以脑钠肽水平指导呋塞米应用对高危患者对比剂肾病的预防作用

发布时间：2018-07-04 17:03

本文选题：脑钠肽 + 呋塞米　；参考：《郑州大学》2017年硕士论文

【摘要】：目的在充分水化的基础上,探讨以脑钠肽水平指导呋塞米应用对高危患者对比剂肾病的预防作用,比较其与单纯水化、呋塞米联合水化的作用区别。方法1研究对象:选取2015年7月-2016年6月来我院心血管内科住院行CAG的患者共160例,其中男性78例(48.75%),女性82例(51.25%),平均年龄(62.14±8.39)岁。入选标准:(1)年龄≥18岁;(2)拟行冠状动脉造影患者;(3)慢性肾功能不全患者,基线估测肾小球滤过率(estimated glomerular filtrate rate,eGFR)15-90 ml/min/1.73m2(简化MDRD公式);(4)签署知情同意书。排除标准:(1)术中死亡患者;(2)需透析治疗的终末期肾衰患者或心脏、肾移植术后;(3)术前72小时内或术后72小时内有急性感染性疾病史或接触放射性对比剂史;(4)急性失代偿心衰;(5)左心室血栓;(6)对放射性对比剂过敏;(7)怀孕、哺乳期妇女;(8)恶性肿瘤或预期寿命1年;(9)严重瓣膜病患者或拟行外科手术患者;(10)电解质紊乱患者;(11)心功能Ⅳ级以及明显水肿等不适合进行水化的患者。2研究方法:将160例行冠状动脉造影的患者随机分为三组,对照组52例,呋塞米组54例,呋塞米联合脑钠肽组54例,三组患者均于术前12小时至术后12小时予以1ml/kg/h的生理盐水水化,术后查BNP,对照组不作处理,呋塞米组患者全部给予呋塞米20mg静脉注射,呋塞米联合脑钠肽组根据BNP决定是否进行呋塞米注射,如BNP100pg/ml或超过术前BNP值50%则静脉注射呋塞米20mg,否则不作处理。术前记录患者年龄、性别、身高、体重、射血分数、肌酐、合并症、是否服用他汀,根据Cockcroft-Gault公式计算血清肌酐清除率:Ccr(ml/min)=(140-年龄)×体重×1.23(×0.85女性)/Scr,根据简化MDRD公式计算肾小球滤过率:eGFR(ml/min/1.73m2)=186×(Scr)-1.154×(年龄)-0.203(×0.742女性)。术后记录是否为冠脉多支病变、是否行PCI,术后72小时查血清肌酐水平并记录,计算并记录eGFR和Ccr。CIN诊断标准:应用对比剂72小时内排除其他原因引起的血肌酐较基线水平升高超过25%或44.2μmol/L(0.5 mg/dl)。3统计学方法:采用SPSS 21.0软件进行分析,分类资料采用率(%)表示,计量资料采用均数±标准差(x—±s)表示。分类变量组间比较采用χ2检验,多组计量资料比较采用F检验,两组计量资料比较采用独立样本的t检验,术前术后肌酐、eGFR和Ccr的组内比较采用配对样本的t检验。以P0.05为差异有统计学意义。结果1受试者一般临床资料的比较:三组患者基线年龄、性别、身高、体重、射血分数、肌酐、肌酐清除率、肾小球滤过率等方面差异无统计学意义(P0.05),三组患者合并高血压、糖尿病无统计学差异(P0.05),三组患者造影结果示多支病变、行PCI手术方面无统计学差异(P0.05),呋塞米联合脑钠肽组服用他汀的患者较多(P0.05)。2肾功能的指标变化:组内比较时,对照组和呋塞米组血清肌酐水平高于术前,有统计学意义(P0.001),血清肌酐清除率、肾小球滤过率低于术前,有统计学意义(P0.001);呋塞米合并脑钠肽组血清肌酐水平、血清肌酐清除率、肾小球滤过率与术前无统计学差异(P0.05)。组间比较时,三组术前血清肌酐、血清肌酐清除率、肾小球滤过率无统计学差异(P0.05),三组术后肌酐有统计学差异(P=0.033),其中对照组与呋塞米组无统计学差异(P=0.969),呋塞米联合脑钠肽组低于对照组和呋塞米组,差异有统计学意义(P0.05)。三组术后肾小球滤过率有统计学差异(P=0.001),其中对照组与呋塞米组无统计学差异(P=0.302),呋塞米联合脑钠肽组高于对照组和呋塞米组,差异有统计学意义(P0.05)。三组术后血清肌酐清除率无统计学差异(P=0.054)。3三组的CIN发生率比较:对照组应用呋塞米0例,呋塞米组应用呋塞米54例,呋塞米联合脑钠肽组应用呋塞米29例。三组的CIN发生率有统计学差异(P=0.041),其中对照组与呋塞米组无统计学差异(P=0.871),呋塞米联合脑钠肽组低于对照组和呋塞米组,差异有统计学意义(P0.05)。结论1.静脉应用呋塞米联合水化较单纯水化无额外的临床获益。2.在充分水化的基础上,以脑钠肽水平为指导应用呋塞米较直接应用呋塞米及单纯水化对高危患者肾功能的保护作用更明显。3.以脑钠肽水平为指导应用呋塞米可降低高危患者CIN的发生率。
[Abstract]:Objective to explore the preventive effect of furosemide on high risk patients with contrast agent nephropathy with the level of brain natriuretic peptide (BNP), and to compare the difference between the effect of furosemide and the hydration of furosemide. Method 1 subjects: 160 patients in the hospital of cardiovascular medicine in our hospital in June -2016 July 2015 were selected. Male 78 (48.75%), female 82 (51.25%), average age (62.14 + 8.39) years old. (1) age > 18 years old; (2) coronary angiography patients; (3) chronic renal insufficiency patients, baseline estimation of glomerular filtration rate (estimated glomerular filtrate rate, eGFR) 15-90 ml/min/1.73m2 (Simplified MDRD formula); (4) signed informed consent. Exclusion criteria: (1) patients who died in the operation; (2) after dialysis treatment of end-stage renal failure or heart, renal transplantation; (3) history of acute infectious disease within 72 hours or 72 hours after operation; (4) acute decompensated heart failure; (5) left ventricular thrombus; (6) allergic to radiocontrast agent; (7) pregnant, lactation women Women; (8) malignant tumor or life expectancy for 1 years; (9) patients with severe valvular disease or surgical operation; (10) patients with electrolyte disorders; (11) cardiac function IV and obvious edema, and other patients who were not suitable for hydration: 160 cases of coronary arteriography were randomly divided into three groups, 52 cases in the control group, 54 in furasim group, and furosemide. 54 patients were treated with brain natriuretic peptide group. The three groups were treated with 1ml/kg/h saline hydration from 12 hours before operation to 12 hours after operation. After operation, the patients were examined BNP, the control group was not treated. All patients in the furasim group were given furosemide 20mg intravenous injection. Furosemide combined with brain natriuretic peptide group determined whether the furosemide injection was carried out according to BNP, such as BNP100pg/ml or surpass operation. The former BNP value 50% was intravenous furosemide 20mg, otherwise no treatment. Preoperative records of patients' age, sex, height, body weight, ejection fraction, creatinine, complication, statins, and serum creatinine clearance according to the Cockcroft-Gault