本文選題：腦鈉肽 + 呋塞米�。� 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：目的在充分水化的基礎(chǔ)上,探討以腦鈉肽水平指導(dǎo)呋塞米應(yīng)用對高�；颊邔Ρ葎┠I病的預(yù)防作用,比較其與單純水化、呋塞米聯(lián)合水化的作用區(qū)別。方法1研究對象:選取2015年7月-2016年6月來我院心血管內(nèi)科住院行CAG的患者共160例,其中男性78例(48.75%),女性82例(51.25%),平均年齡(62.14±8.39)歲。入選標(biāo)準(zhǔn):(1)年齡≥18歲;(2)擬行冠狀動脈造影患者;(3)慢性腎功能不全患者,基線估測腎小球?yàn)V過率(estimated glomerular filtrate rate,eGFR)15-90 ml/min/1.73m2(簡化MDRD公式);(4)簽署知情同意書。排除標(biāo)準(zhǔn):(1)術(shù)中死亡患者;(2)需透析治療的終末期腎衰患者或心臟、腎移植術(shù)后;(3)術(shù)前72小時內(nèi)或術(shù)后72小時內(nèi)有急性感染性疾病史或接觸放射性對比劑史;(4)急性失代償心衰;(5)左心室血栓;(6)對放射性對比劑過敏;(7)懷孕、哺乳期婦女;(8)惡性腫瘤或預(yù)期壽命1年;(9)嚴(yán)重瓣膜病患者或擬行外科手術(shù)患者;(10)電解質(zhì)紊亂患者;(11)心功能Ⅳ級以及明顯水腫等不適合進(jìn)行水化的患者。2研究方法:將160例行冠狀動脈造影的患者隨機(jī)分為三組,對照組52例,呋塞米組54例,呋塞米聯(lián)合腦鈉肽組54例,三組患者均于術(shù)前12小時至術(shù)后12小時予以1ml/kg/h的生理鹽水水化,術(shù)后查BNP,對照組不作處理,呋塞米組患者全部給予呋塞米20mg靜脈注射,呋塞米聯(lián)合腦鈉肽組根據(jù)BNP決定是否進(jìn)行呋塞米注射,如BNP100pg/ml或超過術(shù)前BNP值50%則靜脈注射呋塞米20mg,否則不作處理。術(shù)前記錄患者年齡、性別、身高、體重、射血分?jǐn)?shù)、肌酐、合并癥、是否服用他汀,根據(jù)Cockcroft-Gault公式計算血清肌酐清除率:Ccr(ml/min)=(140-年齡)×體重×1.23(×0.85女性)/Scr,根據(jù)簡化MDRD公式計算腎小球?yàn)V過率:eGFR(ml/min/1.73m2)=186×(Scr)-1.154×(年齡)-0.203(×0.742女性)。術(shù)后記錄是否為冠脈多支病變、是否行PCI,術(shù)后72小時查血清肌酐水平并記錄,計算并記錄eGFR和Ccr。CIN診斷標(biāo)準(zhǔn):應(yīng)用對比劑72小時內(nèi)排除其他原因引起的血肌酐較基線水平升高超過25%或44.2μmol/L(0.5 mg/dl)。3統(tǒng)計學(xué)方法:采用SPSS 21.0軟件進(jìn)行分析,分類資料采用率(%)表示,計量資料采用均數(shù)±標(biāo)準(zhǔn)差(x—±s)表示。分類變量組間比較采用χ2檢驗(yàn),多組計量資料比較采用F檢驗(yàn),兩組計量資料比較采用獨(dú)立樣本的t檢驗(yàn),術(shù)前術(shù)后肌酐、eGFR和Ccr的組內(nèi)比較采用配對樣本的t檢驗(yàn)。以P0.05為差異有統(tǒng)計學(xué)意義。結(jié)果1受試者一般臨床資料的比較:三組患者基線年齡、性別、身高、體重、射血分?jǐn)?shù)、肌酐、肌酐清除率、腎小球?yàn)V過率等方面差異無統(tǒng)計學(xué)意義(P0.05),三組患者合并高血壓、糖尿病無統(tǒng)計學(xué)差異(P0.05),三組患者造影結(jié)果示多支病變、行PCI手術(shù)方面無統(tǒng)計學(xué)差異(P0.05),呋塞米聯(lián)合腦鈉肽組服用他汀的患者較多(P0.05)。2腎功能的指標(biāo)變化:組內(nèi)比較時,對照組和呋塞米組血清肌酐水平高于術(shù)前,有統(tǒng)計學(xué)意義(P0.001),血清肌酐清除率、腎小球?yàn)V過率低于術(shù)前,有統(tǒng)計學(xué)意義(P0.001);呋塞米合并腦鈉肽組血清肌酐水平、血清肌酐清除率、腎小球?yàn)V過率與術(shù)前無統(tǒng)計學(xué)差異(P0.05)。組間比較時,三組術(shù)前血清肌酐、血清肌酐清除率、腎小球?yàn)V過率無統(tǒng)計學(xué)差異(P0.05),三組術(shù)后肌酐有統(tǒng)計學(xué)差異(P=0.033),其中對照組與呋塞米組無統(tǒng)計學(xué)差異(P=0.969),呋塞米聯(lián)合腦鈉肽組低于對照組和呋塞米組,差異有統(tǒng)計學(xué)意義(P0.05)。三組術(shù)后腎小球?yàn)V過率有統(tǒng)計學(xué)差異(P=0.001),其中對照組與呋塞米組無統(tǒng)計學(xué)差異(P=0.302),呋塞米聯(lián)合腦鈉肽組高于對照組和呋塞米組,差異有統(tǒng)計學(xué)意義(P0.05)。三組術(shù)后血清肌酐清除率無統(tǒng)計學(xué)差異(P=0.054)。3三組的CIN發(fā)生率比較:對照組應(yīng)用呋塞米0例,呋塞米組應(yīng)用呋塞米54例,呋塞米聯(lián)合腦鈉肽組應(yīng)用呋塞米29例。三組的CIN發(fā)生率有統(tǒng)計學(xué)差異(P=0.041),其中對照組與呋塞米組無統(tǒng)計學(xué)差異(P=0.871),呋塞米聯(lián)合腦鈉肽組低于對照組和呋塞米組,差異有統(tǒng)計學(xué)意義(P0.05)。結(jié)論1.靜脈應(yīng)用呋塞米聯(lián)合水化較單純水化無額外的臨床獲益。2.在充分水化的基礎(chǔ)上,以腦鈉肽水平為指導(dǎo)應(yīng)用呋塞米較直接應(yīng)用呋塞米及單純水化對高危患者腎功能的保護(hù)作用更明顯。3.以腦鈉肽水平為指導(dǎo)應(yīng)用呋塞米可降低高危患者CIN的發(fā)生率。
