非离子造影剂对老年冠状动脉造影患者肾功能的影响

目的观察非离子造影剂对老年冠状动脉(冠脉)造影患者肾功能的影响。方法选择具有冠脉造影适应证并行冠状动脉介入诊断、经皮冠脉介入治疗(PCI)的老年患者41例,年龄60~84(66±6)岁。于冠脉造影前、后第2天、第5天分别检查各项肾功能指标。以造影后2天内血清肌酐(Cr)比造影前增加44μmol/L或增加25%,或内生肌酐清除率(CCr)比造影前下降25%为诊断造影剂肾病的标准。结果PCI术后第2天血清尿素氮(BUN)、Cr、尿微量白蛋白浓度(UMALB)及24 h微量白蛋白总量(24 h UMALB)升高,24 h尿肌酐(UCr)、CCr较术前下降(P<0.05)。术后第5天上述指标与术前比较差异无显著性(P>0.05)。自由水清除率(free water clearance,CH2O)冠脉造影后第2天较术前升高(P<0.05),术后第5天未能恢复到术前水平(P<0.05)。按照造影剂肾病的诊断标准,共有8例患者可诊断造影剂肾病。结论非离子造影剂对行冠脉造影术的老年患者肾功能有一定损害,但多数属可逆性。     

不同剂量阿托伐他汀对冠状动脉介入术后发生造影剂肾病的影响

目的探讨不同剂量阿托伐他汀对PCI术后发生造影剂肾病(CIN)的影响,以及中性粒细胞明胶酶相关载脂蛋白(NGAL)对PCI术后发生CIN的早期诊断意义。方法随机选取我院心内科收治的PCI患者212例,随机分为高剂量他汀治疗组(A组)108例,常规剂量他汀治疗组(B组)104例,均完成冠状动脉造影及PCI,检测2组术前及术后4、24、48和72h血肌酐、尿NGAL水平,采用ROC曲线分析NGAL的价值。结果 A组术后CIN发生率明显低于B组(5.6%vs 18.3%,P=0.012)。2组术后4、24、48和72h尿NGAL水平较术前升高,于72h达峰值,且B组较A组升高更明显(P0.05)。ROC曲线分析显示,术后4、24、48和72h尿NGAL的ROC曲线下面积分别为0.917、0.919、0.928、0.953,诊断CIN的敏感性为92.10%,特异性为100.00%。结论高剂量阿托伐他汀可能减少CIN的发生,尿NGAL较血肌酐更早反映PCI术后肾功能的变化,可作为CIN的早期预测指标。     

冠状动脉造影术和腔内成形术后造影剂肾病与血红蛋白水平的关系

目的: 探讨基础血红蛋白与冠状动脉造影术（CAG）及经皮冠状动脉成形术（PCI）后由于造影剂引起的肾病（Contrast-induced nephropathy,CIN）间的关系。方法: 2005年10月1日～2007年11月31日住院接受CAG及PCI患者1 386例, 均应用低渗非离子型造影剂（碘海醇）。测定介入治疗术前及术后48 h内血清肌酐浓度。若发生CIN,其血清肌酐浓度较基础值升高44 μmol/L,则继续观察血清肌酐浓度至正常。结果: 在1 386例患者中,发生CIN 29例,发生率为2.1%。在基础肌酐清除率<60 ml/min的患者中26.8%的患者出现贫血。在基础肌酐清除率<30 ml/min的患者中,并发贫血与非贫血时CIN的发生率分别为22.3%和14.8%。贫血明显增加了基础肌酐清除率30～59 ml/min患者发生CIN的风险 (5.8% vs 2.8%; P<0.05)。 在CIN组和非CIN组两组患者造影剂剂量接近［(160±72)ml vs (148±68)ml］,无统计学差异。多因素回归因素分析发现基础肌酐清除率、血红蛋白、利尿剂使用是CIN的独立危险因素。当把贫血代替血红蛋白进入回归方程式,它亦是CIN的独立危险因素(OR 2.765, 95%CI 1.486-3.657, P<0.01)。结论: 既往有肾功能不全贫血及使用利尿剂是CIN发生的独立危险因素。     

