Renal Angina
Lakhmir S. Chawla, MD
Associate Professor of Medicine
Renal Angina
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What the &#$@ are you talking about?
Do I need to know this?
Implementation
Outcomes
Angina – Troponin – ACS/MI
Angina
ACS/MI
Diagnostics
• EKG
• Troponin
Land of AKI Biomarkers
Troponin
Worship
50%
40.6%
Am J Cardiol, 2008; 102:509 - 512
Conclusion
• Troponin performance significantly
deteriorates when used outside of the clinical
syndrome of angina
• AKI Biomarkers will only perform well when
used in the appropriate context
Renal Angina?
Acute Flank Pain
“Simply put, AKI does not hurt”
Cardiac Angina
Risk Factors
Clinical Syndrome
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DM
HTN
Elevated Cholesterol
Family History
Tobacco Use
Elephant on my chest
Squeezing/pressure
Jaw pain
Dyspnea
If RF + Diagnostics > Threshold
HIGH Likelihood of ACS
Renal Angina
Risk Factors
Renal Angina
Risk Factors
• Mechanical Ventilation
• Vasopressors
• Nephrotoxins
• Sepsis
• MSOF
• SCT
• Volume Depletion
Clinical Syndrome
• Early evidence of AKI
If RF + Diagnostics > Threshold
HIGH Likelihood of ACS
Pediatric Renal Angina: Risk Factors
• Moderate Risk (4.5% AKI rate)
– ICU admission
• High Risk (11%-21% AKI rate)
– Stem cell transplantation
• Very High Risk (51% AKI rate)
– Invasive mechanical ventilation
– One vasoactive medication
Pediatric Clinical Signs: Gradation
Chest Pain Equivalent
• Creatinine increase
• Estimated creatinine clearance decrease
(pRIFLE)
• Fluid Accumulation from ICU admission
MV
1+ pressor
Decomp HF
SCT
Ped ICU
2+Nephrotoxin
Putting Renal Angina to the Test
• Preliminary data from CCHMC
• Retrospective chart review of 150 patients
admitted to the PICU
– Median ICU LOS is 3 days
• Assigned each patient risk category
• Assessed for clinical signs (creatinine or fluid
accumulation based)
• Outcome: Day 0, 1 prediction of AKI at 72
hours
• Secondary: PICU LOS, Mortality
Basu, Wheeler, Chawla, Goldstein
Calculating Renal Angina Index
Risk Level
Description
Risk Score
Moderate
High
Very High
ICU status
History of Transplantation
Mechanical ventilation + Inotropy
1
3
5
= Renal Angina Index Score
Angina > 8
Injury (Creatinine)
No ↓eCrCl / No ↑[SCr]
0<x<25% ↓eCrCl / 0-33%
↑[SCr]
25%-50% ↓eCrCl / 33-100%
↑[SCr]
>50% ↓eCrCl / >100%
↑[SCr]
Injury (Fluid
Overload)
< 5%
>5 %
Injury
Score
1
2
>10 %
4
>15 %
8
RA on Day 0
to Predict AKI on Day 3
Multivariate analysis for Renal Angina, patient age, inotropy
score and PRISM II score
OR for Renal Angina on Day 1 to predict AKI on Day 3
=7.1 (1.9-27, p=0.004)
Basu, Wheeler, Chawla, Goldstein: ASN 2011
C statistic = 0.75-0.82
C statistic = 0.68-0.77
Summary/Conclusions
• AKI biomarkers hold promise for earlier
diagnosis of AKI development and intensity
• Risk stratification based on demographics
alone may not sufficiently enrich the
population to optimize AKI biomarker utility
• Renal Angina, a concept that combines risk
stratification and clinical signs may serve well
to optimize biomarker utility
Take Home Points
• Context
• Comparative performance
Stu Goldstein