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What Constitutes

Nephrology
Clearance?
Oscar Naidas, MD
Frederick Ogbac, MD
What he will say ...
Nephrology Clearance vs Nephrology
Risk Stratification / Assessment and
Management
Composition of Nephrology Clearance
Pre employment Nephrology
Clearance
CT-Scan with IV contrast
Coronary angiography or PCI
General Surgery
MRI with gadolinium contrast
Define Nephrology Clearance vs
Risk Stratification / Assessment
and its Management
Definition of Clearance ( )
Official authorization for something to
proceed or take place
Example:
Do not schedule the patient for CT
Scan of the abdomen with IV contrast
until you are given clearance by the
nephrologist

Oxford Advance Learners Dictionaries


Nephrology Risk
Assessment and
Management
Type of potential ischemic / nephrotoxic
insult
Assessment of risk factors of the patient
An estimate of the risk (quantitative or
semi-quantitative)
Management / intervention to reduce risk
Risk vs Benefit
Communication with the referring
physician and/or the patient
The seafarer with chronic
GN
The seafarer with chronic
GN

35 M, asymptomatic,
BP:140/90mmHg, Ht 57, Wt 70 kg,
Urine rbc 10-15/hpf, prot trace
(UPCR 0.6)
Scr 1.4mg/dl (eGFR 68ml/min)
US KUB(-)
LPD, Losartan (130/80mmHg), UPCR
0.3
Ffup q 6 mos for 3 years, stable
The seafarer with chronic
GN

Asymptomatic, BP
130/80mmHg,
Ht 57, Wt 70 kg,no edema,
Urine rbc 15-20/hpf, protein(-)
ACR 110 mg/g
Scr 1.5mg/dl (eGFR 62ml/min)
US KUB(-)
The seafarer with chronic
GN

Chronic GN probably IgAN


The seafarer with chronic
GN

Chronic GN probably IgAN, CKD


G2A2 (moderate risk of
progression)
The seafarer with chronic
GN

No indication for kidney


biopsy, stable for past 3 yrs,
LPD and Losartan 50mg OD
(<BP130/80mmHg ), slows
the fall in GFR to 3ml/min/yr
The seafarer with chronic
GN

No indication for kidney biopsy, stable for


past 3 yr
LPD and Losartan 50mg OD
(<BP130/80mmHg ), slows the fall in GFR
to 3ml/min/yr (62ml/min to 59ml/min)
Low risk of progression of CKD
Low probability of progression of CKD
that will require hospitalization or dialysis
within next 9 to 12 months
Repeat BP, Scr, UPCR after 9 to 12 months
Patient w/ CKD will undergo
CT Scan w/ IV contrast
56 F, DM2, HTN, HF symptoms
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 130/90 mmHg Wt: 60kg Ht: 51
SCr 1.5 (eGFR 38.5 ml/min) Uprot: +2
Chronic abdominal pain
US pancreatic mass?
Will undergo whole abdomen CT-Scan with
contrast

Referred for Nephrology Clearance


(38.5 ml/min)
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

J Am Coll Cardiol,
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

Total =
13

J Am Coll Cardiol,
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

Risk Score Risk of CIN Risk of


(%) Dialysis (%)
<5 7.5 0.04
6 to 10 14 0.12
11 to 16 26.1 1.09
> 16 57.3 12.6
Total =
13

J Am Coll Cardiol,
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD
Estimate your patients risk G3bA3,DM2,HF will undergo
after an event (CI AKI) without abdominal CT w IV contrast
treatment (Rc) with a risk of CI AKI 26%
(MODERATE RISK)
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD
Estimate your patients risk G3bA3,DM2,HF will undergo
after an event (CI AKI) without abdominal CT w IV contrast
treatment (Rc) with a risk of CI AKI 26%
(MODERATE RISK)
STEP 2
Estimate the RR using the
study result
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD
Estimate your patients risk G3bA3,DM2,HF will undergo
after an event (CI AKI) without abdominal CT w IV contrast
treatment (Rc) with a risk of CI AKI 26%
(MODERATE RISK)
STEP 2 Saline hydration+ NAC,
Estimate the RR using the reduces the risk of CI AKI
study result RR = 0.68
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal CT w IV
after an event (CI AKI) without contrast with a risk of CI AKI
treatment (Rc) 26% (MODERATE RISK)
STEP 2 Saline hydration+ NAC,
Estimate the RR using the reduces the risk of CI AKI
study result RR = 0.68
STEP 3 Rt = Rc x RR
Estimate your individual = 26% x 0.68
patients risk for an event (CI = 18%
AKI)with treatment
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD
Estimate your patients risk G3bA3,DM2,HF will undergo
after an event (CI AKI) without abdominal CT w IV contrast
treatment (Rc) with a risk of CI AKI 26%
(MODERATE RISK)
STEP 2 Saline hydration+ NAC,
Estimate the RR using the reduces the risk of CI AKI
study result RR = 0.68
STEP 3 Rt = Rc x RR
Estimate your individual = 26% x 0.68
patients risk for an event (CI = 18%
AKI) with treatment
STEP 4 ARR = Rc Rt
Estimate the individualized = 26% - 18%
ARR = 8% (LOW RISK)
Composition of a Nephrology Risk
Assessment and Management
Type of potential ischemic/nephrotoxic insult CT Scan w IV contrast

