, 16 tweets, 9 min read Read on Twitter
Very nice review on contrast associated (not contrast induced) AKI in @NEJM nejm.org/doi/full/10.10…
Written by stalwarts in the field
Gated, but definitely worth a read 1/
But I will have minor quibbles of course!
Here’s what they say on pathogenesis
With references from the 1990s! The era of high osmolar contrast media 🙄
Why not use this? ncbi.nlm.nih.gov/m/pubmed/29863… from @jclinicalinvest 2017? 2/
At least the pathophysiology image is better looking than @VijayanMD favorite one 😅
3/
On dose of contrast there’s conflicting advice
4 ml/kg or 2x GFR? Or 350 ml?
Isn’t it just sensible to say use as less as possible and ignore the need for pretty pictures? 4/
This is on NAC
As much as I like PRESERVE, anyone with a 🧠 who had read ncbi.nlm.nih.gov/m/pubmed/21859… & ncbi.nlm.nih.gov/m/pubmed/18001… &/or a dash of common sense knew NAC was 🐄 💩 5/
This is well written on whether contrast AKI exists
It does - but some more definitive statements would have been nice
Eg
It is not a myth
But need for dialysis is <<<<1%
6/
They do mention the problems with the small rise in creatinine problem
Time for me to plug the Bora-Bora criteria twitter.com/i/moments/1018… 7/
On risk scores, they claim all scores use post-procedural variables
The first author score is
But Citation 34 is ncbi.nlm.nih.gov/m/pubmed/25516… based only on pre-procedural data - and was best according to this SR: ncbi.nlm.nih.gov/m/pubmed/28545… 8/
All this on volume expansion
Unnecessary aspersions cast on AMACING IMO
But no mention of oral fluids?
Ahem, See ncbi.nlm.nih.gov/m/pubmed/23555… 9/
Though I agree with the Coca SR,
This ignores the POSEIDON trial though nephjc.com/poseidon which may be chance. Or maybe not 10/
Overall it is quite sensible, well written
I am nitpicking as always
I would have loved stronger opinions 🤔
Read it here nejm.org/doi/full/10.10…
Nicely done @Drroxmehran @stevenweisbord 👏🏼
11/11
Last point h/t @annlbugeja
In figure there is ‘suspend nephrotoxic medication’ advice
The text is more explicit - but lot of peeps might misconstrue this to stop RAS blockade. Don’t do that
RAS blockade is good
Stopping them to prevent a bump in creatinine is bad 12/11
Calling RAS blockade nephrotoxic also activates the @CharlieTomson klaxon

BTW, there’s a small RCT that shows stopping RAS in this setting doesn’t help ncbi.nlm.nih.gov/m/pubmed/18438… 13/11
And I wish they had been less wishy-washy on the metformin issue
If severe contrast AKI is so rare, then do we need to hold it in the vast majority of patients? 14/11
Ending with my favorite quote on metformin & contrast
15/11
And for what I mean by @VijayanMD favorite schematic, scroll down in this #NephMadness scouting report ajkdblog.org/2018/03/15/nep… 16/11
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