对比剂诱导的肾损伤：它如何影响长期心脏死亡率？

Contrast-induced kidney injury: how does it affect long-term cardiac mortality?

机构信息

aDivision of Cardiology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino bDepartment of Oncology, Radiation Oncology cDepartment of Surgical Sciences, University of Turin dDepartment of Nephrology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin eInterventional Cardiology Unit, San. Raffaele Scientific Institute, Milan, Italy.

出版信息

J Cardiovasc Med (Hagerstown). 2017 Nov;18(11):908-915. doi: 10.2459/JCM.0000000000000543.

DOI:10.2459/JCM.0000000000000543

PMID:28678146

Abstract

AIMS

Contrast-induced acute kidney injury (CIAKI) is a common complication after coronary angiography or percutaneous revascularization (PCI). This study aimed to investigate the association of CIAKI with long-term cardiovascular adverse events.

METHODS

In total, 980 patients undergoing coronary angiography/PCI were assessed in this prospective cohort study. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) and cardiac death (CVD) during an 8-year follow-up. Glomerular filtration rate change during the follow-up was the secondary endpoint.CIAKI was defined as a serum creatinine increase at least 0.3 mg/dl in 48 h or at least 50% in 7 days.

RESULTS

CIAKI was observed in 69 patients (7%). Chronic kidney disease [relative risk (RR) = 4, P < 0.01], reduced ejection fraction (RR = 2.88, P < 0.01), CIAKI risk score at least 4 (RR = 2.64, P = 0.02), and emergency coronary angiography/PCI (RR = 3.87, P < 0.01) increased CIAKI risk, whereas statins were protective (RR = 0.32, P < 0.01).Patients with CIAKI had higher rates of 8-year cardiovascular adverse events: 54 versus 15% MACCE (RR = 6.67, P < 0.01), 38 versus 4% CVD (RR = 15.73, P < 0.01). Among other factors, CIAKI was the strongest predictor of 8-year MACCE (RR = 3.16, P < 0.01) and CVD (RR = 7.34, P < 0.01).During the follow-up, glomerular filtration rate declined drastically in CIAKI patients: 70 versus 39% had chronic kidney disease stage worsening (P < 0.01) and 8 versus 0.3% started hemodialysis (P < 0.01).

CONCLUSION

We found a strong correlation between CIAKI and poor long-term cardiac outcomes. Apparently showing up as a transient, functional impairment of kidney function, CIAKI implies an organic damage with structural modifications leading to significant kidney deterioration over time, responsible for an increased risk of long-term cardiac events. Statins significantly reduced CIAKI occurrence. A careful management of high-risk patients is needed to limit long-term complications of coronary angiography/PCI.

摘要

目的

对比剂诱导的急性肾损伤（CIAKI）是冠状动脉造影或经皮血运重建（PCI）后常见的并发症。本研究旨在探讨 CIAKI 与长期心血管不良事件的关系。

方法

在这项前瞻性队列研究中，评估了 980 例接受冠状动脉造影/PCI 的患者。主要终点是 8 年随访期间的主要不良心脑血管事件（MACCE）和心脏死亡（CVD）。随访期间肾小球滤过率变化为次要终点。CIAKI 定义为血清肌酐在 48 小时内至少增加 0.3mg/dl 或在 7 天内至少增加 50%。

结果

69 例（7%）患者发生 CIAKI。慢性肾脏病（RR=4，P<0.01）、射血分数降低（RR=2.88，P<0.01）、CIAKI 风险评分至少 4 分（RR=2.64，P=0.02）和急诊冠状动脉造影/PCI（RR=3.87，P<0.01）增加 CIAKI 风险，而他汀类药物具有保护作用（RR=0.32，P<0.01）。发生 CIAKI 的患者 8 年心血管不良事件发生率更高：54% vs 15% MACCE（RR=6.67，P<0.01），38% vs 4% CVD（RR=15.73，P<0.01）。在其他因素中，CIAKI 是 8 年 MACCE（RR=3.16，P<0.01）和 CVD（RR=7.34，P<0.01）的最强预测因素。随访期间，CIAKI 患者肾小球滤过率明显下降：70% vs 39%出现慢性肾脏病分期恶化（P<0.01），8% vs 0.3%开始血液透析（P<0.01）。

结论

我们发现 CIAKI 与不良的长期心脏结局密切相关。CIAKI 明显表现为肾功能的短暂、功能性损害，但意味着存在器质性损害，随着时间的推移会发生结构改变，导致肾功能显著恶化，增加长期心脏事件的风险。他汀类药物可显著降低 CIAKI 的发生。需要对高危患者进行仔细管理，以限制冠状动脉造影/PCI 的长期并发症。