Meschi Michele, Detrenis Simona, Musini Sabrina, Strada Elena, Savazzi Giorgio
Resident in Internal Medicine, Department of Internal Medicine and Nephrology, University of Parma, Parma, Italy.
Crit Care Med. 2006 Aug;34(8):2060-8. doi: 10.1097/01.CCM.0000227651.73500.BA.
The aim of this article is to extract from recent medical literature and nephrologic practice the facts and fallacies concerning the possible prophylaxis of contrast medium-induced nephropathy.
DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: A MEDLINE/PubMed search (1985 to January 2006) was conducted, including all relevant articles investigating the pathogenesis and prevention of contrast medium-induced nephropathy from a nephrologic critical point of view.
Considerable efforts have been made to develop pharmacologic therapy for the prevention of contrast medium-induced nephropathy, especially in patients at risk, such as elderly subjects and those with preexisting renal impairment, hypovolemia, or dehydration. There is general consensus that hydration protocols implemented before and after imaging with contrast medium may be effective in preventing contrast medium-induced nephropathy. However, definitive and convincing data related to amounts to be infused, infusion timing, and type of solutions (half-isotonic, isotonic saline solution, or bicarbonate) are lacking. Forced diuresis with furosemide or mannitol and use of dopamine, together with concomitant hydration, have been proved to be ineffective or even more risky in the event of inadequate maintenance of euvolemia. Various direct or indirect vasodilators have been investigated (atrial natriuretic peptide, calcium channel blockers, angiotensin-converting enzyme inhibitors, and endothelin receptor antagonists), yet results have been inconsistent and inconclusive. Recent large meta-analyses concerning the protective role of antioxidant action of N-acetylcysteine have led to the conclusion that the statistical significance of the results is borderline. Preventive hemodialysis has not proved to be useful; on the contrary, it might worsen the clinical conditions by inducing hypotension. Hemofiltration, despite some positive studies, is too complex and cannot be used extensively.
: It is believed that prevention is actually achieved by correcting hypovolemia, dehydration, or both. Normalization of body fluids is probably the true objective to be achieved by preventive measures in all patients, not only in those at risk. Because limited data have been collected in intensive care units, at present, no firm or specific recommendations can yet be provided for the critically ill.
本文旨在从近期医学文献和肾脏病临床实践中提炼出有关预防造影剂肾病的事实与谬误。
资料来源、研究选择与资料提取：进行了一次MEDLINE/PubMed检索（1985年至2006年1月），纳入了所有从肾脏病学关键视角研究造影剂肾病发病机制及预防的相关文章。
为研发预防造影剂肾病的药物治疗方法已付出诸多努力，尤其是针对高危患者，如老年人以及那些已有肾功能损害、血容量不足或脱水的患者。人们普遍认为，在使用造影剂进行影像学检查前后实施水化方案可能对预防造影剂肾病有效。然而，关于补液量、输注时间以及溶液类型（半张、等渗盐水溶液或碳酸氢盐溶液）的确切且有说服力的数据尚缺乏。使用呋塞米或甘露醇进行强制利尿以及使用多巴胺，再加上同时进行水化，已被证明在血容量维持不当的情况下无效甚至风险更大。已对多种直接或间接血管扩张剂进行了研究（心房利钠肽、钙通道阻滞剂、血管紧张素转换酶抑制剂和内皮素受体拮抗剂），但结果并不一致且尚无定论。近期有关N-乙酰半胱氨酸抗氧化作用保护效果的大型荟萃分析得出结论，结果的统计学意义处于临界状态。预防性血液透析尚未证明有用；相反，它可能因诱发低血压而使临床状况恶化。血液滤过尽管有一些阳性研究结果，但过于复杂且无法广泛应用。
人们认为，预防实际上是通过纠正血容量不足、脱水或两者兼而有之来实现的。体液正常化可能是所有患者（不仅是高危患者）预防措施要实现的真正目标。由于在重症监护病房收集的数据有限，目前尚无法为危重症患者提供确切或具体的建议。
