强生 cordis 学院 cordis 百家病例论坛 pci for patients with chronic renal dysfunction dr....

强生 Cordis 学院

Cordis 百家病例论坛

PCI for patients with Chronic Renal Dysfunction

Dr. LiyiFirst Affiliated Hospital of Sun Yat-sen University



• With the aging of society and development of PCI

techniques, we are facing more and more CAD

patients with CRD

• Our hospital has a very large hemodialysis and

peritoneal dialysis center, we are facing more and

more CRD patients

• Serum creatine level is a very poor indicator for

patient’s renal function

• Depleted renal function means poor prognosis



Szczech L. et al., Szczech L. et al., CirculationCirculation 2002; 105:2253-8. 2002; 105:2253-8.

With DM or CKD (n=2921)

With DM, without CKD (n=611)

Without DM, with CKD (n=46)

With both DM and CKD (n=30)

95%

85%

77%

54%

* * CKD defined as baseline Cr > 1.5 mg/dlCKD defined as baseline Cr > 1.5 mg/dl

Freedom from Cardiac Death for Patients with CKD* and Diabetes (DM) BARI Trial + Registry



DM, <25% creatinine increase No DM, <25% creatinine increase DM, 25% creatinine increaseNo DM, 25% creatinine increase

00%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10 11 12

Time (Months)Time (Months)

Eve

nt-

Fre

e S

urv

ival 80%80%

80%80%

64%64%55%55%

CIN After PCI:

1-Year Event-Free Survival1-Year Event-Free Survival

Cr. Increase & DMCr. Increase & DM

Gruberg, et al. JACC 2000; 36: 1542-8Gruberg, et al. JACC 2000; 36: 1542-8



• The best strategies is to nip CIN in the bud

• So… who are at the high risk ?



Risk Factors for CIN

Patient-related Risk FactorsPatient-related Risk Factors• Renal insufficiencyRenal insufficiency

• Diabetes mellitus withDiabetes mellitus withrenal insufficiencyrenal insufficiency

• AgeAge

• Volume depletionVolume depletion

• HypotensionHypotension

• Low cardiac outputLow cardiac output

• Class IV CHFClass IV CHF

• Other nephrotoxinsOther nephrotoxins(NSAIDs)(NSAIDs)

• Renal transplantRenal transplant

• Hypoalbuminemia (<35 g/L)Hypoalbuminemia (<35 g/L)

Procedure-related Risk FactorsProcedure-related Risk Factors

• Multiple contrast media injectionMultiple contrast media injection

within 72 hrswithin 72 hrs

• Intra-arterial injection siteIntra-arterial injection site

• High volume of contrast mediaHigh volume of contrast media

• High osmolality of contrast mediaHigh osmolality of contrast media



Risk of CIN Relation to Baseline Creatinine

Davidson et al. Annals Int Med (1989)

30

20

10

00.5 1.0 1.5 2.0

Baseline Serum Creatinine(mg/dl)

Pro

bab

ilit

y o

f N

eph

roto

xici

ty

(%)



Prediction of CIN and Dialysis After PCI

Independent risk factors:CrCl>>Diabetes>>Contrast VolumePCI, percutaneous coronary intervention.

Data adapted from: Berns AS. Kidney Int. 1989;36(4):730–740; McCullough PA. Am J Med. 1997;103:386–375;Rihal et al. Circulation. 2002;105:2259–2264.

Mean age=65 years, 72 kg man

0102030405060708090

100

50 40 30 20 10Calculated CrCl (mL/min)

Ren

al E

ven

t R

ate

(%)

No diabeticsDiabetics

n=424n=3695n=7586

CIN

Dialysis

CrCl ~ 30 mL/min

30–40% CIN rate

CrCl ~ 30 mL/min

30–40% CIN rate



CIN: Incidence & Risk Factors

0.010.011.002-1.0131.002-1.0131.0081.008Contrast doseContrast dose

0.010.011.41-21.321.41-21.325.475.47DiabetesDiabetes

<0.001<0.0010.77-0.890.77-0.890.830.83Cr ClearanceCr Clearance

PPCICIORORPredictors of ARF +DialysisPredictors of ARF +Dialysis

1,826 consecutive pts undergoing PCI:1,826 consecutive pts undergoing PCI:CIN CIN without without dialysis occurred 14.5%dialysis occurred 14.5%

CIN CIN withwith dialysis occurred 0.8% dialysis occurred 0.8%

McCullough, et al. Am J Med 1997; 103: 375McCullough, et al. Am J Med 1997; 103: 375



Be aware of small body weight old ladieseg. Female, Scr = 80 umol/L , age =60, wt = 60kg CCr = 62.4 ml/min

Wt = 60kg Age = 60

Age CCr Wt CCr

65 58.5 55 57.2

70 54.6 50 52

75 50.7 45 46.8

80 46.8

if. Female, Scr = 80 umol/L , age = 80 , wt = 45kg CCr = 35.1 ml/min



0

10

20

30

40

50

60

0 or 1 2 3 4 5 6 7 or 8CIN Risk Score

P<.0001 χ2 by trend

Mehran R et al. J Am Coll Cardiol. 2003;41:37A.

