nefropatia da mezzo di contrasto

1. nefropatia da mezzo di contrasto Giuseppe Rombolà La Spezia

2. 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.)

3. 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

4. Carico tubulare di Na e acqua IPOSSIA MIDOLLARE Consumo di ossigeno CIN Apparato Juxtaglomerulare RAS Riassorbimento di Na e acqua nel TALH Vasodilatazione Mezzo di contrasto DIURESI OSMOTICA vasocostrizione

5. 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

6. 40 30 20 Mortality % 10 0 0 25-50 <10 10-25 > 50 % increase in serum creatinine renal function deterioration after PCI and one year outcomes Gruberg et al. JACC 2000

7. Loss of kidney function and mortality after reversible CIN 16±15 ml/min/1.73m2 eGFR 36±7 ml/min/1.73m2 31±15 ml/min/1.73m2 Goldenberg I. Am. J. Nephrol. 2009

8. CIN incidence following CM administration gfr ml/min < 30 50 45- 40 A +CKD+ diabetes A + CKD only 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%) 115 1774 357 58 studies published before 2003 Mc Cullough, J. Cardiov. Med. 2003

9. 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

10. Nephrotoxicity In High-Risk PatientsA Double-Blind, Randomized, Multicenter Study of Iso-Osmolar and Low-Osmolar, Nonionic Contrast Media The NEPHRIC Study

11. NEPHRIC: Primary EndpointMean Peak Increase in SCr Up to Day 3 P=0.001 0.6 CIN -creat. < 0.5 mg/dl- 3 % Iodixanol 26 % iohexol 0.55 0.5 0.4 Increase in SCr (mg/dL) 0.3 0.2 0.13 0.1 0 Iodixanol (n=64) Iohexol (n=65) Adapted from Aspelin P et al. N Engl J Med. 2003;348:491-499.

12. efficacia della NAC nella prevenzione della CIN

13. 119 pts

16. 250 ml i.v. saline 30 min i.v. furosemide (0.5 mg/kg) 48 - 16 min Infusione continua di sol fisiol in volume uguale alla diuresi Controllo parametri ogni 30 min Diuresi > 300 ml/h PROCEDURA 4 ore Volume urine 826±342 ml/hr • In 20% of pts • additional furosemide • (0.5 mg/Kg) was required MYTHOS Protocol RenalGuard

17. CIN Controls RenalGuard -80% -69% -60% 157 pts. baseline GFR 39 ± 10 ml/min. % P=0.028 P=0.03 P NS 25% 16% 10% 6% 5% 4% Elective procedures All patients NSTEMI Marenzi; TCT 2010 Transcatheter Cardiovascular Therapeutics

18. 2003

19. PREVENZIONE CIN & EMOFILTRAZIONE Marenzi G. Am. J. Med. 2006

21. Am J Med 2001

22. CONCLUSIONI • CIN è associata con un peggioramento della funzione renale che aumentando il rischio CV può aumentare la mortalità • CIN sembra rappresentare un rischio indipendente di mortalità sia a breve che a lungo termine • I trattamenti depurativi extracorporei sembrano promettenti nel ridurre questo rischio

23. giuseppe.rombola@asl5.liguria.it