What Constitutes A Nephrology Clearance

What Constitutes
Nephrology
Clearance?
Oscar Naidas, MD
Frederick Ogbac, MD
What he will say ...
Nephrology Clearance vs Nephrology
Risk Stratification / Assessment and
Management
Composition of Nephrology Clearance
Pre employment Nephrology
Clearance
CT-Scan with IV contrast
Coronary angiography or PCI
General Surgery
MRI with gadolinium contrast
Define Nephrology Clearance vs
Risk Stratification / Assessment
and its Management
Definition of Clearance ( )
Official authorization for something to
proceed or take place
Example:
Do not schedule the patient for CT
Scan of the abdomen with IV contrast
until you are given clearance by the
nephrologist
Oxford Advance Learners Dictionaries

Nephrology Risk
Assessment and
Management
Type of potential ischemic / nephrotoxic
insult
Assessment of risk factors of the patient
An estimate of the risk (quantitative or
semi-quantitative)
Management / intervention to reduce risk
Risk vs Benefit
Communication with the referring
physician and/or the patient
The seafarer with chronic
GN
GN
35 M, asymptomatic,
BP:140/90mmHg, Ht 57, Wt 70 kg,
Urine rbc 10-15/hpf, prot trace
(UPCR 0.6)
Scr 1.4mg/dl (eGFR 68ml/min)
US KUB(-)
LPD, Losartan (130/80mmHg), UPCR
0.3
Ffup q 6 mos for 3 years, stable
GN
Asymptomatic, BP
130/80mmHg,
Ht 57, Wt 70 kg,no edema,
Urine rbc 15-20/hpf, protein(-)
ACR 110 mg/g
Scr 1.5mg/dl (eGFR 62ml/min)
US KUB(-)
GN
Chronic GN probably IgAN

GN
Chronic GN probably IgAN, CKD

G2A2 (moderate risk of
progression)
GN
No indication for kidney

biopsy, stable for past 3 yrs,
LPD and Losartan 50mg OD
(<BP130/80mmHg ), slows
the fall in GFR to 3ml/min/yr
GN
No indication for kidney biopsy, stable for

past 3 yr
LPD and Losartan 50mg OD
(<BP130/80mmHg ), slows the fall in GFR
to 3ml/min/yr (62ml/min to 59ml/min)
Low risk of progression of CKD
Low probability of progression of CKD
that will require hospitalization or dialysis
within next 9 to 12 months
Repeat BP, Scr, UPCR after 9 to 12 months
Patient w/ CKD will undergo
CT Scan w/ IV contrast
56 F, DM2, HTN, HF symptoms
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg BID
BP: 130/90 mmHg Wt: 60kg Ht: 51
SCr 1.5 (eGFR 38.5 ml/min) Uprot: +2
Chronic abdominal pain
US pancreatic mass?
Will undergo whole abdomen CT-Scan with
contrast
Referred for Nephrology Clearance

(38.5 ml/min)
A Simple Risk Score for Prediction of
Contrast-Induced Nephropathy After
Percutaneous Coronary Intervention
Mehran R, Aymong ED, Nikolsky E, et al
J Am Coll Cardiol,
Total =
13
J Am Coll Cardiol,
Risk Score Risk of CIN Risk of

(%) Dialysis (%)
<5 7.5 0.04
6 to 10 14 0.12
11 to 16 26.1 1.09
> 16 57.3 12.6
Total =
13
J Am Coll Cardiol,
Individualizing risk
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD
Estimate your patients risk G3bA3,DM2,HF will undergo
after an event (CI AKI) without abdominal CT w IV contrast
treatment (Rc) with a risk of CI AKI 26%
(MODERATE RISK)
management
STEPS HOW TO DO IT
(MODERATE RISK)
STEP 2
Estimate the RR using the
study result
management
STEPS HOW TO DO IT
(MODERATE RISK)
STEP 2 Saline hydration+ NAC,
Estimate the RR using the reduces the risk of CI AKI
study result RR = 0.68
management
STEPS HOW TO DO IT
STEP 1 56F, stable CKD G3bA3,DM2
Estimate your patients risk will undergo abdominal CT w IV
after an event (CI AKI) without contrast with a risk of CI AKI
treatment (Rc) 26% (MODERATE RISK)
STEP 3 Rt = Rc x RR
Estimate your individual = 26% x 0.68
patients risk for an event (CI = 18%
AKI)with treatment
management
STEPS HOW TO DO IT
(MODERATE RISK)
STEP 3 Rt = Rc x RR
patients risk for an event (CI = 18%
AKI) with treatment
STEP 4 ARR = Rc Rt
Estimate the individualized = 26% - 18%
ARR = 8% (LOW RISK)
Composition of a Nephrology Risk
Assessment and Management
Type of potential ischemic/nephrotoxic insult CT Scan w IV contrast
Assessment of risk factors of the patient CKD eGFR 38ml/min

