What Cons*tutes Nephrology Clearance? Oscar Naidas, MD Frederick Ogbac, MD

Transcription

1 What Cons*tutes Nephrology Clearance? Oscar Naidas, MD Frederick Ogbac, MD

2 What he will say... Nephrology Clearance vs Nephrology Risk Stra=fica=on / Assessment and Management Composi=on of Nephrology Clearance Pre employment Nephrology Clearance CT- Scan with IV contrast Coronary angiography or PCI General Surgery MRI with gadolinium contrast

3 Define Nephrology Clearance vs Risk Stra*fica*on / Assessment and its Management Defini=on of Clearance ( ) Official authoriza.on for something to proceed or take place Example: Do not schedule the pa.ent for CT Scan of the abdomen with IV contrast un.l you are given clearance by the nephrologist Oxford Advance Learner s Dic5onaries

4 Composi*on of a Nephrology Risk Assessment and Management Type of poten=al ischemic / nephrotoxic insult Assessment of risk factors of the pa=ent An es=mate of the risk (quan=ta=ve or semi- quan=ta=ve) Management / interven=on to reduce risk Risk vs Benefit Communica=on with the referring physician and/ or the pa=ent

5 The seafarer with chronic GN

6 The seafarer with chronic GN 35 M, asymptoma=c, BP:140/90mmHg, Ht 5 7, Wt 70 kg, Urine rbc 10-15/hpf, prot trace (UPCR 0.6) Scr 1.4mg/dl (egfr 68ml/min) US KUB(- ) LPD, Losartan (130/80mmHg), UPCR 0.3 Ffup q 6 mos for 3 years, stable

7 The seafarer with chronic GN Asymptoma=c, BP 130/80mmHg, Ht 5 7, Wt 70 kg,no edema, Urine rbc 15-20/hpf, protein(- ) ACR 110 mg/g Scr 1.5mg/dl (egfr 62ml/min) US KUB(- )

8 The seafarer with chronic GN Chronic GN probably IgAN

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10 The seafarer with chronic GN Chronic GN probably IgAN, CKD G2A2 (moderate risk of progression)

11 The seafarer with chronic GN No indica=on for kidney biopsy, stable for past 3 yrs, LPD and Losartan 50mg OD (<BP130/80mmHg ), slows the fall in GFR to 3ml/min/yr

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13 The seafarer with chronic GN No indica=on for kidney biopsy, stable for past 3 yr LPD and Losartan 50mg OD (<BP130/80mmHg ), slows the fall in GFR to 3ml/min/yr (62ml/min to 59ml/min) Low risk of progression of CKD Low probability of progression of CKD that will require hospitaliza=on or dialysis within next 9 to 12 months Repeat BP, Scr, UPCR ager 9 to 12 months

14 Pa*ent w/ CKD will undergo CT Scan w/ IV contrast 56 F, DM2, HTN, HF symptoms Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 130/90 mmhg Wt: 60kg Ht: 5 1 SCr 1.5 (egfr 38.5 ml/min) Uprot: +2 Chronic abdominal pain US pancrea=c mass? Will undergo whole abdomen CT- Scan with contrast Referred for Nephrology Clearance

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16 (38.5 ml/min)

17 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al J Am Coll Cardiol, 2004

18 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Total = 13 J Am Coll Cardiol, 2004

19 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Risk Score Risk of CIN (%) Risk of Dialysis (%) < to to > Total = 13 Low Mod Mod High J Am Coll Cardiol, 2004

20 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Risk Score Risk of CIN (%) Risk of Dialysis (%) < to to > Total = 13 Low Mod Mod High J Am Coll Cardiol, 2004

21 Am J Cardiol, 2006

22 Risk Predic*on of Contrast- Induced Nephropathy McCullough PA, Adam A, Becker CR, et al Am J Cardiol, 2006

23 Risk Predic*on of Contrast- Induced Nephropathy McCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, Tumlin J, CIN Consensus Working Panel Am J Cardiol, 2006

24 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F, stable CKD G3bA3,DM2,HF will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK)