Assessment of risk factors of the patient CKD eGFR 38ml/min


DM2,HF

An estimate of the risk ( quantitative or semiquantitative ) CI AKI


26% (MODERATE RISK)

Management/Intervention to reduce risk Saline Hydration +NAC


reduce risk to 8% (LOW RISK)

Risk vs Benefit Confirmation +/- of pancreatic mass with CT


Scan w/ IV contrast outweighs LOW RISK of CI AKI

Communication with the referring physician and/or the patient


The Patient w CKD will Undergo
Coronary Angiography/PCI
56 F, DM2, HTN, with HF symptoms
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 130/90 mmHg Wt: 60kg
SCr 1.5 (eGFR 38ml/min) Uprotein: +2
Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8 mg/dl
ECG: LVH
Dx: CKD St G3bA1, DM Nephropathy, Will
undergo coronary angiogram/PCI ACC / AHA
Class IIb indication

Referred for Nephrology Clearance


Comparison of Renal Risk
Stratifications for CKD
patients prior to CA or PCI
Index No. of Score
variables range
Mehran 8 0 34
JACC 2004

Tziakas 5 08
Am J
Cardiol
2014
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

J Am Coll Cardiol,
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

Total =
13

J Am Coll Cardiol,
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al

Risk Score Risk of CIN Risk of


(%) Dialysis (%)
<5 7.5 0.04
6 to 10 14 0.12
11 to 16 26.1 1.09
> 16 57.3 12.6
Total =
13

J Am Coll Cardiol,
Validation of a New Risk Score to Predict
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic
G, et al

Am J Cardiol, 2014
Validation of a New Risk Score to Predict
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic
G, et al

Am J Cardiol, 2014
Validation of a New Risk Score to Predict
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic
G, et al

Risk Score Risk for CI-AKI


<3 7.5%
>3 34%

Am J Cardiol, 2014
Comparison of Tziakas Risk Score vs Mehran
Risk Stratification in Predicting Contrast-
Induced Acute Kidney Injury among Patients
Undergoing Coronary Angiography at SLMC-
QC
Ogbac FE, Gonzales-Porciuncula L, Buaron MJ, Semeniano R, Cheng F,
Naidas O

AUC
0.69
0.73

SLMC-QC Section of
Comparison of Tziakas Risk Score vs Mehran
Risk Stratification in Predicting Contrast-
Induced Acute Kidney Injury among Patients
Undergoing Percutaneous Coronary
Intervention at SLMC-QC
Ogbac FE, Gonzales-Porciuncula L, Buaron MJ, Semeniano R, Cheng F,
Naidas O

AUC
071
0.79

SLMC-QC Section of
Individualizing risk management
Tziakas
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 7.5% (LOW RISK)
Individualizing risk management
Tziakas
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 7.5% (LOW RISK)

STEP 2 Saline hydration + NAC reduces the risk of


Estimate the RR using the study result CI AKI
RR = 0.68
Individualizing risk management
Tziakas
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 7.5% (LOW RISK)

STEP 2 Saline hydration + NAC reduces the risk of


Estimate the RR using the study result CI AKI
RR = 0.68

STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 7.5% x 0.68
an event (CI AKI) with treatment = 5%
Individualizing risk management
Tziakas
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 7.5% (LOW RISK)

STEP 2 Saline hydration + NAC reduces the risk of


Estimate the RR using the study result CI AKI
RR = 0.68

STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 7.5% x 0.68
an event (CI AKI) with treatment = 5%

STEP 4 ARR = Rc Rt
Estimate the individualized ARR = 7.5% -5%
= 2.5% (LOW RISK)
Individualizing risk management
Mehran
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 26% (MODERATE RISK)

STEP 2 Saline hydration + NAC reduces the risk


Estimate the RR using the study result of CI AKI
RR = 0.68

STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 26% x 0.68
an event (CI AKI) with treatment = 18%

