DOCSLIB.ORG

Evidence-Based Approach for Prevention of Radiocontrast-Induced Nephropathy

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Evidence-Based Approach for Prevention of Radiocontrast-Induced Nephropathy CLINICAL UPDATE CME Evidence-based Approach for Prevention of Radiocontrast-induced Nephropathy Bassam G. Abu Jawdeh, MD Department of Medicine, Case Western Reserve University School of Medicine, Rammelkamp Abbas A. Kanso, MD Center for Research, Cleveland, Ohio. Jeffrey R. Schelling, MD Disclosure: Nothing to report. The frequency of radiocontrast administration is dramatically increasing, with over 80 million doses delivered annually worldwide. Although recently developed radiocontrast agents are relatively safe in most patients, contrast nephropathy (CN) is still a major source of in-hospital and long-term morbidity and mortality, particularly in patients with preexisting kidney disease. Multiple protocols for CN prevention have been studied; however, strict guidelines have not been established, in part because of conflicting efficacy data for most prevention approaches. In this work, we critically review the major trials that have addressed common CN prophylaxis strategies, including type of radiocontrast media, N-acetylcysteine administration, extracellular fluid volume expansion, and hemofiltration/hemodialysis. We conclude with evidence-based recommendations for CN prevention, which emphasize concurrent NaHCO3 infusion and N-acetylcysteine administration. These guidelines should be helpful to hospitalists, who frequently order radiocontrast studies, and could therefore have a significant impact on prevention of CN. Journal of Hospital Medicine 2009;4:500–506. VC 2009 Society of Hospital Medicine. KEYWORDS: acute kidney injury, N-acetylcysteine, NaHCO3, nephrotoxicity, radioiodinated contrast. Since contrast nephropathy (CN) was recognized more than (12.1% vs. 3.7% and 44.6% vs. 14.5%, respectively).7 Another 50 years ago,1 there have been continuous efforts to chemi- study of 1826 patients, who underwent coronary artery cally modify radiocontrast agents to be less nephrotoxic. intervention procedures, showed that 14.4% developed CN Although radiocontrast media have indeed become safer, and 0.8% required hemodialysis. Mortality was 1.1% in which reduces the likelihood of CN per procedure, the indi- patients who did not develop CN, 7.1% in those with CN, cations for radiocontrast administration have dramatically and 35.7% in the hemodialysis-treated CN group.8 Moreover, increased, since over 80 million doses are delivered in the studies by several other groups also support the position world annually.2,3 Furthermore, the number of patients with that CN is associated with increased in-hospital and long- CN risks, which are mainly chronic renal insufficiency (CRI) term mortality.9–11 Although radiocontrast administration and diabetes (Table 1), has also grown. Currently, more than may not be a causal risk factor for mortality, since at-risk 26 million people are estimated to have CRI in the United patients have a number of comorbidities, radiocontrast States4 and 200 million people have diabetes worldwide.5 media should nevertheless at least be viewed as an impor- The combination of increased radiocontrast administration tant marker of acute kidney injury and death risk. frequency and greater prevalence of at-risk patients is likely Despite the enhanced morbidity and mortality associated to result in continued increases in CN events. with CN, there are no strict guidelines for prevention of CN. The incidence of CN varies between studies, depending Part of the reason is that the literature is controversial on risk factors of the cohort and definition of CN, but fig- regarding most prevention strategies. Several interventions ures have been reported to be as high as 50% in studies are commonly proposed to help prevent CN, including dis- enriched with CRI and diabetic patients. However, a very criminate selection of the type of radiocontrast, N-acetylcys- recent study disputes such high incidence rates by demon- teine, volume expansion with saline and/or NaHCO3, and strating that patients receiving no radiocontrast media had prophylactic hemofiltration. The major purpose of this a similar frequency of serum creatinine increases compared review is to discuss these different approaches to CN pre- to a comparable group of historical CN patients.6 This study vention, with the ultimate goal of offering discrete emphasizes that conventional definitions of CN, eg, 