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随着放射诊断技术与介入治疗手段的发展,造影剂的使用越来越广泛。相对的,造影剂所引起的急性肾功能损伤也日益受到临床关注。造影剂肾病(contrast-induced nephropathy, CIN)是接受冠状动脉造影或经皮冠状动脉腔内成形术(percutaneous transluminal coronary angioplasty, PTCA)后常见的不良后果[1]。由于涉及多种危险因素,CIN发病率为0%~24%不等[2]。临床因血管疾病而接受造影的患者,通常合并高血压。《2018美国放射协会手册》指出需要药物治疗的高血压病史且为造影剂肾病的危险因素之一,可能需要在使用碘造影剂前进行肾功能的评估[3]。但降压药物对肾功能具体的影响以及造影术前是否需要停用这些药物还未得到严格的证实。近年来,肾素-血管紧张素-醛固酮系统抑制剂(renin-angiotensin-aldosterone system inhibitors,RAASi)包括血管紧张素转化酶抑制剂(angiotensin convening enzyme inhibitor, ACEI)和血管紧张素受体拮抗剂(angiotensin receptor blockers, ARB)对造影剂急性肾损的影响尚存在争议。一项纳入12篇文献包含4 493名患者的meta分析发现,在接受RAASi和未接受RAASi治疗的患者之间,CIN的发生率没有差异[4],反而术前接受RAASi可降低造影剂急性肾损伤的发生率和医院病死率[5],但也有部分学者认为ACEI/ARB会增加CIN的发生率[6-7]。β受体阻滞剂作为危险因素常被认为与造影剂的过敏样反应相关[3, 8],而对肾功能的影响鲜有研究。另外,在造影前使用CCB类的降压药物预防CIN的作用也存在争议[9],还需进一步考察。本研究回顾分析了常见抗高血压药物对PTCA术后患者短期肾功能的影响,探讨其对CIN的作用及安全性,以期为临床用药提供更多的循证医学证据。
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本研究一共纳入193例患者,如表1所示,4组患者在年龄、性别、BMI、血压、血脂、血糖、尿酸、造影剂用量以及基础肾功能指标等方面,差异均无统计学意义(P>0.05)。
表 1 4组患者基本资料比较[n(%),
$\bar x$ ±s]组别 年龄(岁) 男性 BMI(kg/m2) 收缩压
(mmHg)舒张压
(mmHg)TC
(mmol/L)TG
(mmol/L)HDL-C
(mmol/L)LDL-C
(mmol/L)单纯水化组(n=50) 60.58±11.35 28(56) 23.96±2.91 130.62±16.99 79.98±13.04 4.48±0.91 1.43±0.84 1.26±0.34 2.55±0.71 β-受体阻滞剂组(n=47) 64.40±11.61 32(68) 25.13±3.60 125.79±15.93 74.89±13.19 4.03±0.99 1.50±0.91 1.09±0.35 2.30±082 ACEI/ARB组(n=50) 65.04±6.52 25(50) 24.37±3.05 134.86±17.17 76.52±10.29 4.15±0.97 1.60±0.91 1.16±0.30 2.28±0.80 CCB组(n=46) 65.67±9.25 26(57) 24.45±2.81 139.43±14.57 78.91±9.28 4.23±0.87 1.34±0.61 1.20±0.30 2.38±0.74 组别 UA(μmol/L) FBG
(mmol/L)造影剂用量(ml) Scr
(μmol/L)BUN
(mmol/L)eGFR[ml/
(min·1.73 m2)]eGFR>90 [ml/
(min·1.73 m2)]eGFR<60 [ml/
(min·1.73 m2)]Ccr
(ml/min)单纯水化组(n=50) 330.48±82.36 5.35±1.06 122.32±56.11 63.62±16.01 5.25±1.17 112.04±27.17 11(22) 1(2) 97.86±29.83 β-受体阻滞剂组(n=47) 378.19±87.31 5.32±1.87 124.83±60.38 66.30±14.61 5.32±1.48 107.05±19.59 8(17) 1(2) 95.88±26.84 CEI/ARB组(n=50) 363.88±98.07 5.50±1.25 121.79±59.22 64.94±12.69 5.48±1.30 103.26±20.23 12(24) 1(2) 89.91±23.94 CCB组(n=46) 343.87±81.79 5.40±1.58 126.48±58.76 63.57±13.90 5.51±1.34 106.93±20.12 8(17) 1(2) 91.98±28.75 -
应用造影剂48 h后肾功能指标变化如表2所示。CIN发生率为0%,4组患者的Ccr在手术前后均无变化,组间也无差异。除了单纯水化组,服用抗高血压药物组BUN皆有一定幅度的下降,其中,β受体阻滞剂组术后与术前相比具有显著差异。并且,β受体阻滞剂组术后BUN水平与单纯水化组、CCB组之间也存在组间差异。另外,与术前相比,β受体阻滞剂组患者的eGFR水平在术后也显著降低。差异具有统计学意义(P<0.05)。
表 2 4组患者造影前后肾功能指标的比较
组别 Scr(μmol/L) BUN(mmol/L) eGFR[ml/(min·1.73 m2)] Ccr(ml/min) 术前 术后48 h 术前 术后48 h 术前 术后48 h 术前 术后48 h 单纯水化组(n=50) 63.62±16.01 64.04±16.66 5.25±1.17 5.34±1.33 112.04±27.17 110.27±25.58 97.86±29.83 97.42±30.39 β受体阻滞剂组(n=47) 66.30±14.61 64.53±14.00 5.32±1.48 4.71±1.01*▲ 107.05±19.59 105.61±18.35▲ 95.88±26.84 98.88±28.55 ACEI/ARB组(n=50) 64.94±12.69 64.98±13.28 5.48±1.30 5.26±1.47 103.26±20.23 103.23±20.29 89.91±23.94 90.02±24.70 CCB组(n=46) 63.57±13.90 63.28±13.27 5.51±1.34 5.42±1.30# 106.93±20.12 111.52±24.62 91.98±28.75 92.20±30.06 *P<0.05,与单纯水化组比较;#P<0.05,与β受体阻滞剂组比较;▲P<0.05,与同组术前比较。 -