STEP 4 ARR = Rc Rt
Estimate the individualized ARR = 26% -18%
= 8% (LOW RISK)
Composition of a Nephrology Risk
Assessment and Management
Type of potential ischemic/nephrotoxic insult CA/PCI

Assessment of risk factors of the patient CKD eGFR 38ml/min,


DM2,HF

An estimate of the risk ( quantitative or semiquantitative ) CI AKI


7.5% to 26% (LOW to MODERATE RISK)

Management/Intervention to reduce risk( Saline hydration+NAC


reduce risk to 2.5% to 8% (LOW RISK)

Risk vs Benefit Benefit of CA/PCI outweighs LOW RISK of CI AKI

Communication with the referring physician and/or the patient


The Patient withCKD who will
undergo abdominal surgery
56 F, DM2, HTN
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 130/90 mmHg Wt: 60kg
SCr 1.5 Uprotein: +2 eGFR:38.5 mL/min
Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8mg/dL
CT Scan: solid mass at pancreatic tail, ascites
Coroangio: negative
Pre-op CV: stratification intermediate to high risk of
developing perioperative CV complications
Partial pancreatectomy

Referred for Nephrology Clearance


Development and validation of an Acute
Kidney Injury Risk Index for Patients
Undergoing General Surgery
Kheterpal S, Tremper KK, Heung M, et al

Anesthesiology, 2009
Development and validation of an Acute
Kidney Injury Risk Index for Patients
Undergoing General Surgery
Kheterpal S, Tremper KK, Heung M, et al

Total = 6
Anesthesiology, 2009
Development and Validation of an Acute
Kidney Injury Risk Index for Patients
Undergoing General Surgery
Kheterpal S, Tremper KK, Heung M, et al

Preoperative Risk AKI incidence HR (95%, CI)


Class (%)
Class I (0-2 risk 0.2
factors)
Class II (3 risk 0.8 4.0 (2.9 5.4)
factors)
Class III (4risk 1.8 8.8 (6.6 11.8)
factors)
Class IV (5 risk 3.3 16.1 (11.9
factors) 21.8)
Class V (6+ risk 8.9 46.3 (34.2
factors) 62.6)
Anesthesiology, 2009
Development and validation of an Acute
Kidney Injury Risk Index for Patients
Undergoing General Surgery
Kheterpal S, Tremper KK, Heung M, et al

Preoperative Risk AKI incidence HR (95%, CI)


Class (%)
Class I (0-2 risk 0.2
factors)
Class II (3 risk 0.8 4.0 (2.9 5.4)
factors)
Class III (4risk 1.8 8.8 (6.6 11.8)
factors)
Class IV (5 risk 3.3 16.1 (11.9
factors) 21.8)
Class V (6+ risk 8.9 46.3 (34.2
factors) 62.6)
Anesthesiology, 2009
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal
after an event (AKI) without surgery with a risk of post op
treatment (Rc) AKI 9% (HIGH RISK)
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal
after an event (AKI) without surgery with a risk of post op
treatment (Rc) AKI 9% (HIGH RISK)
STEP 2 Perioperative hemodynamic
Estimate the RR using the optimization, reduces the risk
study result of
post op AKI
RR = 0.64
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal
after an event (AKI) without surgery with a risk of post op
treatment (Rc) AKI 9% (HIGH RISK)
STEP 2 Perioperative hemodynamic
Estimate the RR using the optimization, reduces the risk
study result of
post op AKI
RR = 0.64
STEP 3 Rt = Rc x RR
Estimate your individual = 9% x 0.64
patients risk for an event (AKI) = 6%
with treatment
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal
after an event (AKI) without surgery with a risk of post op
treatment (Rc) AKI 9% (HIGH RISK)
STEP 2 Perioperative hemodynamic
Estimate the RR using the optimization, reduces the risk
study result of
post op AKI
RR = 0.64
STEP 3 Rt = Rc x RR
Estimate your individual = 9% x 0.64
patients risk for an event (AKI) = 6%
with treatment
STEP 4 ARR = Rc Rt
Estimate the individualized = 9% - 6%
ARR = 3% (MODERATE
RISK)
Composition of a Nephrology Risk
Assessment and Management
Type of potential ischemic/nephrotoxic insult Partial
pancreatectomy

Assessment of risk factors of the patient 56F,CKD,DM,2HTN

An estimate of the risk ( quantitative or semiquantitative ) GS AKI


Risk 9% (HIGH RISK)

