Contrast Induced Nephropathy: Predictors, Prevention, and Management Columbia University Medical Center Cardiovascular Research Foundation Roxana Mehran,

Contrast Induced Nephropathy: Contrast Induced Nephropathy: Predictors, Prevention, and Predictors, Prevention, and

Management Management

Columbia University Medical CenterColumbia University Medical CenterCardiovascular Research FoundationCardiovascular Research Foundation

Roxana Mehran, MD

Disclosures:Disclosures:Research Grant to CRF: Tyco, Research Grant to CRF: Tyco, GuerbertGuerbert

Consultant/ Advisory Board:Consultant/ Advisory Board:FlowMedicaFlowMedica

Cardiorenal RiskCardiorenal Risk

CardiacCardiacDiseaseDisease

RenalRenalDiseaseDisease

Acute Renal FailureAcute Renal Failureand Deathand Death

in the Cardiac Patientin the Cardiac Patient

Myocardial Infarction, Myocardial Infarction, Heart Failure, Heart Failure, Arrhythmias, Arrhythmias,

and Cardiac Death in and Cardiac Death in the Renal Patientthe Renal Patient

How to Assess Renal Function?How to Assess Renal Function?

Abbreviated Modification of Diet in Renal Disease equations (MDRD) equation:

eGFR, ml/min/1.73 m2= 186 x (Serum Creatinine [mg/dL]) -1.154 x (Age-0.203x (0.742 if female) x (1.210 if African American)

(140- age) x Body Weight [kg]* Creatinine Clearance, ml/min =

* Multiple by 0.8 in female

Cockcroft-Gault equation:

Serum Creatinine mg/dL] x 72

Predictors of All-Cause Mortality Predictors of All-Cause Mortality to 7 Years BARI Trial + Registryto 7 Years BARI Trial + Registry

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

RRRR 95% CI95% CI PP

CKD (baseline Cr > 1.5 mg/dl)CKD (baseline Cr > 1.5 mg/dl) 2.312.31 1.63-3.281.63-3.28 <0.001<0.001

Sex, female vs. maleSex, female vs. male 0.910.91 0.75-1.100.75-1.10 0.320.32

Race, black vs. non-blackRace, black vs. non-black 1.401.40 1.04-1.891.04-1.89 0.0280.028

Age, yAge, y 1.051.05 1.04-1.061.04-1.06 <0.001<0.001

Diabetes mellitusDiabetes mellitus

Oral hypoglycemicsOral hypoglycemics 1.631.63 1.29-2.061.29-2.06 <0.001<0.001

InsulinInsulin 1.801.80 1.26-2.581.26-2.58 <0.001<0.001

PTCS vs. CABGPTCS vs. CABG 1.041.04 0.87-1.250.87-1.25 0.670.67

Interaction between PTCA and Interaction between PTCA and insulin-treated diabeticsinsulin-treated diabetics

1.731.73 1.11-2.691.11-2.69 0.020.02

Smoking historySmoking history

Prior tobacco usePrior tobacco use 1.301.30 1.06-1.591.06-1.59 0.010.01

Tobacco use at baselineTobacco use at baseline 1.821.82 1.42-2.331.42-2.33 <0.001<0.001

Risk Factors for CINRisk 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

• Renal transplantRenal transplant

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

Procedure-related Risk FactorsProcedure-related Risk Factors

• Multiple contrast media Multiple contrast media injection within 72 hrsinjection within 72 hrs

• Intra-arterial injection siteIntra-arterial injection site

• High volume of contrast mediaHigh volume of contrast media

• High osmolality of contrast High osmolality of contrast mediamedia

RiskRiskScoreScore

RiskRiskof CINof CIN

Risk ofRisk of

DialysisDialysis

≤ ≤ 55 7.5%7.5% 0.04%0.04%

6 to 106 to 10 14.0%14.0% 0.12%0.12%

11 to 11 to 1616 26.1%26.1% 1.09%1.09%

≥ ≥ 1616 57.3%57.3% 12.6%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 ScoreScheme to Define CIN Risk Score

Serum creatinine > 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

Prognostic significance of the proposed risk score for CIN extended to prediction of 1-year mortality. (Red bars = development dataset; blue bars =

validation dataset.)

