摘要
背景：随着冠脉造影数量的增加,对比剂肾病(CIN)发病率逐年升高,增加了患者的住院率和死亡率。目前认为,CIN的高危因素包括基础肾功能不全、糖尿病、大剂量对比剂的使用、充血性心力衰竭等,水化治疗是预防CIN的主要方法。
目的：分析接受冠脉造影术患者CIN的发生情况和影响CIN发生的临床危险因素,探讨水化治疗保护患者近期和远期肾功能的作用。
方法：本试验是单中心、前瞻性队列分析研究。2009年2月至2009年12月择期在我院行冠脉造影的650例患者被纳入队列分析,根据患者血清肌酐水平,用MDRD公式估算患者肾小球滤过率(GFR)水平,将eGFR>60ml/min/1.73m2的患者列入未处理组,eGFR<60ml/min/1.73m2的患者列入水化组,2009年2月至7月入组的患者接受生理盐水水化,8月至12月的患者接受5%碳酸氢钠水化治疗。未处理组不接受任何干预措施。水化组的水化方案是根据患者体重确定滴注速度,将生理盐水或碳酸氢钠以公斤每小时的速度在术中和术后6小时静脉滴注。用病例报告表记录患者的基本病史资料；检测患者术前(基线)、术后48小时内、术后半年的血肌酐水平。计算CIN发生率,分析CIN的临床危险因素。用SPSS软件进行统计分析。
结果：共计595例患者进入队列分析(入选患者650例,排除未记录到术后血清肌酐的49人,术前1周内接受对比剂注射的2人,全因死亡的3人,接受血透的1人)。未处理组(n=543) CIN的发生率为3.32%,水化组(n=52) CIN发生率为0。Logistic回归分析结果,未处理组CIN发生的临床危险因素包括基础eGFR水平降低、高血压病病史、血管造影之前连续服用超过一个月以上的ARB/ACEI类的药物、性别和年龄。水化治疗对患者近期和远期肾功能具有保护作用。展望：水化对远期肾功能的保护作用有待进一步探讨。CIN的预防措施有很大的研究空间。
Backgrounds The morbidity of contrast induced nephropathy(CIN) increases year by year, which also leads to higher mortality and hospitality. The risk factors and preventive measure methods have been discussed extensively these days. Nowadays, the risk factors of CIN include:chronic renal failure with low renal function, diabetes mellitus, the volume of contrast media used, congestive heart failure and so on. Hydration is now considered as one of the most effective methods of CIN prevention.
Object Analysis the morbidity and the clinical risk factors of CIN. Discuss the effect of hydration in protecting patients'acute and long-term renal function.
Method This is a single center, prospective study.650 patients with selective coronary angiography(CAG) were included into the cohort from February to December in 2009, estimated their GFR by MDRD formula according to the blood serum creatinine. The patients with eGFR up to 60ml/min/1.73 m2 were allocated into non-hydration group, and those eGFR below 60ml/min*1.73 m2 were listed into the hydration group. The patients admitted from February to July 2009 were received saline hydration and those from August to December were received 5% sodium bicarbonate hydration. The hydration titrated according to patients' weight, and normal saline or sodium bicarbonate were intravenous at the speed of kg/h during the procedure and within 6 hours after CAG The baseline data of patients and the blood serum creatinine before the CAG、within 48 hours after the CAG、half year after the CAG were recorded in the database. Then SPSS software was used to analyze the morbidity and clinical risk factors of CIN..
Results 595 patients of 650 were collected. (the exclusion were:49 without postoperative serum creatinine; 2 accepted contrast media injections before CAG,3 dead,1 accepted hemodialysis). The morbidity of CIN in non-hydration group (n=543) is 3.32%; there was no CIN happened in hydration group (n=52). In Logistic regression,we found the clinical risk factors of CIN included:reduced eGFR, hypertension, ARB/ACE-I administration before angiography for more than one month, female and the age. It is useful of hydration to protect acute and long-term renal function.
Future It leads to further research to the long-term kidney protection with hydration.
