Marenzi Giancarlo, Lauri Gianfranco, Campodonico Jeness, Marana Ivana, Assanelli Emilio, De Metrio Monica, Grazi Marco, Veglia Fabrizio, Fabbiocchi Franco, Montorsi Piero, Bartorelli Antonio L
Centro Cardiologico Monzino, I.R.C.C.S., Institute of Cardiology of the University of Milan, Milan, Italy.
Am J Med. 2006 Feb;119(2):155-62. doi: 10.1016/j.amjmed.2005.08.002.
Contrast-induced nephropathy is a complication of contrast medium administration during diagnostic and interventional procedures, with important prognostic relevance. Patients with chronic kidney disease have a higher risk for contrast-induced nephropathy and poorer outcome. In patients with chronic kidney disease, hemofiltration reduces contrast-induced nephropathy incidence and improves long-term survival. We assessed the mechanisms involved in the prophylactic effect of hemofiltration and of the most effective hemofiltration protocol to prevent contrast-induced nephropathy in patients with chronic kidney disease.
We randomized 92 patients with chronic kidney disease (creatinine clearance < or =30 mL/min) to three different prophylactic treatments: intravenous hydration with isotonic saline (1 mL x kg x h for 12 hours before and after contrast exposure, control group; n = 30); intravenous hydration for 12 hours before contrast exposure, followed by hemofiltration for 18 to 24 hours after contrast exposure (post-hemofiltration group; n = 31), and hemofiltration performed for 6 hours before and for 18 to 24 hours after contrast exposure (pre/post-hemofiltration group; n = 31). The incidence of contrast-induced nephropathy (>25% increase in creatinine) and the in-hospital clinical course were compared in the three groups.
Twelve patients (40%) in the control group, 8 patients (26%) in the post-hemofiltration group, and 1 patient (3%) in the pre/post-hemofiltration group experienced contrast-induced nephropathy (P = .0013); hemodialysis was required in 9 (30%), three (10%), and zero (0%) patients, respectively (P = .002). In-hospital mortality was 20%, 10%, and 0%, respectively (P = .03).
Hemofiltration is an effective strategy for contrast-induced nephropathy prevention in patients with chronic kidney disease who are undergoing cardiovascular procedures. Pre-hemofiltration is required to obtain the full clinical benefit, suggesting that, among different mechanisms possibly involved, high-volume controlled hydration before contrast media exposure plays a major role.
对比剂肾病是诊断和介入操作过程中使用对比剂引起的并发症，具有重要的预后意义。慢性肾脏病患者发生对比剂肾病的风险更高，预后更差。在慢性肾脏病患者中，血液滤过可降低对比剂肾病的发生率并改善长期生存率。我们评估了血液滤过预防作用的相关机制以及预防慢性肾脏病患者对比剂肾病的最有效血液滤过方案。
我们将92例慢性肾脏病患者（肌酐清除率≤30 mL/min）随机分为三种不同的预防性治疗组：用等渗盐水进行静脉水化（在对比剂暴露前后各12小时，1 mL·kg·h，对照组；n = 30）；在对比剂暴露前静脉水化12小时，然后在对比剂暴露后进行18至24小时的血液滤过（血液滤过后组；n = 31），以及在对比剂暴露前进行6小时和暴露后进行18至24小时的血液滤过（血液滤过前后组；n = 31）。比较三组对比剂肾病（肌酐升高>25%）的发生率和住院临床过程。
对照组12例患者（40%）、血液滤过后组8例患者（26%）、血液滤过前后组1例患者（3%）发生了对比剂肾病（P = 0.0013）；分别有9例（30%）、3例（10%）和0例（0%）患者需要进行血液透析（P = 0.002）。住院死亡率分别为20%、10%和0%（P = 0.03）。
对于接受心血管手术的慢性肾脏病患者，血液滤过是预防对比剂肾病的有效策略。需要进行血液滤过前治疗以获得全面的临床益处，这表明在可能涉及的不同机制中，对比剂暴露前的大容量控制性水化起主要作用。