CIN Risk Score & 1-year MortalityCIN Risk Score & 1-year Mortality

31.2 33.3

15.5

5.51.9 2.0

5.7

13.5

0

5

10

15

20

25

30

35

Low Moderate High Very High

1-y

ea

r m

ort

alit

y

31.2 33.3

15.5

5.51.9 2.0

5.7

13.5

0

5

10

15

20

25

30

35

Low Moderate High Very High

1-y

ea

r m

ort

alit

y

Risk Groups:Risk Score: ≤5 6 to 10 11 to 15 ≥16

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

Preventive TrialsPreventive Trials

HydrationHydration

Optimal Hydration RegimenOptimal Hydration Regimen

Mueller et al Mueller et al Arch Intern MedArch Intern Med 2002 2002

1937 Patients Screened

317 Ineligible or No Consent

685 for Primary End Point Analysis

698 for Primary End Point Analysis

1620 Randomized

809 Received 0.9% Saline

124 Excluded From Primary End Point Analysis

Repeat Catheterization (n=78)Incomplete Data (n=46)

811 Received 0.45% Sodium Chloride

113 Excluded From Primary End Point Analysis

Repeat Catheterization (n=59)Incomplete Data (n=53)Bypass Grafting (n=1)

Optimal HydrationOptimal Hydration0.9% NS vs 0.45% NS0.9% NS vs 0.45% NS

P=.35P=.35

0

1

2

3

CN Mortality Vascular

Inc

ide

nc

e,

%

0.9% Saline0.45% Sodium Chloride

P=.93P=.93

P=.04P=.04

Mueller et al Mueller et al Arch Intern MedArch Intern Med 2002 2002

Prevention of CIN with Prevention of CIN with Sodium BicarbonateSodium Bicarbonate

Merten GJ et al. Merten GJ et al. JAMAJAMA, 2004;291:2328-2334, 2004;291:2328-2334

Patients With Baseline Serum Creatinine >1.8 mg/dlPatients With Baseline Serum Creatinine >1.8 mg/dlwho Underwent Contrast Exposure (Iopamidol in All) who Underwent Contrast Exposure (Iopamidol in All)

N=137N=137

Sodium Chloride Sodium Chloride Hydration (154 mEq/L of Hydration (154 mEq/L of

Sodium Chloride)Sodium Chloride)N=68N=68

Sodium Bicarbonate Sodium Bicarbonate Hydration (154 mEq/L of Hydration (154 mEq/L of

Sodium Bicarbonate)Sodium Bicarbonate)N=69N=69

Primary endpoint: increase in serum creatinine ≥25% Primary endpoint: increase in serum creatinine ≥25% within 2 days post-exposurewithin 2 days post-exposure

Prevention of CIN with Sodium Prevention of CIN with Sodium Bicarbonate: ResultsBicarbonate: Results

EndpointsEndpoints

Sodium Sodium

ChlorideChloride

N=59N=59

Sodium Sodium BicarbonateBicarbonate

N=60N=60

P P valuevalue

Incidence of CIN (%)Incidence of CIN (%) 13.6%13.6% 1.7%1.7% 0.020.02

Incidence of CIN Incidence of CIN (↑SCr 0.5 mg/dL)(↑SCr 0.5 mg/dL)

11.9%11.9% 1.7%1.7% 0.030.03

Merten GJ et al. Merten GJ et al. JAMA,JAMA, 2004;291:2328-2334 2004;291:2328-2334

REMEDIAL Trial REMEDIAL Trial

Saline + NAC Saline + NAC N=118N=118

Bicarbonate + NAC Bicarbonate + NAC N=117N=117

Saline+AA+NAC Saline+AA+NAC N=116N=116

7 excluded7 excluded

Pts with eGFR<40 Pts with eGFR<40 N=393 N=393

Randomized N=351Randomized N=351

Excluded N=42Excluded N=42

NAC = NAC = NN-acetylcysteine, AA = ascorbic acid-acetylcysteine, AA = ascorbic acid

