冠状动脉介入诊疗术后患者尿NGAL对早期造影剂肾病的诊断敏感度和特异度分析

目的:分析探讨冠状动脉介入诊疗术后患者尿中性粒细胞明胶酶相关脂质运载蛋白对早期造影剂肾病的诊断敏感度和特异度。方法:选取我院于2014年05月~2017年05月期间收治的508例接受经皮冠状动脉介入或冠状动脉造影治疗的患者,按照患者术后是否发生对比剂肾病将其划分为CIN组和非CIN组两组,分析两组患者的临床资料,采用Spearman相关分析对患者的尿NGAL和CIN之间的相关性进行分析,并采用Logistic回归分析对影响CIN的危险因素进行多因素分析,分析患者尿NGA对早期CIN诊断的特异度和敏感度。结果:非CIN组患者的术后24 h尿NGAL水平、术后48 h尿NGAL水平以及患者术后24 h相较于术前的尿NGAL水平差值(ΔNGAL24-0 h)和术后48 h的Scr水平均显著低于CIN组患者(均P0.05)。CIN和ΔNGAL24-0 h呈现正相关关系(r=0.481,P0.05);ΔNGAL24-0 h和e GFR均是患者发生CIN的独立危险因素(OR值=1.019,OR值=1.020,均P0.05),而贫血、血脂异常、慢性心力衰竭、糖尿病、高血压、性别、年龄等因素均不是患者出现CIN的独立危险因素(均P0.05)。ROC曲线下面积为0.892(0.852,0.947),切点值为4.67μg/L,特异度和敏感度分别为80.4%和93.6%。结论:冠状动脉介入诊疗术后患者尿中性粒细胞明胶酶相关脂质运载蛋白水平升高对早期造影剂肾病的诊断具有较高的敏感度和特异度,有助于患者CIN的早期诊断,值得在临床上加以推广运用。     

487例冠脉造影后造影剂肾病的临床研究

目的：调查住院冠状动脉造影患者造影剂肾病的发病情况。方法：收集上海市第六人民医院2008年1月~2009年7月31日的回顾性病历,收入2008年~2009年度冠脉造影（coronary angiography）/冠脉干预（percutaneous coronary intervention）病例,分析入选病例的疾病构成和造影剂肾病（contrast-induced nephropathy,CIN）在不同情况下的发病率,比较CIN组与非CIN组患者的各项资料,分析CIN患病的危险因素。结果：入选患者487例中CIN发病率10.5%（51例）,经过Mehran的危险积分分层后提示CIN发病率随着危险积分上升,在极高危的一组中达到18.0%,多因素回归分析显示术前低血压、心衰、贫血、eGFR≤30ml/min是CIN的危险因素。结论：CIN与术前低血压、心衰、贫血、肾功能以及其相应临床指标密切相关;等渗造影剂对与CIN的发病不优于低渗造影剂;需密切关注心内科行CAG的患者CIN的发病率,积极采取有效的措施预防CIN的发生。     

尿液白介素18在冠状动脉介入术后造影剂肾损伤早期诊断中的意义

目的前瞻性研究尿液白介素18（IL-18）在早期预测和诊断冠状动脉造影术后急性肾损伤中的意义。方法收集150例接受冠状动脉造影及介入治疗患者的资料。造影剂肾病（CIN）以传统方法定义。用酶法测术前及术后24 h、48～72 h Scr值。留取患者术前、术后24 h尿液,用ELISA法检测发生CIN患者尿液IL-18、尿N-乙酰-β-D氨基葡萄糖酐酶（NAG）及尿视黄醇结合蛋白（RBP）的水平,并与未发生CIN的患者比较。结果150例患者中13例发生了CIN,发生率为8.7%。使用造影剂后24 h,患者尿液IL-18（ng/L）和NAG（U/L）水平显著升高[分别为15.06（12.21,21.31）比11.62（9.37,13.86）;13.88（7.09,33.23）比10.09 （5.96,16.62）,P均〈0.05];而尿RBP和Scr无显著变化。与非CIN组比较,CIN组术后尿IL-18 （ng/L）显著升高[18.97（13.64,48.57）比14.01（11.91,17.77）,P〈0.05]。相关分析显示,CIN组尿液IL-18与Scr呈正相关（r=0.664,P：0.013）,而尿NAG和RBP与Scr无相关。ROC分析证实,尿液IL-18在CIN早期诊断中的准确性较高,曲线下面积为0.749,P=0.012;当以15.8 ng/L作为诊断截点时,其在CIN诊断中的敏感性和特异性分别为69.2%和74.1%。队列研究结果显示,尿IL-18明显升高患者CIN发病的危险度最高,RR达3.125;而且在CIN患者中,尿IL-18明显上升的构成比最高（P〈0.05）。结论尿IL-18可较Scr更早提示造影剂肾脏损伤的发生,可能为较好的CIN早期诊断标志物。     

