急诊经皮冠状动脉介入治疗术后对比剂诱导的急性肾损伤的危险因素

发布时间：2018-06-21 13:05

本文选题：对比剂诱导的急性肾损伤 + 急诊经皮冠状动脉介入治疗　；参考：《北京协和医学院》2017年硕士论文

【摘要】：第一部分:急诊经皮冠状动脉介入治疗术后对比剂诱导的急性肾损伤的危险因素分析目的:目前关于对比剂诱导的急性肾损伤(contrast-induced acute kidney injury,CI-AKI)的研究主要立足于择期行经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的患者,而行急诊PCI的患者术后出现CI-AKI的危险因素目前尚不完全明确。本研究将在中国人群中探索急诊PCI术后CI-AKI的危险因素。方法:选取2013年1月至2015年6月于中国医学科学院阜外医院行急诊PCI的患者共1061例纳入研究。将所有患者分为CI-AKI组和非CI-AKI组,进行单因素和多因素分析确定急诊PCI术后发生CI-AKI的危险因素。CI-AKI定义为接触碘对比剂后3日内,与基线水平相比,血肌酐值(serumcreatinine,SCr)增高≥25%或≥0.5 mg/dL(44.2 μ mol/L)。结果:行急诊PCI的患者CI-AKI发生率为22.7%(241/1061)0Logistic多因素分析显示体表面积(body surface area,BSA)[OR 0.213,95%CI:0.075-0.607,P=0.004],心肌梗死史[OR 1.642,95%CI:1.079-2.499,P=0.021],术前左室射血分数(left ventricular ejection fraction,LVEF)[OR 0.969,95%CI:0.944-0.994,P=0.015],术前血红蛋白(hemoglobin,Hb)[OR0.988,95%CI:0.976-1.000,P=0.045],术前估算的肾小球滤过率(estimated glomerular filtration rate,eGFR)[OR 1.027,95%CI:1.018-1.037,P0.001],于左前降支(left anterior descending,LAD)置入支架[OR 1.464,95%CI:1.000-2.145,P=0.050]和应用利尿剂[OR 1.850,95%CI,1.233-2.777,P=0.003]是行急诊PCI的患者术后发生CI-AKI的独立预测因素。结论:在行急诊PCI的患者中,伴有MI史、BSA较小、术前LVEF、Hb水平较低、术前eGFR较高、于LAD置入支架以及应用利尿剂的患者术后发生CI-AKI的风险较高。第二部分:行急诊经皮冠状动脉介入治疗的患者血浆大内皮素-1水平与对比剂诱导的急性肾损伤的相关性分析目的:随着经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)技术广泛应用于冠心病的治疗,对比剂诱导的急性肾损伤(contrast-induced acute kidney injury,CI-AKI)已成为冠脉介入治疗的严重并发症之一。研究证明血管内皮功能紊乱是CI-AKI发生的重要机制,本研究将探索行急诊PCI的冠心病患者血浆大内皮素-1水平与术后CI-AKI的相关性。方法:选取2013年1月到2015年6月于中国医学科学院阜外医院行急诊PCI的患者共1061例纳入研究。根据大内皮素-1分布将患者分为低水平、中等水平和高水平三组,分析三组患者基线资料和介入操作特征,以及三组间CI-AKI发生率和术后6月、12月复合终点事件(包括非致死性心肌梗死、再次血运重建、脑卒中和全因死亡)发生率的差异,并进行logistic分析明确CI-AKI的危险因素。CI-AKI定义为接触碘对比剂后3日内,与基线水平相比,血肌酐值(serum creatinine,SCr)增高≥ 25%或≥ 0.5 mg/dL(44.2 μ mol/L)。结果:行急诊PCI的患者术后CI-AKI发生率为22.7%(241/1061)。CI-AKI发生率和6月、12月复合终点发生率在大内皮素-1低、中、高水平的患者中有明显的统计学差异(P分别为0.001,0.001和0.026)。高水平大内皮素-1的患者CI-AKI发生率显著高于低水平(P0.001)和中等水平者(P=0.008)。校正其他变量后,大内皮素-1不论作为连续性变量还是分类变量均显著增加急诊PCI术后CI-AKI的风险。结论:高水平大内皮素-1与急诊PCI患者术后CI-AKI的发生密切相关,血管内皮功能紊乱可能是CI-AKI发生发展的重要机制。第三部分:急诊经皮冠状动脉介入治疗术后对比剂诱导的急性肾损伤新型风险评估模型目的:目前冠心病患者经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术后发生对比剂诱导的急性肾损伤(contrast-induced acute kidney injury,CI-AKI)的风险评分系统大多基于行择期手术的病例资料,并不完全适用于行急诊PCI的患者,而行急诊PCI的患者术后发生CI-AKI的危险因素及其累积效应尚未在大型队列研究中得到很好的探索。本研究的目的是在行急诊PCI的患者中建立一种新的CI-AKI风险评估模型用以评估急诊PCI患者术后CI-AKI的发生风险,并对新建立的风险模型进行初步验证,以便更好地预防急诊PCI患者术后CI-AKI的发生。方法:本研究将2013年1月至2015年6月期间于中国医学科学院阜外医院行急诊PCI的患者共1061例纳入研究。按照手术的时间将所有入选的患者分为两组人群:推导并建立新型风险评分系统的推导组人群(n=761)和对风险评分系统进行初步验证的验证组人群(n=300)。本研究中CI-AKI定义为以下三者之一:一,与基线血肌酐值(serum creatinine,SCr)相比,患者术后72小时内SCr升高≥25%;二,与基线SCr相比,患者术后72小时内SCr升高≥0.5 mg/dL(44.2 μmol/L);三,与基线SCr相比,患者术后7日内SCr升高≥0.5mg/dL(44.2μmol/L)。探索并根据最适宜急诊PCI患者的定义建立此新型风险模型。结果:根据CI-AKI的不同定义,急诊PCI术后CI-AKI的发生率分别为23.5%(定义一即术后72小时内SCr升高≥25%),4.3%(定义二即术后72小时内SCr升高≥0.5 mg/dL或44.2 μ mol/L)和7.0%(定义三即术后7日内SCr升高≥0.5 mg/dL或44.2μmol/L)。鉴于定义一的高敏感性和定义二对晚发CI-AKI具有较大漏诊率,本研究中新型风险模型的建立依据定义三。在行急诊PCI的患者中建立的CI-AKI新型风险评分系统由6个变量组成,各变量及赋值为:体表面积1.6 m2(3分),短暂性脑缺血发作(transient ischemic attack,TIA)/中风史(3 分),白细胞计数(white blood cell count,WBC)15.00X 109/L(2 分),估算的肾小球滤过率(estimated glomerular filtration rate,eGFR)60ml/min·1.73m2(3 分)或基线 SCr133μmol/L(4 分),应用主动脉内球囊反搏术(intro-aortic balloon pump,IABP)(3分)和应用利尿剂(7分)。新型风险评分模型无论在推导组人群还是验证组人群均显示出了良好预测性(推导组人群:c-统计量=0.846,95%CI:0.791-0.901;验证组人群:c-统计量=0.845,95%CI:0.788-0.902)。根据新型风险模型对急诊PCI患者进行CI-AKI风险分层:低风险组(≤5分),中等风险组(6至10分),高风险组(11至15分)和极高风险组(≥16分)。在行急诊PCI的患者中CI-AKI的发生率随着风险分级的增加呈指数形式增长(P0.001)。结论:新型风险评分模型应用简单,可准确预测急诊PCI患者术后CI-AKI的发生风险并对患者进行CI-AKI风险分层。