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29 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (CI AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result HOW TO DO IT 56F, stable CKD G3bA3,DM2,HF will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK)

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31 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (CI AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result HOW TO DO IT 56F, stable CKD G3bA3,DM2,HF will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK) Saline hydra=on+ NAC, reduces the risk of CI AKI RR = 0.68

32 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (CI AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result STEP 3 Es=mate your individual pa=ent s risk for an event (CI AKI)with treatment HOW TO DO IT 56F, stable CKD G3bA3,DM2 will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK) Saline hydra=on+ NAC, reduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 26% x 0.68 = 18%

33 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (CI AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result STEP 3 Es=mate your individual pa=ent s risk for an event (CI AKI) with treatment STEP 4 Es=mate the individualized ARR HOW TO DO IT 56F, stable CKD G3bA3,DM2,HF will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK) Saline hydra=on+ NAC, reduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 26% x 0.68 = 18% ARR = Rc Rt = 26% - 18% = 8% (LOW RISK)

34 Composi=on of a Nephrology Risk Assessment and Management Type of poten=al ischemic/nephrotoxic insult CT Scan w IV contrast Assessment of risk factors of the pa=ent CKD egfr 38ml/min DM2,HF An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) CI AKI 26% (MODERATE RISK) Management/Interven=on to reduce risk Saline Hydra.on +NAC reduce risk to 8% (LOW RISK) Risk vs Benefit Confirma.on +/- of pancrea.c mass with CT Scan w/ IV contrast outweighs LOW RISK of CI AKI Communica=on with the referring physician and/or the pa=ent

35 The Pa*ent w CKD will Undergo Coronary Angiography/PCI 56 F, DM2, HTN, with HF symptoms Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 130/90 mmhg Wt: 60kg SCr 1.5 (egfr 38ml/min) Uprotein: +2 Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8 mg/dl ECG: LVH Dx: CKD St G3bA1, DM Nephropathy, Will undergo coronary angiogram/pci ACC / AHA Class IIb indica*on Referred for Nephrology Clearance

36 Renal Risk Stra*fica*ons for CKD pa*ents prior to CA or PCI Mehran, et al. A simplified risk score for contrast- induced nephropathy ager percutaneous coronary interven=on. JACC, Tziakas, et al. Valida=on of a new risk score to predict contrast- induced nephropathy ager percutaneous coronary interven=on. Am J Cardiol, 2014.

37 Comparison of Renal Risk Stra*fica*ons for CKD pa*ents prior to CA or PCI Index Mehran JACC 2004 No. of variables Score range Tziakas Am J Cardiol

38 J Am Coll Cardiol, 2004

39 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al J Am Coll Cardiol, 2004

40 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Total = 13 J Am Coll Cardiol, 2004

41 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Risk Score Risk of CIN (%) Risk of Dialysis (%) < to to > Total = 13 Low Mod Mod High J Am Coll Cardiol, 2004

42 A Simple Risk Score for Predic*on of Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al Risk Score Risk of CIN (%) Risk of Dialysis (%) < to to > Total = 13 Low Mod Mod High J Am Coll Cardiol, 2004

43 Am J Cardiol, 2014

44 Valida*on of a New Risk Score to Predict Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic G, et al Am J Cardiol, 2014

45 Valida*on of a New Risk Score to Predict Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic G, et al 2 2 Am J Cardiol, 2014

46 Valida*on of a New Risk Score to Predict Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic G, et al Risk Score Risk for CI- AKI < 3 7.5% > 3 34% Am J Cardiol, 2014

47 Valida*on of a New Risk Score to Predict Contrast- Induced Nephropathy ARer Percutaneous Coronary Interven*on Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic G, et al Risk Score Risk for CI- AKI < 3 7.5% > 3 34% Am J Cardiol, 2014

48 Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast- Induced Acute Kidney Injury among Pa*ents Undergoing Coronary Angiography or Percutaneous Coronary Interven*on at SLMC- QC Ogbac FE, Gonzales- Prociuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O O- occurrence of CI- AKI SLMC- QC Sec=on of Nephrology, 2014 P- Pa=ents undergoing coronary angiography and/or PCI at St Luke s QC I- Mehran vs Tziakas

