Management of Renal Insufficiency in Your Complex Patient

Management of Renal Insufficiency in Your Complex Patient by Marsha Holton, CCRN, RCIS, FSICP CRT 2010 Nurse Technologists Symposium 1

Indian Head, MD. Feb 6, 2010 2

DISCLOSURES Marsha Holton, RN I have no real or apparent conflicts of interest to report. However I am open to offers for the school.

Objectives Roxanna Mehran, MD Her work and dedication is why so many of us are more aware Thank you. 4

Objectives • Review basic kidney function – Really basic. One slide basic. • Review the calculation for creatinine clearance – And practice doing it. – Or go to Nephron. com and calculate GFR • Discuss the research and expert advice on identifying the risks and how to manage these patients risk of developing CIN In 20 minutes or less. Right. 5

Kidneys First 1. Produce urine from the blood flow – 2. Filter and reabsorb usable fluid, electrolytes, minerals etc necessary to maintain homeostasis or balance 3. 3 Main Jobs: Clear toxins and wastes using the filtered flow to make the urinary output. 6 6

Blood Goes In Urine Comes Out • 90% of flow recycled • 10% is urine – So your kidneys really have to work • Learn to evaluate their function – every patient every time How you might ask? 7

Two Ways To Calculate 8 8

To Calculate Creatinine Clearance You Need To Know: • • Patient age Patient weight Patient sex Serum Creatinine • And the formula to figure it out. 9 9

Creatinine Clearance Calculations Cockcroft –Gault) Greater than 50 cc/min is normal o. Male: • • (140 -age)y weight in kg) 72 (serum creatinine) Example: 40 y-220 lbs • • 140 -40=100 x 100 kg=10000 divided by 72= 138. 8 multiplied by 1. 0 Cr = 138. 8 cc. min o. Female: • • (140 -age)( weight in kg)(0. 85) 72 (serum creatinine) • Example: 40 y -220 lbs • 140 -40= 100 x 100 kgx 0. 85 = 8500 • • • 8500 divided by 72 = 118 multiplied by 1. 0 Cr = 118 cc. min. And then You Have to Understand another factor… 10 10

Nephron. com • Great website that figures GFR from these qualifiers – – Serum creatinine Age Sex. Race • Really - http: //nephron. com (Regina told me. And it works, even I could do it. And if you have an i. POD… you can download the software) 11

We Need To Figure This Because • X-ray contrast is how we see the vessels • X-ray contrast is toxic to the kidneys • Kidneys clear the contrast • Patients with normal function can still have problems with contrast injections • Patients with diabetes and renal insufficiency are at higher risk for complications • And that is just the beginning. 12 12

Even Normal Patients Are At Risk 13 13

Here is the List • • 1. Diabetes Mellitus 2. Age over 70 3. Female 4. Treating SVG 5. Treating 2 or more vessels at the same time 6. IAPB use 7. Acute coronary syndrome 8. Cr. Cl less than 50 cc. /min. 14 14

As They Add Up 15 15

Then Look for Ways To Reduce The Risks – 1. Reduce amount of contrast – 2. Increase length of time between contrast procedures – 3. Use low osomolarity contrast – 4. Avoid diuretics – 5. Avoid nephrotoxicity drugs NSAIDS, etc – 6. Hydrate, Hydrate 16 16

Now We Can Talk About Patient Management And If You Don’t Know The Answer Ask Your Friends 17

18 School of Athens , Rafael

In Case They Are Not Available Ask More Contemporary Friends 19

How do we reduce the risk of Contrast induced nephrotoxicity? 20 20 20

Prepare Your Patient for the Procedure • Place 2 IV lines. • Some drugs need to be alone. • Empty bladders – yours- theirs - even the doc’s. 21

Use Outcomes Based Research For Your Managment Howard Community College - Card 201 Fall 2008 22 22

Data Showed What Works • Hydration, . 09 works better than 045. 1000 D 5 W fast before contrast works also – • Goal – – “establish brisk diuresis before dye” • Management – – empty bladders before procedure. Pharmacologic Agents for Prevention of Contrast Induced Neuropathy, Eugenia Nikolsky, Ph. D and Roxana Mehran , MD 23 Cardiac Interventions Today Jan/Feb 2008