冠状动脉介入术患者造影剂肾病的危险因素多中心调查

目的：多中心调查住院冠脉造影（CAG）和经皮冠状动脉介入术（PCI）患者造影剂肾病（CIN）的危险因素。方法：前瞻性收集上海浦东地区六家医院接受冠状动脉介入术患者的资料,分析造影剂肾病发生情况及相关危险因素。结果：入选患者197例,CIN发病率8.63%（17/197）。老年人（年龄≥70岁）72例（36.5%）,糖尿病71例（36.0%）,高血压148例（75.1%）,心功能Ⅱ级以上者22例（11.2%）、心梗患者23例（11.7%）。发生CIN患者与非CIN患者在性别、年龄、2型糖尿病、术前心功能、血红蛋白、红细胞压积、总胆固醇、术前及术后肌酐清除率（Ccr）、术后血肌酐（Scr）、术后肾小球滤过率（GFR）、多只冠脉病变等方面差异有统计学意义（P〈0.05）。相关分析Logistic多元逐步回归显示高龄（年龄≥70岁,相对危险度RR=7.3,P〈0.05）、女性（RR=3.6,P〈0.05）、心肌梗死（RR=5.6,P〈0.05）、造影剂剂量≥180ml（RR=4.0,P〈0.05）是CIN的危险因素。结论：心内科住院行CAG和PCI的患者CIN发生率较高,糖尿病、高血压、心功能不全等CIN公认的高危因素普遍存在;年龄70岁以上、女性、心肌梗死、较高造影剂剂量可能是心内科住院行CAG和PCI者CIN发生的危险因素。     

血清胱蛋白酶抑制剂C能用于周围动脉疾病腔内治疗术后造影剂肾病的诊断吗?

目的 分析腔内治疗周围动脉疾病术后造影剂肾病( CIN)发生的危险因素,以及血清胱蛋白酶抑制剂C(Cys C)与血清肌酐(Scr)在诊断肾损伤时的符合情况.方法 本研究为前瞻性、单中心研究,2010年7月至2011年4月在本院血管外科接受非急诊周围动脉疾病腔内治疗术的住院患者入选.根据造影后Scr升高≥25％标准判断是否发生CIN,分为非CIN组和CIN组,比较两组患者的一般临床资料和血液生化指标;行相关危险因素的Logistic回归分析;分析造影前后Scr和血清Cys C变化分布以及两者诊断CIN的符合情况.结果 367例患者入选.CIN组并发糖尿病比例、造影剂用量、术前利尿剂合并用药比例均显著高于非CIN组,差异有统计学意义(P分别＜0.05、＜0.01、＜0.01).Logistic回归分析结果显示,并发糖尿病、造影剂用量为CIN的危险因素.采用术后24 h血清Cys C任何程度的升高、升高≥5％、≥8％、≥10％、≥15％、≥25％及绝对值升高≥0.2 mg/L标准预测Scr诊断标准诊断的CIN的灵敏度均较低.维恩图显示两指标诊断肾损伤患者的集合重叠区域均较小.结论 造影剂用量、糖尿病为CIN发生的独立危险因素.造影后血清Cys C升高标准与Scr标准在诊断肾损伤上符合情况较差.     

外周血管介入术后造影剂肾病患者远期肾功能变化及其影响因素分析

<正>造影剂肾病(CIN)是冠脉介入，外周血管介入等使用造影剂后出现的并发症[1-3]。CIN通常是短暂的，大多数病例在2周内治愈。但是，CIN与术后不良事件、死亡率相关;因此，CIN常用作介入手术之后的质量评估指标[3-6]。目前大多数CIN的研究都是关于冠脉介入术的患者[4,6-12]。随着血管腔内手术时代的来临，外周血管介入(PVI)成为外周血管疾病常用的治疗方法，因此，了解PVI术后患者发生CIN的危险因素及其对远期肾功能的影响非常重要。多篇研究报道了与冠脉介入和PVI术后CIN相关的围手术期因素包括肥胖、低体重、糖尿病、心力衰竭、贫血、术前肾衰竭，严重肢体缺血和造影剂的剂量[2-4]。虽然这些因素可能与CIN相关，     

