1. REMEDIAL II REnal Insufficiency Following Contrast MEDIA Administration II TriaL RenalGuard system in high risk patients for contrast induced acute kidney injury Carlo Briguori, MD, PhD Laboratoy of Interventional Cardiology Clinica Mediterranea, Naples - Italy

2. I, Carlo Briguori DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Disclosure Statement of Financial Interest

3. Background  Contrast-induced acute kidney injury (CI-AKI) is a powerful predictor of unfavorable early and late outcome 1-3  Several studies showed the advantages of the prophylaxis by  sodium bicarbonate solution 4-5  N-acetylcysteine (NAC) 6-7  However, in high risk patients the rate of CI-AKI is still high 1. McCullough PA. J Am Coll Cardiol 2008;51:1419-28 2. Solomon R. et al. Clin J Am Soc Nephrol 2009;4:1162-1169 3. Briguori C, et al. Circulation 2010;121:2117-2122. 4. Merten GJ et al. JAMA 2004;291:2328-2334 5. Briguori C, et al. Circulation 2007;115:1211-1217. 6. Tepel M et al. N Engl J Med 2000;343:180-184. 7. Trivedi H, et al. Am J Med 2009;122:874 e9-15

4. High risk patients Hypotension 5 IABP 5 CHF 5 Age > 75 years 4 Anemia 3 Diabetes 3 Contrast media volume 1 for each 100 cc 3 Serum creatinine >1.5 mg/dl OR eGFR <60 mlmin1.73 m 2 4 2 for 40-60 4 for 20-60 6 for <20 Risk Score Risk of CIAKI Risk of Dialysis 55 7.5%0.04% 6 to 1014%0.12% 11 to 1626.1%1.09%  16 57.3%12.6% J Am Coll Cardiol Mehran R et al J Am Coll Cardiol 2004; 44:1393-9

5. Background  Creating and maintaining a high urine output is beneficial to prevent kidney damage. This high urine flow rate, indeed, should allow the body to rapidly eliminate contrast, reducing its toxic effects.  Data from the PRINCE study indicate that increasing the urine flow rate (≥150 ml/h) reduces the toxic effect of contrast media 1  A forced diuresis regime is usually achieved by high dose of furosemide which may be deleterious, potentially due to a negative fluid balance 2,3 1. Stevens MA et al. J Am Coll Cardiol 1999;33:403-411 2. Weinstein JM et al. Nephron 1992;62:413-415 3. Solomon R, et al. N Engl J Med 1994;331:1416-1420.

6. Background  The RenalGuard TM automated hydration matching system (PLC Medical System, Inc.) was developed in order to achieve precise real-time high volume fluid balance using a closed loop hydration monitoring and infusion system

7. RenalGuard system Resnic F. et al. J Am Coll Cardiol 2009 53: A36

8. RenalGuard System

9.  closed loop fluid management system  high volume fluid pump  high accuracy dual weight measuring system  single use intravenous set; urine collection system that interfaces with a standard Foley catheter  real-time display of urine and hydration fluid volume  user set net fluid gain and fluid bolus administration for patients that require re- hydration prior to and during the procedure  automatic battery back-up  automatic priming of infusion set  timely alerts to drain urine bag or to replace the hydration fluid bag.

10. Purpose  We performed a prospective, randomized study comparing the prophylactic effectiveness of 2 different strategies for preventing CI-AKI:  Sodium Bicarbonate plus N-Acetylcysteine (Control Group)  Hydration with RenalGuard system (RenalGuard Group)

11. REMEDIAL II DESIGN: Prospective, randomized, double-arm, multicenters clinical study Elective contrast media administration in patients at high risk for CI-AKI (risk score ≥11 and/or eGFR≤30 ml/min/1.73 m 2 ) RenalGuard group Control group CI-AKI (sCr ≥0.3 mg/dL at 48 h)

12. Hypothesis: —Reduction in the primary endpoint from 25% in the Control group to 10% in the RenalGuard group Sample size : – A total of 266 patients (133 each group) will be necessary to gave the study 90% power and a significance level <0.05 Sample size

13. Inclusion criteria  Age  18 y  Chronic kidney disease  High risk for CI-AKI:  eGFR ≤30 ml/min/1.73 m 2 and/or  Mehran score ≥ 11

14. Exclusion criteria Primary or rescue PCI  Pregnancy  Recent (≤ 7 days) contrast media exposure  Chronic dialysis and/or history or previous dialysis  multiple myeloma  pulmonary edema  acute myocardial infarction  Administration of theophylline, dopamine, mannitol, or fenoldopam or sodium bicarbonate.

