2. • Definition
• Prognosis
• Pathology
• Risk factor
• Incidence
• Prevention
• Recommendation

3. Case 1
• 69 y/o M with NSTEMI is going for PCI.
Baseline Cr 65. 2 days post PCI Cr is 94 with
good UOP .
• Are you concerned about what happened?

4. Case 2
• 42 y/o F in 5C3 with T2 DM with baseline Cr
of 60 she is scheduled for CT abdomen for
pancreatitis .
• What is her risk of developing CIN?

5. Case 3
• 78 y/o came with IWMI with hypotension
required IABP and pressors is going for
diagnostic angiogram after successful lytic
therapy . Known DM with Cr 150 ,he is
concerned about his kidneys .
• Is there a way to predict his risk ?

6. Case 4
• 65 y/o F smoker ,T2 DM with Cr 100,HTN and
sever PVD underwent 1ry PCI for AWMI. Next
day Cr 200 and you notice periphral cynosis
with rash over Rt leg.
• What is happening with her?

7. Types of radiocontrast agents
• First generation agents are ionic hyperosmolal
monomers( 1500)
• Second generation agents are nonionic
monomers with a lower osmolality than the
first generation (600)
• The nonionic contrast agents are dimers with
an osmolality ( 350)

8. Definition
25% rise in serum creatinine during the first
three days after the procedure is the most
acceptable definition .

9. Prognosis
• Peak in 1-3 days
• Recovery 5-10
• If creatinine >440 moslt likely progress to RF
requiring HD.

10. PATHOGENESIS
The exact mechanism is not well understood .
The two major theories, based mainly on animal
studies:
renal vasoconstriction(endothelin)
direct toxic effects of the contrast agents.

11. INCIDENCE AND RISK FACTORS
The reported incidence of radiocontrast-
induced nephropathy varies widely, ranging
from 0- 50%.

12. Who is in risk
• Underlying renal insufficiency, with the plasma
creatinine exceeding 132 µmol/L(4-11%) and 50% if
exceeding 350µmol/L.
• Diabetic nephropathy with renal insufficiency (9-
30%)
• Multiple myeloma (1.5%)
• Advanced heart failure or other cause of reduced
renal perfusion such as hypovolemia
• High total dose of contrast agent and the type of
the contrast

13. Normal kidney function
Negligible with normal renal function, even if
the patient is diabetic

14. In PCI
In a review of over 7500 patients undergoing a
PCI for coronary heart disease, the incidence
of CIN was 3.3 percent overall and
approximately 25 percent in those with a
baseline serum creatinine above (177 µmol/L)
.

15. PREVENTION

16. Which of the following modalities can
prevent CIN?
• Lasix
• Manitol
• Dobutamin
• Theophyline
• Ca blockers
• ANP
• UF
• HD
• Statin

17. Effective
• Hydration
• NAC
• NaHCO3

18. Oral hydration
• Few small trials have evaluated the
effectiveness of oral hydration or an
outpatient hydration protocol in preventing
contrast nephropathy.
• The results have been conflicting, some
suggested that oral hydration as effective
others less effective .

19. Type of fluid
• Prospective randomized trial of 1620
patients . The incidence of contrast-induced
nephropathy was significantly lower in
patients received NS than 1/2NS

20. Acetylcysteine
• There is inconsistency in the results of clinical
trials regarding the effectiveness of NAC in
prevention of contrast nephropathy .
• The overall direction of the data is towards
benefit .

21. NaHCO3
• A prospective, single-center, randomized trial
showed overall benefit of NaHCO3 compared
to NS .
• Issues with this study

22. SUMMARY AND RECOMMENDATIONS
• Indication of the procedure
• The use of lower doses of contrast and avoidance of
repetitive studies that are closely spaced.
• Avoid of volume depletion
• Avoid NSAID
• Stop metformin 48h before

23. Hydration
Prophylactic regimen is the intravenous
administration of NS at a rate of 1 mL/kg /h for 12
hours before and 12 hours after the radiographic
study .

24. NAC
PO: 600 mg orally BID and administered the day
before and the day of the procedure .
IV: 150 mg/kg in 500 mL NS over 30 minutes
immediately before contrast exposure, then
50 mg/kg in 500 mL NS over four hours .

25. NaHCO3
• A bolus of 3 mL/kg of NaHCO3 one hour prior
to the procedure, and continued at a rate of 1
mL/kg for six hours after the procedure.

26. Contrast
Both low osmolal and iso-osmolal nonionic
agents appear to lower the risk of
nephropathy .

27. HD and UF
• Creatinine >440
• Decrease UOP
• Acidosis
• Hyperkalemia

29. Case 1
• 62 y/o M with NSTEMI is going for PCI.
Baseline Cr 65. 2 days post PCI Cr is 94 with
good UOP .
• Are you concerned about what happened?

30. Case 2
• 42 y/o F in 5C3 with T2 DM with baseline Cr
of 60 she is scheduled for CT abdomen for
pancreatitis .
• What is her risk of developing CIN?

31. Case 3
• 78 y/o came with IWMI with hypotension
requiring IABP is going for diagnostic
angiogram after successful lytic therapy .
Known DM with Cr 150 is concerned about his
kidney function.
• Is there a way to predict his risk ?

33. Case 4
• 65 y/o F smoker ,T2 DM with Cr 100,HTN and
sever PVD underwent 1ry PCI for AWMI. Next
day Cr 200 and you notice periphral cynosis
with rash over Rt leg.
• What is happening with her?

34. Cholesterol embolism
• Low complement
• Eosinophilia
• Eosinophilurea
• Systemic ischemia
• Acute deterioration
• Last upto 8 weeks
• Livedo reticularis

35. THANKS