尿a1-MG和NAG在造影剂早期肾损伤中的应用及水化防治作用探讨

目的 探讨水化治疗对行冠状动脉介入术(PCI)患者造影剂肾病(contrast induced nephropathy,CIN)的防治作用,了解CIN临床发病率,探究早期CIN肾损害部位及敏感检测指标.方法 选择120例接受PCI治疗的患者,随机分为水化治疗组(60例)与对照组(60例).水化治疗组患者在PCI术前6h起开始静脉补液至PCI术后12h.对照组患者确保正常饮食及饮水.两组患者分别于术前、术后第1d、第2d、第3d测定血清肌酐(Scr)、尿素氮(BUN)及血浆胱抑素C(Cys-C),留取尿标本检测尿微量白蛋白(mAlb)、尿a1-微球蛋白(a1-MG)、尿N-乙酰-β-D氨基葡萄糖苷酶(NAG).结果 与术前比较,术后第1dNAG和a1-MG显著升高(P＜0.01),术后第2d尿渗透压和GFR(MDRD公式计算)降低(P＜0.05).术后第2d与术后第1d比较,NAG和a1-MG均降低(P＜0.05);术后第3d渗透压和GFR(MDRD公式计算)较术前无明显变化(P＞0.05).水化治疗组:术后第1d与术前比较,NAG和a1-MG显著升高(P＜0.01),术后第2d渗透压、GFR(MDRD公式计算)无明显变化(P＞0.05).术后第2d与术后第1d比较,NAG和a1-MG均降低(P＜0.05)且与术前基线比较差异无统计学意义(P＞0.05);渗透压和GFR(MDRD公式计算)无明显变化(P＞0.05).两组间:对照组术后第1d与水化治疗组术后第1d相比,NAG和a1-MG升高明显,差异有统计学意义(P＜0.05);术后第2d NAG和a1-MG的升高仍有统计学差异(P＜0.05).两组间渗透压和GFR(MDRD公式计算)差异无统计学意义(P＞0.05).结论 ①NAG和a1-MG是早期发现CIN的可靠指标;②造影剂(CM)首先造成肾小管损害;③水化治疗对防治早期造影剂肾损害效果明显,可能有利于损伤肾小管功能早期恢复;④基础肾功能不全和/或伴有2型糖尿病、高血压病的患者CIN的发生率明显升高;⑤使用GFR(MDRD公式计算)估算肾小球率过滤,能达到评估肾小球滤过功能,但早期发现CIN的作用有限.血浆胱抑素C(Cys-C)早期检测效果有限.     

N-乙酰半胱氨酸对慢性肾功能不全患者造影剂肾病的预防作用

造影剂肾毒性仍然是住院患者急性肾衰竭的常见原因,其发生率在10％以上。其中肾功能不全是造影剂肾病(CIN)的重要危险因素[1]。水化疗法是使用最早、目前被广泛接受的有效减少CIN发生率的方法,但效果不明显,CIN发生率仍然很高。N-乙酰半胱氨酸(NAC)能否预防CIN仍有争议,而以慢性肾功能不全患者为研究对象的研究甚少。我们通过观察NAC对应用造影剂的慢性肾功能不全患者Scr、血清胱抑素C(Cys-C)水平和CIN发生率的影响,研究NAC对CIN的预防作用。     

造影剂肾病的危险因素及防治进展

随着造影剂在诊断和介入诊治术中的广泛应用，造影剂肾病（CIN）已成为当前医院内发生急性肾功能衰竭的第3位常见原因。了解CIN发病的危险因素及防治有助于识别高危患者、采取正确的预防措施、及时诊断和治疗，降低发病率及死亡率。     

冠状动脉瘤样扩张与弥漫性扩张的血管造影特征及心血管危险因素

目的比较冠状动脉瘤样扩张(CAA)与弥漫性扩张(CAE)血管造影特征及心血管危险因素的差异。方法回顾性分析16 778例冠状动脉造影图像。结果 211例存在冠状动脉扩张,包括132例CAA、79例CAE。CAA发病率、合并冠状动脉疾病发生率及其Gensini评分均明显高于CAE(P均0.05);CAA患者冠状动脉血管平均直径小于CAE (P0.05),心肌梗死溶栓(TIMI)血流分级均低于CAE(P均0.05)。血脂异常、吸烟及冠状动脉病家族史为CAA的独立危险因素(P均0.05)。结论 CAA与CAE在血管造影特征及心血管危险因素方面存在显著差异。     

