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Contrast Nephropathy Prevention Measures Coronary Angiography Riyandy Pratama, Abdullah, Maimun Syukri Division of Nephrologi and Hipertension Department of Internal MedicineRSUZA/ Medical Faculty of UNSYIAH Banda Aceh
Abstract Contrast nephropathy is a kidney function decline within 48-72 hours after administration of contrast media. These events often occur after coronary angiography using kontras.Media action containing ionic contrast nephrotoxic. Reported one case of a man, 44 years old will be taken Coronary - angiography, patients diagnosed coronary arterial with AKI stage injury, with a complaint history of chest pain radiating to the left shoulder and left with difficult breathe.ECG results deduced old myocardial infarction inferior + ischemic lateral, vital signs encountered awareness compos mentis, blood pressure, pulse, respiration and temperature in normal urine 2000cc/24 hours. In the laboratory Hb: 16 g / dl, leukocytes 8,700 / ul, erythrocyte 5.730.000/ul, platelets 284.000/ul LED 13 mm / h Ht: 48%, urea 52 mg / dl, creatinine: 2.2 mg / dl , HBsAg: negative, In the management of patients with infusion of Ringer's lactate administration 20 gtt / I, at the time of NaCl 0.9% flush action as much as 2 liters, After action recheck urea: 37 mg / dl and creatinine 1.0 mg / dl urine 700 cc/4 hours. Patients currently undergoing refurbishment and control poly regularly.
I.INTRODUCTION Radiocontrast use led to increased cases of acute renal failure (ARF) nephrotoxic, an estimated 10% of cases occur during treatment pasien.Variasi contrast nephropathy incidents were reported from several studies is influenced by differences in definition, the observation period after the use of contrast and the prevalence of risk factors in a population study 1. Mitchell et al (2010) in his research found radiocontrast nephropathy occurs more than 10% in patients who underwent computed tomography scanning (CT scan) with contrast at the emergensi2. Radiocontrast nephropathy was defined as an increase in serum creatinine 0.5-1.0 mg / dl or 25% -50% of the initial value that occurs the first 24 hours after administration of contrast media and reached the top 5 days later. European Society of Urogenital Radiology define radiocontrast nephropathy is a disorder of renal function (serum kretinin increase> 0.5 mg / dl or> 25%) within 3 days after contrast exposure, without alternative etiology els.according to acut kidney injury network (AKIN ) radiocontrast nephropathy is an increase in serum creatinine> 0.3 mg / dl with oliguria3. absolute increase in serum creatinine> 0.3 mg / dl as sensitive and more specific for severe kidney trouble and complications death.2 The following will be in the report of a coronary heart disease patients who experience acute kidney injury will do the coronary angiography II Cases Reported a case of a male, 44 years of Consult patients in the cardiology section for the action-coronary angiography, patients diagnosed coronary arterial with AKI stage injury, with a complaint history of chest pain radiating to the left shoulder and left with difficult breathe.ECG results deduced old myocardial infarction inferior + ischemic lateral, vital signs encountered awareness compos mentis, BP : 11o/70mmHG, pulse: 88x/i, respiration: 20x/i and temperature : 36,7 C urine 2000cc/24 hours. In the laboratory Hb: 16 g / dl, leukocytes 8,700 / ul, erythrocyte 5.730.000/ul, platelets 284.000/ul LED 13 mm / h Ht: 48%, urea 52 mg / dl, creatinine: 2.2 mg / dl , HBsAg: negative, In the management of patients with infusion of Ringer's lactate administration 20 gtt / I, at the time of NaCl 0.9% flush action as much as 2 liters, After action recheck urea: 37 mg / dl and creatinine 1.0 mg / dl urine 700 cc/4 hours. Patients currently undergoing refurbishment and control poly regularly,
From investigation; reports angiography left anterior descending: Total osteal stenosis, antegrade from the proximal and of left-lateral circumflex got CO from RCA,, Left circumflex: total block on the proximal after antegrade gets old myocardial infarction from distal to proximal, Old myocardial infarction: 60% stenosis in the mid segment osteal and 70%, RCA: total stenosis in the mid segment, antegrade from the proximal and distal RCA gets co-Left anterior lateral desending. Conclusion: three vessel desease..
