Hoorn E J, Zietse R
Erasmus Medisch Centrum, afd. Interne geneeskunde, Rotterdam.
Ned Tijdschr Geneeskd. 2018;161:D2442.
In 2007, a national guideline was issued in the Netherlands to prevent contrast-induced nephropathy. This guideline recommended preventive hydration with 0.9% NaCl in patients with reduced estimated glomerular filtration rate (eGFR 30-69 ml/min/1.73 m2) prior to administration of contrast. The recent AMACING study compared hydration versus no hydration, and found that hydration did not prevent contrast-induced nephropathy but did lead to complications and higher costs. The latest 2017 guideline recommends hydration only for patients with eGFR < 30 ml/min/1.73 m2. Although this is an improvement, an even more recent study, PRESERVE, showed no differences in the incidence of contrast-induced nephropathy between sodium chloride, sodium bicarbonate, acetylcysteine, or placebo - even in patients with lower eGFRs (15-60 ml/min/1.73 m2) undergoing elective angiography. This raises the question whether preventive measures are only effective in patients with the highest risk, i.e. hospitalized patients with multiple risk factors undergoing emergency procedures.
2007年，荷兰发布了一项预防造影剂肾病的国家指南。该指南建议，对于估算肾小球滤过率（eGFR 30 - 69 ml/min/1.73 m²）降低的患者，在使用造影剂之前采用0.9%氯化钠进行预防性水化治疗。最近的AMACING研究对比了水化治疗与不进行水化治疗的情况，发现水化治疗并不能预防造影剂肾病，但确实会导致并发症和更高的费用。最新的2017年指南建议仅对eGFR < 30 ml/min/1.73 m²的患者进行水化治疗。尽管这是一个改进，但更近的一项研究PRESERVE表明，氯化钠、碳酸氢钠、乙酰半胱氨酸或安慰剂之间在造影剂肾病的发生率上没有差异——即使是在接受选择性血管造影、eGFR较低（15 - 60 ml/min/1.73 m²）的患者中也是如此。这就引发了一个问题，即预防措施是否仅对风险最高的患者有效，也就是那些接受急诊手术、具有多种风险因素的住院患者。