胱抑素C早期诊断造影剂肾病的临床研究

目的：探讨血浆胱抑素C（Cys C）在造影剂肾病（CI N）早期诊断中的临床意义。方法：选择使用非离子型低渗造影剂进行血管造影的130例患者为研究对象,所有患者分别于造影前24 h内、造影后8 h、24 h和48 h抽血检测Cys C、肌酐（Scr）、尿素氮（BUN）、尿酸（UA）以及根据公式推算的肾小球滤过率（eGFR）,根据患者在造影后48 h内是否发生造影剂肾病（CI N）,分为CI N组和非CI N组。结果：（1）CI N的发生率为12.3%。（2）CI N组血浆Cys C浓度造影后8 h明显升高,24 h达最高峰,48 h有所降低,但均明显高于造影前以及非CI N组相应时间点的水平,差异均有统计学意义（P〈0.05）。而CI N组Scr造影后8 h无明显变化,24 h开始升高,48 h达最高值,只有48 h的值明显高于造影前以及非CI N组相应时间点的水平,差异有统计学意义（P〈0.05）。非CI N组造影前后各时间点Cys C、Scr等各项指标比较差异无统计学意义（P〉0.05）。（3）患者造影前Cys C与Scr（r=0.431）呈明显正相关,与eGFR（r=-0.392）呈明显负相关。（4）若以造影后8 h和24 h内血浆Cys C浓度较造影前基础值上升25%作为诊断CI N的标准,其敏感性分别为83.2%和89.2%,特异性分别为74.1%和80.5%。阳性预测值分别为45.6%和51.3%,阴性预测值分别为92.5%和94.2%。结论：造影后8 h和24 h的血浆Cys C浓度对CI N的早期诊断有一定的价值,能较Scr更早反映肾功能的变化。     

Clinical survey on contrast-induced nephropathy after coronary angiography

Abstract

Objective: To investigate the incidence and risk factors of contrast-induced nephropathy (CIN) in patients receiving coronary angiography (CAG) in a Chinese medical center. Methods: The medical records of the patients receiving CAG at Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiaotong University from January 2008 to July 2009 were collected to analyze the incidence of CIN under different conditions and the clinical difference between CIN group and non-CIN group. Results: There were 487 cases enrolled in this study and the total incidence of CIN was 10.5%. Through Mehran risk score stratification, incidence of CIN increased with risk scores and in an extremely high-risk group it was as high as 18.0%. Multi-factor regression analysis showed that preoperative hypotension, heart failure, anemia and low estimated glomerular filtration rate (≤30?mL/min) were risk factors of CIN after CAG. Conclusion: CIN post CAG is associated with preoperative hypotension, heart failure, anemia and renal function. Close attention should be paid to CIN in patients receiving CAG.     

Prevention of contrast-induced nephropathy in vascular surgery patients

Presently, only hydration and N-acetylcysteine have been shown to be effective in decreasing the incidence of radiographic contrast-induced nephropathy. We investigated the role of N-acetylcysteine and various hydration protocols in vascular surgery patients undergoing angiography. A single-center, randomized, placebo-controlled trial was conducted in patients with stable, preexisting renal dysfunction undergoing elective, outpatient angiography. Patients were randomized to outpatient oral hydration and N-acetylcysteine, inpatient hydration plus N-acetylcysteine, or our standard therapy of inpatient intravenous hydration alone. Two of twenty-eight (7%) patients who received outpatient oral hydration and N-acetylcysteine developed contrast-induced nephropathy, while two of 25 (8%) who recieved inpatient hydration plus N-acetylcysteine developed contrast-induced nephropathy and two of 25 (8%) who received standard therapy of inpatient intravenous hydration alone developed contrast-induced nephropathy. There was no statistical difference in incidence of contrast-induced nephropathy between the groups. No statistically significant independent risk factors were identified among the patients who developed contrast-induced nephropathy. N-Acetylcysteine did not confer additional benefit to patients treated with inpatient intravenous hydration. Outpatient oral hydration plus N-acetylcysteine was as effective at preventing contrast-induced nephropathy as inpatient therapies and avoided costly hospital admission.     