[Abstract]:Objective to explore the preventive effect of furosemide on high risk patients with contrast agent nephropathy with the level of brain natriuretic peptide (BNP), and to compare the difference between the effect of furosemide and the hydration of furosemide. Method 1 subjects: 160 patients in the hospital of cardiovascular medicine in our hospital in June -2016 July 2015 were selected. Male 78 (48.75%), female 82 (51.25%), average age (62.14 + 8.39) years old. (1) age > 18 years old; (2) coronary angiography patients; (3) chronic renal insufficiency patients, baseline estimation of glomerular filtration rate (estimated glomerular filtrate rate, eGFR) 15-90 ml/min/1.73m2 (Simplified MDRD formula); (4) signed informed consent. Exclusion criteria: (1) patients who died in the operation; (2) after dialysis treatment of end-stage renal failure or heart, renal transplantation; (3) history of acute infectious disease within 72 hours or 72 hours after operation; (4) acute decompensated heart failure; (5) left ventricular thrombus; (6) allergic to radiocontrast agent; (7) pregnant, lactation women Women; (8) malignant tumor or life expectancy for 1 years; (9) patients with severe valvular disease or surgical operation; (10) patients with electrolyte disorders; (11) cardiac function IV and obvious edema, and other patients who were not suitable for hydration: 160 cases of coronary arteriography were randomly divided into three groups, 52 cases in the control group, 54 in furasim group, and furosemide. 54 patients were treated with brain natriuretic peptide group. The three groups were treated with 1ml/kg/h saline hydration from 12 hours before operation to 12 hours after operation. After operation, the patients were examined BNP, the control group was not treated. All patients in the furasim group were given furosemide 20mg intravenous injection. Furosemide combined with brain natriuretic peptide group determined whether the furosemide injection was carried out according to BNP, such as BNP100pg/ml or surpass operation. The former BNP value 50% was intravenous furosemide 20mg, otherwise no treatment. Preoperative records of patients' age, sex, height, body weight, ejection fraction, creatinine, complication, statins, and serum creatinine clearance according to the Cockcroft-Gault formula: Ccr (ml/min) = (140- age) x weight * 1.23 (x 0.85 female) /Scr, according to the simplified MDRD formula to calculate the kidney Small pellet filtration rate: eGFR (ml/min/1.73m2) =186 x (Scr) -1.154 x (age) -0.203 (x 0.742 female). Is the postoperative record of multiple coronary artery disease, PCI, serum creatinine level and record at 72 hours after operation, and the calculation and record of the diagnostic criteria for eGFR and Ccr.CIN: the contrast agent should be used in 72 hours to exclude other causes of serum creatinine than baseline water A statistical method of higher than 25% or 44.2 mol/L (0.5 mg/dl): SPSS 21 software was used for the analysis. The use rate (%) of the classification data was expressed, and the measurement data were expressed by mean number + standard deviation (x - s). The comparison of the classified variables was compared with the x 2 test. The multiple groups of data were compared with F test and the two groups were compared with independent samples. T test, preoperative and postoperative creatinine, eGFR and Ccr group compared with the paired sample t test. The difference between the 1 subjects was statistically significant. Results the comparison of the general