25% recommendations. increase in serum creatinine above baseline, may be too The basis of this semisystematic review was a literature conservative. search using the PubMed database (www.ncbi.nlm.nih.gov/ A retrospective study of 7586 patients showed 22% in- sites/entrez) to identify studies published in English lan- hospital mortality in patients who developed CN vs. 1.4% in guage journals between January 1966 and July 2008 compar- those who did not, after adjusting for comorbidities. One- ing regimens for prophylaxis of CN. Search terms included and 5-year mortality rates were also higher in the CN group contrast, radiocontrast, radioiodinated AND nephropathy, 2009 Society of Hospital Medicine DOI 10.1002/jhm.477 Published online in wiley InterScience (www.interscience.wiley.com). 500 Journal of Hospital Medicine Vol 4 No 8 October 2009 The Iohexol Cooperative Study was a double-blind, TABLE 1. Risk Factors for Contrast Nephropathy randomized, controlled trial (RCT) that randomized 1196 Clear Risks Probable Risks Questionable Risks patients to Iohexol (low osmolarity ) or diatrizoate (hyperos- molar). Definition of CN was a rise in serum creatinine by Estimated GFR Diabetes mellitus* Repeat contrast procedures >1 mg/dL within 48 to 72 hours after the radiocontrast ex- <60 mL/minute/1.73 m2, especially if due to posure. Results were in favor of the iohexol group (3% diabetic nephropathy* developed CN vs. 7% in the diatrizoate group; P ¼ 0.002). Concomitant use of Age >75 years Subgroup analysis of patients with CRI and CRI plus diabe- nephrotoxic drugs tes also revealed less CN in the iohexol vs. diatrizoate Hemodynamic instability Male gender groups (7% vs. 16% and 12% vs. 27%, respectively).13 Congestive heart failure Intraaortic balloon pump Large contrast volume Liver disease An earlier non-RCT of 303 patients undergoing femoral y (>100 mL) angiography compared iohexol/ioxaglate (both are low Intraarterial contrast Peripheral vascular disease osmolar) to diatrizoate (hyperosmolar). Six different CN def- administration initions were used. Each comprised a combination of differ- Hypertension ent magnitudes of rise of serum creatinine over various Anemia z Bence-Jones proteinuria periods of time. Overall, the incidence of CN was 7% in the P ¼ Hyperuricemia low osmolar group vs. 26% in the hyperosmolar group ( 0.001). In subgroup analysis of patients with CRI, and of Abbreviations: CN, contrast nephropathy; CT, computed tomography; GFR, glomerular filtration rate; patients with diabetes, less CN was again observed with low IVC, inferior vena cava.. osmolar agents (10% vs. 41%, P ¼ 0.017, in the CRI group; * Diabetes is neither sufficient nor necessary, but amplifies the risk for CN. y and 10% vs. 31%, P ¼ 0.012, in the diabetes group). Analysis Volumes >100 mL are commonly used in diagnostic and therapeutic cardiac catheterizations, periph- < eral and cerebrovascular angiographies, CT angiography for cardiac imaging and excluding pulmonary of subjects with baseline serum creatinine 1.5 mg/dL embolism. For IVC filter placement, approximately 30 mL is used. showed no differences between the 2 groups, emphasizing z Risk is negligible with newer generation radiocontrast media and adequate hydration. that prior CRI is an important CN risk factor.14 The RECOVER study was a double-blind RCT of 300 patients undergoing coronary angiography, who were nephrotoxicity, renal failure, kidney injury AND N-acetylcys- randomized to iodixanol (isoosmolar) or ioxaglate (low teine, Mucomyst, sodium bicarbonate, NaHCO3, hemofiltra- osmolarity). CN was defined as a rise in serum creatinine by tion, continuous venovenous hemofiltration (CVVH), the- >25% or 0.5 mg/dL at 24 and 48 hours. CN incidence was ophylline, statin, ascorbic acid, dopamine, fenoldopam, 7.9% in the iodixanol group vs. 17% in the ioxaglate group adenosine, and endothelin. The total number of articles that (P ¼ 0.021). Subgroup analyses of patients stratified by met the search criteria exceeded 3000 and over 200 in high severe CRI, diabetes, and contrast volume also favored profile biomedical journals were scrutinized in detail. The iodixanol.15 In a similarly designed, double-blind RCT articles cited in this review were independently considered involving 129 patients with diabetes and CRI randomized to by 2 authors (B.G.A. and J.R.S.) to have the greatest impact. iodixanol or iohexol, CN developed in 3% of iodixanol group We report on prophylactic maneuvers that are either vs. 26% in the iohexol group (P ¼ 0.002).16 These results