49 Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast- Induced Acute Kidney Injury among Pa*ents Undergoing Coronary Angiography at SLMC- QC Ogbac FE, Gonzales- Porciuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O AUC SLMC- QC Sec=on of Nephrology, 2014

50 Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast- Induced Acute Kidney Injury among Pa*ents Undergoing Percutaneous Coronary Interven*on at SLMC- QC Ogbac FE, Gonzales- Porciuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O AUC SLMC- QC Sec=on of Nephrology, 2014

51 Individualizing risk management Tziakas STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK)

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53 Preven*on of CI- AKI Low osmolal or iso- osmolal contrast agents Isotonic saline or isotonic bicarbonate 3 ml/kg 3 hrs prior to procedure and 1 ml/kg/hours for 6 hours ager the procedure Leg ventricular end diastolic pressure guided fluid replacement Acetylcysteine 1200mg BID Discon=nua=on of renal vasoconstric=ng agents Uptodate, 2015

54 Individualizing risk management Tziakas STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK) STEP 2 Estimate the RR using the study result Saline hydration + NAC reduces the risk of CI AKI RR = 0.68

55 Individualizing risk management Tziakas STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK) STEP 2 Estimate the RR using the study result STEP 3 Estimate your individual patient s risk for an event(ci AKI)with treatment Saline hydration + NACreduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 7.5% x 0.68 = 5%

56 Individualizing risk management Tziakas STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK) STEP 2 Estimate the RR using the study result STEP 3 Estimate your individual patient s risk for an event (CI AKI) with treatment Saline hydration + NAC reduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 7.5% x 0.68 = 5%

57 Individualizing risk management Tziakas STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK) STEP 2 Estimate the RR using the study result STEP 3 Estimate your individual patient s risk for an event (CI AKI) with treatment STEP 4 Estimate the individualized ARR Saline hydration + NAC reduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 7.5% x 0.68 = 5% ARR = Rc Rt = 7.5% -5% = 2.5% (LOW RISK)

58 Individualizing the results STEPS STEP 1 Estimate your patient s risk for an event (CIN) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% STEP 2 Estimate the RR using the study result STEP 3 Estimate your individual patient s risk for an event with treatment STEP 4 Estimate the individualized ARR STEP 5 Estimate the individualized NNT Saline hydration + NACreduces the risk of CI AKI RR = Rt = Rc x RR = 7.5% x 0.68 = 5% ARR = Rc Rt = 7.5% -5% = 2.5% NNT = 100/ARR = 100/2.5 = 40

59 Individualizing risk management Mehran STEPS STEP 1 Estimate your patient s risk for an event (CI AKI) without treatment (Rc) HOW TO DO IT 56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 26% (MODERATE RISK) STEP 2 Estimate the RR using the study result STEP 3 Estimate your individual patient s risk for an event (CI AKI) with treatment STEP 4 Estimate the individualized ARR Saline hydration + NAC reduces the risk of CI AKI RR = 0.68 Rt = Rc x RR = 26% x 0.68 = 18% ARR = Rc Rt = 26% -18% = 8% (LOW RISK)

60 Composi=on of a Nephrology Risk Assessment and Management Type of poten=al ischemic/nephrotoxic insult CA/PCI Assessment of risk factors of the pa=ent CKD egfr 38ml/min, DM2,HF An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) CI AKI 7.5% to 26% (LOW to MODERATE RISK) Management/Interven=on to reduce risk( Saline hydra.on+nac reduce risk to 2.5% to 8% (LOW RISK) Risk vs Benefit Benefit of CA/PCI outweighs LOW RISK of CI AKI Communica=on with the referring physician and/or the pa=ent

