- Contrast-induced acute kidney injury (CI-AKI) is a common cause of hospital-acquired acute kidney injury and is caused by the vasoconstrictive effects of iodinated contrast media during imaging procedures.
- The risk of CI-AKI increases significantly with reduced kidney function and other risk factors such as diabetes, dehydration, and older age. Proper hydration helps prevent CI-AKI by increasing renal blood flow and diluting the contrast in the kidneys.
- While IV hydration with crystalloids remains the most effective preventive measure, the optimal hydration protocol has not been firmly established.
SEMINAR PRESENTATION ON CONTRAST INDUCED NEPHROPATHY BY PHARM D STUDENT
IT INCLUDES COMPLETE OVERVIEW OF THE TOPIC CIN.
POST CONTRAST ACUTE KIDNEY INJURY( PC-AKI) WITH TREATMENT AND MANAGEMENT.
Contrast induced nephropathy (CIN) is agenerally reversible form of acute kidney injury (AKI) that occurs soon after the administration of radiocontrast media.
SEMINAR PRESENTATION ON CONTRAST INDUCED NEPHROPATHY BY PHARM D STUDENT
IT INCLUDES COMPLETE OVERVIEW OF THE TOPIC CIN.
POST CONTRAST ACUTE KIDNEY INJURY( PC-AKI) WITH TREATMENT AND MANAGEMENT.
Contrast induced nephropathy (CIN) is agenerally reversible form of acute kidney injury (AKI) that occurs soon after the administration of radiocontrast media.
A ppt about contrast nephropathy: basics, risk factors, comparison of preventive strategies.
critical review of POSEIDON trial and brief about PRESERVE trial.
Ponencia realizada por el Prof. Alberto Zambon en la segunda sesión de CardioVascular Virtual Topic 2022, titulada Residual cardiovascular risk. What is the role of icosapent ethyl?
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
Contrast Induce Nephropathy
its include information about the nephropathy thats caused by the contrast , like in patients undergo PCI or other method of imaging containing contrast
I will discuss the causes with the risk factors then explain the headline of the pathophysiology and clinical presentaion with the mangment,
- Randomized, double-blind, double-dummy phase 3 study comparing once daily oral rivaroxaban (a new oral factor Xa inhibitor) with adjusted-dose oral warfarin for the prevention of stroke in subjects with non-valvular AF
- Population and treatment:
14 000 high-risk patients with AF
Randomized to 20-mg rivaroxaban once daily (or 15 mg in patients with moderate renal impairment at screening) or to dose-adjusted warfarin (titrated to an INR of 2.5)
- Primary outcome:
A composite of stroke and non-CNS embolism
See the article at http://www.theheart.org/article/1148785.do
A ppt about contrast nephropathy: basics, risk factors, comparison of preventive strategies.
critical review of POSEIDON trial and brief about PRESERVE trial.
Ponencia realizada por el Prof. Alberto Zambon en la segunda sesión de CardioVascular Virtual Topic 2022, titulada Residual cardiovascular risk. What is the role of icosapent ethyl?
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
Contrast Induce Nephropathy
its include information about the nephropathy thats caused by the contrast , like in patients undergo PCI or other method of imaging containing contrast
I will discuss the causes with the risk factors then explain the headline of the pathophysiology and clinical presentaion with the mangment,
- Randomized, double-blind, double-dummy phase 3 study comparing once daily oral rivaroxaban (a new oral factor Xa inhibitor) with adjusted-dose oral warfarin for the prevention of stroke in subjects with non-valvular AF
- Population and treatment:
14 000 high-risk patients with AF
Randomized to 20-mg rivaroxaban once daily (or 15 mg in patients with moderate renal impairment at screening) or to dose-adjusted warfarin (titrated to an INR of 2.5)
- Primary outcome:
A composite of stroke and non-CNS embolism
See the article at http://www.theheart.org/article/1148785.do
PERIOPERATIVE RENAL PROTECTION : WHAT IS THE EVIDENCE?Dr Jayashree Patki
PERIOPERATIVE RENAL PROTECTION : WHAT IS THE EVIDENCE?-
Dr. JAYASHREE PATKI
MBBS, MD, PGDHHM
Sr. Consultant
Krishna Institute of Medical Sciences
Hyderabad
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. • Iodinated contrast medium was first used in 1954.