commonly considered by nephrology consultants or contain were further supported by a very recent double-blind RCT sufficient data to warrant a meta-analysis study. Studies comparing iodixanol to iopromide (low osmolar) in 117 involving statins, ascorbic acid, dopamine analogs, endothe- patients with baseline serum creatinine 1.5 mg/dL under- lin antagonists, and theophylline were not addressed in this going CT scans. The incidence of serum creatinine increases review due to insufficient, inconclusive, or predominantly of 0.5 mg/dL or 25% above baseline or glomerular filtra- negative data. Clinical characteristics and pathogenesis of tion rate (GFR) reduction of 5 mL/minute was significantly CN, which include vasoconstriction,
Load more

Recommended publications
  • Targeted High Volume Hemofiltration Could Avoid Extracorporeal Membrane Oxygenation in Some Patients with Severe Hantavirus Cardiopulmonary Syndrome
    Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 5 July 2020 doi:10.20944/preprints202007.0046.v1 Article Targeted High Volume Hemofiltration Could Avoid Extracorporeal Membrane Oxygenation in Some Patients with Severe Hantavirus Cardiopulmonary Syndrome René López1, 2, Rodrigo Pérez-Araos1, 3, Álvaro Salazar1, Mauricio Espinoza1, 2, Cecilia Vial4, Analia Cuiza 4, Pablo A. Vial2, 4, 5, and Jerónimo Graf1, 2* 1. Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago 7650567, Chile; [email protected] (R.L.); [email protected] (R.P-A.); [email protected] (Á .S.); [email protected] (M.E); [email protected] (J.G.) 2. Escuela de Medicina. Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago 7710162, Chile; [email protected] (P.A.V.) 3. Escuela de Kinesiología. Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago 7710162, Chile 4. Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago 7590943, Chile; [email protected] (C.V.); [email protected] (A.C.) 5. Departamento de Pediatría, Clínica Alemana de Santiago, Santiago 7650567, Chile Correspondence: [email protected] Abstract Background: Hantavirus cardiopulmonary syndrome (HCPS) has a high lethality. About two-thirds of the severe cases may be rescued by extracorporeal membrane oxygenation (ECMO). However, about half of the patients supported by ECMO suffer major complications. High volume hemofiltration (HVHF) is a depurative extracorporeal support that provides homeostatic balance allowing hemodynamic stabilization in some critically ill patients. Methods: We implemented HVHF prior to ECMO consideration in the last five severe HCPS patients requiring mechanical ventilation and vasoactive drugs admitted to our intensive care unit.
    [Show full text]
  • Induced Nephropathy by Hemofiltration
    The new england journal of medicine original article The Prevention of Radiocontrast-Agent– Induced Nephropathy by Hemofiltration Giancarlo Marenzi, M.D., Ivana Marana, M.D., Gianfranco Lauri, M.D., Emilio Assanelli, M.D., Marco Grazi, M.D., Jeness Campodonico, M.D., Daniela Trabattoni, M.D., Franco Fabbiocchi, M.D., Piero Montorsi, M.D., and Antonio L. Bartorelli, M.D. abstract background Nephropathy induced by exposure to radiocontrast agents, a possible complication of From the Centro Cardiologico Monzino, percutaneous coronary interventions, is associated with significant in-hospital and long- Istituto di Ricovero e Cura a Carattere Sci- entifico, Institute of Cardiology, Universi- term morbidity and mortality. Patients with preexisting renal failure are at particularly ty of Milan, Milan, Italy. Address reprint high risk. We investigated the role of hemofiltration, as compared with isotonic-saline requests to Dr. Marenzi at Centro Cardio- hydration, in preventing contrast-agent–induced nephropathy in patients with renal logico Monzino, Via Parea 4, 20138 Milan, Italy, or at giancarlo.marenzi@ failure. cardiologicomonzino.it. methods N Engl J Med 2003;349:1333-40. We studied 114 consecutive patients with chronic renal failure (serum creatinine con- Copyright © 2003 Massachusetts Medical Society. centration, >2 mg per deciliter [176.8 µmol per liter]) who were undergoing coronary interventions. We randomly assigned them to either hemofiltration in an intensive care unit (ICU) (58 patients, with a mean [±SD] serum creatinine concentration of 3.0±1.0 mg per deciliter [265.2±88.4 µmol per liter]) or isotonic-saline hydration at a rate of 1 ml per kilogram of body weight per hour given in a step-down unit (56 patients, with a mean serum creatinine concentration of 3.1±1.0 mg per deciliter [274.0±88.4 µmol per liter]).
