在充分水化的基础上以脑钠肽水平为指导予以小剂量呋塞米对造影剂肾病的预防
发布时间：2018-07-26 21:09
【摘要】：目的：至今关于造影剂肾病（CIN）的诊断标准没有统一意见，对于目前国际上广泛应用的定义是欧洲泌尿生殖放射学会于2005年发布的造影剂指南:于血管内应用造影剂3天出现的肾脏损害，主要表现为血清肌酐水平较基础水平升高44.2μmol/L或着是较基础水平升高25%，并且除外其他原因所导致的肾脏损害。一般在应用造影剂后24～48小时发生，3～5天后血肌酐升高达到高峰，7～10天内可恢复正常。CIN确切的发病机制目前还不清楚，但根据大量研究结果归纳起来，造影剂对肾脏的作用主要表现为肾血流动力学改变导致的肾缺血性损伤和造影剂对肾小管的直接毒性作用。目前对于造影剂的预防公认方法有水化及控制危险因素。此外应用N-乙酰半胱氨酸、非诺多泮、茶碱类药物对造影剂肾病的预防作用仍存在争议。 呋塞米作为袢利尿剂，能抑制前列腺素分解酶的活性，使前列腺素E2含量升高，从而可以扩张肾血管，降低肾血管阻力，使肾血流量尤其是肾皮质深部血流量增加。呋塞米在增加肾小管液流量的同时肾小球滤过率不会下降。有实验证明在充分水化的基础上给予小剂量呋塞米可以预防造影剂肾病。 B型利钠肽(BNP)也叫脑尿钠肽，，源于心肌细胞生成的134个氨基酸的Prepro-BNP，在进入血循环后，降解产生一个具有生物活性的BNP和一个无活性的有76个氨基酸组成的片段NT-proBNP，BNP是由心脏分泌的短肽激素，由32个氨基酸组成的多肽，并含一个17个氨基酸组成的环状结构。当负荷增加和心室增大时，BNP就随之分泌增多并释放入血液，通过与RASS系统的拮抗作用进而来控制体液和电解质的动态平衡。BNP具有抑制肾素-血管紧张素-醛固酮系统、舒张血管、利钠、降压、利尿以及抑制交感神经系统等多种生理功能。当以BNP为105pg/ml作判断心衰临界点时，具有较高灵敏度(约为95％)和特异度(86％)。因此BNP对诊断心衰有重要的临床参考价值。 一项前瞻性的实验研究表明：在PCI术后，给患者应用BNP，患者血清肌酐水平会在48小时达到高峰然后开始下降，7天降则可降至正常水平。在对照组并不是如此。在行PCI术后的24小时、48小时和72小时，应用BNP组的患者血清肌酐水平较对照组低。在应用造影剂以后，肾小球滤过率通常会在48小时降至最低，然后开始升高。应用BNP的患者肾小球滤过率较对照组高，CIN的发病率较对照组低。总之，预防性应用BNP能够改善肾脏功能，进而降低CIN的发生。 本实验旨在用BNP作为限制条件，在充分水化基础上给予小剂量呋塞米，对造影剂肾病的预防有无进一步指导意义。 方法：选择2009年9月至2014年1月于我院行冠状动脉造影和（或）冠状动脉内支架植入术（PCI）患者，并排除(NYHA)Ⅲ、Ⅳ级的心力衰竭或其他严重疾病不适宜水化的患者共226例。其中女性78例，男性148例，平均体重为72.57（10.41）千克，平均年龄为57.38（9.48）岁，术中均使用碘普罗胺注射液（370），平均量82.65（39.82）ml。入选的患者随机分为试验组和对照组，其中试验组112例，对照组114例。于冠状动脉造影术前查血清肌酐值及BNP值，依据MDRD公式计算肾小球滤过率：GFR(ml/min/1.73m2)=186×（Scr）-1.154×（年龄）-0.203(×0.742女性)；依据Cockcroft-Gault公式计算血清肌酐清除率：Ccr（ml/min）=[(140-年龄)×体重×(0.85女性)]/(72×Scr)。患者术前4小时开始予以1ml/kg/h的生理盐水进行水化，实验组据BNP结果术后给予呋塞米（术后BNP100pg/ml或超过术前BNP值50%，予以呋塞米20mg静脉注射），对照组不以BNP为指导均给予20mg呋塞米静脉注射。术后两组继续予1ml/kg/h生理盐水水化持续至24小时。记录期间患者的入量及出量。术后48小时复查血清肌酐水平，计算血清肌酐清除率及肾小球滤过率。造影剂肾病定义为应用造影剂后48小时内血清肌酐较前升高25%或升高0.5mg/dL。采用SPSS17.0软件进行统计学分析。比较两组术前及术后48小时患者血清肌酐水平、肾小球滤过率、血清肌酐清除率的变化，以及造影剂肾病发生率有无异同。分类资料采用率（%）表示；计量资料采用均数±标准差或四分位数间距（中位数）表示。两组间血清肌酐水平、肾小球滤过率及血清肌酐清除率的比较则采取重复测量进行分析；造影剂肾病的发生率采用卡方检验；各组内术前、术后各指标的比较则采用了秩和检验进行分析。统计结果以P0.05表示有显著统计学差异。 结果：临床情况年龄、体重、身高、性别、行PCI手术患者、应用造影剂量、糖尿病患者、术前肌酐水平、急性心梗患者在实验组和对照组之间无明显差异(P0.05)。