尿毒清颗粒预防对比剂肾病的临床研究

目的：探讨用尿毒清颗粒预防对比剂肾病（CIN）的临床效用。方法：将拟行择期冠状动脉造影和/或经皮冠状动脉介入术治疗的患者150例,随机分为尿毒清组（75例）及对照组（75例）。尿毒清组患者于术前1 d至术后3 d服用尿毒清颗粒。入院时及术后连续3 d查肾功能。比较两组组间和组内血清肌酐（Scr）的差别。结果：两组患者的主要基线指标差异无统计学意义。两组患者术后3 d Scr最高值均比术前基线Scr值增高[（91.4±40.2）μmol/L vs（71.7±27.4）μmol/L,P〈0.01;（103.7±35.4）μmol/L vs（77.1±21.7）μmol/L,P〈0.01],差异均有统计学意义。CIN的发病率尿毒清组为3例（4.0%）,对照组为10例（13.3%）。与对照组相比,尿毒清组术后3 d Scr最高值降低[（91.4±40.2）μmol/L vs（103.7±35.4）μmol/L,P〈0.05],术前、术后Scr差值降低[（19.7±16.8）μmol/L vs（26.5±20.4）μmol/L,P〈0.05],CIN发生率降低（4.0%vs 13.3%,P〈0.05）,差异均有统计学意义。结论：尿毒清颗粒可以降低动脉内使用对比剂后3 d Scr的最高值和CIN发生率,有一定的预防CIN的作用。     

对比剂肾病的预防及危险分层的研究进展

随着对比剂的广泛应用,对比剂肾病（CIN）发病率逐年增高。根据CIN的危险因素进行危险分层,合理使用对比剂能够有效预防CIN的发生。本文就CIN的预防及危险分层方面的研究进展进行综述。     

对比剂肾病研究及预防进展

自1955年Alwall等报道首例对比剂肾病（contrast-induced nephropathy,CIN）以来,随着影像放射检查诊断技术的进步和介入治疗手段的增多,血管内对比剂（contrastmedia,CM）的应用与日俱增,发生CIN的患者也随之增多.尽管近年来医疗安全受到高度重视,CIN依然成为继重大手术后肾损害、药源性肾损害之后的院内获得性急性肾损伤的第三大原因.     

N-乙酰半胱胺酸对高龄患者对比剂肾病的预防作用

目的 探讨N-乙酰半胱氨酸（N-acetylcysteine,NAC）对行增强CT检查的高龄患者对比剂肾病（contrast-induced nephropathy,CIN）的预防作用.方法 将行增强CT检查的高龄患者56例,采用随机数字表法随机分为NAC组28例、对照组28例.NAC组于增强CT检查前12 h、6 h,检查后6 h、12 h分别口服NAC泡腾片1 200 mg,2组均给予水化治疗,比较CT前后2组患者血肌酐和估算肾小球滤过率（estimated glomerular filtration rate,eGFR）变化,以及2组患者CIN发生率.结果 NAC组与对照组比较,增强CT检查后48 h,2组患者SCr水平均高于CT检查前（P＜0.01）,eGFR水平均低于CT检查前（P＜0.01）;检查前后NAC组SCr升高幅度与对照组比较差异无统计学意义（P＞0.05）,检查前、后NAC组eGFR下降幅度小于对照组,差异有统计学意义（P＜0.05）.NAC组无CIN发生,对照组仅有1例在行CT检查后SCr明显升高（SCr升高19.4 μmol/L,上升幅度28%）,但无临床意义,2组经校正的四格表χ2检验,差异无统计学意义（P＞0.05）.结论 NAC联合水化治疗对患者行增强CT所致CIN的预防作用与单纯水化治疗相当.说明大剂量NAC对对比剂引起的肾损害具有一定的防治作用.     

