【作者】 李倩；

【导师】 朱建华；

【作者基本信息】 浙江大学 ， 内科学（专业学位）， 2013， 博士

【摘要】 [目的]随着冠状动脉造影/冠状动脉介入术的日渐普及,碘造影剂的使用已经广泛渗入到临床实践的各个环节,随之而来的造影剂肾病也日渐凸显。根据渗透压不同,造影剂被分为高渗性造影剂、低渗性造影剂以及等渗性造影剂,由于高渗性造影剂存在诸多弊端,它已逐渐退出冠脉造影/冠脉介入术的舞台。由于低渗性造影剂的渗透压仍高于血浆渗透压,这就可能刺激细胞产生活性氧物质而发挥细胞毒性作用,刺激肾脏产生炎症反应,同时肾小管渗透压增高也可能影响肾脏血流动力学,从诸多方面导致造影剂肾病发生,那我们必然产生一个疑问——等渗性造影剂在预防造影剂肾病方面对比低渗性造影剂是否存在优势?本文将通过对相关随机临床对照研究进行荟萃分析,旨在明确等渗性造影剂是否在预防造影剂肾病方面存在优势；同时对本院心脏病中心行冠状动脉介入术患者术前、术后血清肌酐水平的比较,评估在轻度肾功能不全患者中使用低渗性造影剂碘海醇是否会显著影响患者肾功能。[研究方法]在Web of Science. Cochrane Library以及PubMed数据库中以"contrast-induced nephropathy"、"contrast media"以及"percutaneous coronary intervention"为关键词搜索并选出其中可以获得全文的随机临床对照研究,用Review Manager5.0软件中的‘"Studies and references"、"Data and analyses’’以及‘"Figures"部分进行荟萃分析。收集本院心脏病中心从2013年2月1日至2013年3月20日间所有行PCI术的肾功能不全(MDRD-eGFR<90ml/min)出院患者的资料,包括年龄、性别、基础MDRD-eGFR.基础血清肌酐、造影剂种类、术后6小时血清肌酐、术后24～72小时血清肌酐,定义造影剂肾病为使用造影剂后72小时内血清肌酐较基础值上升大于25%,使用Micro Office2010Excel计算手术前后患者血清肌酐的平均值及标准差,以及双尾配对的t检验结果(定义α=0.05)。[结果]荟萃分析结果发现使用等渗性造影剂并不能有效降低造影剂肾病的发生概率(OR=0.86,95%CI[0.71,1.04])；对肾功能不全患者进行亚族分析同样提示使用等渗性造影剂并不能有效降低造影剂肾病的发生概率(OR=0.89,95%CI[0.71,1.11])。本院心脏病中心入选数据中,有1例发生造影剂肾病,所有符合条件的患者术后6小时平均血清肌酐水平与基础血清肌酐相比有明显下降(p<0.05);术后24小时平均血清肌酐水平与基础相比,二者无明显差异(p=0.10)[结论]等渗性造影剂并不能有效降低造影剂肾病的发生概率,即使在肾功能不全患者中,上述结论也依然成立；对于使用碘海醇的轻度肾功能不全患者,联合术后水化,在术后24小时内患者血清肌酐不会显著升高。更多还原

【Abstract】 [Objective]With the widespread use of coronary artery angiography/percutaneous coronary intervention, iodinated contrast media would be seen in daily life. Contrast-induced nephropathy, a complication of coronary artery angiography/percutaneous coronary intervention in patients, is a well-established independent predictor of increased in-hospital morbidity and mortality. According to different osmolar, contrast-media was divided into3categories:high-osmolar, low-osmolar and iso-osmolar. Since high-osmolar contrast media has sever adverse effect, low-osmolar and iso-osmolar ones become more and more popular. Even the so-called "low-osmolar contrast media", its osmolality is still much higher than plasma, which could increase the production of reactive oxygen species, enhance inflammatory response in mesangial tissue, disturb the hemodynamics in kidney, all of the above may play roles in the development of contrast-induced nephropathy. Whether iso-osmolar contrast media is superior to low-osmolar ones in the prevention of contrast-induced nephropathy still need to be investigated. In this article, we performed a meta-analysis with several randomized clinical trials comparing different osmolar contrast medias on renal function. We also collected patients’information in our heart center to assess the impairment on renal function of iohexol among patients with mild renal dysfunction undergoing elective percutaneous coronary intervention.[Method]We performed a computerized search to identify relevant free full articles from Web of Science, Cochrane Library and PubMed database with the following key words "contrast-induced nephropathy","contrast media" and "percutaneous coronary intervention". We utilized "Studies and references"、"Data and analyses" as well as "Figures" sections of Review Manager5.0to perform a meta-analysis.PCI Patients’ information was collected from1st Feb2013to20th Mar2013with details on age, sex, baseline MDRD-eGFR, baseline serum creatinine, contrast media type,6h serum creatinine after intervention and24h-72h serum creatinine after intervention. The definition of contrast-induced nephropathy is serum creatinine level increases≥25%from baseline within72h after contrast media administration. We calculated the mean serum creatinine levels before and after interventions using Micro Office2010Excel, also performed two-tail t critical (a=0.05).[Result]The result from meta-analysis revealed iso-osmolar contrast media could not decrease the incidence of contrast media nephropathy (OR=0.86,95%CI [0.71,1.04]); in the subgroup analysis with renal dysfunction patients the result was the same (OR=0.89,95%CI [0.71,1.11]).Only1case in our center suffered from contrast-induced nephropathy, compared with baseline serum creatinine level,6h serum creatinine level after intervention was significantly lower (p<0.05); there was no significant change between24h and baseline serum creatinine level (p=0.10).[Conclusion]Iso-osmolar contrast media cannot effectively decrease the incidence of contrast-induced nephropathy in general patients as well as patients with mild to moderate renal dysfunction; among patients with mild renal dysfunction, using iohexol combined with Ringer’s solution hydration, their serum creatinine would not significantly increase within24h after iohexol administration.更多还原