PCI for patients with Chronic Renal Dysfunction

1. PCI for patients with Chronic Renal Dysfunction Dr. Liyi First Affiliated Hospital of Sun Yat-sen University

2. With the aging of society and development of PCI techniques, we are facing more and more CAD patients with CRD • Our hospital has a very large hemodialysis and peritoneal dialysis center, we are facing more and more CRD patients • Serum creatine level is a very poor indicator for patient’s renal function • Depleted renal function means poor prognosis

3. Freedom from Cardiac Death for Patients with CKD* and Diabetes (DM) BARI Trial + Registry 95% 85% 77% 54% With DM or CKD (n=2921) With DM, without CKD (n=611) Without DM, with CKD (n=46) With both DM and CKD (n=30) * CKD defined as baseline Cr > 1.5 mg/dl Szczech L. et al., Circulation 2002; 105:2253-8.

4. 100% 80% 60% 40% 20% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 CIN After PCI: Cr. Increase & DM 1-Year Event-Free Survival 80% 80% 64% 55% Event-Free Survival DM, <25% creatinine increase No DM, <25% creatinine increase DM, 25% creatinine increase No DM, 25% creatinine increase Time (Months) Gruberg, et al. JACC 2000; 36: 1542-8

5. The best strategies is to nip CIN in the bud • So… who are at the high risk ?

6. Risk Factors for CIN

7. Risk of CIN Relation to Baseline Creatinine 30 20 10 0 Probability of Nephrotoxicity (%) 0.5 1.0 1.5 2.0 Baseline Serum Creatinine(mg/dl) Davidson et al. Annals Int Med (1989)

8. 100 90 80 70 60 50 40 30 20 10 0 Prediction of CIN and Dialysis After PCI Mean age=65 years, 72 kg man CIN CrCl ~ 30 mL/min 30–40% CIN rate n=424 n=3695 n=7586 Dialysis Renal Event Rate (%) No diabetics Diabetics 50 40 30 20 10 Calculated CrCl (mL/min) Independent risk factors: CrCl>>Diabetes>>Contrast Volume PCI, percutaneous coronary intervention. Data adapted from: Berns AS. Kidney Int. 1989;36(4):730–740; McCullough PA. Am J Med. 1997;103:386–375;Rihal et al. Circulation. 2002;105:2259–2264.

9. Predictors of ARF +Dialysis OR CI P Cr Clearance 0.83 0.77-0.89 <0.001 Diabetes 5.47 1.41-21.32 0.01 Contrast dose 1.008 1.002-1.013 0.01 CIN: Incidence & Risk Factors • 1,826 consecutive pts undergoing PCI:CIN without dialysis occurred 14.5%CIN with dialysis occurred 0.8% McCullough, et al. Am J Med 1997; 103: 375

11. Be aware of small body weight old ladies eg. Female, Scr = 80 umol/L , age =60, wt = 60kg  CCr = 62.4 ml/min • if. Female, Scr = 80 umol/L , age = 80 , wt = 45kg  CCr = 35.1 ml/min

12. A Risk Score for Prediction of CIN Multivariate Predictors Diabetes – any Tx Age over 70 SVG treated Multiple vessels treated Female IABP use Acute coronary syndrome CrCl <50 mL/min 60 P<.0001 χ2 by trend 50 40 30 20 10 0 0 or 1 2 3 4 5 6 7 or 8 CIN Risk Score Mehran R et al. J Am Coll Cardiol. 2003;41:37A.

13. Scheme to define CIN risk score Risk Factors Integer Score Hypotension 5 IABP 5 CHF 5 Age >75 years 4 Anemia 3 Diabetes 3 Calculate Contrast media volume 1 for each 100 cc3 Serum creatine > 1.5mg/dl 4 OR 2 for 40 – 60 4 for 20 – 40 6 for < 20 eGFR <60ml/min/1.73 m2 eGFR < 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) Mehran et al. JACC 2004;44:1393-1399.

14. How to prevent … • Minimize Contrast dosage • Hydration • N-AC • Type of Contrast Media ?

15. Minimize Contrast Dosage My Tips • Staged procedure • Use your syringe wisely • Plan twice, inject once • Diluted contrast for visualization vessels • Use roadmap wisely • Use your flat panel DSA wisely

16. Hydration

17. Prevention of CIN: Hydration • 78 Pts with CRI (Cr 1.6-4.2 mg/dl) • IV Fluids: 1/2 NS @ 1ml/kg/hr for 12 hr before & after contrast • Mannitol: 50 g 1 hr before contrast • Furosemide: 80 mg IV 30 min before contrast 60% 43% Non-DM DM 50% 38% 40% 36% % CIN 30% 20% 17% 14% 7% 10% 0% Saline Saline + Mannitol Saline + Furosemide Solomon, et al. NEJM 1994; 331: 1416-1420

18. Sodium Bicarbonate Shea E. Hogan et al. AHJ 2008;156:414

19. Question remaining in hydration • When ? • What ? • How many ? • How ?

20. N-ACETYLCYSTEINE (NAC) ?

21. Meta-analysis: NAC Randomized,13 Controlled Trials : N=1882 Zagler A, et al. AHJ 2006;151:140

22. Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy Kelly, A. M. et. al. Ann Intern Med 2008;148:284-294

23. Contrast Agent – remaining questions Iso-osmolarity vs. Low osmolarity

24. My protocol in dealing high risk patients • Identify high risk patients • Take preventive measures • Check Scr before and after procedure

27. Patients Characteristics • Male, 65yrs • Exertional angina for 1 weeks • History: DM (on oral medication) dyslipidemia, Hypertension • Lab. Exam: LDL: 3.1 mmol/L TNT: 1.1 ng/ml SCr: 135 umol/L

28. Risk Assessment CCr: 44 ml/min Diabetes – any Tx Acute coronary syndrome CrCl <50 mL/min

29. Preventive measures • Hydration • N-AC • Change oral hypoglycemic into insuline • Patients and family consent • Baseline SCr: 135umol/L

33. 下一步的治疗策略： 1，LCX； 2，LAD； 3，RCA。

37. Follow-up D2 Scr: 128 umol/L D3 Scr: 130 umol/L

38. 谢谢！