对比剂肾病的危险因素及其预防

对比剂肾病（contrast-induce nephropathy,CIN）是指患者暴露于对比剂（contrast media）48～72 h内,血清肌酐升高,且绝对增加值大于等于0.5 mg/dl或者相对增高达到或超过基础值的25%,这是目前最为常用的定义[1].Mehran认为对比剂肾病的定义应包含三层含义：肌酐绝对或相对的升高;暴露于对比剂同肌酐升高间具有时间相关性;排除其他原因的肾损害[1].CIN位居医院获得性肾衰竭的第三位,占11%,仅次于肾灌注不足和使用肾毒性药物,其最常见的诱因为冠脉的诊断和介入治疗（percutaneous coronary interventions,PCI）[2].所以目前大部分研究围绕在如何防止冠脉的介入诊断和治疗造成CIN.     

评价对比剂肾病患者继发终末期肾脏病的风险模型及应用性研究

目的搜集与对比剂肾病(CIN)相关的临床指标,构建评判该患者继发终末期肾脏病(ESRD)的风险性模型,并验证其应用性。方法连续性纳入CIN患者为研究队列,分析研究对象初始入院时的各项临床资料及实验室检查结果,并对其进行为期18个月的随访以确认预后,依据随访结果,进行远期风险性预测和相关危重度评判分析。结果本次研究纳入215例CIN患者,14例失访,19例随访期内进展至ESRD。Cox回归分析显示,近期重复接受造影、高MRS量表评分、高尿肾损伤分子-1(uKIM-1)含量、高尿微量蛋白(umAlb)含量、高尿中性粒细胞明胶酶相关脂质运载蛋白(uNGAL)含量为CIN患者发病18个月内继发ESRD的独立危险因素。以umAlb=36.80ng/ml、uNGAL=128.21ng/ml、uKIM-1=137.56pg/ml为临界值预测CIN患者进展至ESRD的ROC曲线下面积分别为0.746、0.756、0.768。结论本研究建立CIN患者继发ESRD的风险预测模型,并对相关危险因素进行了量化,进一步完善了CIN的诊疗体系。     

PCI术前急性血糖升高致对比剂肾病患者的护理

对1例急性心肌梗死并急性血糖升高患者急行冠状动脉支架置入术,即在心内科常规治疗的基础上行连续肾脏替代治疗,同时加强抗疑及对比剂肾病等专项护理。结果患者住院12d康复出院。提出应重视并做好PCI术前急性血糖升高患者对比剂肾病的预防护理,以降低对比剂肾病的风险。     

不同水化途径防治对比剂肾病的临床研究

目的 比较不同水化途径补充生理盐水防治对比剂肾病(contrast induced nephropathy,CIN)的效果,为临床寻找最佳水化治疗途径,提高水化治疗CIN的效果.方法 150例拟行冠状动脉造影术、外周血管造影术患者,随机分为经口、外周静脉、中心静脉途径3组,各组50例,术前、术后均补充生理盐水2 000 ml,观察3组患者术前、术后1～5 d尿量、肾功能、内生肌酐清除率,血、尿β2-微球蛋白浓度变化,同时行床边心脏超声评价充分水化治疗对心功能影响.结果 所有患者术后血肌酐水平、内生肌酐清除率、血和尿β2-微球蛋白较术前均有轻度升高.随时间推移,所有患者尿量增加,血肌酐水平下降,内生肌酐清除率及血、尿β2-微球蛋白浓度降低至手术前水平.经中心静脉途径水化治疗,血肌酐、内生肌酐清除率及血、尿β2-微球蛋白3d恢复,外周静脉途径5d肾功能恢复,经口途径肾功能恢复最晚.3组充分水化治疗不影响左室收缩末期、舒张末期容积,左室射血分数无统计学差异,不影响血流动力学.结论 3种不同水化途径补充生理盐水均可有效预防和治疗CIN,且不影响心功能,但中心静脉途径患者尿量、肾功能恢复更快,方法简单,创伤小,效果最好,疗效可靠.     