15. RenalGuard group REMEDIAL II trial Hydration with normal saline (urine flow ≥ 300 ml/h ) & NAC (1.5 g/L) & limited (0.25 mg/kg) furosemide dose Hydration by sodium bicarbonate (3 ml/Kg i.v. 1 h before and 1 ml/kg for 6 h after) & NAC 1200 mg BID x 2 & 1.5 g e.v. during the procedure Sodium Bicardonate & Acetylcysteine

16. Urine flow rate (ml/h) 0 100 200 300 400 500 600 0306090120150180210240270300330360400 Foley Catheter RenalGuard system Prime (≤250 mL) Furosemide (0.25 mg/kg) Pre-procedureProcedurePost- procedure Patient ready for procedure when urine flow rate is ≥300 ml/h Continuous real-time matched replacement fluid Time (minutes) Biomarkers:  sCr = baseline, 2, 6, 12, 24 and 48 hours  sCyC = baseline, 2, 6, 12, 24 and 48 hours  NGAL = baseline, 2, 6, 12, 24 and 48 hours RenalGuard group

17. RenalGuard System

18. Primary endpoint: – Rate of CI-AKI, defined as a serum creatinine (sCr) increase  0.3 mg/dLat 48 hours Secondary endpoints: – an increase in the sCr concentration  25% and  0.5 mg/dl at 48 hours after contrast exposure – changes in the serum cystatin C (sCyC) concentration at 24 and 48 hours after contrast exposure – the rate of acute renal failure requiring dialysis – the rate of in-hospital, and 1 month major adverse events (MAE), including a) death, b) renal failure requiring dialysis, and c) acute pulmonary edema – changes in the serum and urine NGAL concentrations at 2, 6, 12, 24 and 48 hours after contrast exposure Endpoints

19. Assessed for eligibility ( n= 806) Exclusion (n = 512) Not meeting inclusion/exclusion criteria (n = 485 ) Refused to partecipate (n = 27) Randomized (n = 294) Patients lost at follow-up (n = 0) Discontinued treatment (n = 2) Patients allocated in the RenalGuard group (n = 147) Received allocated treatment (n = 146) Did not receive the allocated treatment (n =1) Patients allocated in the Control group (n = 147) Received allocated treatment (n = 146) Did not receive the allocated treatment (n= 1) Patients analized ( n = 146) Patients excluded from analysis (n = 0) Patients lost at follow-up (n = 0) Discontinued treatement (n = 0) Patients analized ( n = 146) Patients excluded from analysis (n = 0) Enrollement Allocation Follow-up Analysis

20. Clinical Characteristics Control Group (N=146) RenalGuard Group (N=146) P Age, yrs (mean  SD)75  976  8 0.31 Male, %103 (70.5%)88 (60.5%)0.065 BMI (kg/m 2 ) 29  528  5 0.16 Blood pressure (mm Hg) Systolic Diastolic Mean 152±27 78±10 103±13 152±27 77±13 102±15 0.99 0.76 0.85 LVEF, % (mean  SD)48  1046  11 0.10 LVEDP (mm Hg)14±7 0.81 Diabetes mellitus104 (71%)101 (69%)0.51 Hypertension, %144 (98%)143 (98%)0.95 Drugs: ACE inhibitor Calcium channel blocker Angiotensin II receptor inhibitor Diuretics  blocker Statins 67 (46%) 44 (30%) 45 (31%) 85 (58%) 88 (60%) 111 (76%) 70 (48%) 36 (25%) 42 (29%) 93 (64%) 92 (63%) 108 (74%) 0.77 0.37 0.77 0.36 0.66 0.73