61 The Pa*ent withckd who will undergo abdominal surgery 56 F, DM2, HTN Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 130/90 mmhg Wt: 60kg SCr 1.5 Uprotein: +2 egfr:38.5 ml/min Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8mg/dL CT Scan: solid mass at pancrea=c tail, ascites Coroangio: nega=ve Pre- op CV: stra=fica=on intermediate to high risk of developing periopera=ve CV complica=ons Par=al pancreatectomy Referred for Nephrology Clearance

62 Anesthesiology, 2009

63 Development and valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al Anesthesiology, 2009

64 Development and valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al Total = 6 Anesthesiology, 2009

65 Development and Valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al Preopera*ve Risk Class AKI incidence (%) HR (95%, CI) Class I (0-2 risk factors) 0.2 Class II (3 risk factors) ( ) Class III (4risk factors) ( ) Class IV (5 risk factors) ( ) Class V (6+ risk factors) ( ) Anesthesiology, 2009

66 Development and valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al Preopera*ve Risk Class AKI incidence (%) HR (95%, CI) Class I (0-2 risk factors) 0.2 Class II (3 risk factors) ( ) Class III (4risk factors) ( ) Class IV (5 risk factors) ( ) Class V (6+ risk factors) ( ) Anesthesiology, 2009

67 Pre- opera*ve Renal Risk Stra*fica*on of our pa*ent (Class V) The incidence of AKI ager exploratory laparotomy is 9% She is 46x more likely to develop AKI post exploratory laparotomy vs Class I pa=ents

68 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (AKI) without treatment (Rc) HOW TO DO IT 56F, stable CKD G3bA3,DM2 will undergo abdominal surgery with a risk of post op AKI 9% (HIGH RISK)

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70 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result HOW TO DO IT 56F, stable CKD G3bA3,DM2 will undergo abdominal surgery with a risk of post op AKI 9% (HIGH RISK) Periopera=ve hemodynamic op=miza=on, reduces the risk of post op AKI RR = 0.64

71 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result STEP 3 Es=mate your individual pa=ent s risk for an event (AKI) with treatment HOW TO DO IT 56F, stable CKD G3bA3,DM2 will undergo abdominal surgery with a risk of post op AKI 9% (HIGH RISK) Periopera=ve hemodynamic op=miza=on, reduces the risk of post op AKI RR = 0.64 Rt = Rc x RR = 9% x 0.64 = 6%

72 Individualizing risk management STEPS STEP 1 Es=mate your pa=ent s risk for an event (AKI) without treatment (Rc) STEP 2 Es=mate the RR using the study result STEP 3 Es=mate your individual pa=ent s risk for an event (AKI) with treatment STEP 4 Es=mate the individualized ARR HOW TO DO IT 56F, stable CKD G3bA3,DM2 will undergo abdominal surgery with a risk of post op AKI 9% (HIGH RISK) Periopera=ve hemodynamic op=miza=on, reduces the risk of post op AKI RR = 0.64 Rt = Rc x RR = 9% x 0.64 = 6% ARR = Rc Rt = 9% - 6% = 3% (MODERATE RISK)

73 Composi=on of a Nephrology Risk Assessment and Management Type of poten=al ischemic/nephrotoxic insult Par.al pancreatectomy Assessment of risk factors of the pa=ent 56F,CKD,DM,2HTN An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) GS AKI Risk 9% (HIGH RISK) Management/Interven=on to reduce risk Periopera.ve hemodynamic op.miza.on reduces risk to 3% (MODERATE RISK) Risk vs Benefit Benefit of par.al pancreatectomy outweighs MODERATE RISK of post op AKI Communica=on with the referring physician and/or the pa=ent

74 The pa*ent with CKD will undergo MRI w gadolinium contrast 57 F, DM2, and HTN Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 120/90 mmhg Wt: 60kg SCr 1.6 egfr: 35.4 ml/min/1.73m 2 Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5 mg/dl Changes in sensorium t/c CVD vs metastasis Will undergo MRI with gadolinium contrast

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76 American College of Radiology Manual on Contrast Media (Ver 9, 2013) Nephrogenic Sytemic Fibrosis A fibrosing disease primarily involving the skin and subcutaneous =ssues seen in pa=ents with renal problem ACR Manual on Contrast Media, 2013