老年人造影剂肾病的临床危险因素分析

目的 观察老年患者使用低渗非离子造影剂冠状动脉造影(CAG)检查后造影剂肾病(CIN)的发病率,并探讨老年人发生CIN的危险因素. 方法 老年患者195例,造影前6 h和造影后12 h使用静脉等渗生理盐水(1 ml·kg~-1·h~-1)水化,有明显心功能衰竭患者剂量减半;测定造影前3 d内和造影后第2、5天血肌酐、血清胱抑素C(cystatin C). 结果 (1)195例老年患者中,发生CIN 17例(8.7%);造影后3个月,11例血肌酐恢复到术前水平;2例转变为慢性肾衰竭,但不需要肾脏替代治疗;3例肾功能持续恶化,需要维持血液净化治疗;1例因多脏器功能衰竭死亡.(2)造影后第2天血清cystatin C与造影前比较,差异无统计学意义(t=0.137,P=0.891);而造影后第2天血肌酐(89.3±33.8)μmol/L,与造影前(100.1±18.9)μmol/L比较明显下降,差异有统计学意义(t=4.776,P=0.000);造影后第5天血清cystatin C、血肌酐均恢复到术前水平.(3)发生与未发生CIN患者其性别、造影剂剂量、基线血肌酐、冠心病比例,差异无统计学意义;而年龄、基线cystatin C、糖尿病、高血压、充血性心力衰竭,差异有统计学意义.(4)多因素Logistic回归分析表明,充血性心力衰竭(OR=9.597)、糖尿病(OR=8.104)、基线cystatin C(OR=6.654)、基线血肌酐(OR=1.039)是CIN发生的临床危险因素. 结论 老年患者在充分水化后使用低剂量低渗非离子型造影剂,具有较高安全性;发生CIN的危险因素为充血性心力衰竭、糖尿病、基线cystatin C、基线血肌酐;血清cystatin C与血肌酐比较,预测CIN强度更高.     

高血压伴微量白蛋白尿患者冠状动脉介入诊疗术后对比剂肾病的研究

目的 探讨高血压患者中正常白蛋白尿组、微量白蛋白尿（MAU）组冠状动脉介入诊疗术后对比剂肾病（CIN）的发病率及它们之间的关系。方法选择自2009年4月至2011年4月在南京医科大学第一附属医院心内科接受冠状动脉介入诊疗术的高血压患者为研究对象,所有患者均使用低渗对比剂（碘海醇）。记录患者临床资料,测定患者造影前1、2、3d尿白蛋白／肌酐比值,造影前1周内（任意1d）及术后第2天（术后48h）的血肌酐值（SCr）,通过MDRD公式计算肾小球滤过率（GFR）。所有患者根据尿微量白蛋白／肌酐比值分为2组：尿白蛋白／肌酐比值〈30mg：mg/g者为正常白蛋白尿组（A组）,30～300mg/g者为MAU组（B组）。探讨2组患者术后CIN发病率与MAU的美系。结果151例患者中有14例发生CIN,发病率为9．3％。A组CIN发病率为5．5％,B组为19．0％,2组间差异有统计学意义（P〈O．05）。在术前GFR〉75ml／min的患者中CIN发病率为4．4％,在GFR〈75ml／min的患者中发病率50％,两者差异有统计学意义（P〈0．05）。结论冠状动脉介入诊疗术后,MAU会增加CIN的发病风险,相比GFR,MAU能更好地预测CIN的发生。     

造影剂温度对经皮冠状动脉介入治疗患者造影剂肾病发病率的影响

目的 探讨造影剂温度对造影剂肾病（CIN）发病率的影响。方法 将157例经皮冠状动脉介入（PCI）治疗患者随机分为20℃碘克沙醇组（20℃组,n=77）和37℃碘克沙醇组（37℃组,n=80）。 分别于PCI术前、后行血液流变学指标检测;PCI术前24 h内、术后12、24 和48 h检测血浆胱抑素C和肌酐。分析两种温度造影剂对患者肾功能和血液流变学指标的影响。结果 20℃组PCI术后24 h的胱抑素C、48 h的肌酐显著高于术前(P<0.05),全血高切、低切表观黏度亦显著较术前升高,差异有统计学意义（P<0.05）。 37℃组PCI术后24 h的胱抑素C、48 h的肌酐低于20℃组相应时间点水平,且PCI术后全血高切、低切表观黏度亦低于术后20℃组,具有统计学意义（P<0.05）。37℃组CIN发生率（2%）显著低于20℃组（8%）,具有统计学意义（P<0.05）。结论 37℃碘克沙醇的CIN发生率显著低于20℃碘克沙醇。     