21. Biochemical Characteristics Control Group (N=146) RenalGuard Group (N=146) P eGFR (ml/min/1.73 m 2 ) GFR ≤ 30 32  7 62 (44%) 32  9 69 (48.5%) 0.83 0.41 Serum Urea Nitrogen (mg/dL) Baseline after 48 h 78  31 70 ± 30 80  35 71±35 0.57 0.84 Serum Sodium (mEq(L) Baseline after 48 h 140  5 139± 6 140  3 140 ± 5 0.37 0.87 Serum Potassium (mEq/L) Baseline after 48 h 4.7  0.7 4.3 ± 0.6 4.6  0.7 4.2 ± 0.6 0.55 0.17

22. Procedural Characteristics Control Group (N=146) RenalGuard Group (N=146) P Performed procedure coronary angiography PCI coronary angiography & PCI peripheral procedure 60 (41%) 58 (40%) 17 (11%) 11 (6%) 51 (35%) 71 (49%) 11 (7.5%) 13 (9%) 0.36 Volume of contrast media (ml) Contrast ratio >1 145  79 35 (24%) 135  76 28 (19%) 0.29 0.32

23. 13% 72.5% 12.5% 0 20 40 60 80 100 120 Risk score ≥5≥6-10 ≥11-15 ≥16 2% Number of patients Distribution of the Risk score

24. p <0.001 0 500 1000 1500 2000 2500 3000 Control GroupRenalGuard group Urine Volume at 24 hours

25. Urine flow rate (ml/h) 0 100 200 300 400 500 600 0306090120150180210240270300330360400 Foley Catheter RenalGuard system Prime (223±45 mL; range = 50-300) Furosemide (14±8mg; range = 0-50) Pre-procedureProcedurePost- procedure Time to reach Target urine flow rate 58±19 min (30-120) Continuous real-time matched replacement fluid Time (minutes) Biomarkers:  sCr = baseline, 2, 6, 12, 24 and 48 hours  sCyC = baseline, 2, 6, 12, 24 and 48 hours  NGAL = baseline, 2, 6, 12, 24 and 48 hours RenalGuard group 7 h & 54 minutes (4.7-11.5 h)

26. RenalGuard Group

27. Time (minutes) Urine flow rate (ml/h)  Mean urine flow rate: 352±131 ml/h  Target reached in 93% of patients (416±19 ml/h)  Below the target in 7% of patients (117±48 ml/h)

28. 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 Baseline2448 Time (hours) serum creatinine (median) p = 0.008; F = 4.97 Control group RenalGuard group sCr kinetic

29. 0 5 10 15 20 25 Control groupRenalGuard group CI-AKI (%) 30/14616/146 Odds ratio = 0.47; 95% CI= 0.24-0.92 p = 0.025 Primary endpoint 20.5% 11%

30. Secondary endpoints

31. 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 Time (hours) serum cystatin C (median) Baseline2448 Control group RenalGuard group p = 0.004; F = 5.52 sCyC kinetic

32. Secondary endpoint Events rate at 1-month 0 1 2 3 4 5 6 7 8 9 10 DialysisDeathPulmonary Edema Cumulative % p = 0.031 p = 0.62 p = 1.0 p = 0.52 4.8 0.7 2.1 4.1 9.6 6.8 Control Group RenalGuard Group

33. Conclusions The RenalGuard therapy, including hydration with normal saline plus high dose of NAC controlled by the RenalGuard system in combination with limited (0.25 mg/kg) dose of furosemide, is an effective renoprotective strategy for patients at high- risk for CI- AKI.

34. REMEDIAL II Investigators Clinica Mediterranea, Naples – C. Briguori (P.I.) – A. Focaccio – G. Visconti – B. Golia Multimedica IRCCS, Milan – F. Airoldi – D. Tavano – S. Di Biase – S. Bertoli University of Ferrara, Ferrara – M. Valgimigli – R. Ferrari University of Modena, Modena – G.M. Sangiorgi – M. G. Modena