1. 强 生 Cordis 学 院 Cordis 百家病例论坛 PCI for patients with Chronic Renal Dysfunction Dr. Liyi First Affiliated Hospital of Sun Yat-sen University

2. 强 生 Cordis 学 院 Cordis 百家病例论坛 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. 强 生 Cordis 学 院 Cordis 百家病例论坛 Szczech L. et al., Circulation 2002; 105:2253-8. 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) 95% 85% 77% 54% * CKD defined as baseline Cr > 1.5 mg/dl Freedom from Cardiac Death for Patients with CKD* and Diabetes (DM) BARI Trial + Registry

4. 强 生 Cordis 学 院 Cordis 百家病例论坛 DM, <25% creatinine increase No DM, <25% creatinine increase DM,  25% creatinine increase No DM,  25% creatinine increase 0 0% 20% 40% 60% 80% 100% 123456789101112 Time (Months) Event-Free Survival 80% 80% 64% 55% CIN After PCI: 1-Year Event-Free Survival Cr. Increase & DM Gruberg, et al. JACC 2000; 36: 1542-8

5. 强 生 Cordis 学 院 Cordis 百家病例论坛 The best strategies is to nip CIN in the bud So… who are at the high risk ?

6. 强 生 Cordis 学 院 Cordis 百家病例论坛 Risk Factors for CIN Patient-related Risk Factors Renal insufficiency Renal insufficiency Diabetes mellitus with renal insufficiency Diabetes mellitus with renal insufficiency Age Age Volume depletion Volume depletion Hypotension Hypotension Low cardiac output Low cardiac output Class IV CHF Class IV CHF Other nephrotoxins(NSAIDs) Other nephrotoxins(NSAIDs) Renal transplant Renal transplant Hypoalbuminemia (<35 g/L) Hypoalbuminemia (<35 g/L) Procedure-related Risk Factors Multiple contrast media injection within 72 hrs Multiple contrast media injection within 72 hrs Intra-arterial injection site Intra-arterial injection site High volume of contrast media High volume of contrast media High osmolality of contrast media High osmolality of contrast media

7. 强 生 Cordis 学 院 Cordis 百家病例论坛 Risk of CIN Relation to Baseline Creatinine Davidson et al. Annals Int Med (1989) 30 20 10 0 0.51.01.52.0 Baseline Serum Creatinine(mg/dl) Probability of Nephrotoxicity (%)

8. 强 生 Cordis 学 院 Cordis 百家病例论坛 Prediction of CIN and Dialysis After PCI 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. Mean age=65 years, 72 kg man 0 10 20 30 40 50 60 70 80 90 100 5040302010 Calculated CrCl (mL/min) Renal Event Rate (%) No diabetics Diabetics n=424 n=3695 n=7586 CIN Dialysis CrCl ~ 30 mL/min 30–40% CIN rate CrCl ~ 30 mL/min 30–40% CIN rate

9. 强 生 Cordis 学 院 Cordis 百家病例论坛 CIN: Incidence & Risk Factors 0.011.002-1.0131.008 Contrast dose 0.011.41-21.325.47Diabetes <0.0010.77-0.890.83 Cr Clearance PCIOR Predictors of ARF +Dialysis 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

10. 强 生 Cordis 学 院 Cordis 百家病例论坛

11. 强 生 Cordis 学 院 Cordis 百家病例论坛 Be aware of small body weight old ladies eg. Female, Scr = 80 umol/L, age =60, wt = 60kg  CCr = 62.4 ml/min Wt = 60kgAge = 60 AgeCCrWtCCr 65 58.5 55 57.2 70 54.6 50 52 75 50.7 45 46.8 80 46.8 if. Female, Scr = 80 umol/L, age = 80, wt = 45kg  CCr = 35.1 ml/min

12. 强 生 Cordis 学 院 Cordis 百家病例论坛 0 10 20 30 40 50 60 0 or 1234567 or 8 CIN Risk Score P<.0001 χ 2 by trend Mehran R et al. J Am Coll Cardiol. 2003;41:37A. 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

