WhatConstutes “NephrologyClearance”?schd.ws/hosted_files/psnannual2015/31/What... · Whathewillsay... • Nephrology&Clearance&vs&Nephrology&Risk& Straﬁcaon&/&Assessmentand&&Management&

What Cons*tutes “Nephrology Clearance”?

Oscar Naidas, MD Frederick Ogbac, MD

What he will say ... •  Nephrology Clearance vs Nephrology Risk Stra=fica=on / Assessment and Management

•  Composi=on 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 Stra*fica*on / Assessment and its Management

•  Defini=on of Clearance ( ) “Official authoriza.on for something to proceed or take place”

•  Example: “Do not schedule the pa.ent for CT Scan of the abdomen with IV contrast un.l you are given clearance by the nephrologist”

Oxford Advance Learner’s Dic5onaries

Composi*on of a Nephrology Risk Assessment and Management

•  Type of poten=al ischemic / nephrotoxic insult •  Assessment of risk factors of the pa=ent •  An es=mate of the risk (quan=ta=ve or semi-‐quan=ta=ve)

•  Management / interven=on to reduce risk •  Risk vs Benefit •  Communica=on with the referring physician and/or the pa=ent

The seafarer with chronic GN


35 M, asymptoma=c, BP:140/90mmHg, Ht 5’7”, 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


Asymptoma=c, BP 130/80mmHg, Ht 5’7”, Wt 70 kg,no edema, Urine rbc 15-‐20/hpf, protein(-‐) ACR 110 mg/g

Scr 1.5mg/dl (eGFR 62ml/min) US KUB(-‐)


Chronic GN probably IgAN


Chronic GN probably IgAN, CKD G2A2 (moderate risk of progression)


•  No indica=on for kidney biopsy, stable for past 3 yrs,

•  LPD and Losartan 50mg OD (<BP130/80mmHg ), slows the fall in GFR to 3ml/min/yr


•  No indica=on 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 hospitaliza=on or dialysis within next 9 to 12 months

•  Repeat BP, Scr, UPCR ager 9 to 12 months

Pa*ent 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: 5’1” •  SCr 1.5 (eGFR 38.5 ml/min) Uprot: +2 •  Chronic abdominal pain •  US pancrea=c mass? •  Will undergo whole abdomen CT-‐Scan with contrast

•  Referred for “Nephrology Clearance”

(38.5 ml/min)

A Simple Risk Score for Predic*on of Contrast-‐Induced Nephropathy ARer Percutaneous Coronary Interven*on Mehran R, Aymong ED, Nikolsky E, et al

J Am Coll Cardiol, 2004

Total = 13



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



Low Mod

Mod

High


6 to 10 14 0.12 11 to 16 26.1 1.09 > 16 57.3 12.6

Total = 13



Low Mod

Mod

High

Am J Cardiol, 2006

Risk Predic*on of Contrast-‐Induced Nephropathy McCullough PA, Adam A, Becker CR, et al

Am J Cardiol, 2006

Risk Predic*on of Contrast-‐Induced Nephropathy McCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, Tumlin J, CIN Consensus Working Panel

Am J Cardiol, 2006

Individualizing risk management STEPS HOW TO DO IT

STEP 1 Es=mate your pa=ent’s risk for an event (CI AKI) without treatment (Rc)

56F, stable CKD G3bA3,DM2,HF will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK)




STEP 2 Es=mate the RR using the study result





Saline hydra=on+ NAC, reduces the risk of CI AKI RR = 0.68



56F, stable CKD G3bA3,DM2 will undergo abdominal CT w IV contrast with a risk of CI AKI 26% (MODERATE RISK)



STEP 3 Es=mate your individual pa=ent’s risk for an event (CI AKI)with treatment

Rt = Rc x RR = 26% x 0.68 = 18%






STEP 3 Es=mate your individual pa=ent’s risk for an event (CI AKI) with treatment

Rt = Rc x RR = 26% x 0.68 = 18%

STEP 4 Es=mate the individualized ARR

ARR = Rc – Rt = 26% -‐ 18% = 8% (LOW RISK)