对比剂肾病临床防治策略

对比剂肾病（contrast—induced nephropathy,CIN）又称造影剂肾病,是指应用造影剂（contrast medium,CM）后新出现的急性肾损害或原有肾损害加剧,并排除其他原因所导致的肾功能障碍;其实质是造影剂诱发的急性肾损害。随着医学影像学的发展、介入检查及治疗技术的广泛应用,对比剂在临床中的应用越来越多,特别是在高龄、糖尿病、肾衰竭、心功能不全、容量不足等患者中的应用,使对比剂肾病（cIN）成为医院获得性肾衰竭的第三大主要原因。     

对比剂肾病的临床危险因素

随着放射诊断技术和介入治疗的发展,对比剂在临床上的使用日益广泛。同时由于人口老龄化,接受对比剂患者高龄、慢性肾脏病、糖尿病肾脏病和心血管疾病等所占比例逐年上升,对比剂肾病（contrast-induced nephropathy,CIN）的发生率也随之升高。     

经导管动脉栓塞术中使用对比剂对肾功能的影响

目的探讨经导管动脉栓塞术(TAE)术中使用对比剂对外伤患者肾功能的影响。方法回顾性分析因腹部或盆腔急性外伤而接受TAE的80例患者,比较其术前及术后血清肌酐水平。结果术前血清肌酐为(1.02±0.24)mg/dl,术后为(0.94±0.26)mg/dl,略低于术前(P=0.01)。肾衰竭高危患者TAE后血清肌酐总体水平无明显增高。术后5例(5/80,6.25%)发生对比剂肾病,对比剂肾病发生率的95%可信区间为2%～11%;血清肌酐水平均于术后5天内恢复至基线水平。结论外伤患者TAE后可能发生对比剂肾病,但多为一过性的,TAE中使用对比剂是较为安全的。     

The usefulness of carvedilol and nebivolol in preventing contrast nephropathy in rats

Abstract

Background: Oxidative stress and vasoconstriction appear to be important components of contrast nephropathy (CN) pathogenesis, and both carvedilol and nebivolol are known to have vasodilatory and antioxidant effects. Aims: This study aimed to investigate whether carvedilol and nebivolol play preventive roles against developing CN and to compare the effects of each. Materials and methods: Wistar albino rats were divided into control (C, n?=?6), contrast material (CM, n?=?6), carvedilol (CV, n?=?7), carvedilol?+?contrast material (CV?+?CM, n?=?7), nebivolol (N, n?=?7), and nebivolol?+?contrast (N?+?CM, n?=?7) groups. Following 3 days of dehydration, 6?mL/kg diatrizoate was administered to each rat. Carvedilol was given at a dose of 2?mg/kg and nebivolol at a dose of 1?mg/kg by way of oral gavage. After scarification, total antioxidant capacity (TAC), malondialdehyde (MDA), and superoxide dismutase (SOD) were studied in renal tissue. Histopathological findings were graded as mild (+), moderate (++), and severe (+++). Results and discussion: Most of the histopathological findings and MDA levels were significantly higher in the CM group than that in the C, CVCM, and NVCM groups, whereas there was no significant difference between the C, CVCM and NVCM groups. TAC level in the CM group was significantly lower than in all other groups. There was no difference in SOD among groups. Conclusions: Carvedilol and nebivolol both prevent development of nephropathy related to CMs by decreasing oxidative stress. Neither is superior to the other.     

肾康注射液联合前列地尔治疗糖尿病肾病的荟萃分析

目的:探究肾康注射液联合前列地尔治疗糖尿病肾病的有效性及安全性,为临床用药提供统计学证据。方法:计算机检索cochrane,Pubmed,Embase,CBM,万方数据库,维普和知网,筛选文献,录入数据,通过Cochrane风险评估工具对文献进行质量的评估,用Rev Man5.3进行统计分析,得出结论。结果:在降低24 h蛋白尿方面,观察组疗效优于对照组(MD:-0.22,95%IC[-0.44,-0.01])。在降低血肌酐(Scr)、血尿素氮(BUN)方面,观察组疗效也更好(Scr MD:-11.87,95%IC[-13.11,-10.63];BUN MD:-2.11,95%IC[-2.44,-1.78])。通过亚组分析发现在大体上,随着原有Scr、BUN基础值的水平增高,观察组治疗降低Scr、BUN优势更明显。结论:肾康注射液联合前列地尔在治疗糖尿病肾病优于单用前列地尔,且肾功能较差时,效果更显著。     

