重组人脑利钠肽预防造影剂肾病
发布时间：2018-07-24 09:17
【摘要】：背景:随着冠脉造影(CAG)及经皮冠状动脉介入治疗(PCI)的发展,随之而来的是对比剂应用所导致的对比剂肾病(CIN)的发病率逐渐升高。CIN通常是指在应用对比剂之后48小时内,肌酐值较基础值升高25%或超过0.5 mg/d L(44μmol/L)。发生后无特殊的临床表现,多表现为非少尿肾衰,7-10天可恢复,部分需要短暂透析维持。其发病率介于0-20%之间,危险因素(肾功能不全、糖尿病、心衰、低血压、对比剂用量大等)越多,发病率越高。CIN会使患者住院时间延长,增加透析及死亡风险。由于CIN无特殊治疗方案,预防至关重要。目前关于CIN的预防措施研究颇多,但除了水化治疗,其他方法的效果尚不确定。水化治疗是目前公认的预防CIN的措施,但水化对于心血管病人来说,尤其是心衰患者,也存在着增加心脏负荷的风险。因此,CIN已成为继支架术后“血栓形成”及支架术后“再狭窄”之后的第三大难题。如何将CIN发病率降至最低以及积极寻求CIN的有效预防措施已成为心血管医生的重要课题。而且,临床上冠心病合并慢性肾脏疾病(CKD)的发生率也逐渐增多,文献报道其发生率可达20~40%,这部分患者接受CAG甚至PCI的病例也逐年增加,怎样预防对比剂进一步损害肾脏功能,也成为临床实践中的棘手问题!脑利钠肽(BNP)是心室分泌的一种多肽,具有舒张血管、降低心脏的前后负荷、抑制心室重构、拮抗肾素-血管紧张素-醛固酮系统(RAAS)和交感神经系统(SNS)、增加肾小球滤过率,降低近端小管和集合管对钠的重吸收等多种心肾保护作用。因此BNP有可能对预防CIN有效,已有研究显示BNP对腹部和心脏外科手术围手术期的肾功能有改善作用,但BNP对于CAG或PCI围手术期CIN的预防作用研究,尚未见报道。本研究旨在明确重组人脑利钠肽(rh BNP)对CAG或PCI围手术期CIN的发生是否有预防作用,为提出新的CIN的预防措施提供临床依据。第一部分冠脉造影、冠脉介入治疗导致对比剂肾病的发生率及危险因素目的:本研究旨在调查,不稳定型心绞痛患者在接受CAG或非急诊PCI时,在水化治疗基础上CIN的发生率及其危险因素分析。方法:经过医院的伦理委员会批准并且签订知情同意书后500名不稳定型心绞痛患者入选本研究。采集入选研究患者的一般情况。所有患者于CAG或非急诊PCI前进行水化治疗(术前12小时至术后12小时静脉输注0.9%氯化钠1.0ml/kg/h),并于术前、术后24小时、48小时、72小时及1周测定患者胱抑素C(Cys C)、血清肌酐水平(Scr)及肾小球滤过率(e GFR),计算入选患者CIN的发生率。CIN定义为使用对比剂后48小时内出现血肌酐上升超过其基础值的25%或超过0.5mg/d L(44μmol/L)。并依据CIN发生与否,将患者分为CIN组及非CIN组,比较两组一般情况。评估CIN组CAG或非急诊PCI前后肾功能变化情况。对两组患者进行CIN危险评分(Mehran评分系统),探讨CIN发生的危险因素。结果:(1)500例入选患者中72例发生了CIN,发生率14.4%,其中行PCI患者的CIN发生率高于CAG者(16.9%vs 9.7%,P0.05),差异有统计学意义。依据CIN发生与否将患者分为CIN组及非CIN组,比较两组一般情况,可见年龄、入院Cys C、Scr、e GFR、高血压史、糖尿病史、冠脉严重程度、手术操作方式、对比剂用量及Mehran评分差异有统计学意义,而其他一般情况无统计学意义。(2)CIN组Scr于造影后24小时开始升高,48小时达峰,72小时逐渐回落,一周基本恢复至基线水平。e GFR变化规律同Scr。而Cys C于造影后24小时达峰,48小时便开始回落,72小时恢复至基线水平。(3)经过危险因素分析,结果显示:对比剂的用量(OR=3.57,95%CI 1.25~5.88,P0.05)、糖尿病病史(OR=1.92,95%CI 0.88~3.36,P0.05)、入院Cys C(OR=2.20,95%CI1.62~4.11,P0.05)、e GFR(OR=3.10,95%CI 1.99~5.48,P0.05)及Mehran评分(OR=4.46,95%CI 2.16~6.88,P0.01)是CIN的独立预测因子,其中Mehran评分相关性最好。结论:CIN在行CAG或非急诊PCI的不稳定型心绞痛患者中很常见,即使预防性应用水化治疗发病率仍然很高。Cys C对CIN的评估较为敏感,将Cys C及Scr结合起来,有利于提高CIN的检出率。糖尿病病史、基础肾功能不全、对比剂用量及Mehran评分是CIN的独立危险因素,其中Mehran评分相关性最好。不稳定型心绞痛患者在行CAG或非急诊PCI前最好应用Mehran评分进行危险分层,有利于识别CIN的高危人群。在条件允许情况下,尽量减少对比剂的用量,以减少CIN的发生。第二部分重组人脑利钠肽预防对比剂肾病的机制目的:探讨不稳定型心绞痛患者在接受CAG或非急诊PCI时,rh BNP对CIN是否有预防作用。方法:经过医院的伦理委员会批准并且签订知情同意书后1000名不稳定型心绞痛患者自愿者入选本研究。采集入选研究患者的一般情况。将所有入选患者随机分为两组:水化组,n=500,于CAG或非急诊PCI术前12小时至术后12小时给予0.9%氯化钠以1.0ml/kg/h静点;rh BNP组,n=500,于CAG或非急诊PCI术前24小时给予低剂量的rh BNP(0.005μg/kg/min)。所有患者于术前及术后24小时、48小时、72小时和第7天检测Cys C,Scr和e GFR,评估两组CIN的发生率及CAG或非急诊PCI术前后肾功能的变化情况。并观察术前、术后24小时血清肿瘤坏死因子α(TNF-α)和醛固酮(Adl)变化情况。结果:(1)两组术前一般情况比较无统计学差异。(2)rh BNP组CIN的发生率显著低于水化治疗组(5.6%vs 14.4%,P0.01)。两组行PCI的患者CIN发生率均高于行CAG的患者(P0.05)。(3)两组受试者在CAG或非急诊PCI前Cys C、Scr及e GFR差异无统计学意义(P0.05)。在术后24小时、48小时及72小时,rh BNP组的e GFR较对照组更高,而Cys C和Scr较对照组更低,差异有统计学意义(P0.05)。两组Cys C、Scr及e GFR术后24小时、48小时与术前差异有统计学意义,72小时差异无统计学意义,三项指标均于7天时恢复到基线水平。(4)对于发生CIN的患者,rh BNP组Scr术后24小时、48小时、72小时均低于水化组,差异具有统计学意义(P0.05)。两组术后24小时和48小时Scr值均高于术前(P0.05)。术后72小时,水化肌酐值仍明显高于术前,但rh BNP组差异无统计学意义。(5)两组术前TNF-α和Adl基线水平无统计学差异(P0.05),术后24小时TNF-α和Adl较术前均有明显升高(P0.05)。与rh BNP组比较水化组升高更明显(P0.05)。结论:CAG或非急诊PCI术前使用低剂量的rh BNP对预防CIN有效,其效果优于水化治疗。即使发生CIN,rh BNP也能减轻肾功能损伤程度,并且缩短肾功能恢复正常的时间。rh BNP预防CIN的作用可能是通过抑制炎症反应和RAAS的机制实现的。第三部分重组人脑利钠肽预防对比剂进一步加重肾脏损害的机制目的:探讨合并中度慢性肾功不全(CKD)的不稳定型心绞痛患者在接受CAG或非急诊PCI时,rh BNP对CIN预防的作用。方法:将合并中度CKD的不稳定型心绞痛患者(30ml/min/1.73m2≤e GFR60ml/min/1.73m2),随机分为两组:水化组,n=103,于CAG或非急诊PCI术前12小时至术后12小时给予0.9%氯化钠以1.0ml/kg/h静点;rh BNP组,n=106,于CAG或非急诊PCI术前24小时给予低剂量的rh BNP(0.005μg/kg/min)。分别于CAG或非急诊PCI术前、造影后24小时、48小时、1周、1月采集Cys C、SCr、e GFR等指标。