    [Show full text]
  • Providing Continuous Renal Replacement Therapy in Patients on Extracorporeal Membrane Oxygenation
    Kidney Case Conference: How I Treat Providing Continuous Renal Replacement Therapy in Patients on Extracorporeal Membrane Oxygenation Nithin Karakala and Luis A. Juncos CJASN 15: 704–706, 2020. doi: https://doi.org/10.2215/CJN.11220919 Nephrology Section, Case Presentation vein or by using two catheters; one in the internal Central Arkansas A 34-year-old male was admitted for respiratory jugular and one in the femoral vein. VV-ECMO is used Veterans Healthcare fl System, Little Rock, failure due to H1N1 in uenza. His hypoxia worsened in refractory hypoxemia (2). Arkansas despite maximal ventilator support and thus initiated Department of on venovenous extracorporeal membrane oxygena- Medicine/ tion (VV-ECMO). Whereas this stabilized his respira- AKI and Extracorporeal Membrane Oxygenation Nephrology, tory and hemodynamic status, his creatinine increased Patients on ECMO are severely ill and frequently University of Arkansas . for Medical Sciences, (from 1.2 to 2.4 mg/dl), urine output declined (despite develop AKI; its incidence is 50% in adults, more Little Rock, Arkansas furosemide), and his weight had increased from 79 to than one-half of whom require KRT (3). The etiology 92 kg. Ultrasound assessment revealed a noncollaps- of AKI in these patients is comparable to that in Correspondence: ing vena cava and B-lines in his lungs. Nephrology critically ill patients not on ECMO, except that ECMO- Dr. Luis A. Juncos, was consulted for management of AKI and vol- related variables (e.g., hemorheological variations, Central Arkansas ume overload. systemic inflammation, hemolysis, etc.) can also pro- Veterans Healthcare System, 4300 W. 7th mote AKI (2).
    [Show full text]
  • Download PDF File
    INTERVENTIONAL CARDIOLOGY Cardiology Journal XXXX, Vol. XX, No. X, X–X DOI: 10.5603/CJ.a2020.0039 Copyright © 2020 Via Medica ORIGINAL ARTICLE ISSN 1897–5593 Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit Agnieszka Kośka1, Christopher J. Kirwan2, Maciej M. Kowalik3, Anna Lango-Maziarz4, Wiktor Szymanowicz1, Dariusz Jagielak5, Romuald Lango3 1Department of Cardiac Anesthesiology, University Clinical Center, Gdansk, Poland 2Department of Adult Critical Care, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom 3Department of Cardiac Anesthesiology, Medical University of Gdansk, Poland 4Department of Gastroenterology and Hepatology, Medical University of Gdansk, Poland 5Department of Cardiovascular Surgery, Medical University of Gdansk, Poland Abstract Background: Regional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group. Methods: Consecutive cardiovascular surgery patients treated with postdilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence
    [Show full text]
  • Smoking Cessation
    PHYSICIAN-RELATED SERVICES/ HEALTH CARE PROFESSIONAL SERVICES Provider Guide April 1, 2014 Physician-Related Services/Health Care Professional Services About this guide* This publication takes effect April 1, 2014, and supersedes earlier guides to this program. Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state- only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority. What has changed? Reason for Subject Change Change Nonemergency services Added policy information regarding nonemergency Added language out-of-state services provided out-of-state which mirrors WAC Substitute physicians Fixed link to United States Code Erroneous link Expedited Prior EPA# 1300 Injection, Romiplostim, 10 Microgram – AMGEN Authorization Removed requirement for prescriber and client to be discontinued enrolled in NEXUS Program. This change is NEXUS program, retroactive to 12/6/2011. 12/6/2011 Payment for blood and Removed CPT 88240 from list This code is not blood products covered. Payment for Primary Added policy for higher payment for certain primary Chapter 42.447.400 Care Providers care services RCW Rate Increase for Added policy for rate increase for independent ARNPs 3ESSB 5034, Sec. Independent ARNPS 213, Subsec. (26) & PN 14-19 Oral surgery coverage Removed CPT codes 13150 and 15320 CPT codes updates, table Added CPT codes 15275, 15278, 99242, 99244, 99252, policy changes, and 99254, 99255 added CPT codes SBIRT criteria Removed limitation of one (1) per client, per provider, Removed limit per per year CMS Smoking cessation Clarified process client must follow when Tobacco Housekeeping Quitline recommends a smoking cessation prescription Medical necessity Remove the limit of one per day for MRA, MRI, and All require medical review PETCT necessity reviews Pre-/intra- Removed chart.
