Roghi Alberto, Savonitto Stefano, Cavallini Claudio, Arraiz Gustavo, Angoli Luigi, Castriota Fausto, Bernardi Guglielmo, Sansa Mara, De Servi Stefano, Pitscheider Walter, Danzi Gian Battista, Reimers Bernhard, Klugmann Silvio, Zaninotto Martina, Ardissino Diego
De Gasperis' Department of Cardiology, Niguarda Ca' Granda Hospital, Milan, Italy.
J Cardiovasc Med (Hagerstown). 2008 Apr;9(4):375-81. doi: 10.2459/JCM.0b013e3282eee979.
Acute renal failure (ARF) following percutaneous coronary intervention (PCI) has been shown to be associated with a worse outcome. Whether this event should be considered as a marker of disease severity or an independent contributor to mortality is still unclear.
In a multicenter, prospective cohort study we investigated the predictive variables and the impact of postprocedural ARF on 2-year all-cause mortality in 2860 consecutive patients (50% with stable angina and 50% with non-ST-elevation acute coronary syndromes) undergoing PCI. Serum creatinine determinations were made immediately before and 24 h after PCI. ARF was defined as an increase in serum creatinine of > or =0.5 mg/dl over baseline.
One hundred and six patients (3.7%) experienced ARF. At logistic regression analysis, ARF was associated with pre-existing low values of estimated glomerular filtration rate, reduced left ventricular ejection fraction, hypertension, and prior coronary bypass surgery. Mortality data at 2 years were available for all patients: 119 patients (4.16%) had died, 3.9% of those without and 11.3% of those with ARF (univariate hazard ratio 3.16; 95% confidence interval 1.68-5.94; P = 0.0004). At Cox regression analysis, the significant predictors of mortality were age, ejection fraction, preprocedural estimated glomerular filtration rate, PCI failure, atrial fibrillation, diabetes mellitus, and fluoroscopy time. In this comprehensive mortality model, ARF maintained a borderline statistical significance (hazard ratio 1.83, 95% confidence interval 0.98-3.44; P = 0.06).
ARF following PCI occurs almost exclusively in patients with chronic kidney disease or left ventricular dysfunction. These risk factors are also among the most powerful predictors of long-term mortality and are likely to explain most of the association between postprocedural ARF and long-term mortality. After correction for clinical determinants, however, postprocedural ARF maintains a clinically significant impact on mortality that must be taken into account for benefit vs. risk evaluation of PCI in individual patients.
经皮冠状动脉介入治疗（PCI）后发生的急性肾衰竭（ARF）已被证明与更差的预后相关。该事件应被视为疾病严重程度的标志物还是死亡率的独立影响因素仍不清楚。
在一项多中心前瞻性队列研究中，我们调查了2860例连续接受PCI的患者（50%为稳定型心绞痛患者，50%为非ST段抬高型急性冠状动脉综合征患者）的预测变量以及术后ARF对2年全因死亡率的影响。在PCI前及PCI后24小时测定血清肌酐。ARF定义为血清肌酐较基线水平升高≥0.5mg/dl。
106例患者（3.7%）发生ARF。经逻辑回归分析，ARF与既往估计肾小球滤过率低值、左心室射血分数降低、高血压及既往冠状动脉搭桥手术相关。所有患者均有2年死亡率数据：119例患者（4.16%）死亡，无ARF患者中死亡率为3.9%，有ARF患者中死亡率为11.3%（单因素风险比3.16；95%置信区间1.68 - 5.94；P = 0.0004）。经Cox回归分析，死亡率的显著预测因素为年龄、射血分数、术前估计肾小球滤过率、PCI失败、心房颤动、糖尿病及透视时间。在这个综合死亡率模型中，ARF保持了临界统计学显著性（风险比1.83，95%置信区间0.98 - 3.44；P = 0.06）。
PCI后ARF几乎仅发生于慢性肾脏病或左心室功能不全患者。这些危险因素也是长期死亡率的最强预测因素之一，可能解释了术后ARF与长期死亡率之间的大部分关联。然而，在校正临床决定因素后，术后ARF对死亡率仍有临床显著影响，在对个体患者进行PCI的获益与风险评估时必须予以考虑。