主要终点事件为CIN的发生率,次要终点观察Cys C、SCr、e GFR手术前后的变化。并观察术前、术后24小时血清肿瘤坏死因子α(TNF-α)和醛固酮(Adl)变化情况。结果:(1)两组术前一般情况比较无统计学差异。(2)rh BNP组CIN的发生率显著低于水化治疗组(8.5%vs 23.3%,P0.01)。两组行PCI的患者CIN发生率均高于行CAG的患者(P0.05)。(3)两组患者在CAG或非急诊PCI前Cys C、Scr及e GFR差异无统计学意义(P0.05)。rh BNP组的e GFR在术后48小时及1周较水化组更高,而Scr及Cys C较水化组更低,差异有统计学意义(P0.05)。水化组Cys C、Scr在术后24小时开始升高,1周达峰,1月时恢复至基线水平。e GFR变化规律同Scr。rh BNP组肾功能恢复较快,Cys C、Scr于术后24小时开始升高,48小时达峰,1周便已接近基线水平。(4)两组术前TNF-α和Adl基线水平无统计学差异(P0.05),术后24小时TNF-α和Adl较术前均有明显升高(P0.05)。与rh BNP组比较水化组升高更明显(P0.05)。结论:合并中度CKD的不稳定型心绞痛患者行CAG或非急诊PCI后更易发生CIN,即使预防性应用水化治疗和等渗对比剂,发病率仍然很高。于CAG或非急诊PCI术前使用低剂量的rh BNP预防CIN安全、有效,其效果优于水化治疗。而且rh BNP也能减轻肾功能损伤程度,并且缩短肾功能恢复时间。rh BNP预防CIN的作用可能是通过抑制炎症反应和RAAS的机制实现的。
[Abstract]:Background: with the development of coronary angiography (CAG) and percutaneous coronary intervention (PCI), the incidence of contrast agent nephropathy (CIN), resulting from contrast agent application, is gradually increased by 25% or more than 0.5 mg/d L (44 mol/L) within 48 hours after the use of contrast agents. The clinical manifestation is non oliguria renal failure, 7-10 days can be recovered, part of the need for temporary dialysis maintenance. Its incidence is between 0-20%, the risk factors (renal insufficiency, diabetes, heart failure, hypotension, the amount of contrast medium), the higher the incidence of.CIN will prolong the patient's time of hospitalization, increase the risk of dialysis and death. Because of CIN The prevention of special treatment is very important. There is a lot of study on the prevention of CIN, but the effect of other methods is still uncertain except for hydration therapy. Hydration therapy is currently recognized as a measure to prevent CIN. But hydration has a risk of increasing heart load for cardiovascular patients, especially heart failure. Therefore, CIN has already been used. It has become the third major problem following "thrombosis" after stenting and "restenosis" after stenting. How to minimize the incidence of CIN and to actively seek effective preventive measures for CIN have become an important subject for cardiovascular doctors. Moreover, the incidence of chronic renal disease (CKD) in clinical coronary heart disease is increasing, and the literature is also increasing. It is reported that its incidence is up to 20~40%, and the cases of this part of patients receiving CAG and even PCI are increasing year by year. How to prevent the contrast agent to further damage the renal function is also a difficult problem in clinical practice. Brain natriuretic peptide (BNP) is a polypeptide of ventricular secreting, which has Shu Zhangxue tube, reduces the load of the heart, inhibits ventricular remodeling and antagonism. The renin angiotensin aldosterone system (RAAS) and the sympathetic nervous system (SNS) increase the glomerular filtration rate and reduce a variety of cardionenal protective effects on the reabsorption of sodium in the proximal tubules and collecting tubes. Therefore, BNP may be effective in preventing CIN. Studies have shown that BNP has improved the renal function in the perioperative period of abdominal and cardiac surgery. But the study of the preventive effect of BNP on CIN in the perioperative period of CAG or PCI has not been reported. This study aims to clarify whether the recombinant human brain natriuretic peptide (RH BNP) has a preventive effect on the occurrence of CIN in the perioperative period of CAG