    [Show full text]
  • Early Implementation of Veno-Venous Hemofiltration and Use Of
    Case Report Clinical Case Reports Volume 10:11, 2020 DOI: 10.37421/jccr.2020.10.1400 ISSN: 2165-7920 Open Access Early Implementation of Veno-Venous Hemofiltration and Use of Rotational Atherectomy in a Patient with ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: A Case Report Monika Durak*, Marek Tomala, Bartłomiej Adam Nawrotek, Andrzej Machnik and Jacek Legutko Department of Interventional Cardiology, Jagiellonian University Medical College Institute of Cardiology, Prądnicka 80 Krakow, Poland Abstract Background: We report the case of a patient with Cardiogenic Shock (CS) in a course of acute Right Ventricular (RV) Myocardial Infarction (MI) following occlusion of the proximal Right Coronary Artery (RCA). Our case highlights the use of Continuous Veno-Venous Hemofiltration (CVVH) as a novel routine treatment option for Acute Kidney Injury (AKI) in the setting of CS and the use of Rotational Atherectomy (RA) in patients with MI. This finding has important implications for patient treatment plans in the future. Case summary: The patient was treated with the primary Percutaneous Coronary Intervention (PCI) using three drug-eluting stents in the main RCA and strong right ventricular branch. RA was used to facilitate lesion expansion and stent implantation because of massive calcification. Six hours after the procedure, AKI manifested as anuria, required CVVH for four days until hemodynamic stabilization and restoration of diuresis. Six weeks after MI, the patient underwent coronary artery bypass surgery due to advanced coronary disease in the left coronary artery. There were no peri-or post-procedural complications, and at the end of a cardiac rehabilitation program, the patient was discharged.
    [Show full text]
  • National Kidney Foundation K/DOQI Clinical Practice Guidelines for Bone
    The Official Journal of the National Kidney Foundation American Journal of Kidney Diseases AJKDEditorial correspondence and manuscript submis- The appearance of the code at the bottom of the first sions should be addressed to Bertram L. Kasiske, MD, page of an article in this journal indicates the copyright Editor-in-Chief, AJKD, Hennepin Faculty Associates, owner’s consent that copies of the article may be made for 600 HFA Building, Room D508, 914 South 8th Street, personal or internal use, or for the personal or in- Minneapolis, MN 55404. Telephone: (612) 347-7770 ternal use of specific clients. This consent is given on the Business correspondence (subscriptions, change condition, however, that the copier pay the stated per-copy of address) should be addressed to the Publisher, fee through the Copyright Clearance Center, Inc (222 W.B. Saunders, Periodicals Department, 6277 Sea Rosewood Dr, Danvers, MA 01923; (978) 750-8400) for Harbor Dr, Orlando, FL 32887-4800. E-mail: elspcs@ copying beyond that permitted by Sections 107 or 108 of elsevier.com the US Copyright Law. This consent does not extend to Change of address notices, including both the old and other kinds of copying, such as copying for general distri- new addresses of the subscriber, should be sent at least one bution, for advertising or promotional purposes, for creat- month in advance. ing new collective works, or for resale. Absence of the code Customer Service: 1-800-654-2452; outside the United indicates that the material may not be processed through States and Canada, 1-407-345-4000. the Copyright Clearance Center, Inc.
