Journal Club 2017/05/30 Tomohiro Matsumoto PGY-2

本の論 March 21, 2017 2

Introduc)on 3

: (CIN) 3 25% 44µmol/L(0.5mg/dL) CIN 4 European Society of Urogenital Radiology. ESUR guidelines on contrast media, version 9.0. September 2014. hkp://www.esur.org/ esur-guidelines/

Pathogenesis of CI-AKI. (Modified from Brown JR, McCullough PA: Contrast nephropathy and kidney injury. In Thompson CA [ed]: Textbook of Cardiovascular Intervention. New York, Springer, 5 2011.)

- CI-AKI J Am Coll Cardiol. 2008 Apr 15;51(15):1419-28. 6

egfr 7 J Am Coll Cardiol. 2008 Apr 15;51(15):1419-28.

egfr<60ml/ /1.73m2 egfr<45ml/ /1.73m2 (NYHA III IV ) LVEF (< 24 ) >70 European Society of Urogenital Radiology. ESUR guidelines on contrast media, version 8 9.0. September 2014. hkp://www.esur.org/ esur-guidelines/

2 3 European Society of Urogenital Radiology. ESUR guidelines on contrast media, version 9.0. September 2014. hkp://www.esur.org/ esur-guidelines/ 9

60 3 2-5 1% James MT, Samuel SM, Manning MA, et al. Contrast-induced acute kidney injury and risk of adverse clinical outcomes a_er coronary angiography: a systema`c review and metaanalysis. Circ Cardiovasc Interv 2013; 6: 10 37 43.

CKD 4 CKD 5 (GFR< 30mL/ ) CKD 3(GFR 30 60mL/ ) 7 1 11

/ 12

6 1.0 1.5mL/kg/ (154mEq/L 5% ) 1 3mL/kg/h 6 1mL/kg/h European Society of Urogenital Radiology. ESUR guidelines on contrast media, version 9.0. September 2014. hkp://www.esur.org/ esur-guidelines/ 14

8 24h 7500 CKD 8-16% 6-1200 15

P STEMI PCI n=408 I C O 25%, 0.5 mg/dl Result 11% VS 21% (p = 0.016) Jurado-Román A et al. Role of hydration in contrast-induced nephropathy in patients who underwent primary percutaneous coronary intervention. Am J Cardiol 2015; 115: 1174 78. 18

P STEMI PCI n=216 I n=108 C n=108 O 25%, 0.5 mg/ dl Result 20.4%(22/108) VS 35.2% (38/108) (p = 0.015) 19 Luo Y et al. Intern Med 2014; 53: 2265 72

P PE n=138 I n=67 C n=71 O 48-96h 25%, 0.5 mg/dl Result 0.14% (15.1% -12.0%) VS 0.32% (9.7% -10.1%) (difference 0.19%, 95%, CI -5.88% to 6.25%, P-value non-inferiority < 0.001) 20 Kooiman J. et al. J Thromb Haem 2014; 12: 1658 66.

STEMI PCI CT 21

本の論 March 21, 2017 22

AMACING PCI 23

Methods

2014/6/17 2016/7/17 35 3 25

PICO P egfr30 59 CKD3 I C O 2 6 Cr 25% 0.5mg/dl 26

EVIDENCE 1 LaBounty TM, etal. Within-hospital and 30-day outcomes in 10 7994 patients undergoing invasive coronary angiography with different low-osmolar iodinated contrast media. Am J Cardiol 2012; 109: 1594 99. Katzberg Rwet al. Intravenous contrast medium-induced nephrotoxicity: is the medical risk really as great as we have come to believe? Radiology 2010; 256: 21 28. James MT, Samuel SM, Manning MA, et al. Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circ Cardiovasc Interv 2013; 6: 37 43. 27

Primary endpoint 2 6 25 0.5 /dl Secondary endpoint 2 6 26 35 26 35 egfr <15mL /m/1.73 10eGFR 30mL / /1.73 2 28

Inclusion criteria egfr 30 45mL / /1.73m² (CKD G3b) MM MUGS egfr 45 59mL / /1.73m²(CKD G3a) 2 > 75 NSAIDs 29

Exclusion criteria egfr<30ml/min/1.73m 2 CKD G4 ICU IC 30

0.9% NaCl 3 4 ml/kg /h 4 0.9% NaCl 1 ml/kg / h 12 31

Randomisation and masking H+ group H- Group ALEA screening and enrolment applica`on so_ware egfr (<45 vs 45 ml per min/ 1 73 m²), vs VS 32

Randomisation and masking 2.4% 2.1% power80% one-sided alpha5% 1300 660 332 328 307/332 92% 296/328 90% ITT per-protocol 33

Results 35

28803 1833 egfr<60ml/m/1.73m 2 660 IC 26970 egfr>60ml/m/1.73m 2 713 inclusion criteria 460 IC 328 332 36

328 32 2-6 296 2-6 68 26-35 260 26-35 332 25 2-6 307 2-6 72 26-35 260 26-35 38

35 ICU 328 0 328 332 0 332 39

10% 40

Primary outcome 25 44μmol/ L mg H + 8/296 2.7 H- 8/307 2.6 (no hydration vs hydration) absolute difference 0 10% (one-sided 95% CI 2 25 to 2 06; onetailed p=0 4710). 41

Secondary outocome 42

egfr 10 4% 43

600 1200 egfr 30 60mL / /1.73 47

Discussion 48

CONSORT Title Background and objec`ves Par`cipants Interven`ons: Outcome Outcome Sample size: Sta`s`cal methods: 2side confiden`al approrch 1 sidide Outcome and es`ma`on: Interpreta`on: 49

18 5.5 13 4 1 0.3 4 1.2 50

Jurado-Román A et al. Role of hydra`on in contrast-induced nephropathy in pa`ents who underwent primary percutaneous coronary interven`on. Am J Cardiol 2015; 115: 1174 78. Luo Y et al. Remedial hydra`on reduces the incidence of contrast-induced nephropathy and short-term adverse events in pa`ents with ST-segment eleva`on myocardial infarc`on: a single-center, randomized trial. Intern Med 2014; 53: 2265 72. 51

9 AMACING AMACING 2.6-2.7 52

2 1 53

25 0.5 /dl 48-72 2 6 48 72 2 6 48 4 5 54

LIMITATION 95 CI 2.1% 56

CKD1-3 PCI angio 57