clinical data of the 1 subjects: the baseline age, sex, height, body weight, creatinine, creatinine clearance, glomerular filtration rate in the three groups were not statistically significant (P 0.05), there was no statistical difference between the three groups of patients with hypertension (P0.05), the three groups showed multiple lesions, and there was no statistical difference in the PCI operation (P0.05). The more (P0.05).2 renal function of the furosemide combined with the brain natriuretic peptide group was compared with the serum creatinine levels in the control group and the furosemide group. Higher than preoperative, statistically significant (P0.001), serum creatinine clearance, glomerular filtration rate was lower than preoperative, statistically significant (P0.001); serum creatinine level, serum creatinine clearance rate and glomerular filtration rate were no significant difference between furosemide and brain natriuretic peptide group (P0.05). Serum creatinine and serum creatinine before operation were compared between groups. There was no statistical difference in the rate of glomerular filtration (P0.05). There was statistical difference between the three groups (P=0.033). There was no statistical difference between the control group and the furosemide group (P=0.969), the furosemide combined brain natriuretic peptide group was lower than the control group and the furosemide group, the difference was statistically significant (P0.05). The glomerular filtration rate after operation was statistically significant (P=0.0 01), there was no statistical difference between the control group and the furosemide group (P=0.302), the furosemide combined brain natriuretic peptide group was higher than the control group and the furosemide group, the difference was statistically significant (P0.05). There was no statistical difference in serum creatinine clearance rate between the three groups (P=0.054), the incidence of CIN in the.3 three groups was compared: the control group was used furosemide in 0 cases, furosemide group was used furosemide 5 4 cases, furosemide combined brain natriuretic peptide group used furasim 29 cases. The incidence of CIN in the three groups was statistically different (P=0.041), there was no statistical difference between the control group and the furosemide group (P=0.871), the furosemide combined brain natriuretic peptide group was lower than the control group and the furosemide group, the difference was statistically significant (P0.05). Conclusion 1. intravenous furosemide combined with hydration is more than single. Pure hydration has no additional clinical benefit.2. on the basis of full hydration, with brain natriuretic peptide level as the guidance of furosemide and the protection of direct application of furosemide and pure hydration to the renal function of high-risk patients more obviously.3. with brain natriuretic peptide level as the guidance of the use of furosemide to reduce the incidence of CIN in high-risk patients.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R692

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