Madsen Troy E, Pearson Robert R, Muhlestein Joseph B, Lappé Donald L, Bair Tami L, Horne Benjamin D, Anderson Jeffrey L
Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
Crit Pathw Cardiol. 2009 Dec;8(4):167-71. doi: 10.1097/HPC.0b013e3181bda03b.
It is proposed that contrast-induced nephropathy (CN) correlates with the use of increasing contrast volumes during coronary angiography. This supposition has led to the current recommendation to limit the dose of contrast in patients at high risk for renal dysfunction. Limits in contrast dosing may negatively impact the evaluation of patients undergoing cardiac catheterization for myocardial infarction and acute coronary syndrome. The objective of this study was to empirically assess, in a large population, the presence and strength of this correlation. Baseline blood samples and clinical information were obtained from 5256 consenting patients hospitalized for coronary angiography. Levels of serum creatinine were measured pre- and postcatheterization, and the total change in serum creatinine was calculated. Nephropathy was defined as a change of > or =0.5 mg/dL. The total volume of contrast dye (iopamidol, nonionic) used during the angiography procedure was recorded. Logistic regression was used for the primary analysis.The average age was 64 +/- 14 years, and 67% of patients were male. Paradoxically, the incidence of CN was inversely related to the volume in the overall population: 16%, 14%, 8%, and 7% for quartile (Q) 1 (<115 mL), Q2 (115-160 mL), Q3 (161-225 mL), and Q4 (>225 mL) of contrast, respectively (P-trend <0.001). In multivariable regression, this trend toward lower CN remained (Q1 (referent) OR = 1.0, Q2: 1.02, Q3: 0.60, Q4: 0.53, P < 0.001). Other predictors included age, left ventricular ejection fraction, diabetes, and baseline creatinine level (all P < 0.001). For patients at high risk, with a baseline creatinine >2.0 mg/dL (n = 415), contrast volume (Q1: <75 mL, Q2: 75-120 mL, Q3: 121-170 mL, Q4: >170 mL) did not predict either increased or decreased risk of CN (48%, 42%, 49%, 43%, respectively, P-trend = 0.76). This lack of predictive value remained after multivariable adjustment.In this large population, no association was found between the amount of contrast used during angiography and the incidence of CN in patients at initial high risk. The apparent inverse relation of risk with volume in the overall population is likely explained by clinical practice bias. If confirmed, these results may have important clinical implications.
有人提出，造影剂诱导的肾病（CN）与冠状动脉造影期间造影剂用量的增加相关。这一假设导致了目前建议限制肾功能不全高危患者的造影剂剂量。造影剂剂量的限制可能会对因心肌梗死和急性冠状动脉综合征而接受心脏导管插入术的患者的评估产生负面影响。本研究的目的是在大量人群中实证评估这种相关性的存在及其强度。从5256名同意接受冠状动脉造影住院的患者中获取基线血样和临床信息。在导管插入术前和术后测量血清肌酐水平，并计算血清肌酐的总变化。肾病定义为血清肌酐变化≥0.5mg/dL。记录血管造影过程中使用的造影剂（碘帕醇，非离子型）的总体积。主要分析采用逻辑回归。平均年龄为64±14岁，67%的患者为男性。矛盾的是，在总体人群中，CN的发生率与造影剂用量呈负相关：造影剂四分位数（Q）1（<115mL）、Q2（115 - 160mL）、Q3（161 - 225mL）和Q4（>225mL）对应的发生率分别为16%、14%、8%和7%（P趋势<0.001）。在多变量回归中，这种CN发生率降低的趋势仍然存在（Q1（参照）OR = 1.0，Q2：1.02，Q3：0.60，Q4：0.53，P < 0.001）。其他预测因素包括年龄、左心室射血分数、糖尿病和基线肌酐水平（均P < 0.001）。对于基线肌酐>2.0mg/dL的高危患者（n = 415），造影剂用量（Q1：<75mL，Q2：75 - 120mL，Q3：121 - 170mL，Q4：>170mL）既不能预测CN风险增加也不能预测风险降低（分别为48%、42%、49%、43%，P趋势 = 0.76）。多变量调整后这种缺乏预测价值的情况仍然存在。在这个大量人群中，未发现血管造影期间使用的造影剂用量与初始高危患者的CN发生率之间存在关联。总体人群中风险与用量之间明显的负相关可能是由临床实践偏差所解释。如果得到证实，这些结果可能具有重要的临床意义。