9 excluded9 excluded9 excluded9 excluded

107 included 107 included into analysisinto analysis



Briguorio C. et al, Briguorio C. et al, CirculationCirculation 2007 2007

REMEDIAL Trial: Results REMEDIAL Trial: Results

Saline + NAC Bicarbonate +

NAC

Saline + Ascorbic Acid

+ NAC P Value

N=111 N=108 N=107

Serum creatinine increase by ≥25%

11 (9.9%) 2 (1.9%)* 10 (10.3%) 0.010

Serum creatinine increase by ≥0.5 mg/dL

12 (10.8%) 1 (0.9%)† 12 (11.2%) 0.026

eGFR decrease by ≥25%

10 (9.2%) 1 (0.9%)† 10 (10.3%) 0.018

*P=0.019P=0.019, †P<0.01P<0.01 vs. saline + NAC group

Briguorio C. et al, Briguorio C. et al, CirculationCirculation 2007 2007

MEENAMEENA

DesignDesign• DESIGN: Prospective,

randomized, parallel-group, single-center clinical evaluation of two hydration strategies for patients undergoing coronary angiography

• OBJECTIVE: To compare the incidence of CIN between periprocedural hydration with sodium bicarbonate vs. sodium chloride (0.9%, normal saline)

• PRIMARY ENDPOINT: Decrease in estimated GFR by ≥ 25% within 4 days of coronary angiography

• DESIGN: Prospective, randomized, parallel-group, single-center clinical evaluation of two hydration strategies for patients undergoing coronary angiography

• OBJECTIVE: To compare the incidence of CIN between periprocedural hydration with sodium bicarbonate vs. sodium chloride (0.9%, normal saline)

• PRIMARY ENDPOINT: Decrease in estimated GFR by ≥ 25% within 4 days of coronary angiography

353 patients enrolled between January 2006 and January 2007

353 patients enrolled between January 2006 and January 2007

236 patients assigned to sodium

chloride


chloride


bicarbonate


bicarbonate

156 evaluable patient


Brar, S et. al., i2/ACC 2007



22 excluded

22 excluded

28 excluded

28 excluded

Hydration ProtocolHydration Protocol•3 mL/kg for 1 hr before the procedure•1.5 mL/kg during and for 4hrs post-procedure

Hydration ProtocolHydration Protocol•3 mL/kg for 1 hr before the procedure•1.5 mL/kg during and for 4hrs post-procedure

MEENAMEENA

p = 0.97p = 0.97p = 0.82p = 0.82

Sodium BicarbonateSodium BicarbonateStudyStudy NN

(Saline, Bicarb)(Saline, Bicarb)ProcedureProcedure Baseline Baseline

FunctionFunction(mL/min/(mL/min/1.73m2)1.73m2)

Fluid protocolFluid protocol CIN rate CIN rate (%)(%)

pp

RANDOMIZEDRANDOMIZED

BrarBrar 353 353 (175, 178)(175, 178)

CardiacCardiac 48484848

SalineSalineBicarbonateBicarbonate

13.613.613.513.5

0.970.97

BriguoriBriguori 219219(108, 111)(108, 111)

Cardiac Cardiac PeripheralPeripheral

32323535


9.99.91.91.9

0.020.02

MertenMerten 119 119 (59, 60)(59, 60)

Cardiac Cardiac PeripheralPeripheral

45454141


13.713.71.71.7

0.020.02

Masuda*Masuda* 5959(29, 30)(29, 30)

Emergency Emergency cardiaccardiac

39394040


353577

0.010.01

NON-RANDOMIZEDNON-RANDOMIZED

CARECARE 414414(246, 168)(246, 168)

CardiacCardiac 50505050

Bicarbonate Bicarbonate (-NAC)(-NAC)Bicarbonate Bicarbonate (+NAC)(+NAC)

10.610.6

11.911.9

NSNS

N-ACETYLCYSTEINE (NAC)N-ACETYLCYSTEINE (NAC)

CIN: Effect of n-AcetylcysteineCIN: Effect of n-Acetylcysteine

• Prospective, randomizedProspective, randomized

• 83 high risk patients83 high risk patients CrCl < 50 ml/minCrCl < 50 ml/min Diabetes 33%Diabetes 33%

• IV CONTRAST for CT (75 IV CONTRAST for CT (75 ml of Low Osmolar CM)ml of Low Osmolar CM)

• n-AC 600 bid x 2 days pre-n-AC 600 bid x 2 days pre-

• CIN definition: creatinine CIN definition: creatinine increase of 0.5 mg/dl increase of 0.5 mg/dl

• Hydration with 0.45% @ 1 Hydration with 0.45% @ 1 ml/kg/h x 24 hml/kg/h x 24 h

21%

2%

0%

5%

10%

15%

20%

25%

Control (42) AC (41)

CIM

(%

)

Tepel Tepel NEJMNEJM 2000 2000

p= 0.01p= 0.01

Zagler et al. Am Heart J 2006;151:140-145.