Composi=on of a Nephrology Risk Assessment and Management

•  Type of poten=al ischemic/nephrotoxic insult CT Scan w IV contrast

•  Assessment of risk factors of the pa=ent CKD eGFR 38ml/min DM2,HF

•  An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) CI AKI 26% (MODERATE RISK)

•  Management/Interven=on to reduce risk Saline Hydra.on +NAC reduce risk to 8% (LOW RISK)

•  Risk vs Benefit Confirma.on +/-‐ of pancrea.c mass with CT Scan w/ IV contrast outweighs LOW RISK of CI AKI

•  Communica=on with the referring physician and/or the pa=ent

The Pa*ent w CKD will Undergo Coronary Angiography/PCI

•  56 F, DM2, HTN, with HF symptoms •  Insulin 10u SQ OD •  Telmisartan 40mg OD, Metoprolol 50mg BID •  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 indica*on


Renal Risk Stra*fica*ons for CKD pa*ents prior to CA or PCI

•  Mehran, et al. A simplified risk score for contrast-‐induced nephropathy ager percutaneous coronary interven=on. JACC, 2004.

•  Tziakas, et al. Valida=on of a new risk score to predict contrast-‐induced nephropathy ager percutaneous coronary interven=on. Am J Cardiol, 2014.

Comparison of Renal Risk Stra*fica*ons for CKD pa*ents prior to CA or PCI

Index No. of variables

Score range

Mehran JACC 2004

8 0 – 34

Tziakas Am J Cardiol

2014

5 0 – 8




Total = 13




6 to 10 14 0.12 11 to 16 26.1 1.09 > 16 57.3 12.6

Total = 13



Low Mod

Mod

High


6 to 10 14 0.12 11 to 16 26.1 1.09 > 16 57.3 12.6

Total = 13



Low Mod

Mod

High

Am J Cardiol, 2014

Valida*on of a New Risk Score to Predict Contrast-‐Induced Nephropathy ARer Percutaneous Coronary Interven*on Tziakas D, Chalikias G, Stakos D, Altun A, Sivri N, Yetkin E, Gur M, Stankovic G, et al

Am J Cardiol, 2014


Am J Cardiol, 2014

2

2

Risk Score Risk for CI-‐AKI < 3 7.5% > 3 34%


Am J Cardiol, 2014

Risk Score Risk for CI-‐AKI < 3 7.5% > 3 34%


Am J Cardiol, 2014

Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast-‐Induced Acute Kidney Injury among Pa*ents Undergoing Coronary Angiography or Percutaneous Coronary Interven*on at SLMC-‐QC Ogbac FE, Gonzales-‐Prociuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O •  P-‐ Pa=ents undergoing coronary

angiography and/or PCI at St Luke’s QC

•  I-‐ Mehran vs Tziakas

• O-‐ occurrence of CI-‐AKI SLMC-‐QC Sec=on of Nephrology, 2014

Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast-‐Induced Acute Kidney Injury among Pa*ents Undergoing Coronary Angiography at SLMC-‐QC Ogbac FE, Gonzales-‐Porciuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O

SLMC-‐QC Sec=on of Nephrology, 2014

AUC

0.69 0.73

Comparison of Tziakas Risk Score vs Mehran Risk Stra*fica*on in Predic*ng Contrast-‐Induced Acute Kidney Injury among Pa*ents Undergoing Percutaneous Coronary Interven*on at SLMC-‐QC Ogbac FE, Gonzales-‐Porciuncula L, Buaron MJ, Semeniano R, Cheng F, Naidas O

SLMC-‐QC Sec=on of Nephrology, 2014

AUC

071 0.79

Individualizing risk management Tziakas

STEPS HOW TO DO IT STEP 1 Estimate your patient’s risk for an event (CI AKI) without treatment (Rc)

56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5% (LOW RISK)

Preven*on of CI-‐AKI •  Low osmolal or iso-‐osmolal contrast agents •  Isotonic saline or isotonic bicarbonate 3 ml/kg 3 hrs prior to procedure and 1 ml/kg/hours for 6 hours ager the procedure

