Renal Angina

Lakhmir S. Chawla, MDAssociate Professor of Medicine

Renal Angina

• What the &#$@ are you talking about?• Do I need to know this?• Implementation• Outcomes

Angina – Troponin – ACS/MI

Angina

Diagnostics• EKG• Troponin

ACS/MI

TroponinWorship

Land of AKI Biomarkers

50%

40.6%

Am J Cardiol, 2008; 102:509 - 512

Conclusion

• Troponin performance significantly deteriorates when used outside of the clinical syndrome of angina

• AKI Biomarkers will only perform well when used in the appropriate context

Renal Angina?

Acute Flank Pain

“Simply put, AKI does not hurt”

Cardiac AnginaRisk Factors

• DM• HTN• Elevated Cholesterol• Family History• Tobacco Use

Clinical Syndrome

• Elephant on my chest• Squeezing/pressure• Jaw pain• Dyspnea

If RF + Diagnostics > Threshold

HIGH Likelihood of ACS

Renal AnginaRisk Factors

Renal Angina

Risk Factors• Mechanical Ventilation• Vasopressors• Nephrotoxins• Sepsis• MSOF• SCT• Volume Depletion

Clinical Syndrome

• Early evidence of AKI

If RF + Diagnostics > Threshold

HIGH Likelihood of ACS

Pediatric Renal Angina: Risk Factors

• Moderate Risk (4.5% AKI rate)– ICU admission

• High Risk (11%-21% AKI rate)– Stem cell transplantation

• Very High Risk (51% AKI rate)– Invasive mechanical ventilation– One vasoactive medication

Pediatric Clinical Signs: GradationChest Pain Equivalent

• Creatinine increase• Estimated creatinine clearance

decrease (pRIFLE)• Fluid Accumulation from ICU

admission

MV1+ pressor

Decomp HFSCT

Ped ICU2+Nephrotoxin

Putting Renal Angina to the Test

• Preliminary data from CCHMC• Retrospective chart review of 150 patients

admitted to the PICU– Median ICU LOS is 3 days

• Assigned each patient risk category• Assessed for clinical signs (creatinine or fluid

accumulation based)• Outcome: Day 0, 1 prediction of AKI at 72

hours• Secondary: PICU LOS, Mortality

Basu, Wheeler, Chawla, Goldstein

Calculating Renal Angina Index

Risk Level Description Risk Score

Moderate ICU status 1 High History of Transplantation 3

Very High Mechanical ventilation + Inotropy 5

Injury (Creatinine) Injury (Fluid Overload)

Injury Score

No ↓eCrCl / No ↑[SCr] < 5% 10<x<25% ↓eCrCl / 0-33%

↑[SCr]>5 % 2

25%-50% ↓eCrCl / 33-100% ↑[SCr]

>10 % 4

>50% ↓eCrCl / >100% ↑[SCr]

>15 % 8

= Renal Angina Index Score Angina > 8

RA on Day 0 to Predict AKI on Day 3

Multivariate analysis for Renal Angina, patient age, inotropy score and PRISM II score

OR for Renal Angina on Day 1 to predict AKI on Day 3 =7.1 (1.9-27, p=0.004)

Basu, Wheeler, Chawla, Goldstein: ASN 2011

C statistic = 0.75-0.82

C statistic = 0.68-0.77

Summary/Conclusions• AKI biomarkers hold promise for earlier

diagnosis of AKI development and intensity

• Risk stratification based on demographics alone may not sufficiently enrich the population to optimize AKI biomarker utility

• Renal Angina, a concept that combines risk stratification and clinical signs may serve well to optimize biomarker utility

Take Home Points

• Context• Comparative performance

Stu Goldstein