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OUTCOMES OF THOSE REQUIRING DIALYSIS FOLLOWING PCIGruberg, Mehran, Dangas, et al. American College of Cardiology. 2000;Poster:1129–1175. Anaheim, CA. Days or % of Patients n = 12,054 Chronic dialysis: $51,000/yr3 Transplantation: $18,000/yr3 Dialysis-requiring ARF $128,000 per QALY saved2 Inpatient expenses: $1,227/day1 1Department of Health and Human Services, HCFA, Healthcare Indicators, 3Q 1999. 2Hamel MB, Phillips RS, Davis RB, et al. Ann Intern Med. 1997;127(3):195–202. 3Economic cost of ESRD and Medicare spending by modality in Excerpts from United States Renal Data System 1999 Annual Data Report. Am J Kid Dis. 1999;34:S124–S139. Pathogenesis of Radiocontrast Nephropathy Pathogenesis of Contrast Nephropathy Toxicity of Contrast to Cells Direct cellular toxicity (ionic concentration dependent) Tubular sluffing Thick ascending limb ? Tamm- Horsfall protein Renal Ischemic Effects of Contrast **Intrarenal vasoconstriction (endothelin, histamine, ? NO)** Ischemic tubular injury Additive Insults to Injury Atheroembolism Systemic Hypotension-induced ? renal blood flow The outer juxtamedullary nephron is at the greatest risk for ischemia because of its limited perfusion. Susceptibility to injury is high when contrast exposure results in intrarenal constriction and shunting of blood flow from this zone. BLOOD FLOW AND INTERSTITIAL OXYGEN CONTENT REGIONAL DISTRIBUTION IN RENAL CORTEX AND MEDULLA Extracts 80% Extracts 18% Aortic DebrisKeeley EC, Grines CL. Scraping of aortic debris by coronary guiding catheters: a prospective evaluation of 1,000 cases J Am Coll Cardiol. 1998 Dec;32(7):1861-5. Model Direct Toxicity Decreased GFR Renal Vasoconstriction Acute Renal Failure Other Factors ↑ Serum Cr Oligouria ATN Volume Overload Uremia Dialysis Outcomes Selection of Patients Preventive Measures Supportive Care Injury Substrate Result Prevention of Radiocontrast Nephropathy PREVIOUS ATTEMPTS AT PREVENTING RCN EITHER NO BENEFIT OR CAUSE HARM d