•  Leg ventricular end diastolic pressure guided fluid replacement

•  Acetylcysteine 1200mg BID •  Discon=nua=on of renal vasoconstric=ng agents

Uptodate, 2015




STEP 2 Estimate the RR using the study result

Saline hydration + NAC reduces the risk of CI AKI RR = 0.68





Saline hydration + NACreduces the risk of CI AKI RR = 0.68

STEP 3 Estimate your individual patient’s risk for an event(CI AKI)with treatment

Rt = Rc x RR = 7.5% x 0.68 = 5%






STEP 3 Estimate your individual patient’s risk for an event (CI AKI) with treatment

Rt = Rc x RR = 7.5% x 0.68 = 5%







Rt = Rc x RR = 7.5% x 0.68 = 5%

STEP 4 Estimate the individualized ARR

ARR = Rc – Rt = 7.5% -5% = 2.5% (LOW RISK)

Individualizing the results STEPS HOW TO DO IT STEP 1 Estimate your patient’s risk for an event (CIN) without treatment (Rc)

56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 7.5%


Saline hydration + NACreduces the risk of CI AKI RR = 0..68

STEP 3 Estimate your individual patient’s risk for an event with treatment

Rt = Rc x RR = 7.5% x 0.68 = 5%


ARR = Rc – Rt = 7.5% -5% = 2.5%

STEP 5 Estimate the individualized NNT

NNT = 100/ARR = 100/2.5 = 40

Individualizing risk management Mehran


56F with stable CKD G3bA3,DM2, HF will undergo coronary angiography /PCI with a CI AKI risk of 26% (MODERATE RISK)




Rt = Rc x RR = 26% x 0.68 = 18%


ARR = Rc – Rt = 26% -18% = 8% (LOW RISK)


•  Type of poten=al ischemic/nephrotoxic insult CA/PCI

•  Assessment of risk factors of the pa=ent CKD eGFR 38ml/min, DM2,HF

•  An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) CI AKI 7.5% to 26% (LOW to MODERATE RISK)

•  Management/Interven=on to reduce risk( Saline hydra.on+NAC reduce risk to 2.5% to 8% (LOW RISK)

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


The Pa*ent withCKD who will undergo abdominal surgery

•  56 F, DM2, HTN •  Insulin 10u SQ OD •  Telmisartan 40mg OD, Metoprolol 50mg BID •  BP: 130/90 mmHg Wt: 60kg •  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 pancrea=c tail, ascites •  Coroangio: nega=ve •  Pre-‐op CV: stra=fica=on intermediate to high risk of developing periopera=ve CV complica=ons

•  Par=al pancreatectomy


Anesthesiology, 2009

Development and valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al


Total = 6



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

Development and Valida*on of an Acute Kidney Injury Risk Index for Pa*ents Undergoing General Surgery Kheterpal S, Tremper KK, Heung M, et al


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



Pre-‐opera*ve Renal Risk Stra*fica*on of our pa*ent (Class V)

•  The incidence of AKI ager exploratory laparotomy is 9%

•  She is 46x more likely to develop AKI post exploratory laparotomy vs Class I pa=ents


STEP 1 Es=mate your pa=ent’s risk for an event (AKI) without treatment (Rc)

56F, stable CKD G3bA3,DM2 will undergo abdominal surgery with a risk of post op AKI 9% (HIGH RISK)





Periopera=ve hemodynamic op=miza=on, reduces the risk of post op AKI RR = 0.64






STEP 3 Es=mate your individual pa=ent’s risk for an event (AKI) with treatment

Rt = Rc x RR = 9% x 0.64 = 6%






STEP 3 Es=mate your individual pa=ent’s risk for an event (AKI) with treatment

Rt = Rc x RR = 9% x 0.64 = 6%

STEP 4 Es=mate the individualized ARR

ARR = Rc – Rt = 9% -‐ 6% = 3% (MODERATE RISK)


•  Type of poten=al ischemic/nephrotoxic insult Par.al pancreatectomy

•  Assessment of risk factors of the pa=ent 56F,CKD,DM,2HTN •  An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) GS AKI