将β受体阻滞剂组患者按照血压水平分级,比较不同血压水平下的肾功能情况,结果如表3所示。SBP≥140或DBP≥90的患者在使用造影剂之前,Scr与Ccr水平均显著高于SBP<140且DBP<90的患者(P<0.05)。
表 3 β受体阻滞剂组不同血压水平造影前后肾功能指标的比较
肾功能指标 SBP<140且DBP<90(n=34) SBP≥140或DBP≥90(n=13) 术前 术后48 h 术前 术后48 h Scr(μmol/L) 64.85±11.72 63.28±11.79 70.08±20.49* 67.81±18.78 BUN(mmol/L) 5.31±1.59 4.71±1.05 5.36±1.19 4.71±0.92 eGFR(ml/(min·1.73 m2) 108.58±18.10 105.40±20.44 103.06±23.38 107.77±12.16 Ccr(ml/min) 95.55±23.13 98.53±25.74 96.74±35.91* 99.75±36.06 *P<0.05,与SBP<140且DBP<90组比较。
Effects of antihypertensive drugs on renal function after percutaneous transluminal coronary angioplasty
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摘要:
目的 评估经皮冠状动脉腔内成形术后应用抗高血压药对患者肾功能损伤的影响。 方法 回顾分析2020年1月至2020年12月在南京鼓楼医院心血管内科行经皮冠状动脉腔内成形术治疗并且规律服用抗高血压药物的患者,共193例。根据用药种类不同分为4组:血管紧张素转化酶抑制剂/血管紧张素受体拮抗剂(ACEI/ARB)组、β受体阻滞剂组、钙离子通道阻滞剂(CCB)组、单纯水化组,所有患者围术期均给予常规水化。比较患者手术前后肌酐(Scr)、尿素氮(BUN)、肾小球滤过率(eGFR)、肌酐清除率(Ccr)的水平变化。 结果 4组患者造影剂术后造影剂肾病的发生率为0。与术前相比,4组患者在Scr与Ccr水平上无明显变化,除单纯水化组,其余3组在术后BUN水平降低,其中,β受体阻滞剂组显著降低,且与单纯水化组、CCB组存在统计学差异。此外,β受体阻滞剂组术后eGFR水平也显著降低,其中,血压高值的患者(SBP≥140或DBP≥90)在术前Scr 与Ccr水平即与正常血压者(SBP<140且DBP<90)存在差异。 结论 冠状动脉造影术前使用ACEI/ARB与CCB类抗高血压药对患者短期内肾功能无影响,β受体阻滞剂可能轻微降低肾功能,应对高血压人群特别关注。 -
关键词:
- 经皮冠状动脉腔内成形术 /
- 造影剂肾病 /
- 血管紧张素转化酶抑制剂 /
- 血管紧张素受体拮抗剂 /
- β受体阻滞剂 /
- 钙离子通道阻滞剂
Abstract:Objective To evaluate the effects of antihypertensive drugs on renal function after percutaneous transluminal coronary angioplasty. Methods A retrospective analysis was performed on 193 patients who underwent percutaneous transluminal coronary angioplasty and took antihypertensive drugs regularly. Those patients were admitted to Nanjing Drum Tower Hospital during January 2020 to December 2020. The patients were divided into ACEI/ARB group, β-blockers, calcium channel blockers and hydration control group. All patients received routine hydration during the perioperative period. The changes of serum creatinine (Scr), blood urea nitrogen (BUN), estimated glomerular filtration rate(eGFR) and endogenous creatinine clearance rate (Ccr) before and after operation were compared. Results The incidence of CIN was 0% in four groups. Compared with the preoperative, there was no significant change in Scr and Ccr in every group. Except for the hydration control group, the BUN levels in three treated groups were reduced after postoperative. Specifically, the BUN reduction in β-blockers group has statistically significant difference compared to the hydration control group and CCB group. In addition, eGFR levels were significantly reduced in the β-blockers group. Preoperative Scr and Ccr levels in patients with high blood pressure (SBP≥140 or DBP≥90) were significantly different from the patients with normal blood pressure (SBP<140 and DBP<90). Conclusion The use of ACEI/ARB and CCB before percutaneous transluminal coronary angioplasty had no effect on renal function in the short term. β-blockers can slightly reduce renal function, especially in patients with high blood pressure, who should receive special attention. -