DM2,HF
An estimate of the risk ( quantitative or semiquantitative ) CI AKI

26% (MODERATE RISK)
Management/Intervention to reduce risk Saline Hydration +NAC

reduce risk to 8% (LOW RISK)
Risk vs Benefit Confirmation +/- of pancreatic mass with CT

Scan w/ IV contrast outweighs LOW RISK of CI AKI
Communication with the referring physician and/or the patient

The Patient w CKD will Undergo
Coronary Angiography/PCI
56 F, DM2, HTN, with HF symptoms
Insulin 10u SQ OD
BP: 130/90 mmHg Wt: 60kg
SCr 1.5 (eGFR 38ml/min) Uprotein: +2
Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8 mg/dl
ECG: LVH
Dx: CKD St G3bA1, DM Nephropathy, Will
undergo coronary angiogram/PCI ACC / AHA
Class IIb indication

Comparison of Renal Risk
Stratifications for CKD
patients prior to CA or PCI
Index No. of Score
variables range
Mehran 8 0 34
JACC 2004
Tziakas 5 08
Am J
Cardiol
2014
J Am Coll Cardiol,
Total =
13
J Am Coll Cardiol,
Risk Score Risk of CIN Risk of

(%) Dialysis (%)
<5 7.5 0.04
6 to 10 14 0.12
11 to 16 26.1 1.09
> 16 57.3 12.6
Total =
13
J Am Coll Cardiol,
Validation of a New Risk Score to Predict
Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic
G, et al
Am J Cardiol, 2014
G, et al
Am J Cardiol, 2014
G, et al
Risk Score Risk for CI-AKI

<3 7.5%
>3 34%
Am J Cardiol, 2014
Comparison of Tziakas Risk Score vs Mehran
Risk Stratification in Predicting Contrast-
Induced Acute Kidney Injury among Patients
Undergoing Coronary Angiography at SLMC-
QC
Ogbac FE, Gonzales-Porciuncula L, Buaron MJ, Semeniano R, Cheng F,
Naidas O
AUC
0.69
0.73
SLMC-QC Section of
Comparison of Tziakas Risk Score vs Mehran
Risk Stratification in Predicting Contrast-
Induced Acute Kidney Injury among Patients
Undergoing Percutaneous Coronary
Intervention at SLMC-QC
Ogbac FE, Gonzales-Porciuncula L, Buaron MJ, Semeniano R, Cheng F,
Naidas O
AUC
071
0.79
SLMC-QC Section of
Individualizing risk management
Tziakas
STEPS HOW TO DO IT
STEP 1 56F with stable CKD G3bA3,DM2, HF will
Estimate your patients risk after an undergo coronary angiography /PCI with a
event (CI AKI) without treatment (Rc) CI AKI risk of 7.5% (LOW RISK)
Tziakas
STEPS HOW TO DO IT
STEP 2 Saline hydration + NAC reduces the risk of

Estimate the RR using the study result CI AKI
RR = 0.68
Tziakas
STEPS HOW TO DO IT

RR = 0.68
STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 7.5% x 0.68
an event (CI AKI) with treatment = 5%
Tziakas
STEPS HOW TO DO IT

RR = 0.68
STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 7.5% x 0.68
STEP 4 ARR = Rc Rt
Estimate the individualized ARR = 7.5% -5%
= 2.5% (LOW RISK)
Mehran
STEPS HOW TO DO IT
event (CI AKI) without treatment (Rc) CI AKI risk of 26% (MODERATE RISK)
STEP 2 Saline hydration + NAC reduces the risk

Estimate the RR using the study result of CI AKI
RR = 0.68
STEP 3 Rt = Rc x RR
Estimate your individual patients risk for = 26% x 0.68
STEP 4 ARR = Rc Rt
Estimate the individualized ARR = 26% -18%
= 8% (LOW RISK)
Type of potential ischemic/nephrotoxic insult CA/PCI
Assessment of risk factors of the patient CKD eGFR 38ml/min,

DM2,HF
An estimate of the risk ( quantitative or semiquantitative ) CI AKI

7.5% to 26% (LOW to MODERATE RISK)
Management/Intervention to reduce risk( Saline hydration+NAC

reduce risk to 2.5% to 8% (LOW RISK)
Risk vs Benefit Benefit of CA/PCI outweighs LOW RISK of CI AKI