Relative Risk for Developing CIN after NACRelative Risk for Developing CIN after NAC

Risk Ratio (Random) Risk Ratio (Random) 95% Cl95% Cl

0.10.1 11 1010Favors treatmentFavors treatment Favors controlFavors control

0.20.2 0.50.5 22 55

RR (Random) RR (Random) 95% Cl95% Cl

ControlControln/Nn/N

NACNACn/Nn/N

Study or Study or substurysubstury

Review: Review: Acetylcysteine and CINAcetylcysteine and CINComparison: Comparison: 01 NAC on CIN01 NAC on CINOutcome: Outcome: 01 CIN01 CIN

Total events: Total events: 124 (NAC), 162 (Control)124 (NAC), 162 (Control)Test for heterogenety: Test for heterogenety: Ch=27.54 (P0.005), 1Ch=27.54 (P0.005), 122=56.4%=56.4%Test for overall effect: Test for overall effect: Z=1.88 (Z=1.88 (P=0.05P=0.05))

Allaqaband et al 8/45 6/40 1.19 (0.45, 3.12)Briguori et al 6/92 10/91 0.59 (0.23, 1.57)Diaz-Sandoval et al 2/25 13/29 0.18 (0.04, 0.72)Durham et al 10/38 9/41 1.20 (0.55, 2.63)Goldenberg et al 4/41 3/39 1.27 (0.30, 5.31)Gomes et al 8/78 8/78 1.00 (0.40, 2.53)Kay et al 4/102 12/98 0.32 (0.11, 0.96)Nguyen-Ho et al 9/95 19/85 0.42 (0.20, 0.89)Oldemeyer 4/49 3/47 1.28 (0.30, 5.41)Pate et al 57/238 50/239 1.14 (0.82, 1.60) RAPIDO 2/41 8/39 0.24 (0.05, 1.05)Shyu 2/60 15/61 0.14 (0.03, 0.57)Fung et al 8/46 6/45 1.30 (0.49, 3.46)

Total: (95% Cl)Total: (95% Cl) 950950 932932 0.68 (0.46, 1.02)0.68 (0.46, 1.02)

Meta-analysis: High vs.Meta-analysis: High vs.Low Osm Contrast MediaLow Osm Contrast Media

• 39 Trials - 5146 patients39 Trials - 5146 patients

• CIN > 0.5 mg/dlCIN > 0.5 mg/dl

• CIN in 7% of all patientsCIN in 7% of all patients

• CIN in 30% of CRI CIN in 30% of CRI patientspatients

• For CRI, NNT=8 (treat 8 to For CRI, NNT=8 (treat 8 to prevent 1 CIN case)prevent 1 CIN case)

• Low osmolal group Low osmolal group included Ioxaglate included Ioxaglate (Hexabrix); Iodixanol (Hexabrix); Iodixanol (Visipaque) not studied(Visipaque) not studied

Barrett and Carlisle Barrett and Carlisle J Am Soc NephrolJ Am Soc Nephrol 92; 92;

1.0

0.61

0.0

0.2

0.4

0.6

0.8

1.0

1.2

High Osm Low Osm

Rel

ativ

e R

isk

of

CIN

The NEPHRIC StudyThe NEPHRIC Study

Nephrotoxicity in High-risk PatientsNephrotoxicity in High-risk Patientsa Double Blind Randomized Multicentre a Double Blind Randomized Multicentre Study of Iso-osmolar and Low-osmolar Study of Iso-osmolar and Low-osmolar

Non-ionic Contrast MediaNon-ionic Contrast Media

NEPHRICNEPHRIC Study: Protocol Study: Protocol

• Randomized, double blind, prospective, multicenterRandomized, double blind, prospective, multicenter

• Primary endpoint: peak increase in serum creatinine Primary endpoint: peak increase in serum creatinine concentration @ 3 days after angiographyconcentration @ 3 days after angiography

Patients with diabetes and serum creatinine 1.5-3.5 mg/dl who Patients with diabetes and serum creatinine 1.5-3.5 mg/dl who underwent coronary or aortofemoral angiographyunderwent coronary or aortofemoral angiography

Iso-osmolar, non-ionicIso-osmolar, non-ionicIodixanol [Visipaque]Iodixanol [Visipaque]

