摘要：
目的 探讨水化治疗对行冠状动脉介入术(PCI)患者造影剂肾病(contrast induced nephropathy,CIN)的防治作用,了解CIN临床发病率,探究早期CIN肾损害部位及敏感检测指标.方法 选择120例接受PCI治疗的患者,随机分为水化治疗组(60例)与对照组(60例).水化治疗组患者在PCI术前6h起开始静脉补液至PCI术后12h.对照组患者确保正常饮食及饮水.两组患者分别于术前、术后第1d、第2d、第3d测定血清肌酐(Scr)、尿素氮(BUN)及血浆胱抑素C(Cys-C),留取尿标本检测尿微量白蛋白(mAlb)、尿a1-微球蛋白(a1-MG)、尿N-乙酰-β-D氨基葡萄糖苷酶(NAG).结果 与术前比较,术后第1dNAG和a1-MG显著升高(P＜0.01),术后第2d尿渗透压和GFR(MDRD公式计算)降低(P＜0.05).术后第2d与术后第1d比较,NAG和a1-MG均降低(P＜0.05);术后第3d渗透压和GFR(MDRD公式计算)较术前无明显变化(P＞0.05).水化治疗组:术后第1d与术前比较,NAG和a1-MG显著升高(P＜0.01),术后第2d渗透压、GFR(MDRD公式计算)无明显变化(P＞0.05).术后第2d与术后第1d比较,NAG和a1-MG均降低(P＜0.05)且与术前基线比较差异无统计学意义(P＞0.05);渗透压和GFR(MDRD公式计算)无明显变化(P＞0.05).两组间:对照组术后第1d与水化治疗组术后第1d相比,NAG和a1-MG升高明显,差异有统计学意义(P＜0.05);术后第2d NAG和a1-MG的升高仍有统计学差异(P＜0.05).两组间渗透压和GFR(MDRD公式计算)差异无统计学意义(P＞0.05).结论 ①NAG和a1-MG是早期发现CIN的可靠指标;②造影剂(CM)首先造成肾小管损害;③水化治疗对防治早期造影剂肾损害效果明显,可能有利于损伤肾小管功能早期恢复;④基础肾功能不全和/或伴有2型糖尿病、高血压病的患者CIN的发生率明显升高;⑤使用GFR(MDRD公式计算)估算肾小球率过滤,能达到评估肾小球滤过功能,但早期发现CIN的作用有限.血浆胱抑素C(Cys-C)早期检测效果有限.%Objectives Explore the role of hydration treatment of percutaneous coronary intervention(PCI) prevention of contrast-induced nephropathy in the treatment of patients,understanding CIN clinical incidence,explore the early kidney damage parts that CIN caused and sensitive detection indicators.Methods One hundred and twenty one hundred and twenty patients receiving PCI were randomly assigned to the control group and treatment group,60 in each.The patients of treatment group were received rehydration therapy through intravenous fluid infusion(2mL/kg · h).Control group were received a normal diet and drinking water.Urinary a1-MG,mAlb,NAG and osmotic pressure were checked for evidence of tubular or glomerular damage at start,1 day and 2 days after the administration of a radiocontrast agent.The levels of serum creatinin,BUN and cystatin C were also assessed at the same time.Results In control group,comparison with the value before coronary angiography,urinary a1-MG and NAG significantly increased at day 1 after angiography(P ＜0.01) ;urinary osmotic pressure and GFR(MDRD) levels decreased at day 2 after angiography.In comparison to the levels at day 1 after angiography,urinary a1-MG and NAG decreased at day 2 after angiography(P ＜ 0.05) ;urinary osmotic pressure and GFR(MDRD) levels at day 2 after angiography had no significantly change compared with the value of day 3 (P ＞ 0.05).In treatment group,co-mparison with the value before coronary angiography,urinary a1-MG and NAG significantly increased at day 1 after angiography(P ＜0.01),but urinary osmotic pressure and GFR(MDRD) levels at day 2 after angiography had no significantly change(P ＞ 0.05).In comparison to the levels at day 1 after angiography,urinary a1-MG and NAG decreased but had no significantly change compared to baseline (P ＞ 0.05) ; urinary osmotic pressure and GFR (MDRD) levels had no significantly change at day 2 after angiography(P ＞ 0.05).To compare to the treatedment group,the values of urinary a1-MG and NAG increased at day 1 after angiography in control group (P ＜ 0.05) ; the values of urinary a1-MG and NAG still increased at day 2 (P ＜ 0.05) too,but those of urinary osmotic pressure and GFR (MDRD) levels had no significantly change at day 1 or 2 after angiography between the two groups(P ＞ 0.05).Conclusions ①NAG and a1-MG are both reliable indicators of early detection of CIN.②The early CIN first caused renal tubular damage.③The obvious effect of hydration therapy on the prevention and treatment of early contrast agent kidney damage is conducive to injury in renal tubular function early recovery.④The basis of renal insufficiency and / or associated with type 2 diabetes,hypertension in patients will have significantly higher incidence of CIN.⑤GFR (the MDRD formula) can reach the assessment of glomerular filtration rate,but early detection of CIN role is limited.The detection effect of cystatin C is not obvious.
