N-乙酰半胱氨酸对行直接经皮冠状动脉介入治疗的 ST 段抬高型心肌梗死患者预防对比剂相关急性肾损伤的效果：一项随机对照试验的系统评价和荟萃分析。

Effect of N-acetylcysteine on prevention of contrast-associated acute kidney injury in patients with STEMI undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis of randomised controlled trials.

机构信息

Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.

Cardiology, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.

出版信息

BMJ Open. 2020 Oct 16;10(10):e039009. doi: 10.1136/bmjopen-2020-039009.

OBJECTIVE

Several studies evaluating the preventive effect of N-acetylcysteine (NAC) on contrast-associated acute kidney injury (CA-AKI) among patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) have suggested inconsistent results and that a systematic review and meta-analysis should be performed.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov and the Cochrane Central databases were searched from inception to 15 November 2019.

ELIGIBILITY CRITERIA

Randomised controlled trials assessing use of NAC compared with non-use of NAC (eg, placebo) in preventing CA-AKI in patients with STEMI following PPCI were included.

DATA SYNTHESIS

Relative risks with 95% CIs were pooled using a random-effects model. Evidence level of conclusions was assessed by Cochrane GRADE measure.

RESULTS

Seven trials including 1710 patients were identified. Compared with non-use of NAC, use of NAC significantly reduced the incidence of CA-AKI by 49% (risk ratio (RR) 0.51, 95% CI 0.31 to 0.82, p<0.01) and all-cause in-hospital mortality by 63% (RR 0.37, 95% CI 0.17 to 0.79, p=0.01). The estimated effects on the requirement for dialysis (RR 0.61, 95% CI 0.11 to 3.38, p=0.24) were not statistically significant. Trial sequential analysis conﬁrmed the true positive of NAC in reducing risk of CA-AKI. Subgroup analyses suggested that the administration of NAC had greater benefits in patients with renal dysfunction and in those receiving oral administration and higher dosage of NAC.

CONCLUSIONS

NAC intake reduces the risk of CA-AKI and all-cause in-hospital mortality in patients with STEMI undergoing PPCI. The estimated potential benefit of NAC in preventing dialysis was ambiguous, and further high-quality studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42020155265.

目的

几项评估 N-乙酰半胱氨酸（NAC）对接受直接经皮冠状动脉介入治疗（PPCI）的 ST 段抬高型心肌梗死（STEMI）患者对比剂相关急性肾损伤（CA-AKI）预防作用的研究结果并不一致，因此需要进行系统评价和荟萃分析。

设计

系统评价和荟萃分析。

数据来源

从建库到 2019 年 11 月 15 日，检索了 PubMed、MEDLINE、EMBASE、ClinicalTrials.gov 和 Cochrane 中心数据库。

入选标准

纳入比较 NAC 与不使用 NAC（如安慰剂）预防 PPCI 后 STEMI 患者 CA-AKI 的随机对照试验。

数据综合

使用随机效应模型汇总了相对风险比及其 95%可信区间。结论的证据水平采用 Cochrane GRADE 量表进行评估。

结果

共纳入 7 项试验，包括 1710 例患者。与不使用 NAC 相比，使用 NAC 可使 CA-AKI 的发生率显著降低 49%（风险比（RR）0.51，95%CI 0.31 至 0.82，p<0.01），全因住院死亡率降低 63%（RR 0.37，95%CI 0.17 至 0.79，p=0.01）。但对透析需求的影响（RR 0.61，95%CI 0.11 至 3.38，p=0.24）不具有统计学意义。试验序贯分析证实了 NAC 降低 CA-AKI 风险的真实性。亚组分析表明，NAC 给药在肾功能不全患者以及接受口服和更高剂量 NAC 治疗的患者中获益更大。

结论

NAC 可降低接受 PPCI 的 STEMI 患者 CA-AKI 和全因住院死亡率的风险。估计 NAC 在预防透析方面的潜在获益不明确，需要进一步开展高质量研究。

PROSPERO 注册号：CRD42020155265。