引文
1. Antoniol L, Bartorelli, F.E.S.C, et al. Contrast-Induced Nephropathy. Journal of Interventional Cardiology 2008;21:74-84
2. Gupta R, Binbaum Y, Uresky BF. The renal patient with coronary artery disease.Current concepts and dilemmas. J Am Coll Cardiol 2004;44:1343-1353
3. P A.McCullough. Contrast-induced Acute Kidney Injury[J].J Am Coll Cardiol,2008,51(15):1419-1428
4. Michael R, Harold F. Contrast-induced nephropathy:what are the true clinical consequences? Clin J Am Soc Nephrol 2008;3:263-272
5. Rihal C, Textor S, Grill D, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 2002,105:2259-2264
6. Natalia V, Minara S, Marina V, et al. Contrast-induced nephropathy in patients with type 2 diabetes during coronary angiography:risk factors and prognostic value. Dibetes research and clinical practice.2009,86S:63-69
7. Kang H, Sang R, Kyung P, et al. Periprocedural Hemoglobin Drop and Contrast-induced nephropathy in percutaneous Coronary Intervention Patients.The Korean Society of Cardiology 2009,21:68-73
8. Best PJ, Lennon R, Ting HH, et al. The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions.J Am Coll Cardiol 2002;39:1113-1119
9.李玉兰,周旭晨,黄榕翀。行PCI术的老年患者发生对比剂肾病危险因素分析。《中国现代医药杂志》2009；11：40-42
10.孙瑜,卜军,宋玮等。急性心肌梗死患者急诊经皮冠状动脉介入治疗后对比剂肾病的研究。《内科理论和实践》,2009；3：192-195
11. James T, Fulvio S, Andy A. Pathophysiology of contrast-induced nephropathy. The Am J of Cardiology 2006; 98:14-20
12. McCullough PA, et al.Contrast-induced nephropathy. Crit Care Clin 2005;21:261-280
13. Persson PD.Editorial:contrast medium-induced nephropathy.Nephrol Dial Transplant 2005;20:1-10
14. Floege J, Burg M, Abdul N, et al. Expression of interferon-inducible Mx-proteins in patients with IgA nephropathy or Henoch-Schonlein purpura. National Kidney foundation 2005;47:235-244
15. Heyman Sn, Rosen S, Rosenberger C. Renal parenchymal hypoxia, hypoxia adaptation and the pathogenesis of radiocontrast nephropathy. Clin J Am Soc Nephrol 2008;3:288-296
16. Basnakian AG, Kaushal GP, Ueda N, et al. Toxicology of the kidney.CRC Press, 2005;99:499-523
17. John C, Ivan P. Advanced in contrast media and contrast injectors.Cardiology Clinics,2009; 27:407-415
18. Charles D, Fulvio S, James T. Contrast media use.The American Journal of Cardiology,2006; 98:42-58
19. Hiromichi U, Takahisa Y, Yuji O.prevention of contrast-induced nephropathy with bolus injection of sodium bicarbonate in patients with chronic kidney disease undergoing an emergent coronary procedure:a prospective randomized controlled trial. The American Journal of Cardiology,2010; 98:42-58
20. Rahul K, Piotr S, Christoph A,et al. Prevention of intravenous contrast-induced nephropathy in hospital inpatients.Critical pathways in cardiology,2008; 7:222-224
21. Akira T, Yukie G, Kumie M,et al. Efficacy of Sigle-Bolus administration of sodium bicarbonate to prevent contrast-induced nephropathy in inpatients with mild renal insufficiency undergoing an elective coronary procedure. Am J Cardil 2009; 104:921-925
22. Kevin A, Sterling T, Michael R, clinical significance and preventive strategies for contrast-induced nephropathy. Nephropathy and Hypertension 2008; 17:616-623
23. Ozcan EA, Guneri S, Akdeniz B,et al. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radio-contrast-induced nephropathy. Am Heart J 2007; 154:539-544
24. Adis T, Dilok P, Supachai T. Protection of radiocontrast-induced nephropathy by Vitamin E:a randomized controlled study. J Med Assoc Thai 2009;92:1273-1281
25. Mark N, Mauree B,Renee G. Mitigation contrast-induced kidney injury associated with cardiac catheterization. Cardiology in Review 2009; 17:263-269
