Marenzi Giancarlo, Marana Ivana, Lauri Gianfranco, Assanelli Emilio, Grazi Marco, Campodonico Jeness, Trabattoni Daniela, Fabbiocchi Franco, Montorsi Piero, Bartorelli Antonio L
Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Institute of Cardiology, University of Milan, Milan, Italy.
N Engl J Med. 2003 Oct 2;349(14):1333-40. doi: 10.1056/NEJMoa023204.
Nephropathy induced by exposure to radiocontrast agents, a possible complication of percutaneous coronary interventions, is associated with significant in-hospital and long-term morbidity and mortality. Patients with preexisting renal failure are at particularly high risk. We investigated the role of hemofiltration, as compared with isotonic-saline hydration, in preventing contrast-agent-induced nephropathy in patients with renal failure.
We studied 114 consecutive patients with chronic renal failure (serum creatinine concentration, >2 mg per deciliter [176.8 micromol per liter]) who were undergoing coronary interventions. We randomly assigned them to either hemofiltration in an intensive care unit (ICU) (58 patients, with a mean [+/-SD] serum creatinine concentration of 3.0+/-1.0 mg per deciliter [265.2+/-88.4 micromol per liter]) or isotonic-saline hydration at a rate of 1 ml per kilogram of body weight per hour given in a step-down unit (56 patients, with a mean serum creatinine concentration of 3.1+/-1.0 mg per deciliter [274.0+/-88.4 micromol per liter]). Hemofiltration (fluid replacement rate, 1000 ml per hour without weight loss) and saline hydration were initiated 4 to 8 hours before the coronary intervention and were continued for 18 to 24 hours after the procedure was completed.
An increase in the serum creatinine concentration of more than 25 percent from the base-line value after the coronary intervention occurred less frequently among the patients in the hemofiltration group than among the control patients (5 percent vs. 50 percent, P<0.001). Temporary renal-replacement therapy (hemodialysis or hemofiltration) was required in 25 percent of the control patients and in 3 percent of the patients in the hemofiltration group. The rate of in-hospital events was 9 percent in the hemofiltration group and 52 percent in the control group (P<0.001). In-hospital mortality was 2 percent in the hemofiltration group and 14 percent in the control group (P=0.02), and the cumulative one-year mortality was 10 percent and 30 percent, respectively (P=0.01).
In patients with chronic renal failure who are undergoing percutaneous coronary interventions, periprocedural hemofiltration given in an ICU setting appears to be effective in preventing the deterioration of renal function due to contrast-agent-induced nephropathy and is associated with improved in-hospital and long-term outcomes.
接触放射性造影剂所致肾病是经皮冠状动脉介入治疗的一种可能并发症，与显著的住院及长期发病率和死亡率相关。已有肾功能衰竭的患者风险尤其高。我们比较了血液滤过与等渗盐水水化在预防肾功能衰竭患者造影剂所致肾病中的作用。
我们研究了114例连续接受冠状动脉介入治疗的慢性肾功能衰竭患者（血清肌酐浓度>2mg/dl[176.8μmol/L]）。我们将他们随机分为重症监护病房（ICU）血液滤过组（58例，平均[±标准差]血清肌酐浓度为3.0±1.0mg/dl[265.2±88.4μmol/L]）或在普通病房以每小时1ml/kg体重的速率给予等渗盐水水化组（56例，平均血清肌酐浓度为3.1±1.0mg/dl[274.0±88.4μmol/L]）。血液滤过（液体置换率为每小时1000ml且无体重减轻）和盐水水化在冠状动脉介入治疗前4至8小时开始，并在手术完成后持续18至24小时。
冠状动脉介入治疗后血清肌酐浓度较基线值升高超过25%的情况在血液滤过组患者中比在对照组患者中更少见（5%对50%，P<0.001）。25%的对照组患者和3%的血液滤过组患者需要临时肾脏替代治疗（血液透析或血液滤过）。血液滤过组的住院事件发生率为9%，对照组为52%（P<0.001）。血液滤过组的住院死亡率为2%，对照组为14%（P=0.02），累积一年死亡率分别为10%和30%（P=0.01）。
在接受经皮冠状动脉介入治疗的慢性肾功能衰竭患者中，在ICU环境下进行围手术期血液滤过似乎能有效预防造影剂所致肾病导致的肾功能恶化，并与改善的住院及长期结局相关。