N=64N=64Mean Contrast Volume = 163 mlMean Contrast Volume = 163 ml

PTCA – 17% PTCA – 17%

Low-osmolar, non-ionicLow-osmolar, non-ionicIohexol [Omnipaque]Iohexol [Omnipaque]

N=65N=65Mean Contrast Volume =Mean Contrast Volume = 162 ml162 ml

PTCA – 25% PTCA – 25%

Aspelin P et al,Aspelin P et al, NEJM NEJM, 2003; 348: 491-499, 2003; 348: 491-499

Primary Endpoint –Primary Endpoint –Peak Increase in Scr from Baseline to Day 3Peak Increase in Scr from Baseline to Day 3

(µmol/l) (µmol/l) p=0.002p=0.002

Iodixanol Iodixanol (Visipaque)

Iohexol Iohexol (Omnipaque)

n=62n=62 n=64n=64

MeanMean 11.2 ±19.711.2 ±19.7 41.5 ± 68.641.5 ± 68.6

MinimumMinimum - 19.0- 19.0 - 21.0- 21.0

MaxMax 74.074.0 331.0331.0

RECOVER Trial – Renal Toxicity Evaluation and Comparison RECOVER Trial – Renal Toxicity Evaluation and Comparison Between Visipaque and Hexabrix in Patients With Renal Between Visipaque and Hexabrix in Patients With Renal

Insufficiency Undergoing Coronary AngiographyInsufficiency Undergoing Coronary Angiography

Jo et al. JACC 2006; 48:924-30

Prospective, randomized trialProspective, randomized trial

300 patients with CrCl ≤ 60 ml/min

149 pts. (135 pts. included in primary analysis)

ioxaglate

151 pts. (140 pts. included in primary analysis)

iodixanol

Primary endpoint – Incidence of CIN Increase in SCr ≥ 25% or ≥ 0.5 mg/dl

RECOVER Trial – Incidence of CIN RECOVER Trial – Incidence of CIN

Jo et al. JACC 2006; 48:924-30

17.0%

7.9%

0.0%

10.0%

20.0%

CIN

ioxaglate

iodixanol

P=0.021P=0.021

N=300

24.2%16.2%

0%

10%

20%

30%

Ioxaglate Iodixanol

ICON ICON TTrialrial

Patients Patients wwith ith cchronic hronic rrenal enal iinsufficiencynsufficiencyuundergondergoinging PCI PCI wwith at ith at lleast 150cc of east 150cc of ccontrast ontrast vvolumeolume

Patients Patients wwith ith cchronic hronic rrenal enal iinsufficiencynsufficiencyuundergondergoinging PCI PCI wwith at ith at lleast 150cc of east 150cc of ccontrast ontrast vvolumeolume

IoxaglateIoxaglateN=74N=74

IoxaglateIoxaglateN=74N=74

IodixanolIodixanolN=71N=71

IodixanolIodixanolN=71N=71

NN=130=130

P=0.26P=0.26

Incidence of CIN

Mehran R. et al, Transcatheter Cardiovascular Therapeutics. 2006.

Renal Failure in Patients Undergoing Coronary Renal Failure in Patients Undergoing Coronary Procedures using Iso-osmolar or Low-osmolar Procedures using Iso-osmolar or Low-osmolar

Contrast MediaContrast Media

Liss et al. Kidney International 2006

Contrast Contrast media (CM)media (CM) CM propertiesCM properties NN Time periodTime period

IodixanolIodixanol iso-osmolar, nonionic, iso-osmolar, nonionic, 45 48545 485 2000-20032000-2003

IoxaglateIoxaglate low-osmolar, nonionic, low-osmolar, nonionic, 12 44012 440 2000-20032000-2003

• Swedish Coronary Angiography and Angioplasty Registry• Swedish Hospital Discharge Registry

Rehospitalization with Renal Failure as a Rehospitalization with Renal Failure as a Primary Diagnosis Primary Diagnosis


0.02% 0.03%

0.10%0.07%

0.20%

0.30%

0.00%

0.10%

0.20%

0.30%

0.40%

Within 1 w eek Within 1 month Within 3months

Ioxaglate

Iodixanol P<0.001P<0.001P<0.001P<0.001

P<0.001P<0.001P<0.001P<0.001

P=0.022P=0.022P=0.022P=0.022

Start of Dialysis after Coronary Start of Dialysis after Coronary Angiography or PCI Angiography or PCI


0.00%0.02%

0.10%

0.02%

0.10%

0.20%

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

Within 1 week Within 1 month Within 3 months

Ioxaglate

Iodixanol

P=0.098P=0.098P=0.098P=0.098

P=0.010P=0.010P=0.010P=0.010

P=0.009P=0.009P=0.009P=0.009

1-year Follow-up 1-year Follow-up


* Groups differ in time period !