77 American College of Radiology Manual on Contrast Media (Ver 9, 2013) Risk Factors for NSF Gadolinium based contrast agent administra=on Hemodialysis Chronic Kidney Disease Acute Kidney Injury High dose and mul=ple exposure ACR Manual on Contrast Media, 2013

78 American College of Radiology Manual on Contrast Media (Ver 9, 2013) For Inpa*ents: egfr should be obtained within 2 days prior to giving gadolinium ACR Manual on Contrast Media, 2013

79 American College of Radiology Manual on Contrast Media (Ver 9, 2013) For Inpa*ents: egfr should be obtained within 2 days prior to giving gadolinium ACR Manual on Contrast Media, 2013

80 American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents with egfr < 30 ml/min/1.73m 2 : Gadolinium agents should be avoided If gadolinium enhanced MRI is deemed essen=al, use of the lowest possible dose is recommended For pa*ents with egfr ml/min/1.73m 2 : NSF is rare, but precau=ons are recommended For pa*ents with egfr ml/min/1.73m 2 : NSF is rare, with no precau=ons For pa*ents with egfr > 60 ml/min/1.73m 2 : No evidence of increased risk of developing NSF ACR Manual on Contrast Media, 2013

81 American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents with AKI Gadolinium agents should only be administered if absolutely necessary ACR Manual on Contrast Media, 2013

82 American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents on dialysis: Gadolinium enhanced MRI be performed as closely as before hemodialysis ACR Manual on Contrast Media, 2013

83 Composi=on of a Nephrology Risk Assessment and Management Type of poten=al ischemic/nephrotoxic insult MRI w Gadolinium Contrast Assessment of risk factors of the pa=ent 56F,CKD,DM2,HTN,eGFR 35ml/ min An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) NSF is rare Management/Interven=on to reduce risk? Lower dose of gadolinium Risk vs Benefit Benefit of MRI w gadolinium contrast outweighs VERY LOW RISK of NSF Communica=on with the referring physician and/or the pa=ent

84 What he just said... Nephrology Clearance vs Nephrology Risk Stra=fica=on / Assessment and Management Composi=on of Nephrology Clearance Type of poten=al ischemic/nephrotoxic insult Assessment of risk factors of the pa=ent An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) Management/Interven=on to reduce risk Risk vs Benefit Communica=on with the referring physician and/or the pa=ent

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86 Our Pa*ent 56 F, DM2, HTN, with HF symptoms, non smoker Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 130/90 mmhg Wt: 60kg BMI= 25.8 SCr 1.5 Uprotein: +2 egfr 38.5 Hb/Hct: 11/30 HbA1C: 7% Alb: 3.8 mg/dl EF: 65% with LVH, hypokinesia of LV wall CA: 4VD with Leg main coronary artery involvement Will undergo CABG

87 Predic*ve Indices for Es*ma*ng Risk of Post- Cardiac Surgery RRT SRI Wijeysundera, et al. Deriva=on and valida=on of a simplified predic=ve index for renal replacement therapy ager cardiac surgery. JAMA, Mehta, et al. Bedside Tool for predic=ng the risk of postopera=ve dialysis in pa=ents undergoing cardiac surgery. Circula=on, 2006 Thakar, et al. A clinical score to predict acute renal failure ager cardiac surgery. J AM Soc Nephrol, 2005.

88 Comparison of Predic*ve Indices for Es*ma*ng Risk of Post- Cardiac Surgery RRT Index No. of variables Score range AUC (Toronto cohort) SRI ( ) Mehta ( ) Thakar ( )

89 JAMA, 2007

90 Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery (SRI) Wijeysundera DN, Karkou= K, Dupuis JY, et al JAMA, 2007

91 Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery (SRI) Wijeysundera DN, Karkou= K, Dupuis JY, et al Total = 3 JAMA, 2007

92 Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery (SRI) Wijeysundera DN, Karkou= K, Dupuis JY, et al Risk Categories Risk of RRT (%) Low Risk (0 to 1 point) 0.4 Intermediate Risk (2 to 3 points) 3 High Risk (> 4 points) 10 JAMA, 2007

