nefropatiada mezzo

di contrasto

Giuseppe RombolàLa Spezia

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.)

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

ApparatoJuxtaglomerulare

RAS

Mezzo di contrastoDIURESI

OSMOTICA

vasocostrizione

Riassorbimento di Na e acqua

nel TALH

Carico tubulare di Na e acqua

Consumo diossigeno

IPOSSIAMIDOLLARE

CIN

Vasodilatazione

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 CECTMultivariate analysis RR

Lencioni R. Acta Radiol. 2010

7856 pts. after PCIMultivariate analysis RR

Rihal C. Circulation 2002

CONNECT STUDY

Mo

rtal

ity

%

% increase in serum creatinine

0 <10 10-25 25-50 > 500

10

20

30

40

Gruberg et al. JACC 2000

renal function deterioration after PCI andone year outcomes

Goldenberg I.Am. J. Nephrol. 2009

Loss of kidney function andmortality after reversible CIN

eGFR 36±7 ml/min/1.73m2

31±15ml/min/1.73m2

16±15ml/min/1.73m2

58

115

357

1774

50 45- 40 < 30

CIN incidence following CM administration

0

10

20

30

40

50

60

1 2 3

GFR mL/min

CIN

in

cid

en

ce

%

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

90 Arteria volume di mdc …… 248 ± 112 ml00 …… 122 ± 55 10 …… 117 ± 19

Infusione venosa < 100 ml

Strategie preventive Espansione VEC (salina o bicarbonato)NAC

Linee guida ESUR1-1.5 ml/Kg/h 3-12 hrs pre e 12-24 hrs dopo mdcBicarbonato isotonico 1.4%:3 ml/kg/h: 1 hr pre e 1 ml/kg/h per 6 hrs dopo mdc

Nephrotoxicity In High-Risk PatientsA Double-Blind, Randomized, Multicenter Study of Iso-Osmolar and

Low-Osmolar, Nonionic Contrast Media

The NEPHRIC Study

NEPHRIC: Primary EndpointMean Peak Increase in SCr Up to Day 3

0Iodixanol

(n=64)Iohexol(n=65)

Incr

ea

se

in S

Cr

(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 % Iodixanol26 % iohexol

N pazienti RR

Birck

Lancet 2003

805 0.43 (0.21 – 0.87)

Kshirsagar

JASN 2004

1538 efficace nel 33 %

Nallamothu

Am.J. Med.2004

2195 0.73 (0.52 – 1.0)

Alonso

Am.J. Kid. Dis. 2004

885 0.55 ( 0.34 – 0.91)

Zagler

Am. Heart J. 2006

1892 0.68 (0.46 – 1.01)

efficacia della NAC nella prevenzione della CIN

119 pts

•In 20% of ptsadditional furosemide(0.5 mg/Kg) was required

MYTHOS Protocol R

enal

Gu

ard

i.v. furosemide(0.5 mg/kg)

Volume urine826±342 ml/hr

48 - 16 min

30 min

PROCEDURA

4 ore

Diuresi > 300 ml/h

250 mli.v. saline

Infusionecontinua di

sol fisiolin volumeuguale alla

diuresi

Controlloparametri

ogni30 min

CIN 157 pts.baseline GFR 39 ± 10 ml/min.

Controls

RenalGuard

0

5

10

15

20

25

30

%

All patients NSTEMI Elective procedures

16%

5% 6%

10%

25%

P=0.028

4%

P=0.03 P NS

-69%

-80%

-60%

Marenzi; TCT 2010Transcatheter Cardiovascular Therapeutics

2003

Marenzi G. Am. J. Med. 2006

PREVENZIONE CIN & EMOFILTRAZIONE

Am J Med 2001

CONCLUSIONI

1. CIN è associata con un peggioramento della funzione renale che aumentando il rischio CV può aumentare la mortalità

2.CIN sembra rappresentare un rischio indipendente di mortalità sia a breve che a lungo termine

3.I trattamenti depurativi extracorporei sembrano promettenti nel ridurre questo rischio

giuseppe.rombola@asl5.liguria.it