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Renal Angina

Renal Angina. Lakhmir S. Chawla, MD Associate Professor of Medicine. Renal Angina. What the &#$@ are you talking about? Do I need to know this? Implementation Outcomes. Angina – Troponin – ACS/MI. Land of AKI Biomarkers. Troponin Worship. 50%. 40.6%.

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Renal Angina

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  1. Renal Angina Lakhmir S. Chawla, MDAssociate Professor of Medicine

  2. Renal Angina • What the &#$@ are you talking about? • Do I need to know this? • Implementation • Outcomes

  3. Angina – Troponin – ACS/MI

  4. Land of AKI Biomarkers Troponin Worship

  5. 50% 40.6%

  6. Am J Cardiol, 2008; 102:509 - 512

  7. Conclusion • Troponin performance significantly deteriorates when used outside of the clinical syndrome of angina • AKI Biomarkers will only perform well when used in the appropriate context

  8. Renal Angina? Acute Flank Pain

  9. “Simply put, AKI does not hurt”

  10. Cardiac Angina Risk Factors • DM • HTN • Elevated Cholesterol • Family History • Tobacco Use Clinical Syndrome • Elephant on my chest • Squeezing/pressure • Jaw pain • Dyspnea If RF + Diagnostics > Threshold HIGH Likelihood of ACS

  11. Renal Angina Risk Factors

  12. Renal Angina Risk Factors • Mechanical Ventilation • Vasopressors • Nephrotoxins • Sepsis • MSOF • SCT • Volume Depletion Clinical Syndrome • Early evidence of AKI If RF + Diagnostics > Threshold HIGH Likelihood of ACS

  13. Pediatric Renal Angina: Risk Factors • Moderate Risk (4.5% AKI rate) • ICU admission • High Risk (11%-21% AKI rate) • Stem cell transplantation • Very High Risk (51% AKI rate) • Invasive mechanical ventilation • One vasoactive medication

  14. Pediatric Clinical Signs: GradationChest Pain Equivalent • Creatinine increase • Estimated creatinine clearance decrease (pRIFLE) • Fluid Accumulation from ICU admission

  15. MV 1+ pressor Decomp HF SCT Ped ICU 2+Nephrotoxin

  16. Putting Renal Angina to the Test • Preliminary data from CCHMC • Retrospective chart review of 150 patients admitted to the PICU • Median ICU LOS is 3 days • Assigned each patient risk category • Assessed for clinical signs (creatinine or fluid accumulation based) • Outcome: Day 0, 1 prediction of AKI at 72 hours • Secondary: PICU LOS, Mortality Basu, Wheeler, Chawla, Goldstein

  17. Calculating Renal Angina Index = Renal Angina Index Score Angina > 8

  18. RA on Day 0 to Predict AKI on Day 3 Multivariate analysis for Renal Angina, patient age, inotropy score and PRISM II score OR for Renal Angina on Day 1 to predict AKI on Day 3 =7.1 (1.9-27, p=0.004) Basu, Wheeler, Chawla, Goldstein: ASN 2011

  19. C statistic = 0.75-0.82

  20. C statistic = 0.68-0.77

  21. Summary/Conclusions • AKI biomarkers hold promise for earlier diagnosis of AKI development and intensity • Risk stratification based on demographics alone may not sufficiently enrich the population to optimize AKI biomarker utility • Renal Angina, a concept that combines risk stratification and clinical signs may serve well to optimize biomarker utility

  22. Take Home Points • Context • Comparative performance

  23. Stu Goldstein

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