Hydration and Bicarb • in 2004 published a study by the Sanger Cardiology Group published this conclusion: • Hydration with sodium bicarbonate before contrast exposure is more effective than hydration with sodium chloride for prophylaxis of contrast-induced renal failure. Key word: ‘before” • Results: NS group 13. 6% Bicarb Group 1. 7% CIN rate • Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonton CA 3 rd, Rittase RA, Norton HJ, Kennedy TP. Department of Internal Medicine, Sanger Cardiology, Sanger Cardiovascular Surgery, and Metrolina Nephrology, Carolinas Medical Center, Charlotte, NC 28232, USA. 24

How To Mix… • Na. Hco 3 (sodium bicarbonate) added to D 5 W Mix: Add: Run: 1000 ml of D 5 W remove 150 cc fluid from bag 3 – 50 ml Amps of Na. HCO 3 to bag which equals 1000 ml’s again 3 ml/kg for one hour 1 ml/kg after that until finished *This is a guideline. Assess patient risk for heart failure first 25

Other Therapies • Statins before the procedure helped more than those not pretreated with statins • Prostaglandins may be beneficial, because levels of this hormone is decreased in patient with CIN • What about n-acetyl-L-cystine? 26

• This debate is still ongoing. Do You Give NAC? • Two studies showed it worked • Two studied showed it didn’t. • Show of Hands: 27

What Did Not Work • Renal dopamine was a hard therapy to stop – it even sounded good • Flush and force diuresis with Lasix and Mannitol sounded good also • Fenoldopam sounded good but the patients got hypotensive – Targeted delivery studies are ongoing 28 28

Fenoldpam • FENOLDPAM IV DIDN’T WORK – but direct renal artery infusion with the Benephit catheter and fenoldpam did. – Cannulate the kidneys and infuse directly – In 285 patients who received TRT with fenoldopam and were followed for at least 48 hours, the incidence of CIN was 71% lower than predicted • CONCLUSION: The Benephit system and TRT during coronary and endovascular procedures in patients at high risk for renal failure is simple to use and safe. With the infusion of intrarenal fenoldopam, the incidence of CIN was significantly lower than predicted by risk score calculations. 2009: Weisz Giora; Filby Steven J; Cohen Mauricio G; Allie David E; Weinstock Barry S; Kyriazis Dimitris; Walker Craig M; Moses Jeffrey W; Danna Paolo; Fearon William F; Sachdev Naveen; Wiechmann Bret N; Vora Kishor; Findeiss Laura; Price Matthew J; Mehran Roxana; Leon Martin B; Teirstein Paul S Safety and performance of targeted renal therapy: the Be-RITe! Registry. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists 2009; 16(1): 1 -12. 29 29

Take Home Messages • Identify your patients at risk and reduce all risk factors you can – • We are here to help and as many have said in the past… “Above all do no harm” Hippocrates. Or at least do the least amount of damage you have to get the job done. 30 30

Don’t Give Up – Winter Will Be Over Soon. 31

Any Questions? 32

• • Credits and Acknowledgements Roxanna Mehran, MD, and her presentations from TCT, CRT, 2002 -2008 2009: Weisz Giora; Filby Steven J; Cohen Mauricio G; Allie David E; Weinstock Barry S; Kyriazis Dimitris; Walker Craig M; Moses Jeffrey W; Danna Paolo; Fearon William F; Sachdev Naveen; Wiechmann Bret N; Vora Kishor; Findeiss Laura; Price Matthew J; Mehran Roxana; Leon Martin B; Teirstein Paul S Safety and performance of targeted renal therapy: the Be-RITe! Registry. Journal of endovascular therapy : an official journal of International Society of Endovascular Specialists 2009; 16(1): 1 -12. Solomon, et al. NEJM 1994; 331: 1416 -1420, slide 36. Holton, M. Kidneys and Contrast, Above All Do No Harm. Cath Lab Regionals 2004 HMP Communications • Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, Bersin RM, Van Moore A, Simonton CA 3 rd, Rittase RA, Norton HJ, Kennedy TP. Department of Internal Medicine, Sanger Cardiology, Sanger Cardiovascular Surgery, and Metrolina Nephrology, Carolinas Medical Center, Charlotte, NC 28232, USA. • • • And of course here a few www. Sites for you to visit: http: //philippinehealthconnections. wordpress. com/2009/05/18/a-case-for-medicine http: //nephron. com www. tctmd. com www. crt. com www. hmpcommunications. com www. sicp. com www. scai. com My thanks to all who shared their information and slides with us for this and many other presentations. Any omission for correct credit is not purposeful, please contact me if you see any omissions and I will correct it immediately. 33