多支病变患者、高血压、他汀类药物应用方面在试验组和对照组之间存在差异（P0.05）。试验组血清肌酐水平、肾小球滤过率术后高于术前，有统计学意义（P0.001），试验组血清肌酐清除率术后与术前相比，无统计学意义(P=0.76)；对照组血清肌酐水平术后高于术前，有统计学意义(P0.001），对照组肾小球滤过率、血清肌酐清除率术后低于术前，有统计学意义（P0.001）。试验组与对照组相比术前血清肌酐相比无统计学意义（P=0.58）。试验组与对照组在手术前后血清肌酐水平、肾小球滤过率及血清肌酐清除率的变化程度不同，与试验组相比，对照组血清肌酐水平升高的程度，肾小球滤过率、血清肌酐清除率下降的程度更明显（P0.001）。试验组统计结果显示造影剂肾病的发生率为5.67%，对照组统计结果显示造影剂肾病的发生率为32.56%，有统计学意义（P0.001）。 结论：在充分水化的基础上以脑钠肽水平作为限制条件对造影剂肾病的预防有指导意义。
[Abstract]:Objective: to date, there is no unified opinion on the diagnostic criteria for contrast agent nephropathy (CIN). The internationally widely used definition is the European Urogenital Radiology Society's angiographic guide published in 2005: 3 days of renal impairment in the use of intravascular contrast agents, mainly as the level of serum creatinine increased by 44.2 Mu than the basic level. Ol/L or an increase of 25% on the basis of a more basic level, except for other causes of kidney damage. Usually 24~48 hours after the use of contrast agents, 3~5 days after the peak of serum creatinine, and the exact pathogenesis of normal.CIN can be restored within 7~10 days. The main manifestations are the renal ischemic injury caused by renal hemodynamic changes and the direct toxic effect of contrast agents on renal tubules. The current recognized methods of contrast agents are hydrated and control risk factors. In addition, the preventive effect of N- acetylcysteine, non nobepam, and theophylline on contrast agent nephropathy still exists. It's in dispute.
Furosemide, as a loop diuretic, can inhibit the activity of prostaglandin and increase the content of prostaglandin E2, thereby dilating the renal blood vessels, reducing renal vascular resistance, and increasing the renal blood flow, especially the deep renal blood flow. The glomerular filtration rate will not decrease when the flow of renal tubules is increased. Giving low dose of furosemide on the basis of adequate hydration can prevent contrast induced nephropathy.
