Van Praet Jens T, De Vriese An S
Department of Internal Medicine, University of Gent, Gent, Belgium.
Curr Opin Nephrol Hypertens. 2007 Jul;16(4):336-47. doi: 10.1097/MNH.0b013e3281ca6fe5.
Although contrast-induced nephropathy (CIN) is common and portends a significant morbidity and mortality, only few large and well designed trials have assessed the available prophylactic measures and there are no clear evidence-based guidelines that can easily be adopted by the clinician. We critically discuss the evidence for periprocedural hydration, pharmacological agents, periprocedural withdrawal of medication, application of renal replacement therapy and the use of contrast media.
Pending confirmation of the superiority of sodium bicarbonate, NaCl 0.9% remains the fluid of choice for periprocedural hydration. A recent trial found a dose-dependent beneficial effect of acetylcysteine on CIN and mortality, adding to the controversy on the prophylactic use of this agent. Publication bias of acetylcysteine trials may have confounded the results of the meta-analyses, since negative results were more likely to be published as an abstract only. Periprocedural haemofiltration protected against CIN in a high-risk population, but the results require confirmation before the technique can be recommended.
Pending randomized controlled trials with rigorous scientific design, we propose practical mixed evidence-based and opinion-based guidelines for the prevention of CIN, using a stratification of patients into three risk groups, based on their renal function and a risk-prediction model.
尽管对比剂肾病（CIN）很常见，且预示着较高的发病率和死亡率，但仅有少数大型且设计良好的试验评估了现有的预防措施，并且没有明确的循证指南可供临床医生轻松采用。我们对围手术期补液、药物、围手术期停药、肾脏替代治疗的应用以及造影剂的使用证据进行了批判性讨论。
在碳酸氢钠的优越性得到证实之前，0.9%氯化钠溶液仍是围手术期补液的首选液体。最近一项试验发现乙酰半胱氨酸对CIN和死亡率有剂量依赖性的有益作用，这增加了该药物预防性使用的争议。乙酰半胱氨酸试验的发表偏倚可能混淆了荟萃分析的结果，因为阴性结果更有可能仅以摘要形式发表。围手术期血液滤过在高危人群中可预防CIN，但在推荐该技术之前，结果需要得到证实。
在进行严格科学设计的随机对照试验之前，我们基于患者的肾功能和风险预测模型，将患者分为三个风险组，提出了实用的基于混合证据和观点的CIN预防指南。
