Idée J M, Beaufils H, Bonnemain B
Laboratoire Guerbet, Centre de Recherches, Roissy-Charles de Gaulle, France.
Fundam Clin Pharmacol. 1994;8(3):193-206. doi: 10.1111/j.1472-8206.1994.tb00799.x.
Administration of iodinated contrast media (CM) for radiographic purposes is a preoccupying cause of acute renal failure. This review of the literature deals with what is known about physiopathology, clinical course, risk factors and prevention. Factors involved in the pathophysiology of CM-induced acute renal failure are vasoconstriction, direct tubular cell injury and tubular obstruction by casts. In the case of pre-existing renal hypoperfusion, CM may disturb the complex interaction between factors which modulate renal haemodynamics by increasing vasoconstrictor factors, notably endothelin peptides. The renal medulla, a zone characterized by a high metabolic activity and a low oxygen tension, may be a specific target for CM-induced effects. CM-induced nephropathy (CMN) is essentially observed in patients with one or more associated risk factors (chronic renal failure, dehydration, diabetes mellitus with impaired renal function, multiple myeloma, large CM volume, intra-arterial rather than intravenous route, etc). There is much debate as to whether newer low osmolar CM (LOCM) are better tolerated than conventional high osmolar CM (HOCM). Most of the animal studies clearly demonstrate the advantages of LOCM over HOCM. Clinical literature is far more confusing, although some recent studies and one meta-analysis demonstrate that LOCM are better tolerated in patients with impaired renal function. The low number of comparative clinical trials carried out in high risk patients, wide variability in CMN definitions, limited number of patients enrolled and inadequacy of various selected endpoints may explain difficulties experienced in demonstrating this advantage. Furthermore, while hydration is correctly maintained during clinical trials, this is not always true in clinical practice. Such a discrepancy could lead to underestimation of the potential advantage of LOCM over HOCM. Effective prevention should associate the correct hydration of patients, identification and, when possible, optimal correction of risk factors, avoidance of repeated CM injections within a short period of time and temporary disruption of treatment with other nephrotoxic drugs (non steroidal antiinflammatory drugs, aminoglycosides, etc).
为进行放射造影而使用碘化造影剂（CM）是导致急性肾衰竭的一个令人担忧的原因。本文献综述探讨了关于其病理生理学、临床病程、危险因素及预防方面的已知情况。CM 所致急性肾衰竭的病理生理学涉及的因素包括血管收缩、肾小管细胞直接损伤以及管型导致的肾小管阻塞。在存在肾脏灌注不足的情况下，CM 可能通过增加血管收缩因子，尤其是内皮素肽，扰乱调节肾脏血流动力学的各种因素之间的复杂相互作用。肾髓质是一个代谢活动高而氧张力低的区域，可能是 CM 所致效应的特定靶点。CM 所致肾病（CMN）主要见于有一个或多个相关危险因素的患者（慢性肾衰竭、脱水、肾功能受损的糖尿病、多发性骨髓瘤、CM 用量大、动脉内而非静脉内给药途径等）。关于新型低渗 CM（LOCM）是否比传统高渗 CM（HOCM）耐受性更好存在很多争议。大多数动物研究清楚地表明了 LOCM 相对于 HOCM 的优势。临床文献则更加令人困惑，尽管一些近期研究和一项荟萃分析表明 LOCM 在肾功能受损患者中耐受性更好。在高危患者中进行的比较临床试验数量较少、CMN 定义差异很大、入选患者数量有限以及各种选定终点不充分，可能解释了在证明这一优势方面所遇到的困难。此外，虽然在临床试验期间能正确维持水化，但在临床实践中情况并非总是如此。这种差异可能导致低估 LOCM 相对于 HOCM 的潜在优势。有效的预防措施应包括患者的正确水化、识别并尽可能优化纠正危险因素、避免在短时间内重复注射 CM 以及暂时中断与其他肾毒性药物（非甾体类抗炎药、氨基糖苷类等）的联合治疗。
