nefropatia
da mezzo
di contrasto
Giuseppe Rombolà
La 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
Mezzo di contrasto
DIURESI
OSMOTICA
Vasodilatazione
Carico
tubulare di
Na e acqua
IPOSSIA
MIDOLLARE
vasocostrizione
Apparato
Juxtaglomerulare
RAS
Consumo di
ossigeno
CIN
Riassorbimento
di Na e acqua
nel TALH
7856 pts. after PCI
Multivariate analysis RR
Rihal C. Circulation 2002
493 pts. following CECT
Multivariate analysis RR
Lencioni R. Acta Radiol. 2010
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
CONNECT
STUDY
renal function deterioration after PCI and
one year outcomes
40
Mortality %
30
20
10
0
0
Gruberg et al. JACC 2000
<10
10-25
25-50
> 50
% increase in serum creatinine
Loss of kidney function and
16±15
eGFR
mortality
after reversible CIN
36±7
ml/min/1.73m2
ml/min/1.73m2
31±15
ml/min/1.73m2
Goldenberg I.
Am. J. Nephrol. 2009
CIN incidence following CM administration
60
gfr ml/min
50
45- 40
< 30
CIN incidence %
50
40
30
115
1774
20
357
58
10
0
1
A +CKD+ diabetes
A + CKD only
2
3
GFR mL/min
studies published
before 2003
Mc Cullough, J. Cardiov. Med. 2003
A. in 5 RCT studies (2007-2009) (diabetes 28-100 %)
2 V. in 4 studies (2008-2010) (diabetes 29-100 %)
3 V. in 1 study (2010) (diabetes 32%)
90 Arteria volume di mdc …… 248 ± 112 ml
00
…… 122 ± 55
10
…… 117 ± 19
Infusione venosa < 100 ml
Strategie preventive
Espansione VEC (salina o bicarbonato)
NAC
Linee guida ESUR
1-1.5 ml/Kg/h 3-12 hrs pre e 12-24 hrs dopo mdc
Bicarbonato isotonico 1.4%:
3 ml/kg/h: 1 hr pre e 1 ml/kg/h per 6 hrs dopo mdc
Nephrotoxicity In High-Risk Patients
A Double-Blind, Randomized, Multicenter Study of Iso-Osmolar and
Low-Osmolar, Nonionic Contrast Media
The NEPHRIC Study
NEPHRIC: Primary Endpoint
Mean Peak Increase in SCr Up to Day 3
P=0.001
Increase in SCr (mg/dL)
0.6
0.55
0.5
0.4
0.3
0.2
0.13
0.1
0
Iodixanol
(n=64)
Adapted from Aspelin P et al. N Engl J Med. 2003;348:491-499.
Iohexol
(n=65)
CIN -creat. < 0.5 mg/dl3 % Iodixanol
26 % iohexol
efficacia della NAC nella prevenzione
della CIN
Birck
Lancet 2003
Kshirsagar
JASN 2004
Nallamothu
Am.J. Med.2004
Alonso
Am.J. Kid. Dis. 2004
Zagler
Am. Heart J. 2006
N pazienti
805
RR
0.43 (0.21 – 0.87)
1538
efficace nel 33 %
2195
0.73 (0.52 – 1.0)
885
0.55 ( 0.34 – 0.91)
1892
0.68 (0.46 – 1.01)
119 pts
MYTHOS Protocol
250 ml
i.v. saline
30 min
RenalGuard
48 - 16
min
•In 20% of pts
additional furosemide
(0.5 mg/Kg) was required
i.v. furosemide
(0.5 mg/kg)
Diuresi > 300 ml/h
PROCEDURA
4 ore
Volume urine
826±342 ml/hr
Infusione
continua di
sol fisiol
in volume
uguale alla
diuresi
Controllo
parametri
ogni
30 min
CIN
%
157 pts.
baseline GFR 39 ± 10 ml/min.
P=0.028
P=0.03
30
P NS
25%
25
20
15
Controls
-80%
16%
RenalGuard
-69%
10% -60%
10
5%
6%
4%
5
0
All patients
NSTEMI
Elective
procedures
Marenzi; TCT 2010
Transcatheter Cardiovascular Therapeutics
2003
PREVENZIONE CIN & EMOFILTRAZIONE
Marenzi G. Am. J. Med. 2006
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
[email protected]