CMCM N of ptsN of pts

iodixanoliodixanol 54 61654 616

ioxaglateioxaglate 24 47924 479

* * iohexoliohexol 6 8546 854

Renal failureRenal failure Iodixanol

Iohexol

Ioxaglate

f

Time (years)

%

6

5

4

3

2

1

0

0 1 2 3 4 5 6 7 8 9 10 11 12

CARECARE

DesignDesign

• DESIGN: Prospective, randomized, double-blind, parallel-group, multi-center clinical evaluation ipamidol-370 and iodixanol-320

• OBJECTIVE: To compare the incidence of CIN between iopamidol-370 and iodixanol-320

• PRIMARY ENDPOINT: Increase in SCr ≥ 0.5 mg/dL from baseline to 45 to 120 hours after administration

• DESIGN: Prospective, randomized, double-blind, parallel-group, multi-center clinical evaluation ipamidol-370 and iodixanol-320

• OBJECTIVE: To compare the incidence of CIN between iopamidol-370 and iodixanol-320

• PRIMARY ENDPOINT: Increase in SCr ≥ 0.5 mg/dL from baseline to 45 to 120 hours after administration

482 patients enrolled between July 2005 and June 2006 in 25 clinical site in North

America

482 patients enrolled between July 2005 and June 2006 in 25 clinical site in North

America

14 patients withdrew consent

14 patients withdrew consent

468 assigned to a treatment arm468 assigned to a treatment arm

236 patients assigned to

Iodixanol-320


Iodixanol-320


Iopamidol-370


Iopamidol-370



Solomon, RJ et. al., Circulation 115, 3189 (2007)



26 excluded

26 excluded

26 excluded

26 excluded

CARECARE

p = 0.39p = 0.39 p = 0.44p = 0.44 p = 0.15p = 0.15

CARECARE

p = 0.11p = 0.11 p = 0.37p = 0.37 p = 0.20p = 0.20

Diabetic SubgroupDiabetic Subgroup

Conclusions (1)Conclusions (1)

• CRI is one of the most important independent CRI is one of the most important independent predictors of poor outcome post PCIpredictors of poor outcome post PCI

• CIN remains a frequent source of acute renal CIN remains a frequent source of acute renal failure and is associated with increased morbidity failure and is associated with increased morbidity and mortality, and higher resource utilizationand mortality, and higher resource utilization

• Several factors predispose patients to CINSeveral factors predispose patients to CIN

• Preventive measures pre procedure, as well as Preventive measures pre procedure, as well as careful post procedure management should be careful post procedure management should be routine in all patientsroutine in all patients

Conclusions (2)Conclusions (2)

• Hydration pre-PCI (12 hours recommended)Hydration pre-PCI (12 hours recommended)

• D/C nephrotoxic drugs (NSAIDS, antibiotics, etc)D/C nephrotoxic drugs (NSAIDS, antibiotics, etc)

• Role of n-acetylcysteine is disputableRole of n-acetylcysteine is disputable

• No Role for IV FenoldopamNo Role for IV Fenoldopam

• Sodium bicarbonate may be useful, but need more definitive Sodium bicarbonate may be useful, but need more definitive data data

• Limit contrast agent volumeLimit contrast agent volume

• Low-osmolar agents are better than high-osmolarLow-osmolar agents are better than high-osmolar

Within non-ionic contrast, the data are contradictory Within non-ionic contrast, the data are contradictory

• Role of local drug delivery for prevention of CIN requires Role of local drug delivery for prevention of CIN requires further investigationfurther investigation

• Role of Cooling Therapy is being examined: COOL CIN StudyRole of Cooling Therapy is being examined: COOL CIN Study

Contrast Induced Nephropathy: Predictors, Prevention, and Management Columbia University Medical Center Cardiovascular Research Foundation Roxana Mehran,

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