大剂量碘克沙醇对合并糖尿病患者冠状动脉介入术后肾功能的影响

目的 评估大剂量碘克沙醇(＞300 mL)对糖尿病患者经皮冠状动脉介入治疗(PCI)术后72 h内肾功能的影响。方法 顺序筛选2015年10月—2017年12月4个中心的987例冠状动脉介入治疗术中使用大剂量(＞300 mL)碘克沙醇的患者,最终204例合并糖尿病患者被纳入,进一步评价术后72 h内对比剂诱导的急性肾损伤(CI-AKI)的发生情况。结果 204例糖尿病患者使用大剂量碘克沙醇(＞300 mL)对比剂诱导的急性肾损伤总发生率为3.9%(8/204)。其中碘克沙醇300～500 mL亚组和＞500 mL亚组对比剂诱导的急性肾损伤发生率分别为4.3%(7/161)和2.3%(1/43);基线eGFR＜60 mL/(min·1.73 m²)的患者对比剂诱导的急性肾损伤发生率为6.9%(2/29)。多因素Logistic回归分析显示,合并慢性肾功能不全、贫血、行急诊冠状动脉介入治疗术以及高Mehran评分是对比剂诱导的急性肾损伤的独立危险因素。对比剂诱导的急性肾损伤发生率与对比剂剂量的增加似乎无关。结论 合并糖尿病患者使用大剂量(＞300 mL)碘克沙醇后对比剂诱导的急性肾损伤发生率不高。     

冠状动脉造影检查术造影剂对肾功能的影响

随着对冠状动脉介入诊断治疗冠心病价值的肯定,冠状动脉造影检查已在许多医院推广应用,同时造影剂肾病[1](radiocontrast-induced nepropathy,RCINP)逐渐受到临床工作者的重视.     

冠状动脉介入术后并发血肿20例临床分析

20例冠状动脉（简称冠脉）介入术后并发血肿的患者,依据血管超声分析血肿的临床特点和处理方法。观察1周时间,16例单纯性血肿未经特殊处理血肿直径缩小,4例假性动脉瘤超声指导下压迫修复3例。可见,单纯性血肿预后好,通常无需特殊处理,假性动脉瘤超声指导下压迫修复成功率高。     

冠状动脉造影对肾功能影响1087例分析

目的 探讨心血管造影剂对肾功能影响;引起造影剂肾病(contrast media induced nephropathy,CIN)的易患因素及其防治.方法 回顾分析近2年多来接受冠状动脉造影和经皮冠状动脉介入术患者1 087例,造影后24～72h血肌酐较原来增高25%或者44 μmol/L(0.5 mg/dl)定义为CIN.结果 术前血肌酐正常1 069例,选用低渗造影剂碘普罗胺,CIN发生率为3%,CIN与造影剂量,术前补液量及糖尿病密切相关(P＜0.05).住院期间心脏事件,总死亡率及平均住院日数明显高于非CIN组(P＜0.05).术前血肌酐异常者18例用等渗造影剂碘克沙醇未发生CIN,但例数过少,不具说服力.结论 造影剂可引起一过性肾功能改变,CIN与造影剂、补液量和糖尿病有关.     

冠状动脉介入术患者对比剂肾病的相关危险因素分析

目的:研究冠状动脉造影(CAG)和经皮冠状动脉介入治疗(PCI)患者对比剂肾病(CIN)的发病率及危险因素。方法:选择2010年10月至2011年4月南京军区南京总医院接受CAG和PCI的患者672例,以术后48h血清肌酐(SCr)较术前升高25%或升高44.2μmol/L(0.5mg/dl)作为CIN的诊断标准,分析CIN的发病率及危险因素。结果:672例患者中,年龄≥65岁者292例(43.5%),冠心病588例(87.5%),高血压461例(68.6%),糖尿病144例(21.4%),术前SCr≥110μmol/L者30例(4.5%),贫血42例(6.3%),服用血管紧张素转换酶抑制剂344例(51.2%),利尿剂95例(14.1%),二甲双胍39例(5.8%),对比剂用量≥200ml者237例(35.3%)。672患者中55例(8.2%)发生CIN,发生CIN者与非CIN者在年龄≥65岁、冠心病、对比剂用量≥200ml及利尿剂等方面有明显差异(P<0.05)。Logistic多因素回归分析显示,年龄≥65岁、对比剂用量≥200mL是CIN的独立危险因素。结论:在CAG和PCI患者的CIN发病率较高,年龄≥65岁和对比剂用量≥200mL是其独立危险因素。     