Management/Intervention to reduce risk Perioperative


hemodynamic optimization reduces risk to 3% (MODERATE
RISK)

Risk vs Benefit Benefit of partial pancreatectomy outweighs


MODERATE RISK of post op AKI

Communication with the referring physician and/or the patient


The patient with CKD will undergo
MRI w gadolinium contrast
57 F, DM2, and HTN
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 120/90 mmHg Wt: 60kg
SCr 1.6 eGFR: 35.4 ml/min/1.73m2
Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5
mg/dl
Changes in sensorium t/c CVD vs
metastasis

Will undergo MRI with gadolinium contrast


American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

Nephrogenic Sytemic Fibrosis


A fibrosing disease primarily involving
the skin and subcutaneous tissues seen
in patients with renal problem

ACR Manual on Contrast Media,


American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

Risk Factors for NSF


Gadolinium based contrast agent
administration
Hemodialysis
Chronic Kidney Disease
Acute Kidney Injury
High dose and multiple exposure

ACR Manual on Contrast Media,


American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

For Inpatients:
eGFR should be obtained within 2 days prior to giving gadolinium

ACR Manual on Contrast Media,


American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

For Inpatients:
eGFR should be obtained within 2 days prior to giving gadolinium

ACR Manual on Contrast Media,


American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

For patients with eGFR < 30 ml/min/1.73m 2:


Gadolinium agents should be avoided
If gadolinium enhanced MRI is deemed essential, use of
the lowest possible dose is recommended

For patients with eGFR 30-39 ml/min/1.73m 2:


NSF is rare, but precautions are recommended

For patients with eGFR 40-59 ml/min/1.73m 2:


NSF is rare, with no precautions

For patients with eGFR > 60 ml/min/1.73m2:


No evidence of increased risk of developing NSF
ACR Manual on Contrast Media,
American College of Radiology
Manual on Contrast Media (Ver 9, 2013)

For patients with AKI


Gadolinium agents should only be
administered if absolutely necessary

ACR Manual on Contrast Media,


Composition of a Nephrology Risk
Assessment and Management
Type of potential ischemic/nephrotoxic insult MRI w Gadolinium
Contrast

Assessment of risk factors of the patient 56F,CKD,DM2,HTN,eGFR


35ml/min

An estimate of the risk ( quantitative or semiquantitative ) NSF is rare

Management/Intervention to reduce risk ? Lower dose of gadolinium

Risk vs Benefit Benefit of MRI w gadolinium contrast outweighs


VERY LOW RISK of NSF

Communication with the referring physician and/or the patient


What he just said ...
Nephrology Clearance vs Nephrology Risk
Stratification / Assessment and
Management
Composition of Nephrology Clearance
Type of potential ischemic/nephrotoxic insult
Assessment of risk factors of the patient
An estimate of the risk ( quantitative or
semiquantitative )
Management/Intervention to reduce risk
Risk vs Benefit
Communication with the referring physician
and/or the patient
Our Patient
56 F, DM2, HTN, with HF symptoms, non
smoker
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 130/90 mmHg Wt: 60kg BMI= 25.8
SCr 1.5 Uprotein: +2 eGFR 38.5
Hb/Hct: 11/30 HbA1C: 7% Alb: 3.8 mg/dl
EF: 65% with LVH, hypokinesia of LV wall
CA: 4VD with Left main coronary artery
involvement

Will undergo CABG


Predictive Indices for
Estimating Risk of Post-
SRICardiac Surgery
Wijeysundera, RRT and
et al. Derivation
validation of a simplified predictive
index for renal replacement therapy
after cardiac surgery. JAMA, 2005.
Mehta, et al. Bedside Tool for predicting
the risk of postoperative dialysis in
patients undergoing cardiac surgery.
Circulation, 2006
Thakar, et al. A clinical score to predict
acute renal failure after cardiac surgery.
J AM Soc Nephrol, 2005.
Comparison of Predictive
Indices for Estimating Risk of
Post-Cardiac Surgery RRT
Index No. of Score AUC
variables range (Toronto
cohort)
SRI 2007 8 08 0.78
(0.72-0.84)
Mehta 10 0 83 0.75
2005 (0.66-0.83)
Thakar 13 0 17 0.81
2005 (0.74-0.86)
JAMA, 2007
Derivation and Validation of a Simplified
Predictive Index for Renal Replacement
Therapy After Cardiac Surgery (SRI)
Wijeysundera DN, Karkouti K, Dupuis JY, et al

JAMA, 2007
Derivation and Validation of a Simplified
Predictive Index for Renal Replacement
Therapy After Cardiac Surgery (SRI)
Wijeysundera DN, Karkouti K, Dupuis JY, et al