26. Manoucherhr A,Mojtaba S, Alireza A. N-acetylcysteine does not prevent contrast-induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease:a randomized clinical trial.Amini 2009;2:1-6
27.罗敏琪,吴凡等。中国南方地区正常人群血清肌酐水平的变化其临床意义。《中国病理生理杂志》,2009；9：1843-1847
28.季乃泉,赵锡忠,季勇。药物致老年急性肾衰竭临床分析,《四川医学》,2008；12：1689-1691
29.闫君,李险峰,李聪革,李思进肾动态显像法测定肾小球滤过率在慢性肾功能衰竭患者的适用性,《山西医科大学学报》,2009；40：1108-1110
30.赵金玲,周宏博,刘立峰,郑慧丽。血清半胱氨酸蛋白酶抑制剂C、肌酐及改良MDRD方程在糖尿病肾功能损害中诊断价值的研究。《现代检验医学杂志》,2009；3：52-54
31.张立等,血清分离胶对检验结果的影响,《临床检验杂志》,2008；26：418
32.孙一帆,李慧妍等。酶法测定健康成年人血清肌酐生物参考区间调查,《实验与检验医学》,2009；27：253-254
33. Michael P, Hitinder S, Richard M, et al. Percutaneous Coronary Intervention Complications and Guide Catheter Size:Bigger Is Not Better. JACC:Cardiovascular Interventions 2009;2:636-644
34.庞天赐,逐步Logistics回归算法,《中国卫生统计》,1992；5：24-29
35.曹瑾,张双德等,卫生统计学中T检验的几点标记,《中国现代医生》,2009；30：229-231
36. Samuel N, Seymour R, MOgher K, et al. Reactive Oxygen Species and the Pathogenesis of Radiocontrast-induced Nephropathy. Invest Fadiol 2010;45:188-195
37. Beth A, Kishore J, Srinivas D,et al. Impact of ontrast-induced Nephropathyafter percutaneous coronary intervention and a method for risk strtification. Am J Cardiol 2004;93:1515-1519
38. Mehran R, Aymong ED,NIkolsky E,et al. A simple risk score for prediction of contrast-induced Nephropathy.after percutaneous coronary intervention:development and initial validation. J Am Coll Cardiol 2004; 6:1393-1399
39. Bagshaw SM, Culleton BF.contrast-induced Nephropathy:epidemiology and prevention.Minerva Cardiology 2006;54:109-129
40. John G, Gordon E, Karin H,et al. A randomized cotrolled trial of intravenous N-acetylcysteine for the prevention of contrast-induced Nephropathy after cardiac catheterization:lack of effect.American Heart J 2004;48:423-429
41. Conti CR, contrast-induced Nephropathy or contrast creatinopathy. Clin Cardiol 2003;26:53-54
42. Zaid A, Joseph W, Giora Z.F,The biochemical pharmacology of renin inhibitors: Implications for translational medicine in hypertension, diabetic nephropathy and heart failure:Expectations and reality,Biochemical Pharmacology,2009;78:933-940
43. Aspelin P, Aubry P, Fransson SG,et al.Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med,2003;248:491-499
44. Jarl A. Jakobsen, Physiological effects of contrast media for use in multidetector row computed tomography.European Journal of Radiology,2007;62:14-25
45. Tsuyoshi N, Ichiro M, Taku I,et al. Contrast medium volume to estimated glomerular filtration rate ratio as a predictor of contrast-induced nephropathy developing after elective percutaneous coronary intervention. Journal of Cardiology,2009;54:214-220
46. Shea E, Phillipe L, Stanley C, et al. Current role of sodium bicarbonate-based preprocedural hydration for the prevention of contrast-induced acute kidney injury:a meta-analysis.American Heart J,2008; 156:415-421
47. Wang Y, Chen K, Morcos S, Radiographic contrast miedia induced nephropathy: experimental observations and the protective effect of calcium channel blockers. Br J Radiol 2009;74:1103-1108
48. Mehmet K, Adrian C, Steven G.Sodium bicarbonate for the prenvention of contrast-induced nephropathy:a meta-analysis of 17 randomized trials. Int Urol Nephrol 2009;41:617-627
49. Dangas G,Iakovou I, Nikolsky E,et al.contrast-induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol 2004;95:13-19
50. Biguori C,Airoldi F,Andrea D.renal insufficiency following contrast media administration trial:a randomized comparison of 3 pre-ventive strategies.Circulation 2007;115:1211-1217
51. Maioli M,Toso A,Leonici M,et al.Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention
[1]P A.McCullough. Contrast-induced Acute Kidney Injury[J].J Am Coll Cardiol,2008,51(15):1419-1428.