The Patient withCKD who will
undergo abdominal surgery
56 F, DM2, HTN
Insulin 10u SQ OD
SCr 1.5 Uprotein: +2 eGFR:38.5 mL/min
Hb/Hct: 11/30 HbA1C: 7% Alb: 2.8mg/dL
CT Scan: solid mass at pancreatic tail, ascites
Coroangio: negative
Pre-op CV: stratification intermediate to high risk of
developing perioperative CV complications
Partial pancreatectomy

Development and validation of an Acute
Kidney Injury Risk Index for Patients
Undergoing General Surgery
Kheterpal S, Tremper KK, Heung M, et al
Anesthesiology, 2009
Total = 6
Development and Validation of an Acute
Preoperative Risk AKI incidence HR (95%, CI)

Class (%)
Class I (0-2 risk 0.2
factors)
Class II (3 risk 0.8 4.0 (2.9 5.4)
factors)
Class III (4risk 1.8 8.8 (6.6 11.8)
factors)
Class IV (5 risk 3.3 16.1 (11.9
factors) 21.8)
Class V (6+ risk 8.9 46.3 (34.2
factors) 62.6)
Preoperative Risk AKI incidence HR (95%, CI)

Class (%)
Class I (0-2 risk 0.2
factors)
Class II (3 risk 0.8 4.0 (2.9 5.4)
factors)
Class III (4risk 1.8 8.8 (6.6 11.8)
factors)
Class IV (5 risk 3.3 16.1 (11.9
factors) 21.8)
Class V (6+ risk 8.9 46.3 (34.2
factors) 62.6)
management
STEPS HOW TO DO IT
Estimate your patients risk will undergo abdominal
after an event (AKI) without surgery with a risk of post op
treatment (Rc) AKI 9% (HIGH RISK)
management
STEPS HOW TO DO IT
STEP 2 Perioperative hemodynamic
Estimate the RR using the optimization, reduces the risk
study result of
post op AKI
RR = 0.64
management
STEPS HOW TO DO IT
study result of
post op AKI
RR = 0.64
STEP 3 Rt = Rc x RR
patients risk for an event (AKI) = 6%
with treatment
management
STEPS HOW TO DO IT
study result of
post op AKI
RR = 0.64
STEP 3 Rt = Rc x RR
patients risk for an event (AKI) = 6%
with treatment
STEP 4 ARR = Rc Rt
Estimate the individualized = 9% - 6%
ARR = 3% (MODERATE
RISK)
Type of potential ischemic/nephrotoxic insult Partial
pancreatectomy
Assessment of risk factors of the patient 56F,CKD,DM,2HTN
An estimate of the risk ( quantitative or semiquantitative ) GS AKI

Risk 9% (HIGH RISK)
Management/Intervention to reduce risk Perioperative

hemodynamic optimization reduces risk to 3% (MODERATE
RISK)
Risk vs Benefit Benefit of partial pancreatectomy outweighs

MODERATE RISK of post op AKI

The patient with CKD will undergo
MRI w gadolinium contrast
57 F, DM2, and HTN
Insulin 10u SQ OD
SCr 1.6 eGFR: 35.4 ml/min/1.73m2
Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5
mg/dl
Changes in sensorium t/c CVD vs
metastasis
Will undergo MRI with gadolinium contrast

American College of Radiology
Manual on Contrast Media (Ver 9, 2013)
Nephrogenic Sytemic Fibrosis

A fibrosing disease primarily involving
the skin and subcutaneous tissues seen
in patients with renal problem
ACR Manual on Contrast Media,

Risk Factors for NSF

Gadolinium based contrast agent
administration
Hemodialysis
Chronic Kidney Disease
Acute Kidney Injury
High dose and multiple exposure

For Inpatients:
eGFR should be obtained within 2 days prior to giving gadolinium

For Inpatients:
eGFR should be obtained within 2 days prior to giving gadolinium

For patients with eGFR < 30 ml/min/1.73m 2:

Gadolinium agents should be avoided
If gadolinium enhanced MRI is deemed essential, use of
the lowest possible dose is recommended
For patients with eGFR 30-39 ml/min/1.73m 2:

NSF is rare, but precautions are recommended
For patients with eGFR 40-59 ml/min/1.73m 2:

NSF is rare, with no precautions
For patients with eGFR > 60 ml/min/1.73m2:

