Nefropatia da mezzo di contrasto Giuseppe Rombolà La Spezia

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  • nefropatia da mezzo di contrasto Giuseppe Rombol La Spezia
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  • CIN (CI-AKI) Both clinical studies and ESUR definition (Thomsen H. Curr. Opin. Urol. 2007; 17: 70) Increase in serum creatinine (sCr) 0.5 mg/dL and/or 25% from baseline within 3 days of CM exposure And the absence of other causes (e.g. atheromatous embolic disease, ischemia, other nephrotoxins, etc.)
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  • CIN (CI-AKI) definition Stage I AKIN definition Increase in sCr 0.3 mg/dL or 15 to 20 % from baseline (Metha R. Crit.Care 2007) CIN definition: sCr. Increase 0.3mg/dL Solomon R. Clin. JASN 2009 Mitchell A. Clin JASN 2010 Briguori C. Circulation 2010
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  • Apparato Juxtaglomerulare RAS Mezzo di contrasto DIURESI OSMOTICA vasocostrizione Riassorbimento di Na e acqua nel TALH Carico tubulare di Na e acqua Consumo di ossigeno IPOSSIA MIDOLLARE CIN Vasodilatazione
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  • Chronic Kidney Disease (scr. 2-2.9 mg/dl) 7.37 (4.7-11) Diabetes 1.61 (1.21-2.18) Congestive heart failure 1.53 (1.12-2.10) Periferal vascular disease 1.71 (1.23-2.37) Age 60 years: 1-Y increment 1.02 (1.01-1.03) CM dose (100 ml) 1,12 493 pts. following CECT Multivariate analysis RR Lencioni R. Acta Radiol. 2010 7856 pts. after PCI Multivariate analysis RR Rihal C. Circulation 2002 CONNECT STUDY
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  • Mortality % % increase in serum creatinine 0 50 0 10 20 30 40 Gruberg et al. JACC 2000 renal function deterioration after PCI and one year outcomes
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  • Goldenberg I. Am. J. Nephrol. 2009 Loss of kidney function and mortality after reversible CIN eGFR 367 ml/min/1.73m2 3115 ml/min/1.73m2 1615 ml/min/1.73m2
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  • 58 115 357 1774 5045- 40 < 30 CIN incidence following CM administration gfr ml/min 2 V. in 4 studies (2008-2010) (diabetes 29-100 %) 3 V. in 1 study (2010) (diabetes 32%) A. in 5 RCT studies (2007-2009) (diabetes 28-100 %) A +CKD+ diabetes A + CKD only studies published before 2003 Mc Cullough, J. Cardiov. Med. 2003
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  • 90 Arteria volume di mdc 248 112 ml 00 122 55 10 117 19 Infusione venosa < 100 ml Strategie preventive Espansione VEC (salina o bicarbonato) NAC Linee guida ESUR 1-1.5 ml/Kg/h 3-12 hrs pre e 12-24 hrs dopo mdc Bicarbonato isotonico 1.4%: 3 ml/kg/h: 1 hr pre e 1 ml/kg/h per 6 hrs dopo mdc
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  • Nephrotoxicity In High-Risk Patients A Double-Blind, Randomized, Multicenter Study of Iso-Osmolar and Low-Osmolar, Nonionic Contrast Media The NEPHRIC Study
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  • NEPHRIC: Primary Endpoint Mean Peak Increase in SCr Up to Day 3 0 Iodixanol (n=64) Iohexol (n=65) Increase in SCr (mg/dL) P=0.001 0.13 0.55 0.1 0.2 0.3 0.4 0.5 0.6 Adapted from Aspelin P et al. N Engl J Med. 2003;348:491-499. CIN -creat. < 0.5 mg/dl- 3 % Iodixanol 26 % iohexol
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  • N pazienti RR Birck Lancet 2003 8050.43 (0.21 0.87) Kshirsagar JASN 2004 1538efficace nel 33 % Nallamothu Am.J. Med.2004 21950.73 (0.52 1.0) Alonso Am.J. Kid. Dis. 2004 8850.55 ( 0.34 0.91) Zagler Am. Heart J. 2006 18920.68 (0.46 1.01) efficacia della NAC nella prevenzione della CIN
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  • 119 pts
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  • In 20% of pts additional furosemide (0.5 mg/Kg) was required MYTHOS Protocol RenalGuard i.v. furosemide (0.5 mg/kg) Volume urine 826342 ml/hr 48 - 16 min 30 min PROCEDURA 4 ore Diuresi > 300 ml/h 250 ml i.v. saline Infusione continua di sol fisiol in volume uguale alla diuresi Controllo parametri ogni 30 min
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  • CIN 157 pts. baseline GFR 39 10 ml/min. Controls RenalGuard % All patientsNSTEMI Elective procedures 16% 5% 6% 10% 25% P=0.028 4% P=0.03P NS -69% -80% -60% Marenzi; TCT 2010 Transcatheter Cardiovascular Therapeutics
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  • 2003
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  • Marenzi G. Am. J. Med. 2006 PREVENZIONE CIN & EMOFILTRAZIONE
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  • Am J Med 2001
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  • CONCLUSIONI 1. CIN associata con un peggioramento della funzione renale che aumentando il rischio CV pu aumentare la mortalit 2.CIN sembra rappresentare un rischio indipendente di mortalit sia a breve che a lungo termine 3.I trattamenti depurativi extracorporei sembrano promettenti nel ridurre questo rischio
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  • giuseppe.rombola@asl5.liguria.it