• Association of contrast use with renal impairment was
first made with use of iodopyracet, a di-iodinated
pyridine derivative ≥ 50yrs ago
45
Recognition of high risk groups.
40
35
30
25
20 Prevention
15 controversy
10
5
0
1960 1970 1980 1990 2000
3. • It is one of the common causes of AKI
hospitalized patients.
• CI-AKI was reported to be the third most
common cause of AKI in hospitalized patients.
Nash et al. AJKD 2002;39:930-6.
• Reported incidence varies from 1.7-2% of
patients without predisposing factors and up to
10-45% of patients with predisposing factors.
4. All agents are chemical modifications of a 2,4,6-tri-iodinated benzene ring.
6. CIN consensus working panel(2006)
• Consensus statement 6: In patients at increased risk for CIN
undergoing intra-arterial administration of contrast, ionic high-
osmolality agents pose a greater risk for CIN than low-
osmolality agents. Current evidence suggests that for intra-
arterial administration in high-risk patients with chronic kidney
disease, particularly those with diabetes mellitus, nonionic,
iso-osmolar contrast is associated with the lowest risk of CIN.
• Consensus statement 7: Higher contrast volumes (>100 mL) are
associated with higher rates of CIN in patients at risk. However,
even small (30 mL) volumes of iodinated contrast in very high-
risk patients can cause CIN and acute renal failure requiring
dialysis, suggesting the absence of a threshold effect.
• Consensus statement 8: Intra-arterial administration of
iodinated contrast medium appears to pose a greater risk for
CIN above that with intravenous administration.
7. CARE Study
• It was a multicenter, randomized, double-blind
comparison of iopamidol and iodixanol in patients (414
pts) with chronic kidney disease (eGFR, 20 to 59
mL/min) who underwent cardiac angiography or PCI.
• There was no statistical difference in the development
Radiology 250(1); January 2009
of CI-AKI after IA inj of either of the agents even in
Iodixanol is not associated with a significantly reduced risk
those with and without diabetes.
of CIN compared with the LOCM pooled together.
• Thus, either agent can be safely used for coronary
interventions in patients with renal insufficiency
Circulation. 2007;115:3189-3196
8. Left ventricular &-----: 30-45 mL
aortic angiography
PCI-----------------------:150-200 mL
CECT scan--------------:uses 100-150 mL
IVU-----------------------:100-mL bolus of a 50%–60%
(weight-to-volume ratio) contrast
material.
FFA uses Na fluorescein and not assoc with CIN
9. Definition
• In 2008, contrast-induced acute kidney injury (CIAKI)
was proposed as the consensus name for what was
formerly termed ‘contrast-induced nephropathy’
Arch. Intern. Med. 168, 1325–1332 (2008).
Defined by a fixed (0.5 mg/dl [44 μmol/L]) or
proportionate (25 %) rise in serum creatinine
levels assessed 48 hours after exposure to the
contrast medium, in the absence of any other
apparent cause.
11. Risk factors contd…..
Procedure related factors:
• Type of radiocontrast medium (HOCM>LOCM/IOCM).
• Dose of contrast used.
• Repeated exposure to radiocontrast material within 72
hours.
• Mode of administration (IA>IV)
• Primary coronary intervention for acute MI
12. 120
Risk factors contd…..
100
•80 Many risk factors are covariates rather than
independent variables. This may account for reports
60 that fail to determine causality of independent
variables.
40
• Incidence increases proportional to the number of
20
cosexisting risk factors.
0
0 1 2 3 4
number of risk factors
Arch Intern Med 1990;150
13. Renal insufficiency & risk of CI-AKI
• The risk of CIAKI increases marked when CCl<60ml/min
& rises further when other risk factors are present.
• Reduced GRF makes the functioning nephrons secrete
greater load of contrast.
• Lack of functional reserve to buffer acute losses in
glomerular filtration.
• Studies show that risk dramatically increases at lower
GFR.
14. Evaluation of risk
• Proper history and physical examination is imperative.
• Various risk-prediction models have been developed
for pts undergoing PCI.
• Serum creatinine at baseline should be checked if the
contrast is being given IA or any risk factors are
present. GFR should be calculated.
• Always consider alternate imaging techniques in those
with risk factors.
