2. Kidney in CV disease Cardiorenal overlap CKD is important
independent predictor of mortalityin patients with CAD (BERRY
trial) Even in absence of CV risk factors, pts with
renalinsufficiency have elevated risk of CV disease Mild elevation
in CR(>1.5mg/dl) are associated withdevelopment of CV events
Microalbuminuria is independent risk factor for CVevents, with RR
higher than serum Cr ( 1.59 vs. 1.40) Hall Wo et al Am J Med Sci
,1999 Mann JF et al, Ann Intern Med 2001 3. Kidney in CV disease
Acute Renal failure Contrast induced nephropathy(CIN) Postbypass
ARF CIN is now the 3rd leading cause of in-hospital ARF* CIN in
patients with PCI Poor procedural success Longer hospital stay and
increased mortality* Nash et al , Am J kidney Dis ,2002;39:930 4.
BASIC PRINCIPLES OF CONTRAST MEDIA 5. Contrast Media classification
6. Contrast media used in Cath Lab 7. Contrast Pharmacology
Contrast sole function is to attenuate X-ray Radio-opacification
achieved by given volume ofcontrast is function of iodine
concentration Rough estimate : 125 ml contrast = 500ml of
plasmavolume expansion Excreted by kidney exclusively Anticoagulant
and antiplatelet effect of CM has noclinical relevance 8. Side
effects of contrast Allergic reactionNon IgE
mediatedIonic>Nonionic,(0.27%, SCAI registry) Ioxoglate
(Hexabrix) significantly higher allergic reaction ascompared to
Iopamidol (Isovue) * Cardiovascular ElectrophysiologicalHeart
blocksArrhythmiasHemodynamic Vasodilatation (hypotension) Increased
volume overload * Gertz et al, JACC,1992;19:899-906 9.
Pathophysiology of CIN 10. Contrast Media Induce Medullary Hypoxia
A temporary increase in renal transport work in the thick ascending
limb of Henles loop ( in oxygen consumption) + Constriction of
medullary capillaries ( in medullary oxygen delivery) LEAD
TOMEDULLARY ANGINASolomon, et al. Kidney Int 1998; 230-242 11.
CI-AKI or CINDefinition: New onset acute kidney injury (absolute Cr
rise 0.5 mg- 1mg/dl or relative, 25%-50% from baseline) after
contrastadministration and in the absence of other etiologyTime
course of CI-AKI: Occurs after 24-48 hrs of contrast Cr peaks in
3-5days and normalizes in 7-10 days(70%) In 30%, 3 weeks to return
baseline or progress to CKD Predominantly non-oliguric AKI and with
mild proteinuria 12. Epidemiological Issues Small numbers not mega
RCT Varying treatments used Differing hydration regimens Varying
definitions Outcomes vary by definitions How much of CIN is due to
contrast? Atheroembolism, hemodynamics Cause and effect??? 13. CIN
definition in clinical trials 14. CIN-definition 15. McCullough PA,
Am J Med 1997 16. Incidence Incidence ranges from 1%-35% Low risk
population incidence is 1.5% Mayo retrospective series evaluated
7852 pts. who had undergone cath /PCI found an incidence of 3.3% *
ARF defined as 0.5 mg/dl Baseline Cr was predictor* Rihal CS et al,
Circulation 2002 17. RISK FACTORSNon modifiable Modifiable CKD
Volume depletion DM Volume of contrast Age(>75yr) Multiple
injection of contrast Class IV CHF within 72 hrs Renal tx
Intraarterial vs. intravenous ? High osmolal contrast (Not used
anymore) 18. CIN and High risk groups Baseline Cr < 2.0 mg/dl,
diabetic patients had higherrisk of ARF than nondiabetic pts Cr
< 1.1(risk 3.7 % vs 2.0%, p=0.05) Cr 1.2-1.9(risk 4.5% vs 1.9%,
p 2.0 mg/dl, risk high regardless ofdiabetes status Cr. 2.0-2.9
mg/dl, risk 22.4% Cr > 3 mg/dl, risk 30.6% 19. Predictors of ARF
requiring dialysisafter PCI Mean contrast vol 250cc,(Cath+ PCI)
Mean age 65yrs Predictors of CIN Crcl >DM> contrast dose 20.
OUTCOMES OF CIN 21. CIN & Mortality Retrospective case
controlstudy of 16,248 hospitalizedpatients who receivedcontrast
Cases with CIN(n=183)matched with controls(n=174) Matched for
baseline creatinine APACHE score Levy EM,JAMA 1995 22. CIN after
PCI & MortalityDerivation-validationmethod in 1800
patiensIncidence of CIN 14% andARF requiring HD was7.7%Multivariate
predictors:CrCl, diabetes and contrastdoseNo case of CIN in
patientswith contrast dose of 1.8 All well hydrated, all received
non ionic dye 161 pts(37%) had increase in serum cr > 25%and
278(63%) did not 26. CIN prognosis after PCI in CKDIn hospital
outcomeOne year outcomeNo Cr Rise 25% CrNo Cr Rise 25% Cr P