[2]Safirstein R, Andrade L, Vieira JM. Acetylcysteine and nephrotoxic:effects of radiographic contrast agents—a new use for an old drug[J]. N Engl J Med, 2000,343(3):210-212.
[3]Sidhu RB, Brown JR, Robb JF, et al. Interaction of gender and age on post cardiac catheterization contrast-Induced acute kidney injury[J]. Am J Cardiol, 2008,102(11):1482-1486.
[4]Tumlin J, Stacul F,,Adam A, et al. Pathophysiology of contrast-Induced nephropathy[J]. Am J Cardiol.2006,98(6A):14K-20K.
[5]Rudnick MR, Davidson C, Laskey W,et al. Nephrotoxicity of iodixanol versus ioversol in patients with chronic kidney disease:the visipaque angiography/interventions with laboratory outcomes in renal insufficiency[J]. Am Heart J,2008,156 (4):776-782.
[6]Reed PS, Dixon SR, Boura JA, et al. Comparison of the usefulness of gadodiamide and iodine mixture versus iodinated contrast alone for prevention of contrast-Induced nephropathy in patients with chronic kidney disease undergoing coronary angiography[J]. Am J Cardio,2007,100(7):1090-1093
[7]Eric Alamartine, Manolie Phayphet, Damien Thibaudin, et al.Contrast medium-induced acute renal failure and cholesterol embolism after radiological procedures:incidence, risk factors, and compliance with recommendations[J]. Eur J Intern Med,2003,114(7):426-431
[8]Chen SL, Zhang J, Yei F, et al. Clinical outcomes of contrast-induced-nephropathy in patients undergoing percutaneous coronary intervention:A prospective, multicenter, randomized study to analyze the effect of hydration and acetylcysteine[J]. Int J Cardiol,2008,126(3):407-413.
[9]Webb JG, Pate GE, Humphries KH, et al. A randomized controlled trial of intravenous N-acetylcysteine for the prevention of contrast induced nephropathy after cardiac catheterization:lack of effect[J]. Am Heart J,2004, 148 (3):422-429.
[10]Aditya Kapoof, Nakul Sinha, R.K. Sharmab, et al. Use of dopamine in prevention of contrast induced acute renal failure-a randomised study[J]. Int J Cardiol,1996 53(3):233-236.
[11]Zhao JL, Yang YJ, Zhang Yh, et al. Effect of statins on contrast-induced nephropathy in patients with acute myocardial infarction treated with primary angioplasty[J]. Int J Cardiol,2008,126(3):435-436.
[12]Leung N, Croatt AJ, Haggard JJ, et al. Acute cholestatic liver disease protects against glycerol-induced acute renal failure in the rat [J]. Kidney Int, 2001,60(3):1047-1057.
[13]Reddan D, Fishman EK. Radiologists' knowledge and perceptions of the impact of contrast-induced nephropathy and its risk factors when performing computed tomography examinations:a survey of European radiologists[J]. Eur J Radiol,2008,6 (6):235-245.
[14]El-Hajjar M, Bashir I, Khan M, et al. Incidence of contrast-Induced nephropathy in patients with chronic renal insufficiency undergoing multidetector computed tomographic angiography treated with preventive measures[J]. Am J Cardiol 2008,102(3):353-356.
[15]陈跃光,吕宝经.对比剂肾功能损害防治的研究进展[J].介入放射学杂志,2006,15(6)：382-384
[16]尚慧,石桂华,金颖.离子型与非离子型对比剂的副反应处理[J].医学影像学杂志,2004,14(4),337—338
[17]卞读军.肖恩华.碘克沙醇——一种新型的更安全的对比剂[J].放射学实践,2005,20(5)：458-459