or PCI, and provides a clinical basis for the prophylaxis of new CIN. First division coronary angiography, coronary intervention leads to contrast nephropathy. Incidence and risk factors: the purpose of this study was to investigate the incidence and risk factors of CIN on the basis of hydration therapy for patients with unstable angina pectoris at CAG or non emergency PCI. Methods: 500 patients with unstable angina pectoris after the hospital ethics committee approved and signed the informed consent book. The general condition of the patients was collected. All patients were treated with hydration before CAG or non emergency PCI (12 hours before operation to 12 hours of intravenous infusion of sodium chloride 1.0ml/kg/h), and before operation, 24 hours, 48 hours, 72 hours and 1 weeks after the operation, the serum creatinine level (Scr) and glomerular filtration rate (E GFR) were measured. The incidence of CIN was defined as 25% or more than 25% or more than 0.5mg/d L (44 mu mol/L) in the 48 hours after the use of contrast agents. According to CIN or not, the patients were divided into CIN group and non CIN group, and the two groups were compared. The changes of renal function before and after the CIN group CAG or non emergency PCI were evaluated. Two The CIN risk score (Mehran scoring system) was used to investigate the risk factors of CIN. Results: (1) 72 of the 500 patients were selected, and the incidence of CIN was 14.4%. The incidence of CIN in the patients with PCI was higher than that of CAG (16.9%vs 9.7%, P0.05), and the difference was statistically significant. The patients were divided into CIN group and non CIN group according to the occurrence of CIN. Two groups of general conditions, visible age, admission Cys C, Scr, e GFR, hypertension history, diabetes history, coronary severity, operation mode, contrast agent dosage and Mehran score difference is statistically significant, but the other general situation is not statistically significant. (2) CIN group Scr in 24 hours after the film began to rise, 48 hours to peak, 72 hours gradually fell down. The change of.E GFR at baseline was basically the same as that of Scr. while Cys C reached the peak 24 hours after the contrast. It began to fall at 48 hours and recovered to the baseline level for 72 hours. (3) through the analysis of risk factors, the results showed that the dosage of contrast agent (OR=3.57,95%CI 1.25~5.88, P0.05), the history of diabetes mellitus (OR=1.92,95%CI 0.88~3.36, P0.05), hospitalized Cys 20,95%CI1.62~4.11, P0.05), e GFR (OR=3.10,95%CI 1.99~5.48, P0.05) and Mehran score (OR=4.46,95%CI 2.16~6.88, P0.01) are independent predictors of CIN. High.Cys C is more sensitive to CIN evaluation. Combining Cys C and Scr is beneficial to improve the detection rate of CIN. The history of diabetes, basic renal insufficiency, the dosage of contrast agent and Mehran score are independent risk factors of CIN, and the Mehran score is best. Risk stratification is beneficial to identify high-risk groups of CIN. Reduce the amount of contrast agents to reduce the incidence of CIN under condition permitting conditions. Second the mechanism of recombinant human brain natriuretic peptide prevention of contrast nephropathy is to explore the prevention of CIN in patients with unstable angina pectoris in CAG or non emergency PCI, and whether RH BNP has the prevention of CIN. Methods: 1000 patients with