Total =
3JAMA, 2007
Derivation and Validation of a Simplified
Predictive Index for Renal Replacement
Therapy After Cardiac Surgery (SRI)
Wijeysundera DN, Karkouti K, Dupuis JY, et al

Risk Categories Risk of RRT


(%)
Low Risk (0 to 1 point) 0.4
Intermediate Risk (2 to 3 3
points)
High Risk (> 4 points) 10

JAMA, 2007
Derivation and Validation of a Simplified
Predictive Index for Renal Replacement
Therapy After Cardiac Surgery
Wijeysundera DN, Karkouti K, Dupuis JY, et al

Risk Categories Risk of RRT


(%)
Low Risk (0 to 1 point) 0.4
Intermediate Risk (2 to 3 3
points)
High Risk (> 4 points) 10

JAMA, 2007
Circulation, 2006
Bedside Tool for Predicting the Risk of
Postoperative Dialysis in Patients
Undergoing Cardiac Surgery
Mehta RH, Grab JD, OBrien SM, et al

Circulation, 2006
Bedside Tool for Predicting the Risk of
Postoperative Dialysis in Patients
Undergoing Cardiac Surgery
Mehta RH, Grab JD, OBrien SM, et al
12
1
0
5
0
2
0
0
0

20
Circulation, 2006
Bedside Tool for Predicting the Risk of
Postoperative Dialysis in Patients
Undergoing Cardiac Surgery
Mehta RH, Grab JD, OBrien SM, et al

Circulation, 2006
Bedside Tool for Predicting the Risk of
Postoperative Dialysis in Patients
Undergoing Cardiac Surgery
Mehta RH, Grab JD, OBrien SM, et al

1.1%

Circulation, 2006
J Am Soc Nephrol,
A Clinical Score to Predict Acute
Renal Failure after Cardiac
Surgery
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP

J Am Soc Nephrol,
A Clinical Score to Predict Acute
Renal Failure after Cardiac
Surgery
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP

Total
=5

J Am Soc Nephrol,
A Clinical Score to Predict Acute
Renal Failure after Cardiac
Surgery
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP
Risk Categories Risk of RRT (%)
02 0.4
35 1.8
68 7.8
9 13 21.5

J Am Soc Nephrol,
Comparison of Predictive
Indices for Estimating Risk of
Post-Cardiac Surgery RRT
Index No. of Score Risk Risk for
variabl range Score RRT
es post
CABG
(%)
SRI 8 08 3 3
2007
Mehta 30 0 83 20 1.1
2005
Thakar 13 0 17 5 1.8
The risk of AKI requiring RRT post-cardiac
2005 surgery is between
Crit Care, 2014
Predictive Models for Kidney Disease:
Improving global Outcomes (KDIGO) defined
Acute Kidney Injury in UK Cardiac Surgery
Birnie K, Verheyden V, Domenico P, et al

P- 20,995 patients underwent


cardiac surgery including surgery to
thoracic aorta (3 different centers)

I- retrospective cohort

O- occurrence of post cardiac


surgery AKI
Crit Care, 2014
http://www.cardiacsurgeryleicester.com/our-research/acute-kidney-injury-risk-
Predictive Models for Kidney Disease:
Improving global Outcomes (KDIGO) defined
Acute Kidney Injury in UK Cardiac Surgery
Birnie K, Verheyden V, Domenico P, et al

Crit Care, 2014


http://www.cardiacsurgeryleicester.com/our-research/acute-kidney-injury-risk-
Perioperative Acute Kidney Injury
Calvet S, Shaw A

Preventive measures for cardiac


surgery
Fluids and goal directed therapy
Avoidance of nephrotoxic agents
Hemodilution and transfusion

Perioper Med, 2012


Our patient post-op
57 F, DM2, and HTN
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg
BID
BP: 120/90 mmHg Wt: 60kg
SCr 1.6 eGFR: 35.4 ml/min
Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5
mg/dl
Histopath: cervical CA

Will undergo cisplatin chemotherapy


Risk Factors for Cisplatin
Nephrotoxicity
Previous cisplatin chemotherapy
Pre-existing kidney damage
Concomitant administration of
potentially nephrotoxic agents
High peak plasma free platinum
concentrations

Uptodate, 2014
Prevention of Cisplatin
Nephrotoxicity
Lower dose of cisplatin
1L isotonic saline + 20 meqs KCl +
2gms MgSO4 3 hours prior to
administering chemotherapy and
minimum of 500ml over 2 hours
following administration

Uptodate, 2015
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