Risk 9% (HIGH RISK)

•  Management/Interven=on to reduce risk Periopera.ve hemodynamic op.miza.on reduces risk to 3% (MODERATE RISK)

•  Risk vs Benefit Benefit of par.al pancreatectomy outweighs MODERATE RISK of post op AKI


The pa*ent with CKD will undergo MRI w gadolinium contrast

•  57 F, DM2, and HTN •  Insulin 10u SQ OD •  Telmisartan 40mg OD, Metoprolol 50mg BID •  BP: 120/90 mmHg Wt: 60kg •  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 =ssues seen in pa=ents with renal problem

ACR Manual on Contrast Media, 2013

American College of Radiology Manual on Contrast Media (Ver 9, 2013) Risk Factors for NSF •  Gadolinium based contrast agent administra=on •  Hemodialysis •  Chronic Kidney Disease •  Acute Kidney Injury •  High dose and mul=ple exposure


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


For Inpa*ents: •  eGFR should be obtained within 2 days prior to giving gadolinium

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


For Inpa*ents: •  eGFR should be obtained within 2 days prior to giving gadolinium

American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents with eGFR < 30 ml/min/1.73m2: •  Gadolinium agents should be avoided •  If gadolinium enhanced MRI is deemed essen=al, use of the

lowest possible dose is recommended For pa*ents with eGFR 30-‐39 ml/min/1.73m2: •  NSF is rare, but precau=ons are recommended For pa*ents with eGFR 40-‐59 ml/min/1.73m2: •  NSF is rare, with no precau=ons For pa*ents with eGFR > 60 ml/min/1.73m2: •  No evidence of increased risk of developing NSF


American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents with AKI •  Gadolinium agents should only be administered if absolutely necessary


American College of Radiology Manual on Contrast Media (Ver 9, 2013) For pa*ents on dialysis: •  Gadolinium enhanced MRI be performed as closely as before hemodialysis



•  Type of poten=al ischemic/nephrotoxic insult MRI w Gadolinium Contrast

•  Assessment of risk factors of the pa=ent 56F,CKD,DM2,HTN,eGFR 35ml/min

•  •  An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve ) NSF is rare

•  Management/Interven=on to reduce risk ? Lower dose of gadolinium

•  Risk vs Benefit Benefit of MRI w gadolinium contrast outweighs VERY LOW RISK of NSF

•  •  Communica=on with the referring physician and/or the pa=ent

What he just said ... •  Nephrology Clearance vs Nephrology Risk Stra=fica=on / Assessment and Management

•  Composi=on of “Nephrology Clearance” – Type of poten=al ischemic/nephrotoxic insult – Assessment of risk factors of the pa=ent – An es=mate of the risk ( quan=ta=ve or semiquan=ta=ve )

– Management/Interven=on to reduce risk – Risk vs Benefit – Communica=on with the referring physician and/or the pa=ent

Our Pa*ent •  56 F, DM2, HTN, with HF symptoms, non smoker •  Insulin 10u SQ OD •  Telmisartan 40mg OD, Metoprolol 50mg BID •  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 Leg main coronary artery involvement

•  Will undergo CABG

Predic*ve Indices for Es*ma*ng Risk of Post-‐Cardiac Surgery RRT

•  SRI – Wijeysundera, et al. Deriva=on and valida=on of a simplified predic=ve index for renal replacement therapy ager cardiac surgery. JAMA, 2005.

•  Mehta, et al. Bedside Tool for predic=ng the risk of postopera=ve dialysis in pa=ents undergoing cardiac surgery. Circula=on, 2006

•  Thakar, et al. A clinical score to predict acute renal failure ager cardiac surgery. J AM Soc Nephrol, 2005.