B type natriuretic peptide (BNP), also called brain natriuretic peptide, is derived from the 134 amino acid Prepro-BNP produced by cardiac myocytes. After entering the blood circulation, it degrade to produce a bioactive BNP and a fragment of an inactive 76 amino acid fragment NT-proBNP. BNP is a short peptide hormone secreted by the heart, a polypeptide of 32 amino acids, and contains one. A circular structure consisting of 17 amino acids. When the load increases and the ventricle increases, the BNP secretes and releases into the blood. Through the antagonism of the RASS system, the dynamic balance of the body fluids and electrolytes is controlled by.BNP to inhibit the renin angiotensin aldosterone system, diastolic blood vessels, natrium, hypotension, diuresis, and inhibition. There are many physiological functions such as the sympathetic nervous system. When BNP is used to judge the critical point of heart failure, it has high sensitivity (about 95%) and specificity (86%). Therefore, BNP has important clinical reference value in the diagnosis of heart failure.
A prospective experimental study showed that after PCI, the serum creatinine level of the patients reached a peak at 48 hours and began to fall to the normal level at 7 days. In the control group, the level of serum creatinine in the group BNP was compared with the control group at 24 hours, 48 hours and 72 hours after PCI. Low glomerular filtration rate was usually lower at 48 hours and then began to rise. The glomerular filtration rate in patients with BNP was higher than that of the control group, and the incidence of CIN was lower than that of the control group. In short, the preventive use of BNP could improve the renal function and then reduce the incidence of CIN.
The aim of this experiment is to give low dose furosemide on the basis of adequate hydration with BNP as the limiting condition, and to further guide the prevention of contrast nephropathy.
Methods: a total of 226 patients were selected from September 2009 to January 2014 in our hospital with coronary angiography and / or coronary stent implantation (PCI), and 226 patients were excluded from (NYHA) III, grade IV congestive heart failure or other serious diseases. There were 78 women and 148 male sex, with an average weight of 72.57 (10.41) kilograms, with an average age of 57.3. 8 (9.48) years of age, using Iopromide Injection (370) and an average of 82.65 (39.82) ml., the patients were randomly divided into experimental and control groups, including 112 cases in the experimental group and 114 cases in the control group. The serum creatinine value and BNP value were examined before coronary angiography, and the glomerular filtration rate was calculated according to the MDRD public formula: GFR (ml/min/1.73m2) =186 x (Scr) -1.154 X. (age) -0.203 (x 0.742 women); the serum creatinine clearance rate was calculated according to the Cockcroft-Gault formula: Ccr (ml/min) = [(140- age) x weight * (0.85 women)] / (72 x Scr). The patients began to hydrate the 1ml/kg/h saline at 4 hours before operation, and the experimental group was given furosemide after BNP results (postoperative BNP100pg/ml or more than the preoperative BNP value 50%). The 20mg intravenous injection of furosemide was given, and the control group was given 20mg furosemide intravenous injection without the guidance of BNP. The two groups continued to give 1ml/kg/h saline hydration to 24 hours after the operation. The amount and quantity of the patients were recorded during the period. The serum creatinine level was rechecked 48 hours after operation, and the serum creatinine clearance rate and glomerular filtration rate were calculated. Contrast agent kidney was calculated. The disease was defined as a statistical analysis of serum creatinine increased by 25% or elevated 0.5mg/dL. within 48 hours after the use of contrast media. The serum creatinine level, glomerular filtration rate, serum creatinine clearance rate and the incidence of creatinine nephropathy were compared between the two groups before and 48 hours after the operation. The rate (%) was expressed. The measurement data were expressed by mean number + standard deviation or four quantile spacing (median). The comparison of serum creatinine level, glomerular filtration rate and serum creatinine clearance rate between the two groups was analyzed by repeated measurements; the incidence of contrast agent nephropathy was checked by chi square test; the comparison of each index before and after operation in each group The rank sum test was used to analyze the results. The statistical results were statistically significant in terms of P0.05.