III Discussion Acute kidney injury is a rapid decrease (within hours to weeks) glomerular filtration rate which generally lasts reversible, followed by failure of the kidneys to excrete residual nitrogen metabolism, with / without fluid and electrolyte balance disorders 4. Causes of Acute Kidney Injury divided into 3 major sections 5,6 : 1. Prerenal: hypovolemia, decreased cardiac output, renal vascular resistance ratio change systemic, renal hypoperfusion with impaired renal autoregulation, hyperviscosity syndrome 2. Renal: renovascular obstruction, glomerular disease, acute tubular necrosis, interstitial nephritis, and deposition intratubular obstruction, renal allograft rejection 3. Post renal: obstruction ureter, bladder neck obstruction, urethral obstruction Classification RIFLE5,6 RIFLE category Risk Serum creatinine criteria Kriteria urine output
The increase in serum creatinine> 1.5 x baseline <0.5 ml / kg / hour for 6 hours value or decreased glomerular filtration rate> 25%
Injury
The increase in serum creatinine> 2x baseline or < 0,5 ml/kg/hour for 12 hours decreased glomerular filtration rate> 50%
Failure
The increase in serum creatinine> 3x baseline or <0.3 ml / kg / hour for 24 decreased glomerular filtration rate> 75% hours or anuria in 12 hours
Loss
function> 4 week ESRD Terminal renal failure Some parameters of the diagnosis of acute kidney injury assessment5,6
1.
2. Urine volume 3. Serum cystatin c level 4. Biological markers (NGAL, interleukin 18) In patients, the result of lab urea: 52 mg / dl, creatinine: 2.2 mg / dl, 2000cc/24 hour urine production in patients diagnosed coronary heart disease and coronary angiography will be performed the patient is examined serum levels of cystatin C because of funding limitations patients, and no examination NGAL and interleukin 18 as no reagents for examination in the laboratory. Contrast nephropathy is a decline in renal function is occurring abruptly within 48-72 hours after patients received the injection of contrast media with an increase in serum creatinine> 25% of the value baseline4. Patients with impaired renal function who receive radiocontrast usually will have a second phase of oliguria after up to five days radiocontrast administration and an improvement of serum creatinine and urine volume on the seventh day.7,8,9 Contrast nephropathy risk factors involving age, male - female, preexisting renal dysfunction, diabetes mellitus, dehydration, congestive heart failure, multiple myeloma and given the volume of radiocontrast.10,11 Risk factors for contrast-induced nephropathy 8 A. Factors related to patient: CKD, CHF, diabetes mellitus, age> 75 years, dehydration, systemic hypotension, nephrotoxic drugs, anemia related to blood loss during PCI, renal transplant, hypoalbuminemia (<3.5 g / dl) B. Factors associated with the procedure: the large volume of contrast media, intra-arterial administration of contrast medium, various contrast media delivery paths within 72 hours, and isotonicity of osmolality contrast media, intraaortic balloon pump, emergent / primary percutaneous coronary intervention (PCI) The bartorelli et al (2008) found several risk factors and combine with other large studies to obtain a prediction scheme radiocontrast nephropathy risk events as8 :
4
Risk factors hypotension Intra-aortic balloon counter pulsation CHF Diabetes Age > 75 tahun Anemia The volume of contrast medium
Serum kreatinin > 1,5 mg/dl or estimated 4 glomerular filtration rate < 60 ml/min/1,73 m2 eLFG (ml/min/1,73m2)= 186,3x( kreatinin)1,154
x(age)-0,203x0,742 if woman)x1,210 if
man eLFG 40-60 eLFG 20-40 eLFG < 20 Risk scores <5 6-10 11-16 >16 2 4 6 Risk of contrast nephropathy 7,5% 14% 26,1% 57,3% Risk of dialysis 0,04% 0,12 % 1,09% 12,6%
Radiocontrast use with low osmolarity (ratio of iodine atoms to osmotic active particles) is useful for reducing the incidence of nephropathy. Meta-analysis of studies comparing high and low osmolality radiocontrast, obtained with low osmolarity radiocontrast nephropathy radiokontras slight lead.7,9,11 Contrast media should be considered in some instances before given such as high osmolarity, ionic contrast, Visikositas contrast media and contrast volume was sendiri.Suatu randomized study states contrasts with high osmolarity (> 1400 mOsm) at greater risk of the occurrence of contrast nephropathy. Iohexol significantly related to increased risk of contrast nephropathy compared Iopamidol or iodixanol.2,3