formula: Ccr (ml/min) = (140- age) x weight * 1.23 (x 0.85 female) /Scr, according to the simplified MDRD formula to calculate the kidney Small pellet filtration rate: eGFR (ml/min/1.73m2) =186 x (Scr) -1.154 x (age) -0.203 (x 0.742 female). Is the postoperative record of multiple coronary artery disease, PCI, serum creatinine level and record at 72 hours after operation, and the calculation and record of the diagnostic criteria for eGFR and Ccr.CIN: the contrast agent should be used in 72 hours to exclude other causes of serum creatinine than baseline water A statistical method of higher than 25% or 44.2 mol/L (0.5 mg/dl): SPSS 21 software was used for the analysis. The use rate (%) of the classification data was expressed, and the measurement data were expressed by mean number + standard deviation (x - s). The comparison of the classified variables was compared with the x 2 test. The multiple groups of data were compared with F test and the two groups were compared with independent samples. T test, preoperative and postoperative creatinine, eGFR and Ccr group compared with the paired sample t test. The difference between the 1 subjects was statistically significant. Results the comparison of the general clinical data of the 1 subjects: the baseline age, sex, height, body weight, creatinine, creatinine clearance, glomerular filtration rate in the three groups were not statistically significant (P 0.05), there was no statistical difference between the three groups of patients with hypertension (P0.05), the three groups showed multiple lesions, and there was no statistical difference in the PCI operation (P0.05). The more (P0.05).2 renal function of the furosemide combined with the brain natriuretic peptide group was compared with the serum creatinine levels in the control group and the furosemide group. Higher than preoperative, statistically significant (P0.001), serum creatinine clearance, glomerular filtration rate was lower than preoperative, statistically significant (P0.001); serum creatinine level, serum creatinine clearance rate and glomerular filtration rate were no significant difference between furosemide and brain natriuretic peptide group (P0.05). Serum creatinine and serum creatinine before operation were compared between groups. There was no statistical difference in the rate of glomerular filtration (P0.05). There was statistical difference between the three groups (P=0.033). There was no statistical difference between the control group and the furosemide group (P=0.969), the furosemide combined brain natriuretic peptide group was lower than the control group and the furosemide group, the difference was statistically significant (P0.05). The glomerular filtration rate after operation was statistically significant (P=0.0 01), there was no statistical difference between the control group and the furosemide group (P=0.302), the furosemide combined brain natriuretic peptide group was higher than the control group and the furosemide group, the difference was statistically significant (P0.05). There was no statistical difference in serum creatinine clearance rate between the three groups (P=0.054), the incidence of CIN in the.3 three groups was compared: the control group was used furosemide in 0 cases, furosemide group was used furosemide 5 4 cases, furosemide combined brain natriuretic peptide group used furasim 29 cases. The incidence of CIN in the three groups was statistically different (P=0.041), there was no statistical difference between the control group and the furosemide group (P=0.871), the furosemide combined brain natriuretic peptide group was lower than the control group and the furosemide group, the difference was statistically significant (P0.05). Conclusion 1. intravenous furosemide combined with hydration is more than single. Pure hydration has no additional clinical benefit.2. on the basis of full hydration, with brain natriuretic peptide level as the guidance of furosemide and the protection of direct application of furosemide and pure hydration to the renal function of high-risk patients more obviously.3. with brain natriuretic peptide level as the guidance of the use of furosemide to reduce the incidence of CIN in high-risk patients.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692

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