Nephrotoxicity of iso-osmolar versus low-osmolar contrast media is equal in low risk patients

BACKGROUND: Contrast media-induced nephropathy (CIN) is an increasing cause of hospital-acquired acute kidney injury and leads to a significant increase in mortality. There is uncertainty whether the use of iso-osmolar contrast media as opposed to the use of low-osmolar contrast media would be associated with a lower incidence of CIN. Therefore, we compared the nephrotoxicity of isoosmotic contrast media iodixanol with the low-osmotic contrast media iopromid in patients receiving contrast media during coronary angiography. METHODS: In this prospective double-blind study we examined 221 patients with normal renal function who received up to 1,000 ml of contrast media during coronary angiography, and compared the effect of iodixanol and iopromid on inducing contrast media nephropathy. Patients received 800 ml fluid orally before contrast media administration and 1,000 ml saline i.v. thereafter. Creatinine clearance, serum creatinine and urine-N-acetyl-beta-D-glucosaminidase (NAG) concentration was obtained 24 h before and 48 h after contrast media administration. Decrease of 20% of the creatinine clearance, increase of 25% of serum creatinine and increase of 20% of the urine concentration of NAG was defined as CIN. RESULTS: Incidence of CIN assessed by decreased creatinine clearance was 22.2% in the iopromid group and 19.7% in the iodixanol group. CIN defined by increased serum creatinine was 6.9% in the iopromid group and 8.6% in the iodixanol group. The difference between these two groups was not significant. Subgroup analysis of the diabetic patients or the patients that received high dose of contrast media revealed no significant difference in the incidence of CIN between the two contrast media. CONCLUSION: The iso-osmolar and the low-osmolar contrast media exhibited the same incidence of CIN in our study population. If fluid administration is sufficient, the selection of either iopromid or iodixanol has no impact on the risk of developing CIN in patients with normal renal function, even when they are diabetic or receive a high dose of more than 500 ml contrast media.     

Frequency and risk factors of contrast-induced nephropathy after cardiac catheterization in type II diabetic patients: a study among Egyptian patients

Contrast-induced nephropathy (CIN) is the third leading cause of acute kidney injury (AKI) in hospitalized patients. Diabetes mellitus remains a consistent independent predictor of contrast nephropathy. Aim: To determine frequency and predictors of contrast-induced nephropathy after cardiac catheterization in type II diabetic patients. Patients and methods: The study included 200 type II diabetic patients who underwent cardiac catheterization; serial measurement of serum creatinine and creatinine clearance (Before contrast exposure and 48?h), creatinine clearance was calculated using Cockcroft–Gault formula. Contrast-induced nephropathy was defined as rise in serum creatinine 48?h after contrast exposure of ≥0.5?mg/dL or increased >25% compared to base line creatinine. Results: incidence of CIN in type II diabetic patients was 21.5%; incidence of CIN in diabetic patients with microalbuminuria was 17%, while incidence of CIN in patients with macroalbuminuria levels was 26%. There was a statistically significant difference between the patients who suffered from CIN post-procedure and patients who did not suffer from CIN regarding the ejection fraction and age with low ejection fraction and older patients in CIN group. Multiple logistic regression analysis for CIN predictors showed that pre-contrast serum creatinine to be the strongest predictor for being at risk of contrast-related, followed by age, and lastly albumin/creatinine ratio. Conclusion: Our findings suggest that diabetic patients, despite having a normal baseline creatinine are at an increased risk of developing CIN post-coronary angiography, patients at risk of CIN are older patients with high pre-contrast serum creatinine and high urine albumin/creatinine ratio.     

Proteinuria as a predictor of renal dysfunction in trauma patients receiving intravenous contrast

Trauma patients have unknown comorbidities, multiple injuries, and incomplete laboratory testing, yet require contrast-enhanced imaging to identify potentially life-threatening problems. Our goal was to characterize contrast-induced nephropathy (CIN) in this population. We retrospectively reviewed characteristics of 402 patients who presented to a Level II trauma center and received contrast-enhanced imaging. CIN was defined as creatinine rise of 0.5 mg/dL or greater or 25 per cent or greater from baseline within 48 hours. CIN occurred in 7.7 per cent and four patients required hemodialysis. Patients with CIN were older, had lower admission hemoglobin, higher Injury Severity Score, and received more blood products. Factors that predicted CIN included: male sex, age older than 46 years, body mass index less than 27 kg/m2, glomerular filtration rate less than 109 mL/min/1.73 m2, hemoglobin less than 12 mg/dL, hematocrit less than 36 per cent, proteinuria, 2 units or more of fresh-frozen plasma in 48 hours, and alcohol use. Odds ratio for developing CIN with two, five, or six of these factors was 3.39, 6.54, and 8.38, respectively. A match-controlled analysis for Injury Severity Score and age in patients with CIN versus non-CIN patients revealed the strongest predictor of CIN was proteinuria (relative risk, 2.5; confidence interval, 1.1 to 5.8). Although it is difficult to truly differentiate CIN from renal dysfunction related to injury severity in trauma patients, proteinuria may be an important factor in identifying nephropathy in this population.