Prevention of contrast induced nephropathy by ischemic preconditioning in patients undergoing percutaneous coronary angiography

Background

Contrast-induced nephropathy (CIN) is the acute deterioration of renal function after parenteral administration of radio contrast media in the absence of other causes. The true incidence of CIN varies because of differences among the published studies in the definition of CIN, the proportion of high-risk patients, the types of contrast media, and the use of preventive measures. Remote ischemic preconditioning (IPC) may offer a non-pharmacological prevention strategy for lowering CIN in patients undergoing coronary procedures. The assumption that IPC produces protective effects on tissues or organs by multiple brief cycles of ischemia and reperfusion applied to another remote tissue or organ.

Preventing radiocontrast-induced nephropathy in chronic kidney disease patients undergoing coronary angiography

Radiocontrast-induced nephropathy(RCIN) is an acute and severe complication after coronary angiography,particularly for patients with pre-existing chronic kidney disease(CKD).It has been associated with both short-and long-term adverse outcomes,including the need for renal replacement therapy,increased length of hospital stay,major cardiac adverse events,and mortality.RCIN is generally defined as an increase in serum creatinine concentration of 0.5 mg/dL or 25%above baseline within 48 h after contrast administration.There is no effective therapy once injury has occurred,therefore,prevention is the cornerstone for all patients at risk for acute kidney injury(AKI).There is a small but growing body of evidence that prevention of AKI is associated with a reduction in later adverse outcomes.The optimal strategy for preventing RCIN has not yet been established.This review discusses the principal risk factors for RCIN,evaluates and summarizes the evidence for RCIN prophylaxis,and proposes recommendations for preventing RCIN in CKD patients undergoing coronary angiography.     

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

目的:了解对比剂对急性心肌梗死行急诊经皮冠状动脉(冠脉)介入治疗(PCI)患者肾功能的影响,探讨对比剂肾病(CIN)的相关因素及其对患者预后的影响。方法:入选118例行急诊PCI的急性ST段抬高心肌梗死患者,测定其术前和术后48、72h的血清肌酐,记录其治疗经过和住院期间发生的不良事件。结果:118例患者中发生CIN(CIN组)28例(23.7%)。CIN组基线肾小球滤过率(GFR)和左心室射血分数(LVEF)低于非CIN组(均P<0.05),而肌酸激酶(CK)峰值高于非CIN组(P<0.05)。CIN组住院时间比非CIN组长(P<0.01),住院期间不良事件发生率更多。Logistic回归分析发现,LVEF3000U/L与CIN的发生有关。结论:CIN是急诊PCI患者的常见并发症,可能增加住院期间不良事件的发生率,临床工作中要积极预防CIN的发生。     

Contrast-induced thrombocytopenia following percutaneous coronary intervention

Contrast-induced thrombocytopenia is a rare complication distinguished by acute and severe platelet consumption, with spontaneous recovery within days. We describe a case of acute thrombocytopenia 6 hours after coronary angioplasty in a patient with a negative antiplatelet factor 4 test. The count reached 1 × 10³/µL, but improved spontaneously to 210 × 10³/µL after 8 days. In conclusion, physicians should be aware of this complication, particularly when dual antiplatelet therapy is being considered.     

Effect of statin therapy on contrast-induced nephropathy after coronary angiography: a meta-analysis

Background

Although the pleiotropic effects of statins are postulated to be renoprotective, clinical studies have demonstrated conflicting results. We undertook a meta-analysis of published trials to evaluate the impact of statin therapy on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography.