13. 强 生 Cordis 学 院 Cordis 百家病例论坛 Risk Score Risk of CIN Risk of Dialysis ≤ 57.5%0.04% 6 to 1014.0%0.12% 11 to 1626.1%1.09% ≥ 1657.3%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 cc 3 Scheme to define CIN risk score Serum creatine > 1.5mg/dl4 eGFR <60ml/min/1.73 m 2 2 for 40 – 60 4 for 20 – 40 6 for < 20 eGFR < 60ml/min/1.73 m 2 = 186 x (SCr) -1.154 x (Age) -0.203 X (0.742 if female) x (1.210 if African American) Calculate OR

14. 强 生 Cordis 学 院 Cordis 百家病例论坛 How to prevent … Minimize Contrast dosage Hydration N-AC Type of Contrast Media ?

15. 强 生 Cordis 学 院 Cordis 百家病例论坛 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. 强 生 Cordis 学 院 Cordis 百家病例论坛 Hydration

17. 强 生 Cordis 学 院 Cordis 百家病例论坛 Prevention of CIN: Hydration Solomon, et al. NEJM 1994; 331: 1416-1420 0% 10% 20% 30% 40% 50% 60% Saline Saline + Mannitol Saline + Furosemide Non-DM DM % CIN 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 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 7% 14% 17% 38% 36% 43%

18. 强 生 Cordis 学 院 Cordis 百家病例论坛 Sodium Bicarbonate Shea E. Hogan et al. AHJ 2008;156:414

19. 强 生 Cordis 学 院 Cordis 百家病例论坛 Question remaining in hydration When ? What ? How many ? How ?

20. 强 生 Cordis 学 院 Cordis 百家病例论坛 N-ACETYLCYSTEINE (NAC) ?

21. 强 生 Cordis 学 院 Cordis 百家病例论坛 Meta-analysis: NAC Randomized, 13 Controlled Trials : N=1882 Zagler A, et al. AHJ 2006;151:140

22. 强 生 Cordis 学 院 Cordis 百家病例论坛 Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy Kelly, A. M. et. al. Ann Intern Med 2008;148:284-294

23. 强 生 Cordis 学 院 Cordis 百家病例论坛 Contrast Agent – remaining questions Iso-osmolarity vs. Low osmolarity

24. 强 生 Cordis 学 院 Cordis 百家病例论坛 My protocol in dealing high risk patients Identify high risk patients Take preventive measures Check Scr before and after procedure

25. 强 生 Cordis 学 院 Cordis 百家病例论坛

26. 强 生 Cordis 学 院 Cordis 百家病例论坛

27. 强 生 Cordis 学 院 Cordis 百家病例论坛 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. 强 生 Cordis 学 院 Cordis 百家病例论坛 Risk Assessment CCr: 44 ml/min Diabetes – any Tx Acute coronary syndrome CrCl <50 mL/min

29. 强 生 Cordis 学 院 Cordis 百家病例论坛 Preventive measures Hydration N-AC Change oral hypoglycemic into insuline Patients and family consent Baseline SCr: 135umol/L

30. 强 生 Cordis 学 院 Cordis 百家病例论坛

31. 强 生 Cordis 学 院 Cordis 百家病例论坛

32. 强 生 Cordis 学 院 Cordis 百家病例论坛

33. 强 生 Cordis 学 院 Cordis 百家病例论坛 下一步的治疗策略： 1 ， LCX ； 2 ， LAD ； 3 ， RCA 。

34. 强 生 Cordis 学 院 Cordis 百家病例论坛

35. 强 生 Cordis 学 院 Cordis 百家病例论坛

36. 强 生 Cordis 学 院 Cordis 百家病例论坛

37. 强 生 Cordis 学 院 Cordis 百家病例论坛 Follow-up D2 Scr: 128 umol/L D3 Scr: 130 umol/L

38. 强 生 Cordis 学 院 Cordis 百家病例论坛 谢谢！