不同剂量阿托伐他汀对慢性肾病患者行冠状动脉介入治疗后对比剂肾病的影响

摘要

目的 观察不同剂量的阿托伐他汀治疗对慢性肾病患者行冠状动脉介入术(PCI)后对比剂肾病的影响.方法 将192例拟行PCI术慢性肾病(CKD,eGFR ＜60 ml·min-1 ·1.73 m-2)患者,采用随机数表法分为强化阿托伐他汀治疗组(96例,其中11例患者因未行PCI术退出研究)和常规剂量阿托伐他汀治疗组(96例),在全部采用水化治疗基础上,强化治疗组患者在住院期间给予阿托伐他40 mg/d,对照组给予常规剂量阿托伐他汀20 mg/d,观察PCI术前基础血清肌酐(Scr)等指标,术后48～ 72 h Scr.使用简化MDRD方程估计肾小球滤过率(eGFR),eGFR ＜30 ml·min-1 ·1.73 m-2定义为重度CKD.PCI术后48～72 h血清肌酐(Scr)的绝对值升高44.2 μmol/L定义为对比剂肾病.观察两组对比剂肾病及其他临床不良事件.结果 最终入选的181例患者中有26例(14%)患者发生了对比剂肾病,强化治疗组对比剂肾病发生率低于常规治疗组(12%比17%,x2=0.348,P=0.348),但两组间差异无统计学意义.两组患者需要肾脏替代治疗(RRT,0比5%,P=0.061)、死亡率(6%比6%,x2=0.011,P=0.918)、需要主动脉球囊反博(IABP)治疗(15%比12%,x2=0.577,P=0.448)、急性心力衰竭(6%比3%,P=0.447)等临床不良事件发生率间差异均无统计学意义.对糖尿病(14%比25%,x2=1.071,P=0.301)、重度CKD( 10%比60%,P=0.057)等进行亚组分析,统计结果显示强化治疗组造影剂肾病发生率均低于常规治疗组,但两组间差异均无统计学意义.结论 强化阿托伐他汀对慢性肾病患者对比剂肾病的发生可能无预防作用.%Objective To evaluate the efficacy of treatment with atorvastatin in different dosage on contrast induced nephropathy (CIN) developed after percuteous coronary intervention (PCI) in patients with chronic renal disease (CKD). Methods A prospective, single-center study of 192 patients with baseline estimated glomerular filtration rate ( eGFR) < 60 ml/min were randomized to receive intensive treatment with atorvastatin 40 mg/day ( n = 96, and 11 patients without PCI was excluded ) or routine treatment with atorvastatin 20 mg/day ( n = 96) after admission. All patients received intravenous saline hydration. Low-osmolar contrast medium was used. The eGFR was calculated using the modified Modification of Diet in Renal Disease (MDRD) equation. We defined severe CKD as eGFR less than 30 ml-min-1 ·1.73 m-2. CIN was defined as an absolute increase of serum creatinine >44. 2 μmol/L within 48 -72 hours after the procedure. Results CIN occurred in 26 (14% ) patients among 181 patients, 10(12%) in the intensive treatment group and 16 (17% ) in the routine group ( P = 0. 348 ) . There was no significant difference between two groups in incidence of requiring renal-replacement therapy (0 vs. 5% ,P =0. 061) , in-hospital death (6% vs. 6% ,P =0. 918) , requiring intra-aortic balloon pump( IABP) (15% vs. 12% ,P =0.448),acute heart failure (6% vs. 3%, P = 0.447). In patients with diabetes mellitus, the rate of CIN in intensive group was less than the routine group (14% vs. 25% ,P=0. 301 ) , and in severe CKD subgroup ( 10% vs. 60% ,P =0. 057), but without any significant difference. Conclusion Intensive treatment with atorvastatin may prevent contrast induced nephropathy after percuteous coronary intervention in patients with chronic kidney disease.