【摘要】：目的：至今關(guān)于造影劑腎�。–IN）的診斷標(biāo)準(zhǔn)沒(méi)有統(tǒng)一意見，對(duì)于目前國(guó)際上廣泛應(yīng)用的定義是歐洲泌尿生殖放射學(xué)會(huì)于2005年發(fā)布的造影劑指南:于血管內(nèi)應(yīng)用造影劑3天出現(xiàn)的腎臟損害，主要表現(xiàn)為血清肌酐水平較基礎(chǔ)水平升高44.2μmol/L或著是較基礎(chǔ)水平升高25%，并且除外其他原因所導(dǎo)致的腎臟損害。一般在應(yīng)用造影劑后24～48小時(shí)發(fā)生，3～5天后血肌酐升高達(dá)到高峰，7～10天內(nèi)可恢復(fù)正常。CIN確切的發(fā)病機(jī)制目前還不清楚，但根據(jù)大量研究結(jié)果歸納起來(lái)，造影劑對(duì)腎臟的作用主要表現(xiàn)為腎血流動(dòng)力學(xué)改變導(dǎo)致的腎缺血性損傷和造影劑對(duì)腎小管的直接毒性作用。目前對(duì)于造影劑的預(yù)防公認(rèn)方法有水化及控制危險(xiǎn)因素。此外應(yīng)用N-乙酰半胱氨酸、非諾多泮、茶堿類藥物對(duì)造影劑腎病的預(yù)防作用仍存在爭(zhēng)議。 呋塞米作為袢利尿劑，能抑制前列腺素分解酶的活性，使前列腺素E2含量升高，從而可以擴(kuò)張腎血管，降低腎血管阻力，使腎血流量尤其是腎皮質(zhì)深部血流量增加。呋塞米在增加腎小管液流量的同時(shí)腎小球?yàn)V過(guò)率不會(huì)下降。有實(shí)驗(yàn)證明在充分水化的基礎(chǔ)上給予小劑量呋塞米可以預(yù)防造影劑腎病。 B型利鈉肽(BNP)也叫腦尿鈉肽，，源于心肌細(xì)胞生成的134個(gè)氨基酸的Prepro-BNP，在進(jìn)入血循環(huán)后，降解產(chǎn)生一個(gè)具有生物活性的BNP和一個(gè)無(wú)活性的有76個(gè)氨基酸組成的片段NT-proBNP，BNP是由心臟分泌的短肽激素，由32個(gè)氨基酸組成的多肽，并含一個(gè)17個(gè)氨基酸組成的環(huán)狀結(jié)構(gòu)。當(dāng)負(fù)荷增加和心室增大時(shí)，BNP就隨之分泌增多并釋放入血液，通過(guò)與RASS系統(tǒng)的拮抗作用進(jìn)而來(lái)控制體液和電解質(zhì)的動(dòng)態(tài)平衡。BNP具有抑制腎素-血管緊張素-醛固酮系統(tǒng)、舒張血管、利鈉、降壓、利尿以及抑制交感神經(jīng)系統(tǒng)等多種生理功能。當(dāng)以BNP為105pg/ml作判斷心衰臨界點(diǎn)時(shí)，具有較高靈敏度(約為95％)和特異度(86％)。因此BNP對(duì)診斷心衰有重要的臨床參考價(jià)值。 一項(xiàng)前瞻性的實(shí)驗(yàn)研究表明：在PCI術(shù)后，給患者應(yīng)用BNP，患者血清肌酐水平會(huì)在48小時(shí)達(dá)到高峰然后開始下降，7天降則可降至正常水平。在對(duì)照組并不是如此。在行PCI術(shù)后的24小時(shí)、48小時(shí)和72小時(shí)，應(yīng)用BNP組的患者血清肌酐水平較對(duì)照組低。在應(yīng)用造影劑以后，腎小球?yàn)V過(guò)率通常會(huì)在48小時(shí)降至最低，然后開始升高。應(yīng)用BNP的患者腎小球?yàn)V過(guò)率較對(duì)照組高，CIN的發(fā)病率較對(duì)照組低。總之，預(yù)防性應(yīng)用BNP能夠改善腎臟功能，進(jìn)而降低CIN的發(fā)生。 本實(shí)驗(yàn)旨在用BNP作為限制條件，在充分水化基礎(chǔ)上給予小劑量呋塞米，對(duì)造影劑腎病的預(yù)防有無(wú)進(jìn)一步指導(dǎo)意義。 方法：選擇2009年9月至2014年1月于我院行冠狀動(dòng)脈造影和（或）冠狀動(dòng)脈內(nèi)支架植入術(shù)（PCI）患者，并排除(NYHA)Ⅲ、Ⅳ級(jí)的心力衰竭或其他嚴(yán)重疾病不適宜水化的患者共226例。其中女性78例，男性148例，平均體重為72.57（10.41）千克，平均年齡為57.38（9.48）歲，術(shù)中均使用碘普羅胺注射液（370），平均量82.65（39.82）ml。入選的患者隨機(jī)分為試驗(yàn)組和對(duì)照組，其中試驗(yàn)組112例，對(duì)照組114例。于冠狀動(dòng)脈造影術(shù)前查血清肌酐值及BNP值，依據(jù)MDRD公式計(jì)算腎小球?yàn)V過(guò)率：GFR(ml/min/1.73m2)=186×（Scr）-1.154×（年齡）-0.203(×0.742女性)；依據(jù)Cockcroft-Gault公式計(jì)算血清肌酐清除率：Ccr（ml/min）=[(140-年齡)×體重×(0.85女性)]/(72×Scr)。患者術(shù)前4小時(shí)開始予以1ml/kg/h的生理鹽水進(jìn)行水化，實(shí)驗(yàn)組據(jù)BNP結(jié)果術(shù)后給予呋塞米（術(shù)后BNP100pg/ml或超過(guò)術(shù)前BNP值50%，予以呋塞米20mg靜脈注射），對(duì)照組不以BNP為指導(dǎo)均給予20mg呋塞米靜脈注射。