unstable angina pectoris were selected after the hospital ethics committee approved and signed the informed consent book. The general situation of the patients was collected and studied. All the selected patients were randomly divided into two groups: the hydrated group, n=500, 12 hours before the CAG or the non emergency PCI operation to 0.9% after the 12 hours after the operation. Sodium chloride was given with 1.0ml/kg/h static point; RH BNP group, n=500, low dose RH BNP (0.005 g/kg/min) were given 24 hours before CAG or non emergency PCI. All patients were tested for Cys C before and 24 hours, 48 hours, 72 hours and seventh days after operation. The incidence of two groups and the changes of renal function before and after non emergency surgery were evaluated. The changes of serum tumor necrosis factor - alpha (TNF- - alpha) and aldosterone (Adl) were observed 24 hours before the operation. Results: (1) there was no statistical difference between the two groups before operation. (2) the incidence of CIN in group RH BNP was significantly lower than that in the hydrated group (5.6%vs 14.4%, P0.01). The incidence of CIN in the two group of PCI patients was higher than that in the patients with CAG (P0.05). (3) two groups. There was no significant difference in Cys C, Scr and E GFR before the CAG or non emergency PCI (P0.05). The e GFR in the RH BNP group was higher than the control group at 24 hours, 48 hours and 72 hours after the operation, and the difference was statistically significant. The difference was statistically significant at 24 hours after the operation and 48 hours after the operation. The difference between the 72 hours was not statistically significant, and the three indexes were all recovered to the baseline level at 7 days. (4) for patients with CIN, Rh BNP group Scr 24 hours, 48 hours, 72 hours were lower than the hydration group, the difference was statistically significant (P0.05). The Scr value of 24 hours and 48 hours after operation in two group was higher than before operation (P0.05). Water creatinine was hydrated after operation after operation (P0.05). There was no significant difference in the value of RH BNP group. (5) there was no statistical difference between the baseline levels of TNF- alpha and Adl before operation (P0.05), and TNF- alpha and Adl were significantly higher than before the operation (P0.05). Compared with the RH BNP group, the hydration group increased more significantly (P0.05). CIN effective, its effect is better than hydration treatment. Even if CIN, Rh BNP can reduce the degree of renal function damage, and shorten the time of renal function recovery..rh BNP to prevent CIN may be achieved by inhibiting the mechanism of inflammation and RAAS. The third part of recombinant human brain natriuretic peptide prevents the contrast agent to further aggravate the renal damage. Objective: To investigate the effect of RH BNP on the prevention of CIN in patients with unstable angina pectoris with moderate chronic renal insufficiency (CKD) when receiving CAG or non emergency PCI. Methods: the patients with moderate CKD of unstable angina pectoris (30ml/min/1.73m2 < e GFR60ml/min/1.73m2) were randomly divided into two groups: the hydration group, n=103, in CAG or non emergency treatment. 