Sinert Richard, Doty Christopher I
Department of Emergency Medicine, State University of New York-Downstate Medical Center, Brooklyn, NY 11203, USA.
Ann Emerg Med. 2007 Sep;50(3):335-45, 345.e1-2. doi: 10.1016/j.annemergmed.2007.01.023. Epub 2007 May 21.
Contrast-induced nephropathy is the third leading cause of hospital-acquired acute renal failure. Expanded use of contrast-enhanced imaging exposes an ever-widening number of patients to this renal toxin. We perform an evidence-based emergency medicine review comparing different therapies to prevent contrast-induced nephropathy. We limit our review to prophylactic therapies that are practical for an emergency department setting.
We searched MEDLINE, EMBASE, and the Cochrane Library for randomized trials comparing a wide range of medications to prevent contrast-induced nephropathy. We defined contrast-induced nephropathy by a commonly used surrogate measure of renal failure: a 25% or 0.5 mg/dL absolute increase in serum creatinine level from baseline 48 to 72 hours postcontrast. We limited our review to only trials for patients with baseline renal insufficiency, who are most at risk for contrast-induced nephropathy. We excluded prophylactic protocols requiring more than 2 hours precontrast to initiate and any trials of experimental medications or those that required invasive monitoring. We used standard criteria to appraise the quality of published trials.
We found 7 randomized trials; 3 using N-acetylcysteine, 2 using theophylline, and 1 each using bicarbonate and ascorbic acid. Although many of these trials showed statistically significant reductions in the risk for contrast-induced nephropathy, none were sufficiently powered to detect reductions in mortality rate or the need for dialytic therapy.
Evidence from randomized trials shows that these interventions (theophylline, bicarbonate, and ascorbic acid) under review were appropriate to an ED setting and decreased the risk of contrast-induced nephropathy. The case for the effectiveness (N-acetylcysteine) was less certain.
对比剂肾病是医院获得性急性肾衰竭的第三大主要原因。对比增强成像的广泛应用使越来越多的患者暴露于这种肾毒素中。我们进行了一项基于循证医学的急诊医学综述，比较不同疗法预防对比剂肾病的效果。我们将综述局限于适用于急诊科环境的预防性疗法。
我们检索了MEDLINE、EMBASE和Cochrane图书馆，查找比较多种预防对比剂肾病药物的随机试验。我们通过一种常用的肾衰竭替代指标来定义对比剂肾病：对比剂注射后48至72小时血清肌酐水平较基线绝对升高25%或0.5mg/dL。我们将综述仅局限于基线肾功能不全患者的试验，这些患者发生对比剂肾病的风险最高。我们排除了对比剂注射前启动时间超过2小时的预防性方案以及任何实验性药物试验或需要侵入性监测的试验。我们使用标准标准评估已发表试验的质量。
我们找到了7项随机试验；3项使用N-乙酰半胱氨酸，2项使用茶碱，1项分别使用碳酸氢盐和抗坏血酸。尽管这些试验中有许多显示对比剂肾病风险在统计学上有显著降低，但没有一项试验有足够的效力来检测死亡率的降低或透析治疗的需求。
随机试验的证据表明，这些正在研究的干预措施（茶碱、碳酸氢盐和抗坏血酸）适用于急诊科环境，并降低了对比剂肾病的风险。N-乙酰半胱氨酸的有效性证据不太确定。