A Risk Score for Prediction of CINMultivariate Predictors

Diabetes – any Tx

Age over 70

SVG treated

Multiple vessels treated

Female

IABP use

Acute coronary syndrome

CrCl <50 mL/min



RiskScore

Riskof CIN

Risk of

Dialysis

≤ 5 7.5% 0.04%

6 to 10 14.0% 0.12%

11 to 16 26.1% 1.09%

≥ 16 57.3% 12.6%

Mehran et al. JACC 2004;44:1393-1399.

Hypotension

IABP

CHF

Age >75 years

Anemia

Diabetes

Contrast media volume

Risk Factors

5

5

5

4

3

3

Integer Score

1 for each 100 cc3

Scheme to define CIN risk score

Serum creatine > 1.5mg/dl 4

eGFR <60ml/min/1.73 m2

2 for 40 – 604 for 20 – 40

6 for < 20eGFR < 60ml/min/1.73 m2 =186 x (SCr)-1.154 x (Age)-0.203

X (0.742 if female) x (1.210 if African American)

Calculate

OR



How to prevent …

• Minimize Contrast dosage

• Hydration

• N-AC

• Type of Contrast Media ?



Minimize Contrast Dosage

My Tips

• Staged procedure

• Use your syringe wisely

• Plan twice, inject once

• Diluted contrast for visualization vessels

• Use roadmap wisely

• Use your flat panel DSA wisely



Hydration



Prevention of CIN: Hydration

Solomon, et al. NEJM 1994; 331: 1416-1420Solomon, et al. NEJM 1994; 331: 1416-1420

0%0%

10%10%

20%20%

30%30%

40%40%

50%50%

60%60%

SalineSaline Saline + Mannitol Saline + Mannitol Saline + FurosemideSaline + Furosemide

Non-DMNon-DM

DMDM

% C

IN%

CIN

• 78 Pts with CRI (Cr 1.6-4.2 mg/dl) • IV Fluids: 1/2 NS @ 1ml/kg/hr for 12 hr before & after

contrast• Mannitol: 50 g 1 hr before contrast• Furosemide: 80 mg IV 30 min before contrast

• 78 Pts with CRI (Cr 1.6-4.2 mg/dl) • IV Fluids: 1/2 NS @ 1ml/kg/hr for 12 hr before & after

contrast• Mannitol: 50 g 1 hr before contrast• Furosemide: 80 mg IV 30 min before contrast

7%7%

14%14% 17%17%

38%38%36%36%

43%43%



Sodium Bicarbonate

Shea E. Hogan et al. AHJ 2008;156:414



Question remaining in hydration

• When ?

• What ?

• How many ?

• How ?



N-ACETYLCYSTEINE (NAC) ?



Meta-analysis: NAC Randomized,13 Controlled Trials : N=1882

Zagler A, et al. AHJ 2006;151:140



Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy

Kelly, A. M. et. al. Ann Intern Med 2008;148:284-294



Contrast Agent – remaining questions

Iso-osmolarity vs. Low osmolarity



My protocol in dealing high risk patients

• Identify high risk patients

• Take preventive measures

• Check Scr before and after procedure



Patients Characteristics

• Male, 65yrs

• Exertional angina for 1 weeks

• History: DM (on oral medication)dyslipidemia, Hypertension

• Lab. Exam: LDL: 3.1 mmol/L TNT: 1.1 ng/ml SCr: 135 umol/L



Risk Assessment

• CCr: 44 ml/min

• Diabetes – any Tx

• Acute coronary syndrome

• CrCl <50 mL/min



Preventive measures

• Hydration

• N-AC

• Change oral hypoglycemic into insuline

• Patients and family consent

• Baseline SCr: 135umol/L



下一步的治疗策略：1 ， LCX；2 ， LAD；3 ， RCA。



Follow-up

• D2 Scr: 128 umol/L

• D3 Scr: 130 umol/L



谢谢！

强 生 cordis 学 院 cordis 百家病例论坛 pci for patients with chronic renal dysfunction dr....

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强生 cordis 学院 cordis 百家病例论坛 pci for patients with chronic renal dysfunction dr....