Methods

We searched MEDLINE and EMBASE databases through December 2010 for articles evaluating the effect of statins on the incidence of CIN in patients undergoing coronary angiography. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using random effects modeling.

Results

Three randomized controlled trials involving 770 patients (330 in the statin group and 340 in the control group) and 7 non-randomized studies involving 31,959 patients (11,936 statin-pretreated and 20,023 statin-naïve). The definition of CIN varied somewhat among the studies. Based on the pooled estimate across the 3 randomized controlled trials, statin therapy did not significantly reduce the incidence of CIN compared to control (OR = 0.76, 95% CI: 0.41-1.41, p = 0.39). No significant heterogeneity was found in the randomized studies (I² = 0%, p = 0.48). The pooled analysis of the non-randomized studies showed a marginally significant benefit associated with statin therapy (OR = 0.60, 95% CI: 0.36-1.00, p = 0.05). There was significant heterogeneity among the non-randomized studies (I² = 88%, p < 0.00001).

Conclusions

Our meta-analysis suggests that statin therapy might be associated with a significant reduction in the incidence of CIN in patients undergoing coronary angiography. Further studies are warranted to clarify this issue.     

Removal of contrast medium from the coronary sinus during coronary angiography: feasibility of a simple and available technique for the prevention of nephropathy

BACKGROUND: Contrast-induced nephropathy (CIN) is a major complication of percutaneous coronary interventions with currently limited preventive measures. OBJECTIVES: To prevent CIN, we assessed the safety and feasibility of contrast removal from the coronary sinus (CS) during coronary angiography. METHODS: We attempted contrast removal on seven patients undergoing coronary angiography with preexisting renal insufficiency (mean serum creatinine=262+/-56 mg%). RESULTS: In four patients, a balloon catheter could not be successfully deployed in the CS. In three patients, a balloon catheter with distal side holes was positioned in the CS orifice. The balloon was inflated to occlude the CS concurrent with coronary injections, and 12-16 ml of blood was aspirated after each injection. The procedure appeared to be safe, without adverse events and elevations of serum creatinine levels. Contrast media were effectively withdrawn (44%+/-8%) as assessed by fluoroscopy and dilution of blood. The increased venous pressure at the time of injection reduced coronary flow, allowing for small volumes of administered contrast. CONCLUSIONS: Occlusion of the CS during coronary angiography with aspiration of contrast media is safe and effective in reducing contrast load during coronary interventions. This procedure may reduce the risk for CIN in prone patients.     

中性粒细胞/淋巴细胞比值与急性心肌梗死患者行急诊经皮冠状动脉介入治疗术后对比剂肾病发生的相关性

目的 探讨中性粒细胞/淋巴细胞比值（neutrophil/lymphocyte ratio,NLR）与急性ST段抬高心肌梗死（STEMI）患者行急诊经皮冠状动脉介入治疗（PCI）术后发生对比剂肾病（contrastinduced nephropathy,CIN）的相关性.方法 入选500例行急诊PCI的患者,CIN定义为使用对比剂后48～72 h内血肌酸酐（肌酐）值较基线值升高超过44.2 μmol/L或者较原基础值升高25％以上.比较CIN组与非CIN组之间的基线资料及院内不良临床事件发生率.采用受试者工作特征（ROC）曲线及Logistics回归分析评估NLR与CIN风险的相关性.结果 500例患者中,85例（17％）患者发生CIN.CIN组在院内死亡、需要肾脏替代治疗、需使用主动脉内球囊反搏、围术期低血压、急性心力衰竭、新发心律失常等院内不良事件的发生率均较非CIN组明显升高,差异有统计学意义.ROC曲线显示：NLR界值为6.03时,其预测CIN的敏感度为80.1％,特异度为73.7％,曲线下面积0.764.单因素Logistics回归分析显示,NLR水平与CIN发病率明显相关（OR 1.2,95％ CI 1.1～1.3,P＜ 0,01）.多因素Logistic回归分析显示,NLR＞6.03是CIN的独立危险因素（OR 1.3,95％ CI1.2～1.3,P＜0.001）;此外,女性、基础肾功能不全及围术期低血压也是CIN的独立危险因素（P＜0.05）.结论 急性STEMI患者行急诊PCI术前NLR水平与CIN相关,NLR升高的患者发生CIN的风险明显增高.