2012 Updates on Management of Contrast Induced AKI —— Guidelines & New Evidences

Prof. Ben He MD PhD FACCShanghai Renji HospitalShanghai Jiaotong University（上海交通大学医学院附属仁济医院 何奔）

Epidemiology:

Incidence of CI-AKI

A survey in Shanghai China.2010

Data from US

Am J Cardiol 2004;93:1515–1519

Without Significant Reduction in Past Decade

Prognosis:

Circulation. 2012;125:3099-3107.

Death

MACE+DIALYSIS

Poor prognosis, especial for pts with persistent renal damage

5

Mechanisms:

Direct cytotoxic effects

Renal haemodynamics

Renal tubulodynamics

Regional hypoxia

European Heart Journal (2012) 33, 2007–2015

4 Key Factors:

Important Updates on CI-AKI

Guidelines

New Researches

I. Definition• Traditional Definition of CI-AKI

An increase in SCr by more than 25% or 44 μmol/L in the 3 days following intravascular administration of contrast medium (CM) in the absence of an alternative etiology.

• Other Definition of CI-AKIAn increase in CysC by more than 10% in the

24h following intravascular administration of contrast medium (CM).

• New Definition:

I. Definition

Stage 1: SCr increased 1.5–1.9 times baseline SCr increase >0.3mg/dl (26.5 μmol/l) Urinary output < 0.5ml/kg/h during a 6 hour blockStage 2: SCr increase 2.0–2.9 times baseline Urinary output <0.5ml/kg/h during two 6 hour blocksStage 3: SCr increase >3 times baseline SCr increases to >4.0mg/dl (353 μmol/l) Initiation of renal replacement therapy Urinary output <0.3ml/kg/h during more than 24 hours Anuria for more than 12 hours

New criterior increase sen and sep ?

Am Heart J 2012;163:829-34.

Which definition is better? We need further studies!

• Balancing the risk for CIN against the benefit of administering contrast. (Not Graded)

• Considering alternative imaging methods not requiring contrast administration in patients at increased risk for CIN, so long as these yield the same diagnostic accuracy. (Not Graded)

II. Risks Assessment

2011 PCI guideline

11

Mehran Score is proved to predict long-term outcomes.

J Am Coll Cardiol.2004;44:1393–9 Clin. Cardiol. 2013,36, 1, 46–53

Predicting Score: Traditional Methods

Easy for practice

Baseline Kidney Function Screening——MDRD formula is preferredhttp://www.nephron.com/MDRD_GFR.cgi

2011 PCI guideline

3.7

2011 PCI guideline

2.62

• Data from China

Lower than Western Countries ！

New Simple Algorithm: To stratify the risk of CI-AKI

Maximum Allowable Contrast dose (MACD) was defined as 5*body weight/SCr

Increases the positive predictive value of the Mehran risk score (40.7% vs 8.8%)

with the same sensitivity (90.7% vs 83.3%)

Catheterization and Cardiovascular Interventions,2013, doi: 10.1002/ccd.24847

Better Contrast Media:Low- Osmolar vs. Iso- Osmolar CM

Data from Chinese Population

EuroIntervention 2012;8:830-838

2009 PCI guideline

2011 UA/NSTEMI guideline

CKD+DM

CKD

—— No Difference!

EuroIntervention 2012;8:830-838

Among Low- Osmolar CMs:

Iohexol vs. Iopamidol vs. Ioversol : No apparent clinical advantageamong LOCM agents.

Am J Cardiol 2012;109:1594–1599

New Factors Rising Concerns:ACEI or ARB increase the risk of CI-AKI?

Am J Kidney Dis. 60(4):576-582

Further RCTs are warranted !

Retrospective Study

III. Pharmacological Prevention

• Volume expansion with either isotonic NS or SB

(1A)

• Oral route for hydration, on the premise that

adequate intake of fluid and salt are assured (2C)

• Oral N-acetyl cysteine (NAC) only in appropriate

fluid and salt loading (2D). Not using oral NAC as the

only method (1D)

• Do not suggest using theophylline (2C)

• Do not recommend using fenoldopam (1B) 2011 PCI guideline

Optimal Hydration Protocol:

(A) NS 1 mL/kg/h for at least 12 h prior and after the procedure

(B) SB 3 mL/kg for 1 h before and 1 mL/kg/h for 6 h after the

procedure

(C) SB 3 mL/kg over 20 min before the procedure plus sodium

bicarbonate

orally (500 mg per 10 kg).

European Heart Journal (2012) 33, 2071–2079

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24 h sodium chloride 0.9% is superior to sodium bicarbonate.

A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen.

Optimal Hydration Protocol:

European Heart Journal (2012) 33, 2071–2079

Precise Hydration

Renal-Guard System: capable of delivering sterile replacement solution in an amount matched to the volume of urine, avoiding hypovolemia and fluid overload.

J Am Coll Cardiol Intv 2012;5:90 –7

Benefit for pts with CKD !

J Am Coll Cardiol Intv 2012;5:90 –7

Pilot RCT with 170 pts

New hydration agent:

Promising Results!

European Heart Journal doi:10.1093/eurheartj/eht009

RCT

2011 UA/NSTEMI guideline

2308pts were randomized to NAC group or placebo

New Evidence ： ACT trial

HR, 0.97; 95% CI, 0.56-1.69; P=0.92 NAC: ineffective!

High Dose Statin——no yet accepted by guidelines

Meta analysis shows ： high dose statin might be effective

New Evidence ： ARMYDA-CIN trial

NSTEMI patients : totally 120mg atorvastatin within 12 hours prior to PCIEndpoint ： CIN%

阿托伐他汀 安慰剂组

对比

剂肾

病发生

率

(%)

P=0.046

5

13.2

Giuseppe Patti, et al. Am J Cardiol, 2011 online

Perioperative high-dose statin load to reduce perioperative myocardial infarction has been recognized;

Prevention of CIN may be derived from the pleiotropic effects of statins.

29Circulation. 2005;111:3051-3057

Worry Some - Rosuvastatin

Increase the risk of inducing proteinuria and renal function injury - CIN?

TRACK-D trial: to eliminate this concern

Han YL et al. 2012 CIT meeting report.

IV. Renal Replacement Therapy

Do not recommend using prophylactic intermittent haemodialysis (IHD) or haemofiltration (HF) for the purpose of prevention of CIN only. (1C)

New Evidence : Meta-analysis

Risk of CI-AKI: No benefit, Even increase the risk!

Among the CKD stage

Support current guideline!

The American Journal of Medicine Volume 125, Issue 1, January 2012, Pages 66–78.e3

V. Beyond guidelines

Protocol: IPC was accomplished by performing 4 cycles of alternating 5-minute inflation and 5-minute deflation of a standard upper-arm blood pressure cuff to the individual’s systolic blood pressure plus 50 mm Hg to induce transient and repetitive arm ischemia and reperfusion.

Circulation. 2012;126:296-303.

Pros:

Ischemic PreconditioningA Pilot RCT

Simple procedure but maybe effect!

Precise CM volume injectionAutomated Contrast Injection Systems

Incidence of CI-AKI 9% vs 9% P=0.84

Canadian Journal of Cardiology 29 (2013) 372-376

No Benefit !

Cons:

1358 pts undergoing CAG and PCI from January 31 to May 31, 2011

Manual vs Automated injection

Summary:

Something We Gain

A Lot We Still Unknown!

Thank You !