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Contrast nephropathy : Every cardiologist should get trained to shoot with this RIFLE !

Posted Sep 04 2011 12:39pm

This RIFLE  shoots without  bullets . Yes ! it  helps the cardiologist to  trouble shoot  the kidneys which often  suffer from  cath lab cross fires .

As  the cardiologists indulge in sophisticated cardiac procedures ,  in more and  more  sick and co- moribund  patients , it is becoming increasingly  important  for them ,  to   give due  respects  to  other organs as well !

Renal function is an important determinant   in the  over all outcome  in any cardiac patient.

  1. How to assess  the baseline renal function ?
  2. How to measure  the impact  of the  cardiac procedure ?
  3. How to  follow  up and monitor the  progress of  renal function   in coronary  care unit.
  4. How to  reduce the enhanced renal  risk ?
  5. When do you call for  the Nephrology consult ?

Every step becomes  vital . Do not ever think , a  cardiologist’s job is over  once few  stents are deployed . Wheeling   out a  sick  and fragile diabetic  with borderline  creatinine    out of the cath lab  may be  considered   as a procedural success  , but the real success happens only after  every organ of the  your patient  comes  out  unscathed  after the procedure .  In this  context  , we should first aim to  become a nephron  savvy and a nephron friendly cardiologist .

I have witnessed  cardiologists  spend hours  together  in cath lab with liberal injections of contrasts  even in  elderly  who have delicate kidneys .Cardiologist should realise  kidneys are soft and gentle  organs  which unlike the heart  , do not  know  how to cry  (Angina) at times of stress  as they lack  well developed pain fibers  (unmedulated  type c fibers to be precise!) .Only thing they  know  is ( like touch me not plant !)   they  strike work  the next   next morning (What we refer to  technically as Acute renal  shut down !)

Now , we see little  interaction  occurring between a  cardiologist and nephrologist  prior to PCI , even though  those two organs ( The   respective experts behold )  are  constantly in touch  with each other , every minute ,  by neural and hormonal mechanisms. The new generation organ  specialists  has to learn  a lot   from these sincere , interactive  , democratic  human   biological system.

Coronary arteries can gulp any amount of dye but  not the renal  arteries .The   future looks still more frightening ,  as we have a variety of devices lined  up  to invade human vascular tree (TAVI, Renal ablation, per cutaneous aortic pumps etc)

So what should we do ?

  • Patients  prone for  CIN should be promptly  recognized .
  • Ask repeatedly  the question .  Am  I   sure  ?  . . .does this patient  require this  procedure at all ?  If  so , have I taken all the precautions ?
  • Use the nephrologist’s services more liberally

Finally ,  read the basics of  nephrology   lessons  once again .  The international consensus group has  classified   the Acute kidney  injury  (AKI)   with a  simple and lovely criteria  for  risk  triaging .     It is a  five faceted ,  inverted  (Tip less ) triangular  cartoon called  RIFLE .

The beauty of  RIFLE   lies in its  simplicity . All  it requires  is  serum  creatinine   (eGFR)  levels  and urine output.  Let  every  cardiologist  master this scheme of AKI . It will immensely  help  our  patients   and make us  a  complete  physician   instead of   being  labelled as a  “master of  an  organ”   or   ” An accessory sub physician”

Source : http://www.smjr.org/files/nephro/RIFLE.PDF

The CIN prevention recipe.

Source Catheterization and Cardiovascular Interventions 69:135–140 (2007)

References

For review about Contrast nephropathy (CIN)  there are lots of excellent articles.

One company is trying to find a new  solution for  this complication . Let us welcome it ! The device is called rena  guard .


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