Comparison of Predic*ve Indices for Es*ma*ng Risk of Post-‐Cardiac Surgery RRT


Score range AUC (Toronto cohort)

SRI 2007 8 0 – 8 0.78 (0.72-‐0.84)

Mehta 2005 10 0 – 83 0.75 (0.66-‐0.83)

Thakar 2005 13 0 – 17 0.81 (0.74-‐0.86)

JAMA, 2007

Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery (SRI) Wijeysundera DN, Karkou= K, Dupuis JY, et al

JAMA, 2007

JAMA, 2007

Total = 3


Risk Categories Risk of RRT (%) Low Risk (0 to 1 point) 0.4 Intermediate Risk (2 to 3 points) 3 High Risk (> 4 points) 10

JAMA, 2007


Risk Categories Risk of RRT (%) Low Risk (0 to 1 point) 0.4 Intermediate Risk (2 to 3 points) 3 High Risk (> 4 points) 10

JAMA, 2007

Deriva*on and Valida*on of a Simplified Predic*ve Index for Renal Replacement Therapy ARer Cardiac Surgery Wijeysundera DN, Karkou= K, Dupuis JY, et al

Circula5on, 2006

Bedside Tool for Predic*ng the Risk of Postopera*ve Dialysis in Pa*ents Undergoing Cardiac Surgery Mehta RH, Grab JD, O’Brien SM, et al

Circula5on, 2006


Circula5on, 2006

12

1

0 5

0

2 0

0

0

20


Circula5on, 2006

1.1%


Circula5on, 2006

J Am Soc Nephrol, 2005

A Clinical Score to Predict Acute Renal Failure aRer Cardiac Surgery Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP




Total = 5

Risk Categories Risk of RRT (%) 0 – 2 0.4 3 – 5 1.8 6 – 8 7.8 9 – 13 21.5



Comparison of Predic*ve Indices for Es*ma*ng Risk of Post-‐Cardiac Surgery RRT


Score range

Risk Score Risk for RRT post CABG (%)

SRI 2007 8 0 – 8 3 3 Mehta 2005

30 0 – 83 20 1.1

Thakar 2005

13 0 – 17 5 1.8

The risk of AKI requiring RRT post-‐cardiac surgery is between 1.1 to 3%

Crit Care, 2014

•  P-‐ 20,995 pa=ents underwent cardiac surgery including surgery to thoracic aorta (3 different centers)

•  I-‐ retrospec=ve cohort

• O-‐ occurrence of CI-‐AKI and need for RRT

Predic*ve 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

hHp://www.cardiacsurgeryleicester.com/our-‐research/acute-‐kidney-‐injury-‐risk-‐score-‐calculator/

Predic*ve 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

hHp://www.cardiacsurgeryleicester.com/our-‐research/acute-‐kidney-‐injury-‐risk-‐score-‐calculator/

Periopera*ve Acute Kidney Injury Calvet S, Shaw A

Preven*ve measures for cardiac surgery •  Fluids and goal directed therapy •  Avoidance of nephrotoxic agents •  Hemodilu=on and transfusion

Perioper Med, 2012

Our pa*ent post-‐op… •  57 F, DM2, and HTN •  Insulin 10u SQ OD •  Telmisartan 40mg OD, Metoprolol 50mg BID •  BP: 120/90 mmHg Wt: 60kg •  SCr 1.6 eGFR: 35.4 ml/min •  Hb/Hct: 10/30 HbA1C: 7% Alb: 3.5 mg/dl •  Histopath: cervical CA

•  Will undergo cispla=n chemotherapy

Risk Factors for Cispla*n Nephrotoxicity •  Previous cispla=n chemotherapy •  Pre-‐exis=ng kidney damage •  Concomitant administra=on of poten=ally nephrotoxic agents

•  High peak plasma free pla=num concentra=ons

Uptodate, 2014

Preven*on of Cispla*n Nephrotoxicity •  Lower dose of cispla=n •  1L isotonic saline + 20 meqs KCl + 2gms MgSO4 3 hours prior to administering chemotherapy and minimum of 500ml over 2 hours following administra=on

Uptodate, 2015

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Documents

WhatConstutes “NephrologyClearance”?schd.ws/hosted_files/psnannual2015/31/What... · Whathewillsay... • Nephrology&Clearance&vs&Nephrology&Risk& Straﬁcaon&/&Assessmentand&&Management&