No evidence of increased risk of developing NSF
For patients with AKI

Gadolinium agents should only be
administered if absolutely necessary

Type of potential ischemic/nephrotoxic insult MRI w Gadolinium
Contrast
Assessment of risk factors of the patient 56F,CKD,DM2,HTN,eGFR

35ml/min
An estimate of the risk ( quantitative or semiquantitative ) NSF is rare
Management/Intervention to reduce risk ? Lower dose of gadolinium
Risk vs Benefit Benefit of MRI w gadolinium contrast outweighs

VERY LOW RISK of NSF

What he just said ...
Nephrology Clearance vs Nephrology Risk
Stratification / Assessment and
Management
Composition of Nephrology Clearance
Type of potential ischemic/nephrotoxic insult
Assessment of risk factors of the patient
An estimate of the risk ( quantitative or
semiquantitative )
Management/Intervention to reduce risk
Risk vs Benefit
Communication with the referring physician
and/or the patient
Our Patient
56 F, DM2, HTN, with HF symptoms, non
smoker
Insulin 10u SQ OD
BP: 130/90 mmHg Wt: 60kg BMI= 25.8
SCr 1.5 Uprotein: +2 eGFR 38.5
Hb/Hct: 11/30 HbA1C: 7% Alb: 3.8 mg/dl
EF: 65% with LVH, hypokinesia of LV wall
CA: 4VD with Left main coronary artery
involvement
Will undergo CABG

Predictive Indices for
Estimating Risk of Post-
SRICardiac Surgery
Wijeysundera, RRT and
et al. Derivation
validation of a simplified predictive
index for renal replacement therapy
after cardiac surgery. JAMA, 2005.
Mehta, et al. Bedside Tool for predicting
the risk of postoperative dialysis in
patients undergoing cardiac surgery.
Circulation, 2006
Thakar, et al. A clinical score to predict
acute renal failure after cardiac surgery.
J AM Soc Nephrol, 2005.
Comparison of Predictive
Indices for Estimating Risk of
Post-Cardiac Surgery RRT
Index No. of Score AUC
variables range (Toronto
cohort)
SRI 2007 8 08 0.78
(0.72-0.84)
Mehta 10 0 83 0.75
2005 (0.66-0.83)
Thakar 13 0 17 0.81
2005 (0.74-0.86)
JAMA, 2007
Derivation and Validation of a Simplified
Predictive Index for Renal Replacement
Therapy After Cardiac Surgery (SRI)
Wijeysundera DN, Karkouti K, Dupuis JY, et al
JAMA, 2007
Total =
3JAMA, 2007
Risk Categories Risk of RRT

(%)
Low Risk (0 to 1 point) 0.4
Intermediate Risk (2 to 3 3
points)
High Risk (> 4 points) 10
JAMA, 2007
Therapy After Cardiac Surgery
Risk Categories Risk of RRT

(%)
Low Risk (0 to 1 point) 0.4
Intermediate Risk (2 to 3 3
points)
High Risk (> 4 points) 10
JAMA, 2007
Circulation, 2006
Bedside Tool for Predicting the Risk of
Postoperative Dialysis in Patients
Undergoing Cardiac Surgery
Mehta RH, Grab JD, OBrien SM, et al
Circulation, 2006
12
1
0
5
0
2
0
0
0
20
Circulation, 2006
Circulation, 2006
1.1%
Circulation, 2006
J Am Soc Nephrol,
A Clinical Score to Predict Acute
Renal Failure after Cardiac
Surgery
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP
J Am Soc Nephrol,
Surgery
Total
=5
J Am Soc Nephrol,
Surgery
Risk Categories Risk of RRT (%)
02 0.4
35 1.8
68 7.8
9 13 21.5
J Am Soc Nephrol,
Comparison of Predictive
Indices for Estimating Risk of
Post-Cardiac Surgery RRT
Index No. of Score Risk Risk for
variabl range Score RRT
es post
CABG
(%)
SRI 8 08 3 3
2007
Mehta 30 0 83 20 1.1
2005
Thakar 13 0 17 5 1.8
The risk of AKI requiring RRT post-cardiac
2005 surgery is between
Crit Care, 2014
Predictive Models for Kidney Disease:
Improving global Outcomes (KDIGO) defined
Acute Kidney Injury in UK Cardiac Surgery
Birnie K, Verheyden V, Domenico P, et al
P- 20,995 patients underwent

cardiac surgery including surgery to
thoracic aorta (3 different centers)
I- retrospective cohort
O- occurrence of post cardiac

