van den Berk Guido, Tonino Sanne, de Fijter Carola, Smit Watske, Schultz Marcus J
Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
Crit Care. 2005 Aug;9(4):361-70. doi: 10.1186/cc3028. Epub 2005 Jan 7.
An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) iso-osmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. Administration of N-acetylcysteine, theophylline, or fenoldopam, sodium bicarbonate infusion, and periprocedural haemofiltration/haemodialysis have been investigated as preventive measures in recent years. This review addresses the literature on these newer strategies. Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
越来越多的诊断成像程序需要使用静脉注射造影剂，这导致造影剂肾病的发病率相应增加。造影剂肾病发生的危险因素包括既往存在的肾功能不全（尤其是糖尿病肾病和多发性骨髓瘤相关性肾病）、脱水、充血性心力衰竭以及同时使用肾毒性药物（包括氨基糖苷类和两性霉素B）。由于造影剂肾病导致医院获得性肾衰竭显著增加，目前提倡几种预防造影剂肾病的策略，包括使用替代成像技术（不需要造影剂）、使用（尽可能低剂量的）等渗或低渗造影剂（而非高渗造影剂）、水化和强制利尿。近年来，已对N - 乙酰半胱氨酸、茶碱或非诺多泮的给药、碳酸氢钠输注以及围手术期血液滤过/血液透析作为预防措施进行了研究。本综述探讨了关于这些新策略的文献。由于仅对重症监护病房患者进行了一项（非随机）研究，目前很难就重症患者造影剂肾病的预防措施得出确凿结论。需要进一步研究以确定这些预防措施在这组有造影剂肾病风险的患者中的真正作用。基于现有证据，我们建议除用碳酸氢盐溶液进行水化外，优先口服N - 乙酰半胱氨酸或静脉注射茶碱。