    [Show full text]
  • 1. Introduction
    1. Introduction 1. Introduction 1.1 Historical Highlights During the First International Symposium on Plasmapheresis held in Cleveland, Ohio (USA) in 1982, the International Society for Artificial Organs (ISAO) opened a museum to serve as an Inter- national Center for Artificial Organs and Transplantation. The museum located now in Houston, Texas, (USA), shows the efforts made during the last centuries and decades to help humanity by healing diseases in a very impressive way. One can find a collection of instruments, pictures, and documents that focus on „the ancient med- ical belief that removal of a patient´s blood can also lead to the removal of his disease“ (2545). This simplistic concept of „bloodletting,“ or phlebotomy, although widely accepted in the prescientific era, could not, of course, be upheld in the light of modern medicine. Still, it appears to have returned to our clinical practice within the framework of new theories. Specialists use it to treat hemochro- matosis, polycythemia, and acute heart insufficiency. Now, however, phlebotomy is more likely to bring to mind the phlebotomists who draw blood for testing in every hospital. While the practice of plasmapheresis may also call to mind the ancient practice of bloodletting (1468), since blood content is removed from the patients’ body for a period of time, the two thera- py methods are, of course, based on entirely different theoretical bases and are used to treat condi- tions understood within the framework of modern medicine. Figure 1: A motif of bloodletting on an old Greek vase (1893) 1.1.1 Bloodletting Throughout human history, people have held an intuitive belief that impurities or poisons in the body cause disease.
    [Show full text]
  • Hemofiltration in the Prevention of Radiocontrast Agent Induced Nephropathy
    MINERVA ANESTESIOL 2004;70:189-91 Hemofiltration in the prevention of radiocontrast agent induced nephropathy G. MARENZI, A.L. BARTORELLI Aim. The aim of the study was to investigate the Monzino Heart Center, IRCCS, Institute of role of hemofiltration in preventing contrast Cardiology, University of Milan, Milan, Italy nephropathy in patients with renal failure. Methods. We randomized 114 renal failure patients undergoing percutaneous coronary interventions (PCI) to either peri-procedural going PCI, the occurrence of RCN has been hemofiltration or saline hydration. associated with significant in-hospital and Results. Contrast nephropathy occurred in 5% long-term mortality, increased risk of in-hospi- of hemofiltration-treated patients and in 50% tal major adverse cardiac events as well as in controls (P<0.01). In-hospital event rate as with prolonged hospital stay and increased well as in-hospital and 1-year mortality rates 3-5 were lower in patients treated with hemofil- costs of health care . Most of RCN occurs in tration. patients with pre-existing renal insufficiency. Conclusion. In patients with renal failure under- Several strategies have been proposed to going PCI, peri-procedural hemofiltration is provide prophylaxis against RCN. Until recen- effective for the prevention of contrast neph- ropathy, and is associated with improved in- tly, only saline hydration, low osmolality con- hospital and long-term outcome. trast media, and acetylcysteine, an antioxi- dant, have been shown to provide some pro- Key words. Hemofiltration - Angioplasty, tran- sluminal, percutaneous coronary - Kidney tection and to reduce the incidence of RCN. diseases, chemically induced. However, their efficacy in patients with seve- re renal failure who undergo radiographic procedures requiring high contrast volume adiocontrast-induced nephropathy (RCN), is still controversial, and their impact on cli- Rdefined as an absolute or relative increa- nical outcome is unknown.