術(shù)后兩組繼續(xù)予1ml/kg/h生理鹽水水化持續(xù)至24小時(shí)。記錄期間患者的入量及出量。術(shù)后48小時(shí)復(fù)查血清肌酐水平，計(jì)算血清肌酐清除率及腎小球?yàn)V過(guò)率。造影劑腎病定義為應(yīng)用造影劑后48小時(shí)內(nèi)血清肌酐較前升高25%或升高0.5mg/dL。采用SPSS17.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。比較兩組術(shù)前及術(shù)后48小時(shí)患者血清肌酐水平、腎小球?yàn)V過(guò)率、血清肌酐清除率的變化，以及造影劑腎病發(fā)生率有無(wú)異同。分類資料采用率（%）表示；計(jì)量資料采用均數(shù)±標(biāo)準(zhǔn)差或四分位數(shù)間距（中位數(shù)）表示。兩組間血清肌酐水平、腎小球?yàn)V過(guò)率及血清肌酐清除率的比較則采取重復(fù)測(cè)量進(jìn)行分析；造影劑腎病的發(fā)生率采用卡方檢驗(yàn)；各組內(nèi)術(shù)前、術(shù)后各指標(biāo)的比較則采用了秩和檢驗(yàn)進(jìn)行分析。統(tǒng)計(jì)結(jié)果以P0.05表示有顯著統(tǒng)計(jì)學(xué)差異。 結(jié)果：臨床情況年齡、體重、身高、性別、行PCI手術(shù)患者、應(yīng)用造影劑量、糖尿病患者、術(shù)前肌酐水平、急性心�；颊咴趯�(shí)驗(yàn)組和對(duì)照組之間無(wú)明顯差異(P0.05)。多支病變患者、高血壓、他汀類藥物應(yīng)用方面在試驗(yàn)組和對(duì)照組之間存在差異（P0.05）。試驗(yàn)組血清肌酐水平、腎小球?yàn)V過(guò)率術(shù)后高于術(shù)前，有統(tǒng)計(jì)學(xué)意義（P0.001），試驗(yàn)組血清肌酐清除率術(shù)后與術(shù)前相比，無(wú)統(tǒng)計(jì)學(xué)意義(P=0.76)；對(duì)照組血清肌酐水平術(shù)后高于術(shù)前，有統(tǒng)計(jì)學(xué)意義(P0.001），對(duì)照組腎小球?yàn)V過(guò)率、血清肌酐清除率術(shù)后低于術(shù)前，有統(tǒng)計(jì)學(xué)意義（P0.001）。試驗(yàn)組與對(duì)照組相比術(shù)前血清肌酐相比無(wú)統(tǒng)計(jì)學(xué)意義（P=0.58）。試驗(yàn)組與對(duì)照組在手術(shù)前后血清肌酐水平、腎小球?yàn)V過(guò)率及血清肌酐清除率的變化程度不同，與試驗(yàn)組相比，對(duì)照組血清肌酐水平升高的程度，腎小球?yàn)V過(guò)率、血清肌酐清除率下降的程度更明顯（P0.001）。試驗(yàn)組統(tǒng)計(jì)結(jié)果顯示造影劑腎病的發(fā)生率為5.67%，對(duì)照組統(tǒng)計(jì)結(jié)果顯示造影劑腎病的發(fā)生率為32.56%，有統(tǒng)計(jì)學(xué)意義（P0.001）。 結(jié)論：在充分水化的基礎(chǔ)上以腦鈉肽水平作為限制條件對(duì)造影劑腎病的預(yù)防有指導(dǎo)意義。
[Abstract]:Objective: to date, there is no unified opinion on the diagnostic criteria for contrast agent nephropathy (CIN). The internationally widely used definition is the European Urogenital Radiology Society's angiographic guide published in 2005: 3 days of renal impairment in the use of intravascular contrast agents, mainly as the level of serum creatinine increased by 44.2 Mu than the basic level. Ol/L or an increase of 25% on the basis of a more basic level, except for other causes of kidney damage. Usually 24~48 hours after the use of contrast agents, 3~5 days after the peak of serum creatinine, and the exact pathogenesis of normal.CIN can be restored within 7~10 days. The main manifestations are the renal ischemic injury caused by renal hemodynamic changes and the direct toxic effect of contrast agents on renal tubules. The current recognized methods of contrast agents are hydrated and control risk factors. In addition, the preventive effect of N- acetylcysteine, non nobepam, and theophylline on contrast agent nephropathy still exists. It's in dispute.
