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Journal Club

Journal Club. Rakesh Latchamsetty October 5, 2007. Renal Protection for Coronary Angiography in Advanced Renal Failure Patients by Prophylactic Hemodialysis. Lee P, Chou K, Liu C, Mar G, Chung H, et al. JACC, Sept. 11, 2007. Background. Why is Renal Impairment Important?.

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Journal Club

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  1. Journal Club Rakesh Latchamsetty October 5, 2007

  2. Renal Protection for Coronary Angiography in Advanced Renal Failure Patients by Prophylactic Hemodialysis Lee P, Chou K, Liu C, Mar G, Chung H, et al. JACC, Sept. 11, 2007

  3. Background Why is Renal Impairment Important? • CKD is associated with 3 year increased mortality and increased CV events1 1Go AS, Hsu C, et al. NEJM 2004. 351: 1296-1305.

  4. Background 3 Year Outcomes with CKD Go AS, Hsu C, et al. NEJM 2004. 351: 1296-1305.

  5. Background Why is Renal Impairment Important? • Renal insufficiency increases mortality in patients admitted with ACS2 2Eagle KA, Fox KA et al. JAMA 2004. 291: 2727-2733

  6. Background Eagle KA, Fox KA et al. JAMA 2004. 291: 2727-2733

  7. Background Even Temporary ARF has Worse Prognosis • 6 month mortality in patients admitted with ACS is worse with acute renal failure, regardless of improvement in function3 3Latchamsetty R, Eagle KA, et al. AJC 2007. 99(7) 939-942.

  8. Background 6 Month outcomes following ACS admission • A – no change in creatinine • B – Temporary rise in Cr • C – Sustained rise Cr B C A Latchamsetty R, Eagle KA, et al. AJC 2007. 99(7) 939-942.

  9. Background ARF Following PCI has Worse Prognosis4 4Rihal CS, Holmes DR, et al. Circulation 2002. 105(19): 2259-2264.

  10. Background Mechanism of CIN • Multifactorial process • - Vasoconstriction at the corticomedullary junction • - Impairs autoregulatory capacity of kidney through loss of NO production • Direct tubular toxicity • Osmotic diuresis

  11. Background Risk Factors for Developing CIN • Pre-existing renal disease • Diabetes • Amount and type of contrast

  12. Background Mechanism of CIN Tumlin J, McCullough P, et al. AJC 2006. 98 (6A) 21-26.

  13. Background Methods to reduce CIN: • IVF • Low-osmolality contrast • Double dose mucomyst • Reducing contrast • Sodium Bicarbonate • CVVH

  14. Background Low Osmolar Contrast • Originally ionic monomers: hyperosmolar • 1500 to 1800 mOsm/kg • Low-osmolar monomers of iodinated benzene rings (iohexol/omnipaque, iopamidol) • 600 to 850 mOsm/kg • Nonionic dimer of benzene rings (iodaxinol/visipaque) • 290 mOsm/kg

  15. Background N-Acetylcysteine • Scavenges oxygen free radicals • Shown to reduce incidence of CIN, dose-dependent effect6 • Some data on mortality reduction6 6Marenzi G, Bartorelli A, NEJM 2006. 354(26):2773-2782.

  16. Background CVVH • Previous study showing CVVH can reduce renal failure and improve outcomes in CKD7 • Only elective cath/pci • Compared to NS alone • Primary endpoint: 25% increase in Cr • 5 vs 50% (P<.001) • One year mortality also decreased • 10 vs 30% (p=.01) 7Marenzi G, Bartorelli A, et al. NEJM 2003. 349:1333-1340.

  17. Objective To determine whether prophylactic hemodialysis reduces CIN after coronary angiogram

  18. Methods Inclusion Criteria • Consecutive patients at Kaohsiung Veterans GH, Taiwan referred for coronary angiography • > 20 years old • Creatinine >3.5 mg/dl

  19. Methods Exclusion Criteria • Pregnancy or lactation • Contrast in last 7 days • Metformin or NSAIDs in last 48 hrs • ESRD or renal txp • Unstable new diabetes • “Severe concomitant disease” • Adverse contrast reaction in the past

  20. Methods Protocol • All given NS 6 hours before and 12 hours after cath • Randomized to HD or not (control) • Dialysis catheter placed before angiography • Cath performed with nonionic iohexol (omnipaque) • Dialysis performed as soon as possible after cath • No fluid removal during dialysis

  21. Methods Measurements • CrCl by 24 hour urine before and on 4th day after • Serum creatinine on admission, day 4, and throughout hospitalization • Need for emergent dialysis • Oliguria for 48 hours despite 1,000mg lasix per day • K+ > 6 mEq/L

  22. Statistics Methods • Study was designed for significance of 5% and 90% power • Required about 34 subjects in each group • To compare baseline values: • Fisher exact test for categorical • Student unpaired t test for continuous • Multiple regression to analyze variables affecting decrease in CrCl

  23. Methods Endpoints • Primary endpoint: change in CrCl between baseline and day 4 • Secondary enpoints: • Change in Cr between baseline and day 4 • Peak Cr level • Cr level at discharge • Requirement of emergent or permanent dialysis

  24. Results Sample Space 3,724 consecutive patients receiving cath - 3,406 without CKD 318 - 88 with ESRD 230 -122 with Cr <3.5 108 - 18 refused 90 - 8 received NSAIDs/mucomyst/contrast 82Enrolled

  25. Results Demographics • The 2 groups were well matched

  26. Results Change in Creatinine Clearance

  27. Change in Creatinine Results

  28. Results Factors associated with change in creatinine…

  29. Results Further Outcomes • 1 vs 14 needed temporary dialysis • 5 control patients required permanent dialysis after discharge • 2 vs 18 had increase in creatinine greater than 1 at discharge

  30. Results Statistically Speaking… • Cr increased > 1 at discharge: • control (45%) vs dialysis (5%), p<.001 • NNT = 2.5 • Required maintenance dialysis after discharge: • control (13%) vs dialysis (0%) • NNT = 8

  31. Other Data/Outcomes Results • Length of stay: Dialysis Control 6 +/- 3 days 13 +/- 18 days p=0.017 • No major complications in dialysis group

  32. Discussion Limitations • Limited sample size • Single center • Study not blinded • Not compared to double dose mucomyst • Did not use visipaque • Only chose advanced renal disease • Strong Endpoints?

  33. Conclusions Prophylactic HD in Advanced CKD Following Coronary Angiography: • Reduces discharge and maximum creatinine values • Probably reduces hospital stay • Probably prolongs need for permanent dialysis

  34. Conclusions Prophylactic HD in Advanced CKD Following Coronary Angiography: • ? Effects on mortality, CV events • ? Effects on long term dialysis needs

  35. Discussion Will This Change How You Practice?

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