12 hours before operation to 12 hours after operation, 0.9% sodium chloride was given with 1.0ml/kg/h static point; RH BNP group, n=106, low dose RH BNP (0.005 u g/kg/min) were given 24 hours before CAG or non emergency PCI. Before CAG or non emergency PCI, 24 hours, 48 hours, and 1 weeks after the angiography. Rate, secondary end point was observed before and after Cys C, SCr, e GFR, and the changes of serum tumor necrosis factor alpha (TNF- a) and aldosterone (Adl) were observed 24 hours after operation. Results: (1) there was no statistical difference between the two groups before operation. (2) the incidence of CIN in RH BNP group was significantly lower than that in the hydration group (8.5%vs 23.3%, P0.01). Two groups were treated. The incidence of CIN in patients with CAG was higher than that of patients with CAG (P0.05). (3) there was no significant difference in Cys C, Scr and E GFR before PCI in CAG or non emergency PCI group (P0.05) Time began to rise, 1 Zhou Dafeng, January to the baseline level of.E GFR change law and Scr.rh BNP group renal function recovery faster, Cys C, Scr at 24 hours after the operation began to rise, 48 hours of peak, 1 weeks already close to the baseline level. (4) before the two group TNF- a and Adl baseline level of no difference (P0.05), 24 hours postoperatively, TNF- alpha and Adl compared before the operation were all before the operation. There was a significant increase (P0.05). Compared with the RH BNP group, the increase in the hydration group was more obvious (P0.05). Conclusion: the patients with moderate CKD with unstable angina pectoris are more likely to occur CIN after CAG or non emergency PCI, even if the preventive use of hydration and isotonic contrast agents, the incidence is still high. It is safe and effective, its effect is better than hydration therapy. Moreover, Rh BNP can also reduce the degree of renal function damage, and shorten the time of renal function recovery. The effect of.Rh BNP on the prevention of CIN may be achieved by inhibiting the mechanism of inflammatory reaction and RAAS.
【学位授予单位】：河北医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R692
本文编号：2140915
[Abstract]:Background: with the development of coronary angiography (CAG) and percutaneous coronary intervention (PCI), the incidence of contrast agent nephropathy (CIN), resulting from contrast agent application, is gradually increased by 25% or more than 0.5 mg/d L (44 mol/L) within 48 hours after the use of contrast agents. The clinical manifestation is non oliguria renal failure, 7-10 days can be recovered, part of the need for temporary dialysis maintenance. Its incidence is between 0-20%, the risk factors (renal insufficiency, diabetes, heart failure, hypotension, the amount of contrast medium), the higher the incidence of.CIN will prolong the patient's time of hospitalization, increase the risk of dialysis and death. Because of CIN The prevention of special treatment is very important. There is a lot of study on the prevention of CIN, but the effect of other methods is still uncertain except for hydration therapy. Hydration therapy is currently recognized as a measure to prevent CIN. But hydration has a risk of increasing heart load for cardiovascular patients, especially heart failure. Therefore, CIN has already been used. It has become the third major problem following "thrombosis" after stenting and "restenosis" after stenting. How to minimize the incidence of CIN and to actively seek effective preventive measures for CIN have become an important subject