16. Course and Prognosis
Creat rise Creat peak Return to
baseline
In a study on 200 patients undergoing PCI
for acute MI, patients who developed CIN had a
Non-oliguric 48hours longer hospital stay (13 ±7 days as compared
3-5 days 10-14days
CIAKI with 8 ±3 days in subjects without CIN; p<0.001)
and a more complicated clinical course, in
Oliguric CIAKI 48 hours addition to a significantly increased risk of
5-10 days 14-21 days
death.
J Am Coll Cardiol 2004;44:1780 –1785
• 1% may need dialysis & in those with severe involvement, 30% may
have residual renal impairment..
• At 1 year after PCI, the mortality rate in patients undergoing dialysis
had increased to 45.2%, compared with 35.4% in patients with CIN
not requiring dialysis and 19.4% in patients who did not develop CIN.
19. Vasoconstriction
• CIAKI is primarily an ischemic form of AKI caused by the
vasoconstrictive properties of contrast media.
• Animal studies show a biphasic response after contrast
injection. There is an initial renal vasodilation followed
by intense and prolonged (3 hrs) vasoconstriction.
• There is a selective decrease in the medullary blood
flow and oxygen saturation due to an imbalance
between vasodilators and vasoconstrictors
20. • The principal vasoconstrictors are Adenosine and
Endothelin.
• Contrast media seem to reduce renal blood flow
directly through afferent arteriole vasoconstriction via
activation of adenosine receptor A1.
• In concert, contrast agents also disrupt the vasodilatory
systems like NO and prostaglandins bringing about an
intense vasocontriction and reduced medullary bloos
supply
21.
22. Oxidative stress
• The intense vasoconstriction and loss of autoregulatory
capacity can contribute to additional renal injury
through the release of reactive oxygen species (eg,
superoxide [OH].).
• Damage is due to overwhelming of the anti-oxidant
factors by the excess generation of ROS.
• Underlying diseases like CKD and Diabetes already have
high ROS and thus predisposes for CIN.
• Benefit of anti-oxidants gives an indirect clue.
23. Direct tubular toxicity
• Marked osmotic diuresis is observed following contrast
administration.
• “osmotic nephrosis”
• The most common histopathologic features of this
disorder include intense focal or diffuse vacuolization
of the proximal tubules or overt tubular necrosis.
26. • Only 40% of patients with GFR <60ml/min receive any
form of preventive measures.
• Even when they do so, the strategy is not a
standardized one.
27. Hydration
• The benefit of hydration in prevention was
detected by retrospective analysis, and trials on
benefit of hydration is limited by absence of
controls.
• However, it remains the most efficient method of
prevention of CI-AKI.
• IV crystslloids are given @1-
1.5ml/kg/hr, beginning 12 hrs before the
procedure and continuing up to 6-24 hrs after it.
28. Hydration contd….
The mechanisms by which IV hydration decreases the risk
of CI-AKI are:
• IV half-normal (0.5 N) saline may cause an increase in
free water excretion, leading to dilution of the contrast
agents within the tubule lumen.
• 0.9% saline was found better probably due to increased
delivery of sodium to the distal nephron, leading to
reduced activation of the RAS via the macula densa.
• Intravenous volume expansion would also minimize
reductions in the renal production of nitric oxide.
29. Hydration contd….
• Mueller et al compared hydration with 0.45% and 0.9%
NaCl in 1620 patients who were undergoing cardiac
catheterization. The incidence of CIN was 2% and 0.7%
respectively (p=0.04). The benefit was more in those
with diabetes.
Arch. Intern. Med. 162, 329–336 (2002).
• Two small studies suggest that sustained fluid
administration within 12 h before and within 12 h after
administration of contrast medium is superior to bolus
administration at the time of contrast administration
Clin. Nephrol. 62, 1–7 (2004).
J. Invasive Cardiol. 15, 699–702 (2003).
30. Hydration contd….
• In an emergency situation full preprocedure volume
expansion is not possible, and there is a lack of published
evidence to guide clinicians about appropriate alternatives.
• The CIN Consensus Working Panel agreed that in emergency
situations, where the potential benefit from an urgent
investigation outweighs the risks of waiting, the procedure
can be undertaken without knowledge of renal function,
which precludes risk stratification according to renal
function.
• Hence, clinical judgment is needed.
• Appropriate postprocedure intravenous fluids should be
given.