牛奶与钙剂对老年人骨密度作用的8年临床观察

目的 观察牛奶与钙剂对老年人骨密度作用.方法 采用日本东芝公司制造的Xpress-GX螺旋CT(QCT),对本院老年职工进行第3腰椎骨密度(L3BMD)检测.选择L3BMD降低的82名(男性35,女性47)老年人,根据本人意愿(是否饮用牛奶和服用钙剂)分成观察组(n=43)和对照组(n=39),观察组(男性18,女性25),每人每日饮鲜牛奶250 ml～500 ml并日服含维生素D的钙剂(元素钙600～1200 mg、维生素D3 125～300 IU);对照组(男性17,女性22)未饮牛奶、未服钙剂,两组连续观察96个月为终点.在治疗前后分4个时间段(0、6、30、96个月)应用QCT检测参组老人L3BMD值,同时进行肝、肾功能、血清钙、尿钙及肝、胆、肾B超检查,并同步座谈访问,了解治疗后反应.结果 ①两组老人L3BMD均随增龄逐渐降低,其中,男女性观察组在长期钙奶干预下,自身配对比较L3BMD值,虽然逐次降低,但幅度很小;而男女性对照组的L3BMD逐年降低幅度明显增大,但无统计学意义(P>0.05).②两组间(观察组与对照组)分4个时间段成组比较L3BMD值,前3个时间段,对照组比观察组降低,但无明显差异(P>0.05),观察至第4个时间段(96个月)时,男女性对照组L3BMD比观察组明显降低,差异有显著性(P<0.05).结论 老年人长期饮用牛奶与含维生素D钙剂,能有效地延缓中轴骨BMD降低;长期钙奶干预对骨量增加能起到累积效应;对BMD降低而引起临床症状的老年人起到了重要辅助治疗作用;长时间应用钙剂未发现与之相关疾病发生.     

A randomized trial of saline hydration to prevent contrast nephropathy in chronic renal failure patients.

BACKGROUND: Contrast nephropathy (CN) is a common cause of renal dysfunction that may be prevented by saline hydration and by drugs such as theophylline or furosemide. Whether oral saline hydration is as efficient as intravenous saline hydration is unknown. The preventive efficacy of theophylline and furosemide for CN remains controversial. The purpose of the current study was to evaluate the efficacy of oral saline hydration and of intravenous saline hydration plus theophylline or furosemide for the prevention of CN. METHODS: We prospectively studied 312 patients with chronic renal failure (serum creatinine 201+/-81 micromol/l, Cockcroft clearance 37+/-12 ml/min/1.73 m(2)), who were undergoing various radiological procedures with a non-ionic, low osmolality contrast agent. Patients were randomly assigned to four arms. In arm A, patients received 1 g/10 kg of body weight/day of sodium chloride per os for 2 days before the procedure. In arm B, patients received 0.9% saline intravenously at a rate of 15 ml/kg for 6 h before the procedure. In arm C, patients received the same saline hydration as in arm B plus 5 mg/kg theophylline per os in one dose 1 h before the procedure. In arm D, patients received the same saline hydration as in arm B plus 3 mg/kg of furosemide intravenously just after the procedure. RESULTS: Patients were well-matched with no significant differences at baseline in any measured parameters. Acute renal failure, defined as an increase in serum creatinine of 44 micromol/l (0.5 mg/dl), occurred in 27 out of 312 patients (8.7%). There was no significant difference between the rate of renal failure in the different arms of the study: five out of 76 (6.6%) in arm A, four out of 77 (5.2%) in arm B, six out of 80 (7.5%) in arm C and 12 out of 79 (15.2%) in arm D. No patient had fluid overload or a significant increase in blood pressure in the 2 days following the radiological procedure. The independent predictors of CN were diabetes mellitus, high baseline serum creatinine and high systolic blood pressure. CONCLUSIONS: Oral saline hydration was as efficient as intravenous saline hydration for the prevention of CN in patients with stage 3 renal diseases. Furosemide and theophylline were not protective.     

