1. Journal Club Rakesh Latchamsetty October 5, 2007

2. Renal Protection for Coronary Angiography in Advanced Renal Failure Patients by Prophylactic Hemodialysis Lee P, Chou K, Liu C, Mar G, Chung H, et al. JACC, Sept. 11, 2007

3. Why is Renal Impairment Important? CKD is associated with 3 year increased mortality and increased CV events 1 Background 1 Go AS, Hsu C, et al. NEJM 2004. 351: 1296-1305.

4. 3 Year Outcomes with CKD Background Go AS, Hsu C, et al. NEJM 2004. 351: 1296-1305.

5. Why is Renal Impairment Important? Renal insufficiency increases mortality in patients admitted with ACS 2 Background 2 Eagle KA, Fox KA et al. JAMA 2004. 291: 2727-2733

6. Background Eagle KA, Fox KA et al. JAMA 2004. 291: 2727-2733

7. Even Temporary ARF has Worse Prognosis Background 6 month mortality in patients admitted with ACS is worse with acute renal failure, regardless of improvement in function 3 3 Latchamsetty R, Eagle KA, et al. AJC 2007. 99(7) 939-942.

8. 6 Month outcomes following ACS admission A – no change in creatinine B – Temporary rise in Cr C – Sustained rise Cr Background A B C Latchamsetty R, Eagle KA, et al. AJC 2007. 99(7) 939-942.

9. ARF Following PCI has Worse Prognosis 4 Background 4 Rihal CS, Holmes DR, et al. Circulation 2002. 105(19): 2259-2264.

10. Mechanism of CIN Background Multifactorial process -Vasoconstriction at the corticomedullary junction -Impairs autoregulatory capacity of kidney through loss of NO production -Direct tubular toxicity -Osmotic diuresis

11. Risk Factors for Developing CIN Background Pre-existing renal disease Diabetes Amount and type of contrast

12. Mechanism of CIN Background Tumlin J, McCullough P, et al. AJC 2006. 98 (6A) 21-26.

13. Methods to reduce CIN: – IVF – Low-osmolality contrast – Double dose mucomyst – Reducing contrast – Sodium Bicarbonate – CVVH Background

14. Low Osmolar Contrast Originally ionic monomers: hyperosmolar – 1500 to 1800 mOsm/kg Low-osmolar monomers of iodinated benzene rings (iohexol/omnipaque, iopamidol) – 600 to 850 mOsm/kg Nonionic dimer of benzene rings (iodaxinol/visipaque) – 290 mOsm/kg Background

15. N-Acetylcysteine Background Scavenges oxygen free radicals Shown to reduce incidence of CIN, dose- dependent effect 6 Some data on mortality reduction 6 6 Marenzi G, Bartorelli A, NEJM 2006. 354(26):2773-2782.

16. CVVH Previous study showing CVVH can reduce renal failure and improve outcomes in CKD 7 – Only elective cath/pci – Compared to NS alone Primary endpoint: 25% increase in Cr – 5 vs 50% (P<.001) One year mortality also decreased – 10 vs 30% (p=.01) Background 7 Marenzi G, Bartorelli A, et al. NEJM 2003. 349:1333-1340.

17. To determine whether prophylactic hemodialysis reduces CIN after coronary angiogram Objective

18. Inclusion Criteria Consecutive patients at Kaohsiung Veterans GH, Taiwan referred for coronary angiography > 20 years old Creatinine >3.5 mg/dl Methods

19. Exclusion Criteria Pregnancy or lactation Contrast in last 7 days Metformin or NSAIDs in last 48 hrs ESRD or renal txp Unstable new diabetes “Severe concomitant disease” Adverse contrast reaction in the past Methods

20. Protocol All given NS 6 hours before and 12 hours after cath Randomized to HD or not (control) Dialysis catheter placed before angiography Cath performed with nonionic iohexol (omnipaque) Dialysis performed as soon as possible after cath No fluid removal during dialysis Methods

21. Measurements CrCl by 24 hour urine before and on 4 th day after Serum creatinine on admission, day 4, and throughout hospitalization Need for emergent dialysis – Oliguria for 48 hours despite 1,000mg lasix per day – K + > 6 mEq/L Methods

22. Statistics Study was designed for significance of 5% and 90% power Required about 34 subjects in each group To compare baseline values: – Fisher exact test for categorical – Student unpaired t test for continuous Multiple regression to analyze variables affecting decrease in CrCl Methods

23. Endpoints Primary endpoint: change in CrCl between baseline and day 4 Secondary enpoints: – Change in Cr between baseline and day 4 – Peak Cr level – Cr level at discharge – Requirement of emergent or permanent dialysis Methods

24. Sample Space 3,724 consecutive patients receiving cath - 3,406 without CKD 318 - 88with ESRD 230 -122with Cr <3.5 108 - 18refused 90 - 8received NSAIDs/mucomyst/contrast 82Enrolled Results

25. Demographics The 2 groups were well matched Results

26. Change in Creatinine Clearance Results

27. Change in Creatinine Results

28. Factors associated with change in creatinine… Results

29. Further Outcomes 1 vs 14 needed temporary dialysis 5 control patients required permanent dialysis after discharge 2 vs 18 had increase in creatinine greater than 1 at discharge Results

30. Statistically Speaking… Cr increased > 1 at discharge: – control (45%) vs dialysis (5%), p<.001 – NNT = 2.5 Required maintenance dialysis after discharge: – control (13%) vs dialysis (0%) – NNT = 8 Results

31. Other Data/Outcomes Length of stay: DialysisControl 6 +/- 3 days13 +/- 18 daysp=0.017 No major complications in dialysis group Results

32. Limitations Limited sample size Single center Study not blinded Not compared to double dose mucomyst Did not use visipaque Only chose advanced renal disease Strong Endpoints? Discussion

33. Prophylactic HD in Advanced CKD Following Coronary Angiography: – Reduces discharge and maximum creatinine values – Probably reduces hospital stay – Probably prolongs need for permanent dialysis Conclusions

34. Prophylactic HD in Advanced CKD Following Coronary Angiography: – ? Effects on mortality, CV events – ? Effects on long term dialysis needs Conclusions

35. Will This Change How You Practice? Discussion