Furosemide, as a loop diuretic, can inhibit the activity of prostaglandin and increase the content of prostaglandin E2, thereby dilating the renal blood vessels, reducing renal vascular resistance, and increasing the renal blood flow, especially the deep renal blood flow. The glomerular filtration rate will not decrease when the flow of renal tubules is increased. Giving low dose of furosemide on the basis of adequate hydration can prevent contrast induced nephropathy.
B type natriuretic peptide (BNP), also called brain natriuretic peptide, is derived from the 134 amino acid Prepro-BNP produced by cardiac myocytes. After entering the blood circulation, it degrade to produce a bioactive BNP and a fragment of an inactive 76 amino acid fragment NT-proBNP. BNP is a short peptide hormone secreted by the heart, a polypeptide of 32 amino acids, and contains one. A circular structure consisting of 17 amino acids. When the load increases and the ventricle increases, the BNP secretes and releases into the blood. Through the antagonism of the RASS system, the dynamic balance of the body fluids and electrolytes is controlled by.BNP to inhibit the renin angiotensin aldosterone system, diastolic blood vessels, natrium, hypotension, diuresis, and inhibition. There are many physiological functions such as the sympathetic nervous system. When BNP is used to judge the critical point of heart failure, it has high sensitivity (about 95%) and specificity (86%). Therefore, BNP has important clinical reference value in the diagnosis of heart failure.
A prospective experimental study showed that after PCI, the serum creatinine level of the patients reached a peak at 48 hours and began to fall to the normal level at 7 days. In the control group, the level of serum creatinine in the group BNP was compared with the control group at 24 hours, 48 hours and 72 hours after PCI. Low glomerular filtration rate was usually lower at 48 hours and then began to rise. The glomerular filtration rate in patients with BNP was higher than that of the control group, and the incidence of CIN was lower than that of the control group. In short, the preventive use of BNP could improve the renal function and then reduce the incidence of CIN.