Results: there was no significant difference between the experimental group and the control group (P0.05) in the clinical age, weight, height, sex, PCI operation, use of contrast dose, diabetes, preoperative creatinine level, and acute myocardial infarction (P0.05). There was a difference between the experimental group and the control group (P0.05). The level of serum creatinine and glomerular filtration rate in the test group were higher than that before the operation (P0.001). The serum creatinine clearance rate in the test group was not statistically significant compared with that before the operation (P=0.76). The serum creatinine level in the control group was higher than that before the operation (P0.001), the control group glomerular filtration rate and the serum creatinine clearance rate Compared with the control group, the serum creatinine level, the glomerular filtration rate and the serum creatinine clearance rate were different between the experimental group and the control group before and after the operation. Compared with the experimental group, the level of serum creatinine level in the control group was higher than that of the control group. Degree, glomerular filtration rate, and serum creatinine clearance decreased more significantly (P0.001). The results of contrast nephropathy were 5.67% in the experimental group and 32.56% in the control group, which was statistically significant (P0.001).
Conclusion: the level of BNP on the basis of adequate hydration is of guiding significance for the prevention of contrast induced nephropathy.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692
本文编号：2147296
[Abstract]:Objective: to date, there is no unified opinion on the diagnostic criteria for contrast agent nephropathy (CIN). The internationally widely used definition is the European Urogenital Radiology Society's angiographic guide published in 2005: 3 days of renal impairment in the use of intravascular contrast agents, mainly as the level of serum creatinine increased by 44.2 Mu than the basic level. Ol/L or an increase of 25% on the basis of a more basic level, except for other causes of kidney damage. Usually 24~48 hours after the use of contrast agents, 3~5 days after the peak of serum creatinine, and the exact pathogenesis of normal.CIN can be restored within 7~10 days. The main manifestations are the renal ischemic injury caused by renal hemodynamic changes and the direct toxic effect of contrast agents on renal tubules. The current recognized methods of contrast agents are hydrated and control risk factors. In addition, the preventive effect of N- acetylcysteine, non nobepam, and theophylline on contrast agent nephropathy still exists. It's in dispute.
Furosemide, as a loop diuretic, can inhibit the activity of prostaglandin and increase the content of prostaglandin E2, thereby dilating the renal blood vessels, reducing renal vascular resistance, and increasing the renal blood flow, especially the deep renal blood flow. The glomerular filtration rate will not decrease when the flow of renal tubules is increased. Giving low dose of furosemide on the basis of adequate hydration can prevent contrast induced nephropathy.
B type natriuretic peptide (BNP), also called brain natriuretic peptide, is derived from the 134 amino acid Prepro-BNP produced by cardiac myocytes. After entering the blood circulation, it degrade to produce a bioactive BNP and a fragment of an inactive 76 amino acid fragment NT-proBNP. BNP is a short peptide hormone secreted by the heart, a polypeptide of 32 amino acids, and contains one. A circular structure consisting of 17 amino acids. When the load increases and the ventricle increases, the BNP secretes and releases into the blood. Through the antagonism of the RASS system, the dynamic balance of the body fluids and electrolytes is controlled by.BNP to inhibit the renin angiotensin aldosterone system, diastolic blood vessels, natrium, hypotension, diuresis, and inhibition. There are many physiological functions such as the sympathetic nervous system. When BNP is used to judge the critical point of heart failure, it has high sensitivity (about 95%) and specificity (86%). Therefore, BNP has important clinical reference value in the diagnosis of heart failure.
A prospective experimental study showed that after PCI, the serum creatinine level of the patients reached a peak at 48 hours and began to fall to the normal level at 7 days. In the control group, the level of serum creatinine in the group BNP was compared with the control group at 24 hours, 48 hours and 72 hours after PCI. Low glomerular filtration rate was usually lower at 48 hours and then began to rise. The glomerular filtration rate in patients with BNP was higher than that of the control group, and the incidence of CIN was lower than that of the control group. In short, the preventive use of BNP could improve the renal function and then reduce the incidence of CIN.
