Contrast Induced Nephropathy: September 2007

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Contrast induced nephropathy

September 2007
Case discussion
 67 female with
 IHD and previous NSTEMI 2004
 DM CKD stage 3 (Creatinine 206)
 On Ramipril, ISMN, Atenolol and Gliclazide
 Admitted for PCI
 Prevention strategies for contrast induced nephropathy (CIN)

What is currently the best strategy to avoid CIN in medium to high risk patients?
1. Intravenous volume expansion with a saline solution
2. Use of a low- or iso-osmolality contrast agent
3. Limits on the volume of contrast agent
4. Use of N-acetylcysteine (NAC)
5. Avoidance of nephrotoxic drugs peri-procedure
6. None of the above
REMEDIAL TRIAL
Published in Circulation 2007
 Renal insufficiency following contrast media
administration trial
 a randomized comparison of three preventative
strategies
 Briguori C (MD PhD) et al.
 Laboratory of Interventional Cardiology, San Raffaele
Hospital, Milan
 Institute of Medical Statistics and Biometry,
University of Milan, Milan, Italy
Introduction
 CIN: acute reversible form of ARF presenting within 48 hours after the
administration of contrast media

 "Contrast-induced nephropathy" was defined as an increase of 25% or 0.5


mg/dl (44.2 umol/l) in pre-PCI serum creatinine at 48 h after PCI

 No clear guidelines to best prevent CIN


 Most recent guidelines recommend volume expansion with saline and
low-osmolality contrast agent
 Although not firmly recommended, NAC administration is suggested
especially in high-risk patients
 (Kidney Int. 2006; 69: S51–S53)

 CIN estimated 10% of all hospital acquired ARF


Patophysiology: oxidative
tissue damage
 N-Acetylcysteine (NAC) potent anti-oxidant been
used with variable evidence

 More recently sodium bicarbonate and ascorbic acid


use has created considerable interest

 Aim: anti-oxidant combination strategy preventing


CIN
Study methods and design
 Patients with CKD (eGFR<40 ml/min)
 Exclusion criteria applied
 2-centers, randomised double-blind study,
393 consecutive patients scheduled for
coronary and peripheral angiography
with/without angioplasty
 Three randomised arms:
 IV Saline and NAC (Saline) n=111
 IV Sodium Bicarbonate and NAC (Bic) n=108
 IV Saline, Ascorbic Acid and NAC (AscA) n=107
Administration of fluids
 IV Saline 1ml/kg per hour 12 hours before procedure and 12
hours after

 IV Bicarbonate 3ml/kg bolus 1 hour before procedure and


1ml/kg per hour for 6 hours after procedure

 Ascorbic Acid 3g IV bolus 2 hours before, 2g the night and


morning after procedure

NAC (all 3 arms) 1.2 g twice daily day before and day of the
procedure (2 days in total)
Scheme to define contrast-induced nephropathy (CIN) risk score

Mehran, R. et al. J Am Coll Cardiol 2004;44:1393-1399

Copyright ©2004 American College of Cardiology Foundation. Restrictions may apply.


Study end points
 The primary outcome measure was development of CIN
 serum creatinine concentration 25% from the baseline
 at 48 hours after administration of the contrast media
 the need for dialysis.
 Additional efficacy end points
 creatinine concentration 44.2 umol/l at 48 hours after contrast
 and a decrease of eGFR 25% at 48 hours.
 Acute renal failure requiring dialysis
 defined as a decrease in renal function necessitating acute
hemodialysis, ultrafiltration, or peritoneal dialysis
 within the first 5 days after intervention.
TABLE 3. Contrast Agent–Enhanced Nephrotoxicity

 Serum creatinine increase by 25%


 11 (9.9) Saline Plus NAC Group (N=111)
 2 (1.9)* Bicarbonate Plus NAC Group (N=108)
 10 (10.3) Saline Plus Ascorbic Acid Plus NAC Group (N=107)

 Serum creatinine increase by 44.2 umol/l


 12 (10.8) Saline Plus NAC Group (N=111)
 1 (0.9) Bicarbonate Plus NAC Group (N=108)
 12 (11.2) Saline Plus Ascorbic Acid Plus NAC Group (N=107)

 eGFR decrease by 25%


 10 (9.2) Saline Plus NAC Group (N=111)
 1 (0.9) Bicarbonate Plus NAC Group (N=108)
 10 (10.3) Saline Plus Ascorbic Acid Plus NAC Group (N=107)
Discussion
 The main result of the present study
 combined administration of sodium bicarbonate plus NAC

significantly reduces the risk of CIN in a medium- to high-risk


population

 compared with sodium chloride plus NAC or sodium chloride


plus ascorbic acid and NAC.

 This combined approach


 allow us to satisfy the crucial requirement of volume

supplementation and administer a potent antioxidant


treatment.
Summary and recommendations from Up-To-Date database

 Optimal therapy to prevent contrast-induced acute renal failure remains uncertain. Patients
with near-normal renal function are at little risk and few precautions are necessary other than
avoidance of volume depletion.
 Patients at increased risk of contrast nephropathy (serum creatinine 132 mmol/L or an
estimated glomerular filtration rate <60 ml/1.73 m2, particularly in patients with diabetes:
 ultrasonography, MRI without gadolinium contrast, or CT scanning without radiocontrast agents.
 use of iso-osmolal agents rather than low osmolal agents
 Use lower doses of contrast and avoid repetitive, closely spaced studies (eg, <48 hours apart).
 Avoid volume depletion and nonsteroidal antiinflammatory drugs.
 Isotonic intravenous fluids prior to and continued for several hours after contrast administration
 The optimal type of fluid and timing of administration are not well established. We suggest isotonic
bicarbonate rather than isotonic saline
 Despite conflicting data, we suggest acetylcysteine, at a dose of 600 to 1200 mg orally twice daily,
administered the day before and the day of the procedure, based upon its potential for benefit and
low toxicity and cost.
 Based upon the lack of convincing evidence of benefit and the potential risk of anaphylactoid
reactions, we suggest not routinely using intravenous acetylcysteine for the prevention of
contrast nephropathy
 We suggest using diuretics only in patients who are volume overloaded.
 We do not recommend routine use of hemofiltration or hemodialysis.

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