for cardiovascular doctors. Moreover, the incidence of chronic renal disease (CKD) in clinical coronary heart disease is increasing, and the literature is also increasing. It is reported that its incidence is up to 20~40%, and the cases of this part of patients receiving CAG and even PCI are increasing year by year. How to prevent the contrast agent to further damage the renal function is also a difficult problem in clinical practice. Brain natriuretic peptide (BNP) is a polypeptide of ventricular secreting, which has Shu Zhangxue tube, reduces the load of the heart, inhibits ventricular remodeling and antagonism. The renin angiotensin aldosterone system (RAAS) and the sympathetic nervous system (SNS) increase the glomerular filtration rate and reduce a variety of cardionenal protective effects on the reabsorption of sodium in the proximal tubules and collecting tubes. Therefore, BNP may be effective in preventing CIN. Studies have shown that BNP has improved the renal function in the perioperative period of abdominal and cardiac surgery. But the study of the preventive effect of BNP on CIN in the perioperative period of CAG or PCI has not been reported. This study aims to clarify whether the recombinant human brain natriuretic peptide (RH BNP) has a preventive effect on the occurrence of CIN in the perioperative period of CAG or PCI, and provides a clinical basis for the prophylaxis of new CIN. First division coronary angiography, coronary intervention leads to contrast nephropathy. Incidence and risk factors: the purpose of this study was to investigate the incidence and risk factors of CIN on the basis of hydration therapy for patients with unstable angina pectoris at CAG or non emergency PCI. Methods: 500 patients with unstable angina pectoris after the hospital ethics committee approved and signed the informed consent book. The general condition of the patients was collected. All patients were treated with hydration before CAG or non emergency PCI (12 hours before operation to 12 hours of intravenous infusion of sodium chloride 1.0ml/kg/h), and before operation, 24 hours, 48 hours, 72 hours and 1 weeks after the operation, the serum creatinine level (Scr) and glomerular filtration rate (E GFR) were measured. The incidence of CIN was defined as 25% or more than 25% or more than 0.5mg/d L (44 mu mol/L) in the 48 hours after the use of contrast agents. According to CIN or not, the patients were divided into CIN group and non CIN group, and the two groups were compared. The changes of renal function before and after the CIN group CAG or non emergency PCI were evaluated. Two The CIN risk score (Mehran scoring system) was used to investigate the risk factors of CIN. Results: (1) 72 of the 500 patients were selected, and the incidence of CIN was 14.4%. The incidence of CIN in the patients with PCI was higher than that of CAG (16.9%vs 9.7%, P0.05), and the difference was statistically significant. The patients were divided into CIN group and non CIN group according to the occurrence of CIN. Two groups of general conditions, visible age, admission Cys C, Scr, e GFR, hypertension history, diabetes history, coronary severity, operation mode, contrast agent dosage and Mehran score difference is statistically significant, but the other general situation is not statistically significant. (2) CIN group Scr in 24 hours after the film began to rise, 48 hours to peak, 72 hours