Frank H, Werner D, Lorusso V, Klinghammer L, Daniel W G, Kunzendorf U, Ludwig J
Department of Nephrology, Friedrich Alexander University Erlangen-Nürnberg, Germany.
Clin Nephrol. 2003 Sep;60(3):176-82. doi: 10.5414/cnp60176.
Radiocontrast medium- (RM) associated nephrotoxicity continues to be a common cause of acute renal failure and may lead in patients with pre-existing chronic renal insufficiency even to end-stage renal failure requiring chronic dialysis. Since extracorporeal removal of RM after RM administration has been shown to be effective but does not prevent radiocontrast-induced nephropathy, the effect of a simultaneous dialysis during RM administration on renal function is not clear.
In a prospective, randomized and controlled trial, we studied the effect of a 4-hour online dialysis during RM (iomeprol) application in patients with advanced chronic renal failure (serum creatinine > or = 3 mg/dl) undergoing coronary angiography. All patients received hydration with saline before and after standardized coronary angiography and were randomized to receive a simultaneous high-flux hemodialysis (7 patients, HD group) or to control group (10 patients). 24-hour creatinine clearance (CrCl) was measured in all patients before, 1 week and 8 weeks after coronary angiography. The clinical follow-up comprised 8 weeks after RM application. RM plasma levels were measured in both groups 15, 30, 60 minutes, 2, 4, 12, 24, 48 and 72 hours after application by high-pressure liquid chromatography.
At baseline, CrCl (19 +/- 10 vs 17 +/- 7 ml/min), percentage of diabetics (57 vs 70%) and dose of RM (77 +/- 27 vs 86 +/- 21 ml) were similar in both groups. Pharmacokinetics: Total clearance of iomeprol was significantly higher (54 +/- 15 vs 20 +/- 12 ml/min, p < 0.001) and the area under curve (AUC) was significantly lower (23 +/- 10 g x h/l vs 94 +/- 57 g x h/l, p < 0.001) in the HD group compared to control group. RM peak plasma levels 15 min after application were not different in both groups (3.0 +/- 1.1 vs 4.2 +/- 1.7 mmol/l, NS), however, significantly lower 60 min (1.6 +/- 0.4 vs 3.7 +/- 1.5 mmol/l, p < 0.01) and 240 min (0.7 +/- 0.3 vs 2.3 +/- 0.7 p < 0.001) after angiography.
CrCl showed no difference 1 week (24 +/- 11 vs 19 +/- 9 ml/min, ns) and 8 weeks (24 +/- 5 vs 20 +/- 9 ml/min, NS) after angiography from baseline or between the groups. In each group, 2 patients developed end-stage renal disease and requested permanent dialysis during the 8-week follow-up.
Simultaneous dialysis reduces AUC of iomeprol significantly, however, does not influence plasma peak concentration after angiography. Renal function and incidence of end-stage renal failure were not influenced by online-dialysis.
放射性造影剂相关性肾毒性仍然是急性肾衰竭的常见病因，对于已有慢性肾功能不全的患者，甚至可能导致终末期肾衰竭而需要长期透析治疗。虽然在给予放射性造影剂后进行体外清除已证明是有效的，但并不能预防放射性造影剂所致的肾病，因此在给予放射性造影剂期间同时进行透析对肾功能的影响尚不清楚。
在一项前瞻性、随机对照试验中，我们研究了在晚期慢性肾衰竭（血清肌酐≥3mg/dl）且接受冠状动脉造影的患者应用放射性造影剂（碘美普尔）期间进行4小时联机透析的效果。所有患者在标准化冠状动脉造影前后均接受生理盐水水化治疗，并随机分为同时接受高通量血液透析组（7例患者，HD组）和对照组（10例患者）。在冠状动脉造影前、造影后1周和8周测量所有患者的24小时肌酐清除率（CrCl）。临床随访期为应用放射性造影剂后8周。应用高压液相色谱法在应用放射性造影剂后15、30、60分钟，2、4、12、24、48和72小时测量两组患者的放射性造影剂血浆水平。
基线时，两组患者的CrCl（19±10对17±7ml/min）、糖尿病患者比例（57%对70%）和放射性造影剂剂量（77±27对86±21ml）相似。药代动力学：与对照组相比，HD组碘美普尔的总清除率显著更高（54±15对20±12ml/min，p<0.001），曲线下面积（AUC）显著更低（23±10μg·h/l对94±57μg·h/l，p<0.001）。应用放射性造影剂后15分钟时两组的放射性造影剂血浆峰值水平无差异（3.0±1.1对4.2±1.7mmol/l，无统计学意义），然而，在造影后60分钟（1.6±0.4对3.7±1.5mmol/l，p<0.01）和240分钟（0.7±0.3对2.3±0.7，p<0.001）时显著更低。
造影后1周（24±11对19±9ml/min，无统计学意义）和8周（24±5对20±9ml/min，无统计学意义）时，CrCl与基线相比或两组之间均无差异。在每组中，有2例患者在8周随访期间发展为终末期肾病并要求长期透析。
同时进行透析可显著降低碘美普尔的AUC，然而，不影响造影后的血浆峰值浓度。联机透析不影响肾功能和终末期肾衰竭的发生率。
