对比剂对不同心功能患者肾功能的影响

发布时间：2019-06-06 00:30

【摘要】：目的:随着心血管介入诊疗技术的进步，对比剂在临床中的应用越来越多，对比剂肾病(contrast induced nephropathy，CIN)已成为介入诊疗术后的常见并发症，继手术和感染之后医院获得性肾功能衰竭的第三大病因，发生率约为11%[1]。同时CIN也成为介入领域继“再狭窄”、“血栓”后的第三大难题。心血管介入诊疗术后发生CIN往往后果严重，不但增加患者的住院时间和住院费用，亦增加住院期间的病死率和不良事件的发生率。目前，CIN发病机制仍不清楚，尚无肯定有效的治疗方法。充血性心力衰竭是对比剂肾病发生的独立风险因素，心排血量降低导致肾血流量下降时，肾小球滤过率下降。肾小球滤过率越低，能够引起对比剂肾病所需的对比剂剂量越小。多项研究显示，心功能Ⅱ级和Ⅲ级充血性心力衰竭患者，虽无心排血量降低，却与肾功能的受损呈等级关系[2]。研究对比剂对不同心功能状态患者肾功能的影响，为行冠脉介入诊疗的高危患者，术前危险因素的分层评估提供更多的循证医学依据。方法:连续收录2010年11月-2011年10月期间，确诊为冠心病，在河南科技大学第一附属医院择期行冠状动脉介入术的354例患者为研究对象，详细记录患者的基本资料。其中男性271例(76.6%)，女性83例(23.4%)，平均年龄62.18±9.35岁。冠脉造影按Judkins法进行选择性冠脉造影，造影剂选用低渗非离子型造影剂碘普罗胺（优维显370）。所有肾功能异常的患者常规术前6-12小时水化补液治疗，始以1ml/kg h速度静脉滴注0.9％的氯化钠注射液，并维持至术后6-12小时，伴有心功能分级NYHAIII级以上患者剂量减半。据纽约心脏病协会(NYHA)心功能分级，将患者分为三组：心功能I-II级为A组，心功能III级为B组，心功能IV级为C组；三组按血肌酐水平分别分为1，2组：1组≤120μmol/L；2组120μmol/L。观察对比剂碘普罗胺注射液对心功能不同的三组患者肾功能的影响。排除对象：对比剂过敏者，急性心肌梗死，严重的肝功能不全，维持血液透析或腹膜透析，出血倾向，室壁瘤及主动脉夹层，恶性肿瘤，依从性差者等。主要观察指标：1.一般情况及基础疾病；2.NYHA心功能分级；3.入院查血肌酐(Scr)，尿素氮(UN)，尿酸(UA)，心房利钠肽(BNP)，根据血肌酐水平计算肾小球滤过率(GFR)和肌酐清除率(Ccr)，心脏彩超；4.术后48-72小时内复查Scr，UN，UA，GFR，Ccr。采用统计学分析软件SPSS17.0对行冠脉介入手术前后患者肾功能指标的分析，研究对比剂对不同心功能状态患者肾功能的影响，为行冠脉介入诊疗的高危患者，术前危险因素的分层评估提供更多的循证医学依据。结果: 1.血肌酐水平正常的不同心功能状态患者，(1)组间比较：术前肾功能指标Scr、UN、UA、GFR及Ccr无统计学差异，P0.05。术后肾功能指标Scr、UN及UA随心功能的下降，逐渐升高；GFR及Ccr随心功能的下降，逐渐减低；差异均有统计学差异，P0.01。(2)组内比较：A1组Scr较术前略有降低，GFR及Ccr较术前略有升高，但差异无统计学意义，P0.05。B1和C1组Scr较术前升高，GFR及Ccr较术前下降，差异有统计学意义，P0.01。 2.血肌酐水平异常的不同心功能状态患者，(1)组间比较：术前肾功能指标Scr、UN、UA、GFR及Ccr无统计学差异，P0.05。术后肾功能指标Scr及UA随心功能的下降，逐渐升高；GFR及Ccr随心功能的下降，逐渐减低；差异均有统计学差异，P0.05。(2)组内比较： A2组Scr较术前略有升高，GFR及Ccr较术前略有降低，，但差异无统计学意义，P0.05。B2和C2组血Cr较术前升高，GFR及Ccr较术前下降，差异有统计学意义，P0.01。 3.共收录354例冠心病患者，经皮冠脉介入术后，CIN的发生率：A1组5例(5.05％)，B1组12例(10.43％)，C1组36例(33.64%)；A2组1例(16.66%)，B2组3例(25%)，C2组7例(46.66%)。随着心功能分级的升高，即心功能的下降，EF值逐渐降低，CIN的发生率逐渐升高，差别具有统计学意义，P0.01。C2组CIN的发生率最高。 4.(1)心功能不同状态的三组患者，随着心功能下降，BNP、术后Scr的升高值及CIN的发生率逐渐升高，P0.05。(2)血肌酐水平异常组BNP、术后Scr的升高值及CIN的发生率较血肌酐水平正常组都高，P0.05。结论: 1.同一血肌酐水平的不同心功能状态患者，随心功能分级的增高，冠脉介入术后肾功能下降越大，CIN的发生率愈高； 2.同一心功能状态的不同血肌酐水平患者，血肌酐水平异常的患者，冠脉介入术后肾功能下降较大，CIN的发生率较高； 3.血肌酐水平异常且心功能NYHAIV级的C2组，冠脉介入术后肾功能下降最显著；CIN的发生率最高。
[Abstract]:Objective: With the progress of the technology of cardiovascular interventional diagnosis and treatment, the clinical application of the contrast agent is more and more, and the contrast agent nephropathy (CIN) has become a common complication after the interventional diagnosis and treatment, and the third major cause of the acquired renal failure after operation and infection, The incidence was about 11%[1]. At the same time, CIN is the third big problem after the "restenosis" and the "Thrombus" in the intervention field. In addition, the incidence of death and adverse events in the hospital is also increased, and the incidence of death and adverse events in the hospital is also increased. At present, the pathogenesis of CIN is still unclear, and there is no positive effective treatment method. Congestive heart failure is the independent risk factor of the contrast agent nephropathy, and the decrease of the glomerular filtration rate is caused by the decrease in the blood volume of the heart and the decrease of the renal blood flow. The lower the glomerular filtration rate, the smaller the dose of the contrast agent required to cause the contrast nephropathy. A number of studies have shown that patients with cardiac function II and grade III congestive heart failure have a hierarchical relationship with the impairment of renal function[2]. The effect of contrast agent on the renal function of patients with different heart function was studied. Methods: During the period from November 2010 to October 2011, the patients with coronary heart disease were diagnosed as coronary heart disease,354 patients undergoing coronary intervention in the first affiliated hospital of Henan University of Science and Technology were the subject of the study, and the basic resources of the patients were recorded in detail. Of these,271 (76.6%) males and 83 (23.4%) females, with an average age of 62.18 and 9.35 Age: Coronary angiography is performed by the Judkins method for selective coronary angiography, and the contrast medium is selected with low-permeability non-ionic contrast agent, iopromide (Youwei)370 ). All patients with abnormal renal function were treated with hydration fluid for 6-12 hours before