[Abstract]:Part one: analysis of the risk factors for acute renal injury induced by contrast agent after percutaneous coronary intervention: the present study of contrast-induced acute kidney injury (CI-AKI) on contrast induced acute renal injury (CI-AKI) is mainly based on selective percutaneous coronary intervention (percutaneous coronary interve). Ntion, PCI) patients, but the risk factors for postoperative CI-AKI in emergency PCI patients are still not completely clear. This study will explore the risk factors of CI-AKI after emergency PCI in Chinese population. Methods: 1061 cases of emergency PCI from January 2013 to June 2015 in Fuwai Hospital of the Chinese Academy of Medical Sciences were included. Patients were divided into CI-AKI group and non CI-AKI group. Single factor and multifactor analysis were used to determine the risk factor for CI-AKI after PCI operation..CI-AKI was defined as the iodine contrast agent within 3 days. The serum creatinine value (serumcreatinine, SCr) increased more than 25% or more than 0.5 mg/dL (44.2 u mol/L) compared with the baseline level. The incidence of 22.7% (241/1061) 0Logistic multivariate analysis showed that the body surface area (body surface area, BSA) [OR 0.213,95%CI:0.075-0.607, P=0.004], [OR 1.642,95%CI:1.079-2.499 in the history of myocardial infarction, P=0.021], preoperative left ventricular ejection fraction. Hemoglobin, Hb [OR0.988,95%CI:0.976-1.000, P=0.045], estimated glomerular filtration rate, eGFR [OR 1.027,95%CI:1.018-1.037, P0.001]. 2.777, P=0.003] is an independent predictor of postoperative CI-AKI in patients with emergency PCI. Conclusion: in patients undergoing emergency PCI, with the history of MI, BSA is smaller, the preoperative LVEF, Hb level is low, the preoperative eGFR is higher, the risk of CI-AKI on the stent and the use of diuretics in patients with LAD is higher. The second part: emergency percutaneous coronary movement Correlation analysis between plasma endothelin -1 level and contrast induced acute renal injury in patients with pulse interventional therapy Objective: with percutaneous coronary intervention (percutaneous coronary intervention, PCI) technique widely used in the treatment of coronary heart disease, the contrast agent induced acute renal injury (contrast-induced acute kidney injury, C) I-AKI) has become one of the serious complications of coronary intervention. The study has proved that vascular endothelial dysfunction is an important mechanism for the occurrence of CI-AKI. This study will explore the correlation between the level of plasma endothelin -1 in patients with coronary heart disease in emergency PCI and postoperative CI-AKI. Methods: from January 2013 to June 2015 in the Chinese Academy of Medical Sciences. A total of 1061 patients with PCI were enrolled in the study. According to the -1 distribution of the macroendothelin, the patients were divided into three groups of low, medium and high levels. The baseline data and intervention features of the three groups were analyzed, and the incidence of CI-AKI in the three groups and the combined endpoints of June and December after the operation (including non fatal myocardial infarction, re revascularization, The difference in the incidence of cerebral apoplexy and all cause death, and logistic analysis that the risk factor for CI-AKI was defined as.CI-AKI within 3 days after exposure to the iodine contrast agent, and the serum creatinine (serum creatinine, SCr) increased more than 25% or more than 0.5 mg/dL (44.2 mu mol/L) compared with baseline levels. Results: the incidence of CI-AKI in patients with emergency PCI was 22.7% (2). 41/1061) the incidence of.CI-AKI and the incidence of the compound end point in June and December at the low level of the great endothelin -1 (P was 0.001,0.001 and 0.026). The incidence of CI-AKI in patients with high level endothelin -1 was significantly higher than those of low level (P0.001) and middle level (P=0.008). Correction of other variables, large endothelium -1, either as a continuous variable or a classified variable, significantly increases the risk of CI-AKI after emergency PCI operation. Conclusion: high level endothelin -1 is closely related to the occurrence of