The importance of a histology-based diagnosis of interstitial nephropathy in two patients with renal insufficiency.

Case 1 A 68-year-old Belgian woman was referred in November 1997 forevaluation of renal failure (serum creatinine 2.8 mg/dl). Herpast medical history included hypothyroidism treated by L-thyroxinsince 1992, resection of an endometrial polyp in 1996 and chronicconstipation for many years. Her current treatment includedvarious laxatives (lactulose, bisacodyl) and anxiolytics (flupentixol).She acknowledged the previous intake of phenacetin and dexfenfluramine,but denied that of Chinese herbs or any other herbal phytotherapy. View larger version (147K): [in this window] [in a new window]   Fig. 1.  Extensive cortical and medullary hypocellular interstitial fibrosis with tubular atrophy (case 1). Few ischaemic glomeruli are still visible in the deep cortex. Intimal fibrous thickening and mucoid fibrous hyperplasia of interlobular and arcuate arteries, respectively. HE x40.   On admission, the patient was thin: body weight 49 kg, height1.59 m; her blood pressure was 200/90     

Spectrum of renal failure in elderly patients

This prospective study was undertaken to study the spectrum of renal failure and the outcome in elderly patients. Patients included in the study group were elderly (age > 60 years) who either attended outpatient renal clinic and or were hospitalized. Renal failure was classified as acute renal failure (ARF), rapidly progressive renal failure (RPRF) and chronic renal failure (CRF). A total of 4255 elderly patients were seen, of these 236 (5.5%) had renal failure. Mean age was 65.1 ± 4.2 years (60–86 years). CRF was the commonest, seen in 137 (58.1%) followed by ARF 69 (29.2%) and RPRF in 30 (12.7%) patients. Diabetic nephropathy was the commonest cause of CRF, seen in 58.4% followed by chronic interstitial nephritis in 9.5% and chronic glomerulonephritis in 8.7% of patients. Of 137 patients 53 (38.7%) presented in end stage renal disease (ESRD). Of these 41 (77.3%) were initiated on maintenance hemodialysis and 12 (22.6%) on continuous ambulatory peritoneal dialysis. Only 15 patients were on dialytic support at the end of 1 year. Sepsis contributed to ARF in 75.4% of cases. Forty of 69 patients (57.9%) needed dialytic support. Forty (57.9%) were critically ill, defined as presence of two or more organ system failures (excluding renal failure). Forty two patients (60.9%) died patients. Acute interstitial nephritis (AIN) was the commonest cause of RPRF seen in 10 (33.3%) patients followed by vasculitis in 7 (23.3%). Myeloma cast nephropathy contributed towards RPRF in 20% of patients. Of 30 patients, 10 (33.3%) reached ESRD at end of 3 months of follow up, 4 (13.3%) died due to sepsis. Only 2 showed complete recovery while 14 (46.6%) had partial improvement. AIN patients had a relatively better outcome.     

Safety of gadolinium contrast angiography in patients with chronic renal insufficiency