In this case a man - 44 years old at diagnosis of coronary artery disease encountered in awareness of the vital signs that compost mentis, blood pressure, pulse, respiration and temperature within normal limits. Urea: 52 mg / dl, creatinine: 2.2 mg / dl, using the contrast agent iopamiro 370 50 ml mild risk factor for radiocontrast nephropathy Recommendation and selection of patients for the prevention of contrast nephropathy 10,12,13 1. Patients who received angiography scheduled to be checked serum creatinine 2. Kliren examination creatinine 3. Patients with moderate to severe risk : a. Selection of imaging examinations (gadolinium angiography) b. Cessation of NSAIDs, dipiridamol, metformin 48 hours before the procedure c. Stop diuretics and ACE inhibitors 24 hours before the procedure d. Hydration Moderate risk: 0.45% saline (1.0-1.5 ml / kg / h) 4 hours before the procedure s / d 24 hours after the procedure. Risk weight: 0.45% saline (1.0 to 1.5 ml / kg / hour) 12 hours before the procedure s / d 24 hours after the procedure. e. The use of low molecular radiocontrast f. Radiocontrast volume limited g. Monitor urine output, BUN and serum creatinine examination 24 hours after the procedure. Bartoreli et al (2008) found in some studies of hydration with isotonic saline is superior than isotonic saline as isotonic fluid capacity building extends to the intravascular volume8 .. Fluid administration aims to reduce vasoconstriction stimulation in patients with dehydration, compensate for fluid loss due to the use of osmotic diuresis, lowering the concentration of radiocontrast in intraluminal urinary tubules and reduce the viscosity and reduce the toxicity of the tissue fluid ginjal.pemberian inpatients performed with saline 0.45 % 1 ml / kg / hour for 24 hours and 6-12 hours before tindakan.Pemilihan saline 0.45% is now replaced by saline 0.9%.7,8,12
The guide recommendation of the UK Health care is as follows16: Hydration with saline IVFD 1ml/kg/hr (max 100 ml / hour) 12 hours before and 12 hours post-contrast (total infusion time 24 hours) CHF or left ventricular ejection fraction (LVEF) <40% / 0.5 ml / kg / hour (max 50 ml / hour) 12 hours pre and post contrast (long total infusion for 24 hours) Emergency procedures / (regimen recommended) 500-1000 ml fluid bolus prior to action. Procedures or hydration during and 12 hours later if possible (depending on their clinical status) Preventive pharmacological strategies contrast nephropathy8 Positive results (potentially useful): hydration, theopylin / aminophilin, N-acetylcystein, statins, prostaglandin E1, trimezatidine Results neutral (inconsistent effects): fenoldopam, dopamine, chalcium channel blockers, atrial natriuretic peptide, l-arginine Negative results: furosemide, mannitol, endothelin receptor antagonists In this case the patient in tatalaksanaan with Ringer's lactate infusion administration 20gtt / I, when 0.9% NaCl flush action as much as 2 liters, check the post acts urea: 37 mg / dl and creatinine 1.0 mg / dl. V. COMPLICATIONS Complications of contrast nephropathy can be`17: Residual kidney damage by 30%, and 7% who require dialysis while, hematoma formation,ARDS, stroke,gastrointestinal hemorage, pulmonary embolism,coma .In this case not encountered complications
VI Prognosis Contrast nephropathy is usually a process while the renal function returned to normal 7-14 day delivery kontras.kurang of one third of patients had residual renal damage, patients with diabetes mellitus, hypovolemia, heart failure, liver cirrhosis, hypertension and proteinuria are at high risk for the occurrence of nephropathy this contrasts with patients given contrast nephropathy have a poor prognosis. In this case the patient's prognosis good VII Summary Reported one case of a man - 44 year old be taken Cast - ndiagnosa angiography in CAD with urea: 52 mg / dl, creatinine: 2.2 mg / dl ditatalaksanaan patient with ringer lactate infusion administration GTT 20 / I at the time the action flush Nacl 0 , 9% post actions 2 liter urea: 37 mg / dl and creatinine 1.0 mg / dl and the patient can go home and control back to the cardiology and GH
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