surgery AKI
Crit Care, 2014
http://www.cardiacsurgeryleicester.com/our-research/acute-kidney-injury-risk-
Predictive Models for Kidney Disease:
Improving global Outcomes (KDIGO) defined
Acute Kidney Injury in UK Cardiac Surgery
Birnie K, Verheyden V, Domenico P, et al
Crit Care, 2014

http://www.cardiacsurgeryleicester.com/our-research/acute-kidney-injury-risk-
Perioperative Acute Kidney Injury
Calvet S, Shaw A
Preventive measures for cardiac

surgery
Fluids and goal directed therapy
Avoidance of nephrotoxic agents
Hemodilution and transfusion
Perioper Med, 2012

Our patient post-op
57 F, DM2, and HTN
Insulin 10u SQ OD
Telmisartan 40mg OD, Metoprolol 50mg
BID
SCr 1.6 eGFR: 35.4 ml/min
Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5
mg/dl
Histopath: cervical CA
Will undergo cisplatin chemotherapy

Risk Factors for Cisplatin
Nephrotoxicity
Previous cisplatin chemotherapy
Pre-existing kidney damage
Concomitant administration of
potentially nephrotoxic agents
High peak plasma free platinum
concentrations
Uptodate, 2014
Prevention of Cisplatin
Nephrotoxicity
Lower dose of cisplatin
1L isotonic saline + 20 meqs KCl +
2gms MgSO4 3 hours prior to
administering chemotherapy and
minimum of 500ml over 2 hours
following administration
Uptodate, 2015
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What Constitutes A Nephrology Clearance

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What Constitutes

Oxford Advance Learners Dictionaries

Chronic GN probably IgAN

Chronic GN probably IgAN, CKD

No indication for kidney

No indication for kidney biopsy, stable for

Referred for Nephrology Clearance

Risk Score Risk of CIN Risk of

Assessment of risk factors of the patient CKD eGFR 38ml/min

An estimate of the risk ( quantitative or semiquantitative ) CI AKI

Management/Intervention to reduce risk Saline Hydration +NAC

Risk vs Benefit Confirmation +/- of pancreatic mass with CT

Communication with the referring physician and/or the patient

Referred for Nephrology Clearance

Risk Score Risk of CIN Risk of

Risk Score Risk for CI-AKI

STEP 2 Saline hydration + NAC reduces the risk of

STEP 2 Saline hydration + NAC reduces the risk of

STEP 2 Saline hydration + NAC reduces the risk of

STEP 2 Saline hydration + NAC reduces the risk

Assessment of risk factors of the patient CKD eGFR 38ml/min,

An estimate of the risk ( quantitative or semiquantitative ) CI AKI

Management/Intervention to reduce risk( Saline hydration+NAC

Risk vs Benefit Benefit of CA/PCI outweighs LOW RISK of CI AKI

Communication with the referring physician and/or the patient

Referred for Nephrology Clearance

Preoperative Risk AKI incidence HR (95%, CI)

Preoperative Risk AKI incidence HR (95%, CI)

Assessment of risk factors of the patient 56F,CKD,DM,2HTN

An estimate of the risk ( quantitative or semiquantitative ) GS AKI

Management/Intervention to reduce risk Perioperative

Risk vs Benefit Benefit of partial pancreatectomy outweighs

Communication with the referring physician and/or the patient

Will undergo MRI with gadolinium contrast

Nephrogenic Sytemic Fibrosis

ACR Manual on Contrast Media,

Risk Factors for NSF

ACR Manual on Contrast Media,

ACR Manual on Contrast Media,

ACR Manual on Contrast Media,

For patients with eGFR < 30 ml/min/1.73m 2:

For patients with eGFR 30-39 ml/min/1.73m 2:

For patients with eGFR 40-59 ml/min/1.73m 2:

For patients with eGFR > 60 ml/min/1.73m2:

For patients with AKI

ACR Manual on Contrast Media,

Assessment of risk factors of the patient 56F,CKD,DM2,HTN,eGFR

An estimate of the risk ( quantitative or semiquantitative ) NSF is rare

Management/Intervention to reduce risk ? Lower dose of gadolinium

Risk vs Benefit Benefit of MRI w gadolinium contrast outweighs

Communication with the referring physician and/or the patient

Will undergo CABG

Risk Categories Risk of RRT

Risk Categories Risk of RRT

P- 20,995 patients underwent

O- occurrence of post cardiac

Crit Care, 2014

Preventive measures for cardiac

Perioper Med, 2012

Will undergo cisplatin chemotherapy

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