31. Sodium bicarbonate
• The beneficial role of sodium bicarbonate was first
studied by Merten et al. (RCT of 119 patients).
Significant reduction in CIN with NaHCO3 as compared
to NaCl infusion.
JAMA 291, 2328–2334 (2004)
.
• NaHCO3 is given at a dose of 3ml/kg/hr infusion for 1
hr before procedure of a 154mEq/L NaHCO3 solution
which is continued post procedure @ 1mL/kg/hr for 6
hours.
32. Sodium bicarbonate contd…
• The role of bicarbonate is unclear and controversial. It
might be related to an increase in tubular fluid pH level
and prevent the formation of free radicals.
• But bicarbonate is a pro-oxidant specially in the
presence of ROS.
• In vitro studies also showed that although NAC and
ascorbic acid prevented contrast induced apoptosis of
tubular cells, bicarbonate failed to do so.
33. Trials those who included patients with CKD2-4 as well as
normal renal function.
1. This metanalysis highlights that the perceived benefit of
sodium bicarbonate is largely driven by
small, underpowered RCTs with extreme treatment effects
and wide CIs.
2. Among the large randomized trials there was no evidence
of benefit for hydration with NaHCO3 compared with NaCl
for the prevention of CI-AKI.
Clin J Am Soc Nephrol 4: 1584–1592, 2009
34. 1. Although the summary of the published data favours
bicarbonate but this is due the effect of the smaller, poorer
quality trials .
2. In summary this metanalaysis concluded that the benefit of
bicarb may be over-estimated and the routine clinical use
recommendation maybe still premature
35.
36. This meta-analysis demonstrated a higher incidence of CI-AKI
than recently reported, with important variation among different
Cohorts
There was a protective effect of sodium bicarbonate on the
risk of CI-AKI, especially in patients who underwent coronary
procedures and those with CKD, without effect on need for RRT or
mortality.
Due to the borderline statistical significance, the relative low
quality of the individual studies, heterogeneity and publication bias,
only a limited recommendation can be made in favour of the use of
sodium bicarbonate.
37. N-Acetylcysteine
• Due to the role of ROS in the pathogenesis of CI-AKI it was
postulated that NAC, an antioxidant may be helpful in
The ambiguity the development of CI-AKI.have been due to
preventing of these initial results could
many factors. The main reasons could have been:
• NAC induces glutathione
1. The dose of NAC was low. synthesis. It also plays a role in
counteracting vasoconstriction by ↑NO
2. The ROS generation lasts much longer than anticipated.
3. It is the peak levels of NAC during the procedure that is more
• important. was reported by Tepel et al in 2000 in a trial
First benefit
published in NEJM. (NAC+hydration was compared with
hydration with 0.45% NaCl alone).
• Some other trial published after that showed ambiguous
results.
38. This MA failed to provide conclusive proof of benefit in favor of NAC
39. N Engl J Med 2006;354:2773-82.
354 consecutive patients undergoing primary angioplasty
were randomized to one of three groups:
1. 116 patients were assigned to a standard dose of NAC
(a 600-mg intravenous bolus before primary
angioplasty and 600 mg orally twice daily for the 48
hours after angioplasty),
2. 119 patients to a double dose of NAC(a 1200-mg
intravenous bolus and 1200 mg orally twice daily for
the 48 hours after intervention),
3. 119 patients to placebo.
40. • The serum creatinine concentration increased 25 % or
more from baseline after primary angioplasty in 39 of
the control patients (33%), 17 of the patients receiving
standard-dose N-acetylcysteine (15 %), and 10 patients
receiving highdose N-acetylcysteine (8%, P<0.001).
• NAC has a dose dependent reduction in the risk of
developing CI-AKI with a p<0.001 for this dose-trend.
• Similar findings were also confirmed by 2 earlier trials
the RAPPID study. J Am Coll Cardiol 2003;41:2114-8.
Eur Heart J 2004;25: 206-11.
41. Current status of NAC
ACT Trial (Circulation. 2011;124:1250-1259)
• RCT on 2308 patients undergoing an intravascular angiographic
procedure with at least 1 risk factor for CIAKI randomized to NAC
1200 mg or placebo.
• The incidence of CIAKI (primary end point) was 12.7% in the NAC
group and 12.7% in the control group (relative risk, 1.00; 95% CI
0.81 to 1.25; P=0.97).
