Objectives: Same day cardiac interventions are increasing; concerns that are not immediately apparent may be neglected. We sought to determine if pts at higher risk of contrast nephropathy are identified, appropriately treated and followed.
Background: Contrast induced nephropathy [CIN] impacts on mortality risk; ranging from transient renal impairment with full recovery, to cumulative impairment, to renal failure and the need for permanent dialysis. Preprocedural modifiable [hydration status, contrast reexposure <72 hrs, nephrotoxic medications], partially modifiable [hypotension & heart failure], and non-modifiable [baseline renal function [eGFR<60], age >75 yrs] risk factors influence risk. Procedural factors [contrast volume, hypotension, IABP patients] increase risk. CIN risk is decreased by optimizing risk factors and hydration, minimizing contrast. Post procedure the Mehran CIN predictor is calculated and a 48 hr post IP or 7 day OP creatinine is obtained to identify CIN.
Procedure: From 2016-17 pts undergoing interventional procedures exceeding the lab standard for radiation exposure were selected for review as representing a cohort likely to have increased contrast exposure.
Results: There were 3,996 procedures [2,436 diagnostic, 1,560 interventions] performed in the reviewed period. Of 56 outlier pts, 11 were treated for structural heart disease and 45 underwent coronary angioplasty. Pre procedure risk factors included: age >75 [19/56], DM [19/56], HF [25/56], CKD 3 [12/55; 1 pt on HD]. Opportunities for decreasing contrast: LV gram 7/45, prior contrast exposure within 72 hrs 5/45, multivessel intervention 15/45. Few [7/45] of the pts received periprocedural hydration as recommended by the EHR power plan [cited reason heart failure 25/45]. Contrast use was as high as 475 cc; use of biplane imaging was infrequent. The Mehran CIN risk score was low in 13/55 [7.5% CIN/0.04% HD], intermediate in 36/55 [14.0% CIN/ 0.12 HD], high in 7/55 [26.1-57.3% CIN/ 1.09-12.6% HD]. Pre procedure creatinine was not available in 1 pt and volume of contrast administered undocumented in another pt. 48 hr creatinine was documented in 33/56 pts; 10 of the 33 pts developed post procedure CIN.
Conclusions: Shortened hospitalizations decrease the awareness of and preventive treatment for CIN. A multidisciplinary team has identified multiple opportunities for practice improvement: provider education, review of the EHR power plan [for modification of pre and intraprocedural risk factors, implementation of correctly dosed fluid repletion with renal consultation for high risk patients, appropriate follow-up of creatinine], Preprocedural calculation and intraprocedural monitoring to achieve low risk contrast volume [(ml)/eGFR <3.7}, interventional report embedding CIN risk score, EHR tracking and audit to ensure implementation with appropriate feedback as necessary.