高敏C反应蛋白水平与阿托伐他汀对急性冠状动脉综合征患者对比剂所致肾功能损害影响的关系

目的 研究冠状动脉介入术前高敏C反应蛋白(hs-CRP)水平对急性冠状动脉综合征(ACS)患者术后肾功能改变的影响及阿托伐他汀的干预作用。方法 270例ACS患者根据术前hs-CRP值分为3组：hs-CRP升高组（hs-CRP≥3 mg/L,n=176）、hs-CRP轻度升高组(hs-CRP 1 ～3mg/L,n =60)和hs-CRP正常组(hs-CRP＜1 mg/L,n=34)。根据术前阿托伐他汀的用量,将176例hs-CRP升高组患者进一步分为阿托伐他汀10 mg组(n=49)、20 mg组（n=66）和40 mg组(n=61)。所有患者于术前、术后第1天、术后第2天分别测定血清肌酐(Scr)、尿素氮(BUN)、胱抑素C(Cys C)及hs-CRP,根据Scr计算出肌酐清除率(CCr),据Cys C计算肾小球滤过率(GFR)。以术后发生对比剂急性肾损害(CI-AKI)为因变量,采用多因素logistic逐步回归分析肾功能损害的影响因素。结果 (1)与hs-CRP正常组相比,hs-CRP升高组术后Cys C和Scr较高,而GFR较低(P＜0.05),hs-CRP轻度升高组术后Cys C较高、GFR较低(P＜0.05),而Scr差异无统计学意义。(2)270例患者中106例发生CI-AKI,总发生率39.26％。Hs-CRP升高组76例(43.18％),hs-CRP轻度升高组23例(38.33％);hs-CRP正常组7例(20.59％),3组间CI-AKI发生率差异有统计学意义(X2=6.13,P＜0.05)。(3)在hs-CRP升高患者,40mg阿托伐他汀组术后GFR高于10 mg与20 mg阿托伐他汀组(P＜0.05),Cys C与hs-CRP低于10 mg阿托伐他汀组(P＜0.05),20 mg阿托伐他汀组术后hs-CRP也低于10 mg阿托伐他汀组(P＜0.05)。(4) logistic回归结果显示,使用高剂量阿托伐他汀是术后发生CI-AKI的保护因素(20 mg阿托伐他汀：OR =0.15,95％ CI:0.06 ～0.33,P=0.001;40 mg阿托伐他汀：OR =0.10,95％ CI:0.04 ～0.23,P=0.001),而术前高水平hs-CRP(OR=2.06,95％ CI:1.01 ～4.23,P=0.048)、糖尿病(OR=10.71,95％ CI:5.29 ～21.70,P=0.001)、高龄(OR=2.64,95％ CI:1.05 ～6.63,P=0.038)、肾功能不全（OR =5.14,95％ CI:1.13 ～ 23.39,P=0.034）是CI-AKI的独立危险因素。结论 对比剂对ACS患者可造成肾功能损害,特别是对术前hs-CRP升高患者,高hs-CRP是肾功能损害的独立危险因素。PCI前给予40 mg阿托伐他汀可显著降低术后炎症水平,并减少对比剂对肾功能的损害。

Association between high sensitivity C-reactive protein and contrast induced acute kidney injury in patients with acute coronary syndrome undergoing percutaneous coronary intervention: impact of atorvastatin

Objective To observe the association between preprocedural high sensitivity C-reactive protein (hs-CRP) level and incidence of contrast induced acute kidney injury (CI-AKI) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) and the impact of atorvastatin pretreatment on CI-AKI. Methods According to the level of preprocedural hs-CRP, 270 ACS patients were divided into three groups: high hs-CRP group (hs-CRP≥3 mg/L, n =176), moderate hsCRP group (hs-CRP 1 -3 mg/L, n =60) and normal hs-CRP group ( hs-CRP ＜ 1 mg/L, n =34).According to the dosage of preprocedural atorvastatin, the high hs-CRP group was further divided into 10 mg group (n =49), 20 mg group (n =66) and 40 mg group (n =61 ). Serum creatinine (Ser), blood urea nitrogen (BUN), cystatin C (Cys C), hs-CRP were measured at before and 24 hours, 48 hours after PCI.CCr and GFR were calculated according to Scr and Cys C. Risk factors for CI-AKI were determined by multivariate logistic regression analysis. Results ( 1 ) Cys C was significantly increased and GFR after PCI significantly reduced in high and moderate hs-CRP groups compared with normal hs-CRP group ( P ＜ 0. 05 ).(2) Incidence of CI-AKI was 43. 18％, 38. 33％ , 20. 59％ in high, moderate and normal hs-CRP groups,respectively (P ＜ 0. 05 ). (3) In high hs-CRP group, postprocedural GFR was significantly higher while postprocedural Cys C and hs-CRP were significantly lower in 40 mg statin subgroup than 10 mg and 20 mg statin subgroups (P ＜ 0. 05), similar trends were documented when comparing 20 mg statin subgroup with 10 mg statin subgroup ( P ＜ 0. 05 ). (4) Multivariate logistic regression analysis showed that pretreatment with high dose atorvastatin was a protective factor for post CI-AKI (20 mg atorvastatin: OR =0. 15, 95％ CI 0. 06 -0. 33, P =0. 00 1 ; 40 mg atorvastatin: OR =0. 10, 95 ％ CI 0. 04 -0. 23, P =0. 001 ), while high levels of preprocedural hs-CRP (OR =2. 06, 95％ CI 1.01 -4. 23, P =0. 048), diabetes mellitus (OR =10.71,95％ CI5.29 -21.70, P=0.001), advanced age (OR =2. 64, 95％ CI 1.05 -6. 63, P =0.038)and renal failure ( OR =5. 14, 95％ CI 1.13 - 23.39, P =0. 034 ) were independent risk factors of CIAKI. Conclusion High hs-CRP level is linked with the development of CI-AKI in ACS patients undergoing PCI and pretreatment with 40 mg atorvastatin is associated with lower incidence CI-AKI, possibly by reducing the postprocedural inflammation responses.