The aim of this experiment is to give low dose furosemide on the basis of adequate hydration with BNP as the limiting condition, and to further guide the prevention of contrast nephropathy.
Methods: a total of 226 patients were selected from September 2009 to January 2014 in our hospital with coronary angiography and / or coronary stent implantation (PCI), and 226 patients were excluded from (NYHA) III, grade IV congestive heart failure or other serious diseases. There were 78 women and 148 male sex, with an average weight of 72.57 (10.41) kilograms, with an average age of 57.3. 8 (9.48) years of age, using Iopromide Injection (370) and an average of 82.65 (39.82) ml., the patients were randomly divided into experimental and control groups, including 112 cases in the experimental group and 114 cases in the control group. The serum creatinine value and BNP value were examined before coronary angiography, and the glomerular filtration rate was calculated according to the MDRD public formula: GFR (ml/min/1.73m2) =186 x (Scr) -1.154 X. (age) -0.203 (x 0.742 women); the serum creatinine clearance rate was calculated according to the Cockcroft-Gault formula: Ccr (ml/min) = [(140- age) x weight * (0.85 women)] / (72 x Scr). The patients began to hydrate the 1ml/kg/h saline at 4 hours before operation, and the experimental group was given furosemide after BNP results (postoperative BNP100pg/ml or more than the preoperative BNP value 50%). The 20mg intravenous injection of furosemide was given, and the control group was given 20mg furosemide intravenous injection without the guidance of BNP. The two groups continued to give 1ml/kg/h saline hydration to 24 hours after the operation. The amount and quantity of the patients were recorded during the period. The serum creatinine level was rechecked 48 hours after operation, and the serum creatinine clearance rate and glomerular filtration rate were calculated. Contrast agent kidney was calculated. The disease was defined as a statistical analysis of serum creatinine increased by 25% or elevated 0.5mg/dL. within 48 hours after the use of contrast media. The serum creatinine level, glomerular filtration rate, serum creatinine clearance rate and the incidence of creatinine nephropathy were compared between the two groups before and 48 hours after the operation. The rate (%) was expressed. The measurement data were expressed by mean number + standard deviation or four quantile spacing (median). The comparison of serum creatinine level, glomerular filtration rate and serum creatinine clearance rate between the two groups was analyzed by repeated measurements; the incidence of contrast agent nephropathy was checked by chi square test; the comparison of each index before and after operation in each group The rank sum test was used to analyze the results. The statistical results were statistically significant in terms of P0.05.
Results: there was no significant difference between the experimental group and the control group (P0.05) in the clinical age, weight, height, sex, PCI operation, use of contrast dose, diabetes, preoperative creatinine level, and acute myocardial infarction (P0.05). There was a difference between the experimental group and the control group (P0.05). The level of serum creatinine and glomerular filtration rate in the test group were higher than that before the operation (P0.001). The serum creatinine clearance rate in the test group was not statistically significant compared with that before the operation (P=0.76). The serum creatinine level in the control group was higher than that before the operation (P0.001), the control group glomerular filtration rate and the serum creatinine clearance rate Compared with the control group, the serum creatinine level, the glomerular filtration rate and the serum creatinine clearance rate were different between the experimental group and the control group before and after the operation. Compared with the experimental group, the level of serum creatinine level in the control group was higher than that of the control group. Degree, glomerular filtration rate, and serum creatinine clearance decreased more significantly (P0.001). The results of contrast nephropathy were 5.67% in the experimental group and 32.56% in the control group, which was statistically significant (P0.001).
Conclusion: the level of BNP on the basis of adequate hydration is of guiding significance for the prevention of contrast induced nephropathy.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692
【引证文献】
相关期刊论文 前1条
1 张莉;李若白;张芳;;药物预防造影剂肾病的研究进展[J];中国医师进修杂志;2016年12期
本文编号：2147296
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