operation, and 0.9% sodium chloride injection was intravenously administered at a rate of 1 ml/ kg h and maintained to 6-12 hours after operation, with the dose of patients with cardiac function grade NYHAIII or above decreased. Half. According to the NYHA functional classification of the New York Heart Association (NYHA), the patients were divided into three groups: the heart function I-II was group A, the heart function class III was group B, and the heart function IV was group C; the three groups were divided into 1 and 2 groups according to the level of the blood myocardiac function:1 group and 120. mu. mol/ L; group 2,120. m L. The effect of the contrast agent on the renal function of three groups of patients with different heart function was observed. in response to exclusion: contrast agent, acute myocardial infarction, severe hepatic insufficiency, maintenance of hemodialysis or peritoneal dialysis, bleeding tendency, ventricular aneurysm and aortic dissection, malignancy, poor compliance and the like. The main observation indexes are as follows: 1. General conditions and basic diseases;2. NYHA functional classification; 3. The rate of glomerular filtration (GFR) and the clearance rate (Ccr) of the glomerular filtration rate (Ccr) and the color of the heart of the heart were calculated according to the level of the blood myocardiac muscle, the blood myocaryoid (Scr), the urea nitrogen (UN), the uric acid (UA), the atrial natriuretic peptide (BNP) were calculated. 4. The renal function of the patients with different heart function was analyzed by using the statistical analysis software SPSS17.0. The effect of the contrast agent on the renal function of patients with different heart function was studied. The stratified evaluation of pre-operative risk factors provides more evidence-based medicine. It was reported. Results:1. There was no statistical difference between the pre-operative renal function index, Scr, UN, UA, GFR and Ccr. The results showed that there was a significant difference in GFR and Ccr with the decrease of heart function and the decrease of GFR and Ccr with the function of heart function. There was no significant difference in GFR and Ccr, but there was no significant difference in GFR and Ccr, and the difference was of statistical significance. P0.001.2. There was no statistical difference between the pre-operative renal function index, Scr, UN, UA, GFR and Ccr. The results showed that there was a significant difference in GFR and Ccr with the decrease of heart function, and there was a difference in GFR and Ccr with the decrease of heart function. There was no significant difference in GFR and Ccr, but there was no significant difference in GFR and Ccr, and there was a significant difference in GFR and Ccr before operation. The incidence of CIN after percutaneous coronary intervention was 5 (5.05%) in the A1 group,12 in the B1 group (10.43%),36 in the C1 group (33.64%),1 (16.66%) in the A2 group,3 (25%) in the B2 group, and 7 in the C2 group. (46.66%). With the increase of cardiac function, the decrease of cardiac function and the decrease of EF, the incidence of CIN increased, and the difference was of statistical significance. The CI The incidence of N is the highest.4. (1) Three groups of patients with different cardiac function, with the decrease of heart function, BNP, the increase of Scr and the occurrence of CIN. The results showed that the rate of BNP, the increase of Scr and the incidence of CIN were higher than that of the blood. normal group Conclusion:1. The patients with different heart function in the same level of blood myocardiac function, with the increase of the function of heart function, the renal function after coronary intervention. the greater the decrease, the higher the incidence of CIN;2. the different blood in the same cardiac function Patients with the abnormal level of myocardiac muscle and the level of blood myocaryosis, and after coronary intervention The decrease of renal function was high, and the incidence of CIN was high;3. The level of the blood myocardiac muscle was abnormal and the group C2 of the NYHAIV grade of the heart function and the coronary intervention.
【学位授予单位】：河南科技大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R816.2;R541.4

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