• A combined end point of mortality or need for dialysis at 30 days
was also similar in both groups.
• Consistent effects were observed in all subgroups
analyzed, including those with renal impairment.
Conclusions—NAC does not reduce the risk of CIAKI or other
clinically relevant outcomes in at-risk patients undergoing
coronary and peripheral vascular angiography.
42. Adenosine receptor antagonists
• Adenosine induced vasoconstriction has been
shown to be an important pathogenetic
mechanism in the development of CIAKI.
• When given before contrast media, oral or IV
administered theophylline, a nonselective
adenosine-receptor antagonist, have been shown
to reduce the incidence of CIAKI in many studies.
• Trials have used theophylline in doses of 5 mg/kg
iv, 2.88 mg/kg orally, and 165 mg iv.
43. There was a trend towards reduction in CIAKI use with
theophylline use, and this reduction is comparable with that of
NAC.
The main issue of theophylline use in patients with renal
insufficiency is its safety profile
Role of highly selective A1 receptor antagonists should be
evaluated
45. Role of extracorporeal therapies
HEMODIALYSIS:
• Contrast medium is dialyzable and there were initial reports
that HD was beneficial in preventing CIAKI.
• Later studies showed that in patients not previously on RRT,
HD had no preventive role even if given within 1 hr or
periprocedural and one study even reports a detrimental
effect.
• However, CIN Consensus working Panel agreed that in
patients with severe renal impairment (eGFr <20 ml/min)
who require contrast-medium administration, hemodialysis
should be undertaken if CIAKI develops.
46. Role of extracorporeal therapies contd….
HEMOFILTRATION:
• Single study on patients with Cr>2mg/dl or GFR <50
ml/min with continuous HF starting 6 hrs before till 24
hrs after the procedure showed HF to be protective.
• However, the fact that HF is not an effective contrast
media removing modality, interruption of HF during
the procedure, good intensive care management of pts
on HF and concomitant medications makes this study
difficult to interpret and HF remains an investigative
tool. Requiring further studies
N. Engl. J. Med. 349, 1333–1340 (2003).
47. REMEDIAL trials 1&2
• REMEDIAL I trial, demonstrated that the combined
strategy of volume supplementation with NaHCO3 &
NAC was superior to the administration of NS & NAC
alone or a combination of NS, ascorbic acid, and NAC in
preventing CI-AKI in patients at low to medium risk.
Circulation. 2007;115:1211–1217.
• Investigators of REMEDIAL II trial used furosemide and
justified its use by results of the PRINCE trial and
theoretical principles.
Circulation. 2011;124:1260-1269
48. REMEDIAL trial II contd…
• It was a multicentric RCT, included pts with
GFR<30 mL/min/1.73 m2 and/or a risk score 11.
• They were randomly assigned to NaHCO3 &
NAC(control group) or hydration with saline and
NAC controlled by the RenalGuard System and
furosemide (RenalGuard group).
• Conclusion—RenalGuard therapy is superior to
sodium bicarbonate and N-acetylcysteine in
preventing AKI in high-risk patients.
49. Renal Guard system
Priming hydration of 250 ml
was given followed by furosemide (0.25
mg/kg) iv to achieve an optimal urine
flow of 300 mL/h.
As soon as the urine flow
reached the target value, the patient
wasmoved into the catheterization
laboratory, and the procedure was
started (procedural phase).
Controlled hydration by the
RenalGuard system continued during
the procedure and for 4 hours after the
procedure (postprocedural phase).
Urine flow was monitored and
maintained at the target value
throughout the procedure and during
the next 4 hours
50. Summary of the preventive
strategies
Hydration remains the most imp strategy.
Needs standardization of dosage
Role of NAC & NaHCO3
Promising agents:
unclear.
Theophylline, statins, CIAKI Safety and low cost , can be
ascorbic acid, PGs
tried
Additional studies
are needed to clear
the confusion
51. Take home message
• CI-AKI is one of the most common cause of Aki in
hospitalized patients.
• It is a preventable condition if the risk factors are
vigilantly detected.
• The pathogenesis and preventive measures remain
unclear and controversial.
• Of all the modalities of prevention, good hydration
remains the only proven methodology.
Statins were found protective. PROMISS study (simvastatin was beneficial) 2010 a trial did not show any benefit of statins. Fenoldopam-selective D1 receptor antagonist.