表 1 4组患者基本资料比较[n(%),
$\bar x$ ±s]组别 年龄(岁) 男性 BMI(kg/m2) 收缩压
(mmHg)舒张压
(mmHg)TC
(mmol/L)TG
(mmol/L)HDL-C
(mmol/L)LDL-C
(mmol/L)单纯水化组(n=50) 60.58±11.35 28(56) 23.96±2.91 130.62±16.99 79.98±13.04 4.48±0.91 1.43±0.84 1.26±0.34 2.55±0.71 β-受体阻滞剂组(n=47) 64.40±11.61 32(68) 25.13±3.60 125.79±15.93 74.89±13.19 4.03±0.99 1.50±0.91 1.09±0.35 2.30±082 ACEI/ARB组(n=50) 65.04±6.52 25(50) 24.37±3.05 134.86±17.17 76.52±10.29 4.15±0.97 1.60±0.91 1.16±0.30 2.28±0.80 CCB组(n=46) 65.67±9.25 26(57) 24.45±2.81 139.43±14.57 78.91±9.28 4.23±0.87 1.34±0.61 1.20±0.30 2.38±0.74 组别 UA(μmol/L) FBG
(mmol/L)造影剂用量(ml) Scr
(μmol/L)BUN
(mmol/L)eGFR[ml/
(min·1.73 m2)]eGFR>90 [ml/
(min·1.73 m2)]eGFR<60 [ml/
(min·1.73 m2)]Ccr
(ml/min)单纯水化组(n=50) 330.48±82.36 5.35±1.06 122.32±56.11 63.62±16.01 5.25±1.17 112.04±27.17 11(22) 1(2) 97.86±29.83 β-受体阻滞剂组(n=47) 378.19±87.31 5.32±1.87 124.83±60.38 66.30±14.61 5.32±1.48 107.05±19.59 8(17) 1(2) 95.88±26.84 CEI/ARB组(n=50) 363.88±98.07 5.50±1.25 121.79±59.22 64.94±12.69 5.48±1.30 103.26±20.23 12(24) 1(2) 89.91±23.94 CCB组(n=46) 343.87±81.79 5.40±1.58 126.48±58.76 63.57±13.90 5.51±1.34 106.93±20.12 8(17) 1(2) 91.98±28.75 表 2 4组患者造影前后肾功能指标的比较
组别 Scr(μmol/L) BUN(mmol/L) eGFR[ml/(min·1.73 m2)] Ccr(ml/min) 术前 术后48 h 术前 术后48 h 术前 术后48 h 术前 术后48 h 单纯水化组(n=50) 63.62±16.01 64.04±16.66 5.25±1.17 5.34±1.33 112.04±27.17 110.27±25.58 97.86±29.83 97.42±30.39 β受体阻滞剂组(n=47) 66.30±14.61 64.53±14.00 5.32±1.48 4.71±1.01*▲ 107.05±19.59 105.61±18.35▲ 95.88±26.84 98.88±28.55 ACEI/ARB组(n=50) 64.94±12.69 64.98±13.28 5.48±1.30 5.26±1.47 103.26±20.23 103.23±20.29 89.91±23.94 90.02±24.70 CCB组(n=46) 63.57±13.90 63.28±13.27 5.51±1.34 5.42±1.30# 106.93±20.12 111.52±24.62 91.98±28.75 92.20±30.06 *P<0.05,与单纯水化组比较;#P<0.05,与β受体阻滞剂组比较;▲P<0.05,与同组术前比较。 表 3 β受体阻滞剂组不同血压水平造影前后肾功能指标的比较
肾功能指标 SBP<140且DBP<90(n=34) SBP≥140或DBP≥90(n=13) 术前 术后48 h 术前 术后48 h Scr(μmol/L) 64.85±11.72 63.28±11.79 70.08±20.49* 67.81±18.78 BUN(mmol/L) 5.31±1.59 4.71±1.05 5.36±1.19 4.71±0.92 eGFR(ml/(min·1.73 m2) 108.58±18.10 105.40±20.44 103.06±23.38 107.77±12.16 Ccr(ml/min) 95.55±23.13 98.53±25.74 96.74±35.91* 99.75±36.06 *P<0.05,与SBP<140且DBP<90组比较。 -