gradually fell down. The change of.E GFR at baseline was basically the same as that of Scr. while Cys C reached the peak 24 hours after the contrast. It began to fall at 48 hours and recovered to the baseline level for 72 hours. (3) through the analysis of risk factors, the results showed that the dosage of contrast agent (OR=3.57,95%CI 1.25~5.88, P0.05), the history of diabetes mellitus (OR=1.92,95%CI 0.88~3.36, P0.05), hospitalized Cys 20,95%CI1.62~4.11, P0.05), e GFR (OR=3.10,95%CI 1.99~5.48, P0.05) and Mehran score (OR=4.46,95%CI 2.16~6.88, P0.01) are independent predictors of CIN. High.Cys C is more sensitive to CIN evaluation. Combining Cys C and Scr is beneficial to improve the detection rate of CIN. The history of diabetes, basic renal insufficiency, the dosage of contrast agent and Mehran score are independent risk factors of CIN, and the Mehran score is best. Risk stratification is beneficial to identify high-risk groups of CIN. Reduce the amount of contrast agents to reduce the incidence of CIN under condition permitting conditions. Second the mechanism of recombinant human brain natriuretic peptide prevention of contrast nephropathy is to explore the prevention of CIN in patients with unstable angina pectoris in CAG or non emergency PCI, and whether RH BNP has the prevention of CIN. Methods: 1000 patients with unstable angina pectoris were selected after the hospital ethics committee approved and signed the informed consent book. The general situation of the patients was collected and studied. All the selected patients were randomly divided into two groups: the hydrated group, n=500, 12 hours before the CAG or the non emergency PCI operation to 0.9% after the 12 hours after the operation. Sodium chloride was given with 1.0ml/kg/h static point; RH BNP group, n=500, low dose RH BNP (0.005 g/kg/min) were given 24 hours before CAG or non emergency PCI. All patients were tested for Cys C before and 24 hours, 48 hours, 72 hours and seventh days after operation. The incidence of two groups and the changes of renal function before and after non emergency surgery were evaluated. The changes of serum tumor necrosis factor - alpha (TNF- - alpha) and aldosterone (Adl) were observed 24 hours before the operation. Results: (1) there was no statistical difference between the two groups before operation. (2) the incidence of CIN in group RH BNP was significantly lower than that in the hydrated group (5.6%vs 14.4%, P0.01). The incidence of CIN in the two group of PCI patients was higher than that in the patients with CAG (P0.05). (3) two groups. There was no significant difference in Cys C, Scr and E GFR before the CAG or non emergency PCI (P0.05). The e GFR in the RH BNP group was higher than the control group at 24 hours, 48 hours and 72 hours after the operation, and the difference was statistically significant. The difference was statistically significant at 24 hours after the operation and 48 hours after the operation. The difference between the 72 hours was not statistically significant, and the three indexes were all recovered to the baseline level at 7 days. (4) for patients with CIN, Rh BNP group Scr 24 hours, 48 hours, 72 hours were lower than the hydration group, the difference was statistically significant (P0.05). The Scr value of 24 hours and 48 hours after operation in two group was higher than before operation (P0.05). Water creatinine was hydrated