    [Show full text]
  • Medicare Claims Processing Manual Chapter 16 – Laboratory
    Medicare Claims Processing Manual Chapter 16 - Laboratory Services Table of Contents (Rev. 10615, 03-09-21) Transmittals for Chapter 16 10 - Background 10.1 - Definitions 10.2 - General Explanation of Payment 20 - Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules 20.1 - Initial Development of Laboratory Fee Schedules 20.2 - Annual Fee Schedule Updates 20.3 Clinical Laboratory Fee Schedule Based on Protecting Access to Medicare Act (PAMA) of 2014 30 - Special Payment Considerations 30.1 - Mandatory Assignment for Laboratory Tests 30.1.1 - Rural Health Clinics 30.2 - Deductible and Coinsurance Application for Laboratory Tests 30.3 - Method of Payment for Clinical Laboratory Tests - Place of Service Variation 30.4 - Payment for Review of Laboratory Test Results by Physician 40 - Billing for Clinical Laboratory Tests 40.1 - Laboratories Billing for Referred Tests 40.1.1 - Claims Information and Claims Forms and Formats 40.1.1.1 - Paper Claim Submission to A/B MACs (B) 40.1.1.2 - Electronic Claim Submission to A/B MACs (B) 40.2 - Payment Limit for Purchased Services 40.3 - Hospital Billing Under Part B 40.3.1 - Critical Access Hospital (CAH) Outpatient Laboratory Service 40.4 - Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests 40.4.1 - Which A/B MAC (A) or (B) to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a Skilled Nursing Facility (SNF) 40.5 - Rural Health Clinic (RHC) Billing 40.6 - Billing for End Stage Renal Disease (ESRD) Related Laboratory Tests 40.6.1 - Automated
    [Show full text]
  • Efficacy and Safety of Endovascular Therapy by Diluted Contrast Digital
    Heart and Vessels (2019) 34:1740–1747 https://doi.org/10.1007/s00380-019-01412-2 ORIGINAL ARTICLE Efcacy and safety of endovascular therapy by diluted contrast digital subtraction angiography in patients with chronic kidney disease Naoki Hayakawa1 · Satoshi Kodera1,2 · Noriyoshi Ohki3 · Junji Kanda1 Received: 15 January 2019 / Accepted: 12 April 2019 / Published online: 15 April 2019 © Springer Japan KK, part of Springer Nature 2019 Abstract This study was performed to evaluate the efcacy and safety of endovascular therapy (EVT) by diluted contrast digital subtraction angiography (DSA) in patients with chronic kidney disease (CKD). Patients with peripheral artery disease (PAD) often have CKD; thus, EVT carries a risk of contrast-induced nephropathy (CIN). Reducing the amount of contrast medium is, therefore, important in these patients. We developed a novel EVT method using DSA with diluted contrast medium. DSA parameters were adjusted for diluted contrast angiography (1:10 dilution), and we defned this technique as low-concentration DSA (LC-DSA). We retrospectively analyzed 122 patients with CKD [estimated glomerular fltration rate (eGFR), < 45 mL/min/1.73 m2] from June 2012 to November 2017 and classifed them into two groups: EVT with diluted contrast (LC-DSA group, n = 63) and conventional EVT (control group, n = 59). Patients with aortoiliac lesions and those undergoing hemodialysis were excluded. The primary endpoint was the incidence of CIN as defned by an absolute increase in serum creatinine of ≥ 0.5 mg/dL or relative increase of ≥ 25% 2–5 days after the procedure. The secondary endpoints were worsening renal function (defned as an eGFR reduction of ≥ 25% compared with that before the procedure), the amount of contrast medium used for EVT, freedom from complications related to LC-DSA, and procedural success.
    [Show full text]
  • HEMOFILTRATION Development
    REVIEW Hernofiltration: treating and preventing infection Paul C. Turner' and Hilary Humphreys2 'Public Health Laboratory and 'Division of Microbiology, University Hospital, Queen's Medical Centre, Nottingham, UK Key words: Hernofiltration, infection, intensive care, kidney failure, catheterization GENERAL PRINCIPLES OF HEMOFILTRATION development. Furthermore, fluid balance can be accurately controlled and regulated, allowing other Renal failure is a recognized feature of the acutely ill, support measures such as total parenteral nutrition to intensive care patient, often in association with multi- be used [3]. Unlike CH, peritoneal dialysis is less suited organ failure. Henlofiltration is now routinely used for to the ICU as there is a delay before beneficial effects treating acute renal failure in the intensive care unit are seen and it cannot be used in the presence of intra- (ICU). Unlike hemodialysis and peritoneal dialysis, abdominal wounds, infection, ileus, or with a vascular both of which rely upon diffusion of molecules prosthesis [4]. across a concentration gradient, hemofiltration utilizes Although the underlying principle remains the convective solute transport (known as solvent drag) same, several modifications of hernofiltration are in whereby molecules are swept along by a moving stream use [5]. The two commonest variations are continuous of solvent [l]. This is analogous to the filtration that venovenous hernofiltration (CVVH) and continuous occurs naturally through the glomerulus. A special arteriovenous hemofiltration (CAVH). CAVH, which filter is used to remove plasma water and unbound requires arterial access, is circulation driven, resulting in particles weighing between 500 and 10 000 Da. The lower flow rates and filtrate volumes than CVHH. For nitrogenous substances traditionally associated with it to be effective, a mean arterial pressure of 60 mmHg uremia are removed, although urea itself is not is required, making it less useful in the septic, hypo- efficiently filtered.
    [Show full text]