[1] MAWRI S, MICHAELS A, GIBBS J, et al. CRT-100.78 ACE inhibitors and ARBs in post-percutaneous coronary intervention contrast-induced nephropathy (CIN): to hold or not to hold? JACC: Cardiovasc Interv,2018,11(4):S22. [2] VACHHARAJANI T, HOSSAIN M, COSTANZO E, et al. Contrast-Induced nephropathy: Pathophysiology, risk factors, and prevention[J]. Saudi J Kidney Dis Transpl,2018,29(1):1. doi: 10.4103/1319-2442.225199 [3] KODZWA R. ACR manual on contrast media: 2018 updates[J]. Radiol Technol,2019,91(1):97-100. [4] JO S H, LEE J M, PARK J, et al. The impact of renin-angiotensin-aldosterone system blockade on contrast-induced nephropathy: a meta-analysis of 12 studies with 4, 493 patients[J]. Cardiology,2015,130(1):4-14. doi: 10.1159/000366473 [5] CHEN Y T, CHAN C K, LI W Y, et al. Renin-angiotensin-aldosterone system inhibition decreased contrast-associated acute kidney injury in chronic kidney disease patients[J]. J Formos Med Assoc,2021,120(1):641-650. doi: 10.1016/j.jfma.2020.07.022 [6] WOLAK T, ALIEV E, ROGACHEV B, et al. Renal safety and angiotensin II blockade medications in patients undergoing non-emergent coronary angiography: a randomized controlled study[J]. Isr Med Assoc J,2013,15(11):682-687. [7] ROSENSTOCK J L, BRUNO R, KIM J K, et al. The effect of withdrawal of ACE inhibitors or angiotensin receptor blockers prior to coronary angiography on the incidence of contrast-induced nephropathy[J]. Int Urol Nephrol,2008,40(3):749-755. doi: 10.1007/s11255-008-9368-1 [8] ROSADO INGELMO A, DOÑA DIAZ I, CABAÑAS MORENO R, et al. Clinical practice guidelines for diagnosis and management of hypersensitivity reactions to contrast media[J]. J Investig Allergol Clin Immunol,2016,26(3):144-155; quiz2pfollowing155. doi: 10.18176/jiaci.0058 [9] 李飞, 杨定平. 对比剂肾病的发病机制及防治[J]. 临床肾脏病杂志, 2013, 13(9):426-429. [10] 陈彩玲, 黄铮, 赖雯苑, 等. ACEI/ARB与CCB防治高血压病伴慢性肾功能不全患者发生造影剂肾病的效果比较[J]. 心脏杂志, 2015, 27(6):703-707. [11] OGUZHAN N, CILAN H, SIPAHIOGLU M, et al. The lack of benefit of a combination of an angiotensin receptor blocker and calcium channel blocker on contrast-induced nephropathy in patients with chronic kidney disease[J]. Ren Fail,2013,35(4):434-439. doi: 10.3109/0886022X.2013.766566 [12] 王仁秀, 姜松, 解秀芬, 等. 经皮冠状动脉介入治疗后并发造影剂肾病危险因素的Meta分析[J]. 实用心脑肺血管病杂志, 2020, 28(9):74-80. doi: 10.3969/j.issn.1008-5971.2020.09.015 [13] MOLEN A J, REIMER P, DEKKERS I A, et al. Post-contrast acute kidney injury - Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors[J]. Eur Radiol,2018,28(7):2845-2855. doi: 10.1007/s00330-017-5246-5 [14] 王琼涛, 吉六舟, 张进锋, 等. 冠心病患者经皮冠状动脉介入术后发生造影剂肾病的危险因素[J]. 中华实用诊断与治疗杂志, 2019, 33(11):1078-1081. [15] WANG M, ZHANG L, YUE R Z, et al. Significance of cystatin C for early diagnosis of contrast-induced nephropathy in patients undergoing coronary angiography[J]. Med Sci Monit,2016,22:2956-2961. doi: 10.12659/MSM.897241 [16] DAVENPORT M S, PERAZELLA M A, YEE J, et al. Use of intravenous iodinated contrast media in patients with kidney disease: consensus statements from the American college of radiology and the national kidney foundation[J]. Kidney Med,2020,2(1):85-93. doi: 10.1016/j.xkme.2020.01.001