after operation after operation (P0.05). There was no significant difference in the value of RH BNP group. (5) there was no statistical difference between the baseline levels of TNF- alpha and Adl before operation (P0.05), and TNF- alpha and Adl were significantly higher than before the operation (P0.05). Compared with the RH BNP group, the hydration group increased more significantly (P0.05). CIN effective, its effect is better than hydration treatment. Even if CIN, Rh BNP can reduce the degree of renal function damage, and shorten the time of renal function recovery..rh BNP to prevent CIN may be achieved by inhibiting the mechanism of inflammation and RAAS. The third part of recombinant human brain natriuretic peptide prevents the contrast agent to further aggravate the renal damage. Objective: To investigate the effect of RH BNP on the prevention of CIN in patients with unstable angina pectoris with moderate chronic renal insufficiency (CKD) when receiving CAG or non emergency PCI. Methods: the patients with moderate CKD of unstable angina pectoris (30ml/min/1.73m2 < e GFR60ml/min/1.73m2) were randomly divided into two groups: the hydration group, n=103, in CAG or non emergency treatment. 12 hours before operation to 12 hours after operation, 0.9% sodium chloride was given with 1.0ml/kg/h static point; RH BNP group, n=106, low dose RH BNP (0.005 u g/kg/min) were given 24 hours before CAG or non emergency PCI. Before CAG or non emergency PCI, 24 hours, 48 hours, and 1 weeks after the angiography. Rate, secondary end point was observed before and after Cys C, SCr, e GFR, and the changes of serum tumor necrosis factor alpha (TNF- a) and aldosterone (Adl) were observed 24 hours after operation. Results: (1) there was no statistical difference between the two groups before operation. (2) the incidence of CIN in RH BNP group was significantly lower than that in the hydration group (8.5%vs 23.3%, P0.01). Two groups were treated. The incidence of CIN in patients with CAG was higher than that of patients with CAG (P0.05). (3) there was no significant difference in Cys C, Scr and E GFR before PCI in CAG or non emergency PCI group (P0.05) Time began to rise, 1 Zhou Dafeng, January to the baseline level of.E GFR change law and Scr.rh BNP group renal function recovery faster, Cys C, Scr at 24 hours after the operation began to rise, 48 hours of peak, 1 weeks already close to the baseline level. (4) before the two group TNF- a and Adl baseline level of no difference (P0.05), 24 hours postoperatively, TNF- alpha and Adl compared before the operation were all before the operation. There was a significant increase (P0.05). Compared with the RH BNP group, the increase in the hydration group was more obvious (P0.05). Conclusion: the patients with moderate CKD with unstable angina pectoris are more likely to occur CIN after CAG or non emergency PCI, even if the preventive use of hydration and isotonic contrast agents, the incidence is still high. It is safe and effective, its effect is better than hydration therapy. Moreover, Rh BNP can also reduce the degree of renal function damage, and shorten the time of renal function recovery. The effect of.Rh BNP on the prevention of CIN may be achieved by inhibiting the mechanism of inflammatory reaction and RAAS.
【学位授予单位】：河北医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R692
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