OBJECTIVE: To prevent iodinated contrast medium-induced nephrotoxicity, gadolinium has been used increasingly for magnetic resonance angiography (MRA) or conventional digital subtraction angiography (DSA) to visualize arterial anatomy in patients undergoing vascular surgery who are considered at high risk because of chronic renal insufficiency. We assessed the safety of gadolinium-based contrast medium as a substitute for iodinated contrast medium-enhanced examinations. We determined the incidence of gadolinium-induced nephrotoxicity in a clinical setting and searched for contributing risk factors.Patients and methods In a single-center retrospective study from December 1999 to January 2001, 218 inpatients underwent MRA and 42 inpatients underwent DSA, with gadolinium as the sole contrast agent. Patient comorbid conditions, indications for vascular imaging, contrast dose, urine output, baseline and post-procedure serum creatinine concentration (SCr), and outcome were recorded for all patients in whom gadolinium-induced renal failure developed. RESULTS: Of 260 patients who received gadolinium-based contrast agents, at a dose of 0.25 mmol/kg or more, 195 patients (75%) had pre-test baseline chronic renal insufficiency. In 7 of 195 patients (3.5%) acute renal failure developed after gadolinium-based contrast medium administration, for MRA (n = 153) in 3 patients (1.9%) and DSA (n = 42) in 4 patients (9.5%). Average baseline SCr in the 195 patients with chronic renal insufficiency was 38.2 +/- 1.6 mL/min/1.73 m(2), and in the 7 patients in whom acute renal failure developed, baseline SCr was 32.5 +/- 7.8 mL/min/1.73 m(2) (P =.33). Respective intravenous and intra-arterial gadolinium doses in these 7 patients ranged from 0.31 to 0.41 mmol/kg for MRA and 0.27 to 0.42 mmol/kg for DSA. Acute renal failure did not develop in any of 65 patients with normal baseline SCr. CONCLUSION: Despite reports of negligible nephrotoxicity, rarely gadolinium-based contrast agents can cause acute renal failure in patients with underlying chronic renal insufficiency. Estimation of creatinine clearance alone does not enable prediction of which patients are likely to have acute renal failure. Patients at high-risk should be identified, and prophylactic measures should be taken to reduce the risk for nephrotoxicity.     

Conservative outpatient renoprotective protocol in patients with low GFR undergoing contrast angiography: a case series

Background The correct strategy to prevent radiocontrast-induced nephropathy (CIN) in high-risk patients going for cardiac angiography is widely debated in the literature. It is well known that chronic kidney disease (CKD) patients with lower estimated glomerular filtration rates (eGFRs) at baseline are at the greatest risk for a significant loss in kidney function, or even dialysis after a contrast load. For this reason potentially life-saving procedures such as angiography are sometimes withheld or delayed. Methods We describe a case series of 31 well-characterized patients with CKD who underwent cardiac or peripheral vessel angiography, and patients with renal artery stenosis (RAS) who underwent angioplasty and stenting. All were treated with a standardized outpatient protocol of withholding their diuretics and angiotensin-converting enzyme (ACE) inhibitors (ACEs)/angiotensin receptor blockers (ARBs) the day prior to and 2 days after the procedure, restarting the diuretic the day after the procedure and the ACE inhibitor/ARB after 2 days. Calcium channel blockers were prescribed for the 2 days prior to and 2 days after the procedure. Patients had bloodwork on days 2–3 and days 7–10 post-procedure. Results The patients had a mean baseline creatinine of 214 μmol/l (SD = 123), ranging from 87 to 535 μmol/l. This corresponded to a mean baseline eGFR of 34 ml/min (SD = 15.8), ranging from a minimum of 12–59 ml/min. The mean age was 64 ± 13.8 years; 48% were male and 11 (35.5%) were diabetic. All patients enrolled had a baseline eGFR of less than 60 ml/min as calculated by the Modification of Diet in Renal Disease (MDRD) formula. Based on pre-procedure CKD stage, 21 (68%) were stage 3 (eGFR 30–60 ml/min), 5 (16%) were stage 4 (eGFR 15–30 ml/min), and 6 (19%) were stage 5 (eGFR < 15 ml/min). No patient required urgent hemodialysis following their angiography. All patients have had a longitudinal follow up of 26 months, and none developed any change in the rate of progression from prior to procedure. Conclusions This case series provides data in support of a conservative, outpatient-based approach for high-risk CKD patients going for cardiac angiography. This protocol warrants further study in randomized control trials.