The aim of this experiment is to give low dose furosemide on the basis of adequate hydration with BNP as the limiting condition, and to further guide the prevention of contrast nephropathy.
Methods: a total of 226 patients were selected from September 2009 to January 2014 in our hospital with coronary angiography and / or coronary stent implantation (PCI), and 226 patients were excluded from (NYHA) III, grade IV congestive heart failure or other serious diseases. There were 78 women and 148 male sex, with an average weight of 72.57 (10.41) kilograms, with an average age of 57.3. 8 (9.48) years of age, using Iopromide Injection (370) and an average of 82.65 (39.82) ml., the patients were randomly divided into experimental and control groups, including 112 cases in the experimental group and 114 cases in the control group. The serum creatinine value and BNP value were examined before coronary angiography, and the glomerular filtration rate was calculated according to the MDRD public formula: GFR (ml/min/1.73m2) =186 x (Scr) -1.154 X. (age) -0.203 (x 0.742 women); the serum creatinine clearance rate was calculated according to the Cockcroft-Gault formula: Ccr (ml/min) = [(140- age) x weight * (0.85 women)] / (72 x Scr). The patients began to hydrate the 1ml/kg/h saline at 4 hours before operation, and the experimental group was given furosemide after BNP results (postoperative BNP100pg/ml or more than the preoperative BNP value 50%). The 20mg intravenous injection of furosemide was given, and the control group was given 20mg furosemide intravenous injection without the guidance of BNP. The two groups continued to give 1ml/kg/h saline hydration to 24 hours after the operation. The amount and quantity of the patients were recorded during the period. The serum creatinine level was rechecked 48 hours after operation, and the serum creatinine clearance rate and glomerular filtration rate were calculated. Contrast agent kidney was calculated. The disease was defined as a statistical analysis of serum creatinine increased by 25% or elevated 0.5mg/dL. within 48 hours after the use of contrast media. The serum creatinine level, glomerular filtration rate, serum creatinine clearance rate and the incidence of creatinine nephropathy were compared between the two groups before and 48 hours after the operation. The rate (%) was expressed. The measurement data were expressed by mean number + standard deviation or four quantile spacing (median). The comparison of serum creatinine level, glomerular filtration rate and serum creatinine clearance rate between the two groups was analyzed by repeated measurements; the incidence of contrast agent nephropathy was checked by chi square test; the comparison of each index before and after operation in each group The rank sum test was used to analyze the results. The statistical results were statistically significant in terms of P0.05.
Results: there was no significant difference between the experimental group and the control group (P0.05) in the clinical age, weight, height, sex, PCI operation, use of contrast dose, diabetes, preoperative creatinine level, and acute myocardial infarction (P0.05). There was a difference between the experimental group and the control group (P0.05). The level of serum creatinine and glomerular filtration rate in the test group were higher than that before the operation (P0.001). The serum creatinine clearance rate in the test group was not statistically significant compared with that before the operation (P=0.76). The serum creatinine level in the control group was higher than that before the operation (P0.001), the control group glomerular filtration rate and the serum creatinine clearance rate Compared with the control group, the serum creatinine level, the glomerular filtration rate and the serum creatinine clearance rate were different between the experimental group and the control group before and after the operation. Compared with the experimental group, the level of serum creatinine level in the control group was higher than that of the control group. Degree, glomerular filtration rate, and serum creatinine clearance decreased more significantly (P0.001). The results of contrast nephropathy were 5.67% in the experimental group and 32.56% in the control group, which was statistically significant (P0.001).
Conclusion: the level of BNP on the basis of adequate hydration is of guiding significance for the prevention of contrast induced nephropathy.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R692

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 張莉;李若白;張芳;;藥物預(yù)防造影劑腎病的研究進(jìn)展[J];中國(guó)醫(yī)師進(jìn)修雜志;2016年12期

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