postoperative CI-AKI in emergency PCI patients. Vascular endothelial dysfunction may be an important mechanism for the development of CI-AKI. The third part: emergency percutaneous coronary intervention therapy A new risk assessment model for acute renal injury induced by post contrast agents Objective: the risk scoring system for acute renal injury induced by contrast agents (contrast-induced acute kidney injury, CI-AKI) after percutaneous coronary intervention (percutaneous coronary intervention, PCI) in patients with coronary heart disease is mostly based on elective surgery. Case data are not fully applicable to patients with emergency PCI, but the risk factors and cumulative effects of postoperative CI-AKI in emergency PCI patients have not been well explored in large cohort studies. The purpose of this study is to establish a new CI-AKI risk assessment model in emergency PCI patients to assess emergency PCI suffering. The risk of postoperative CI-AKI and a new risk model were preliminarily verified in order to better prevent the occurrence of CI-AKI after operation for emergency PCI patients. Methods: 1061 cases of emergency PCI were enrolled from January 2013 to June 2015 in Fuwai Hospital of the Chinese Academy of Medical Sciences. The selected patients were divided into two groups: the derivation and establishment of a new type of risk scoring system (n=761) and a preliminary verification group (n=300). In this study, CI-AKI was defined as one of the following three: one, compared with baseline serum creatinine (serum creatinine, SCr), SCr increased within 72 hours after the operation. More than 25%, two, compared with baseline SCr, the SCr increased more than 0.5 mg/dL (44.2 mu mol/L) within 72 hours after the operation; three, compared with baseline SCr, the patients were higher than 0.5mg/dL (44.2 mu mol/L) within 7 days after operation. Explore and establish this new risk model according to the definition of the most appropriate emergency PCI patients. The incidence of SCr was 23.5% (defined as higher than 25% within 72 hours after the operation), 4.3% (definition two that SCr increased more than 0.5 mg/dL or 44.2 mol/L within 72 hours after operation) and 7% (definition three, SCr elevation above 0.5 mg/dL or 44.2 mol/L within 72 days after operation). In view of the Gao Mingan nature of the first definition and the greater leakage rate for late CI-AKI The establishment of a new risk model in the study was based on definition three. The new CI-AKI risk scoring system established in the patients undergoing emergency PCI was composed of 6 variables. The variables and assignments were: body surface area 1.6 M2 (3), transient ischemic attack (transient ischemic attack, TIA) / stroke history (3), leukocyte count (white blood cell count, WB) C) 15.00X 109/L (2), estimated glomerular filtration rate (estimated glomerular filtration rate, eGFR) 60ml/min 1.73m2 (3) or baseline mol/L (4). Intra aortic balloon counterpulsation (3) and diuretic (7). The new risk score model is in the derivation group or the test The group showed good predictability (derivation group: c- statistics =0.846,95%CI:0.791-0.901; verifying group: c- statistics =0.845,95%CI:0.788-0.902). CI-AKI risk stratification for emergency PCI patients based on the new risk model: low risk group (less than 5), medium risk group (6 to 10), high risk group (11 to 15 points) and high level. The risk group (> 16). The incidence of CI-AKI in the emergency PCI patients increased exponentially with the increase of risk classification (P0.001). Conclusion: the new risk scoring model is simple to predict the risk of CI-AKI after the operation of emergency PCI patients and to make CI-AKI risk stratification for the patients.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.4;R692.5

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