93 Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery Wijeysundera DN, Karkou= K, Dupuis JY, et al Risk Categories Risk of RRT (%) Low Risk (0 to 1 point) 0.4 Intermediate Risk (2 to 3 points) 3 High Risk (> 4 points) 10 JAMA, 2007

94 Circula5on, 2006

95 Bedside Tool for Predic*ng the Risk of Postopera*ve Dialysis in Pa*ents Undergoing Cardiac Surgery Mehta RH, Grab JD, O Brien SM, et al Circula5on, 2006

96 Bedside Tool for Predic*ng the Risk of Postopera*ve Dialysis in Pa*ents Undergoing Cardiac Surgery Mehta RH, Grab JD, O Brien SM, et al Circula5on, 2006

97 Bedside Tool for Predic*ng the Risk of Postopera*ve Dialysis in Pa*ents Undergoing Cardiac Surgery Mehta RH, Grab JD, O Brien SM, et al Circula5on, 2006

98 Bedside Tool for Predic*ng the Risk of Postopera*ve Dialysis in Pa*ents Undergoing Cardiac Surgery Mehta RH, Grab JD, O Brien SM, et al 1.1% Circula5on, 2006

99 J Am Soc Nephrol, 2005

100 A Clinical Score to Predict Acute Renal Failure arer Cardiac Surgery Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP J Am Soc Nephrol, 2005

101 A Clinical Score to Predict Acute Renal Failure arer Cardiac Surgery Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP Total = 5 J Am Soc Nephrol, 2005

102 A Clinical Score to Predict Acute Renal Failure arer Cardiac Surgery Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP Risk Categories Risk of RRT (%) J Am Soc Nephrol, 2005

103 Comparison of Predic*ve Indices for Es*ma*ng Risk of Post- Cardiac Surgery RRT Index No. of variables Score range Risk Score Risk for RRT post CABG (%) SRI Mehta 2005 Thakar The risk of AKI requiring RRT post- cardiac surgery is between 1.1 to 3%

104 Crit Care, 2014

105 Predic*ve Models for Kidney Disease: Improving global Outcomes (KDIGO) defined Acute Kidney Injury in UK Cardiac Surgery Birnie K, Verheyden V, Domenico P, et al P- 20,995 pa=ents underwent cardiac surgery including surgery to thoracic aorta (3 different centers) I- retrospec=ve cohort O- occurrence of CI- AKI and need for RRT Crit Care, 2014

106 hhp:// research/acute- kidney- injury- risk- score- calculator/

107 Predic*ve Models for Kidney Disease: Improving global Outcomes (KDIGO) defined Acute Kidney Injury in UK Cardiac Surgery Birnie K, Verheyden V, Domenico P, et al Crit Care, 2014

108 hhp:// research/acute- kidney- injury- risk- score- calculator/

109 Periopera*ve Acute Kidney Injury Calvet S, Shaw A Preven*ve measures for cardiac surgery Fluids and goal directed therapy Avoidance of nephrotoxic agents Hemodilu=on and transfusion Perioper Med, 2012

110 Our pa*ent post- op 57 F, DM2, and HTN Insulin 10u SQ OD Telmisartan 40mg OD, Metoprolol 50mg BID BP: 120/90 mmhg Wt: 60kg SCr 1.6 egfr: 35.4 ml/min Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5 mg/dl Histopath: cervical CA Will undergo cispla=n chemotherapy

111 Risk Factors for Cispla*n Nephrotoxicity Previous cispla=n chemotherapy Pre- exis=ng kidney damage Concomitant administra=on of poten=ally nephrotoxic agents High peak plasma free pla=num concentra=ons Uptodate, 2014

112 Preven*on of Cispla*n Nephrotoxicity Lower dose of cispla=n 1L isotonic saline + 20 meqs KCl + 2gms MgSO 4 3 hours prior to administering chemotherapy and minimum of 500ml over 2 hours following administra=on Uptodate, 2015

113 THANK YOU