《2013年急性肾损伤指南英国国家卫生与临床优化研》内容预览

Departments undertaking iodinated contrast procedures have a high volume of suchprocedures. The GDG noted that it would be the preference for these areas to have asimple marker of highrisk status, before they employ an ‘automated’ risk tool. Onesuch marker might, for example, be an eGFR of <30 ml/min/1.73m2. However, theuse of such a cut-off before using risk assessment and preventative measures willmiss a proportion of patients who go on to develop CI-AKI . The GDG observationwas that the difficulties in this area should not be allowed to prevent the routine useof risk assessment for all patients due to have a contrast procedure. For a procedureusing iodinated contrast the risk of CI-AKI should always be assessed.

The GDG felt it important to note as an introduction to their discussions that noscore had been successfully validated in patients with acute coronary syndrome orSTEMI and therefore caution should be taken when assessing risk in these patients(the Mehran score was derived from a mixed group of PCI patients, including about35% with acute coronary syndrome; the Maioli study was derived in patients withelective percutaneous coronary intervention). The GDG felt it was also important tonote that certain risk factors were modifiable and they felt that optimisation of apatient’s diabetic control, heart failure, renal function and fluidstatus should alwaysbe done before performing any elective procedure.

The GDG felt that it was also important to highlight that people should not be deniedprocedures with contrast just because they were at risk of CI-AKI, but that theseprocedures should be undertaken after full and balanced consideration of the risksand benefits of the procedure. The GDG is aware that patients with CKD are beingunnecessarily denied contrast procedures because of concerns about CI-AKI. Theydrafted a consensus recommendation that emphasised discussion with the patientbecause the risk: benefit ratio is very specific to each individual situation and patientpreferences are particularly important here. The assessment of risk and theconsequent use of preventative measures may also vary depending on the urgencyof the procedure (see section 6.2 on prevention of CI-AKI).The GDG noted that clinical judgment was required in assessing risk factors. The listof risk factors has not been given weighting (above), and the finding that a patienthas one of the risk factors (in isolation) on the list does not automatically make themhigh risk. For example, a patient aged over 75 years without other risk factors shouldnot be considered high risk (see also below). In risk scoring, the risk of any adverseevent typically rises dramatically the more risk factors a patient possesses. However,the evidence was such that the GDG was not in a position to state that any patientwith any two or more risk factors, for example, is high risk.

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