ul><li>Endothelin-receptor antagonist </li></ul><ul><li>Dialysis 4 </li></ul>
  12. 12. Prevention <ul><li>0.45% saline 3,9,11 </li></ul><ul><li>N-Acetylcysteine (NAC) 3,10 </li></ul><ul><li>Acetylcysteine + hydration in chronic renal insufficiency 10 </li></ul>
  13. 13. 0.45% Saline <ul><li>Slightly Volume-expanded </li></ul><ul><li>High urine output (>150 ml/hr 11 ) </li></ul><ul><li>Mannitol, crystalloid 11 </li></ul>
  14. 14. N-Acetylcysteine (NAC) <ul><li>Anti-oxidant </li></ul><ul><li>NAC + NO ---> S-nitrothiol (a potent vasodilator) </li></ul><ul><li>Increase the expression of NO synthase </li></ul>
  15. 15. Fenoldopam (Corlopam) <ul><li>Selective dopamine-1 (DA-1) receptor agonist Fenoldopam: Cr>2 (incidence<4% 7, 4.7% vs. 19% 8 ) </li></ul><ul><li>0.1 mcg/kg/minute 1~2 days </li></ul><ul><li>Vasodilation </li></ul><ul><li>Anti-hypertension </li></ul>
  16. 16. Conclusion <ul><li>Risk of contrast nephropathy could be reduced by </li></ul><ul><li>Selection </li></ul><ul><li>Preparation </li></ul>
  17. 17. Selection <ul><li>No! Wait! </li></ul><ul><li>Age > 65 y/o </li></ul><ul><li>Preexisting renal disease: Cr > 2.5 </li></ul><ul><li>Uncontrolled DM </li></ul><ul><li>Dehydration </li></ul><ul><li>Previous contrast nephropathy </li></ul>
  18. 18. Selection <ul><li>It depends </li></ul><ul><li>Heart failure, hypoalbuminemia, liver failure </li></ul><ul><li>Uncontrolled hypertension </li></ul><ul><li>Ongoing infection </li></ul><ul><li>Discuss with --- </li></ul><ul><li>Lower contrast dose </li></ul><ul><li>Nonionic, low-osmolar contrast media </li></ul>
  19. 19. 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
  20. 20. Preparation <ul><li>Follow up BUN, Cr for 3~5 days </li></ul><ul><li>Control hypertension, infection </li></ul><ul><li>Dialysis: can NOT prevent contrast nephropathy </li></ul>
  21. 21. Thanks!

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