Cigarroa R G, Lange R A, Williams R H, Hillis L D
Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas.
Am J Med. 1989 Jun;86(6 Pt 1):649-52. doi: 10.1016/0002-9343(89)90437-3.
Contrast-induced renal dysfunction has been reported to occur in 15% to 42% of patients with underlying azotemia, but there is disagreement as to whether its incidence is reduced by limiting the amount of contrast material. To adjust the amount of contrast material to the severity of azotemia, we have utilized the following formula to calculate a contrast material "limit" in patients with renal disease: Contrast material limit = (formula; see text)
Over a 10-year period, 115 patients (53 men, 62 women, aged 61 +/- 11 [mean +/- SD] years) with renal dysfunction (baseline serum creatinine level greater than or equal to 1.8 mg/dL) underwent cardiac catheterization and angiography, after which the level of serum creatinine was measured daily for five days. The amount of contrast material that was given adhered to the limit in 86 patients (Group I) and exceeded it in 29 (Group II).
Contrast-induced renal dysfunction (an increase in serum creatinine greater than or equal to 1.0 mg/dL) occurred in two (2%) patients in Group I and in six (21%) patients in Group II (p less than 0.001). Of the 48 patients with concomitant diabetes mellitus, the contrast limit was surpassed in 16, six (38%) of whom had contrast nephropathy. Only two of the 32 (6%) diabetic patients in whom the contrast limit was not exceeded had contrast nephropathy (p less than 0.001).
Thus, contrast-induced renal dysfunction occurs infrequently if the amount of contrast material is limited in accordance with the degree of azotemia. Diabetic patients have a high incidence of contrast nephropathy, particularly when they receive an excessive amount of contrast. In patients with diabetes and renal impairment, it may be preferable to perform angiography as a staged procedure or to utilize alternative (non-contrast) techniques to obtain the desired information rather than to exceed the prescribed contrast limit.
据报道，在患有潜在氮质血症的患者中，造影剂诱发的肾功能不全发生率为15%至42%，但对于限制造影剂用量是否能降低其发生率存在分歧。为了根据氮质血症的严重程度调整造影剂用量，我们采用以下公式计算肾病患者的造影剂“限量”：造影剂限量 = （公式；见正文）
在10年期间，115例肾功能不全患者（53例男性，62例女性，年龄61±11 [平均±标准差]岁，基线血清肌酐水平大于或等于1.8 mg/dL）接受了心脏导管插入术和血管造影，术后连续五天每天测量血清肌酐水平。86例患者（第一组）的造影剂用量符合限量，29例患者（第二组）超过了限量。
第一组中有2例（2%）患者发生了造影剂诱发的肾功能不全（血清肌酐升高大于或等于1.0 mg/dL），第二组中有6例（21%）患者发生了造影剂诱发的肾功能不全（p < 0.001）。在48例合并糖尿病的患者中，16例超过了造影剂限量，其中6例（38%）发生了造影剂肾病。在未超过造影剂限量的32例（6%）糖尿病患者中，只有2例发生了造影剂肾病（p < 0.001）。
因此，如果根据氮质血症的程度限制造影剂用量，造影剂诱发的肾功能不全很少发生。糖尿病患者造影剂肾病的发生率较高，尤其是当他们接受过量造影剂时。对于糖尿病和肾功能损害患者，分期进行血管造影或采用替代（非造影）技术获取所需信息可能比超过规定的造影剂限量更为可取。
