【作者】 李湛；

【导师】 吴华；

【作者基本信息】 北京协和医学院 ， 内科肾脏病学， 2010， 硕士

【摘要】 目的了解行冠状动脉(简称冠脉)造影检查和经皮冠状动脉介入治疗(PCI)的老年糖尿病患者临床特点,分析此人群造影剂肾病(CIN)的危险因素,并进一步探讨与CIN病情严重程度相关的危险因素。方法回顾性收集了2007年1月至2009年12月于卫生部北京医院心内科行冠脉造影和PCI的269名老年(>65岁)糖尿病患者相关临床资料,按照是否发生CIN分为CIN组和非CIN组,对可能的危险因素：血糖控制程度,糖尿病并发症、肾功能水平、造影剂用量、炎症状态、介入治疗相关操作、围手术期相关治疗及既往合并疾病等进行分析,并比较它们的组间差异。采用多元逐步logistic回归法分析CIN的独立危险因素。最后,将CIN患者按照术后3天内血肌酐较术前升高是否大于50%分成两组,分别为CIN轻度组(血肌酐升高<50%)和CIN中重度组(血肌酐升高≥50%),比较组间相关因素的差别,单因素分析影响CIN病情的危险因素。结果本研究老年糖尿病患者CIN发生率为9.3%(25/269),按肾小球滤过率估计值(e-GFR)将患者分为四组：,90-60ml/min,60-30ml/min,<30ml/min,各组CIN发生率分别为：2.2%(1/45)、4.4%(6/135)、17.3%(14/81)、50%(4/8),269名患者中,80.7%合并高血压,29.7%合并慢性肾脏病(CKD),24.2%合并心肌梗死,25.7%并发糖尿病肾病,21.9%并发糖尿病视网膜病变,冠脉造影和PCI术前平均e-GFR 70.14±21.55 ml/min,非离子型低渗造影剂碘海醇(欧乃派克)平均用量176.83±71.75 ml；CIN组患者在体重、CKD发生率、糖尿病并发症发生率、术前肾功能水平(e-GFR)、红细胞计数、血清总蛋白水平、炎症状态、尿PH值、造影剂用量、冠脉三支病变发生率、水化预防率、检查季节、冠脉造影和PCI术后皮下血肿发生率、术前术后血肌酐水平、围手术期血管紧张素转化酶抑制剂(ACEI)及袢利尿剂的使用、住院天数方面较非CIN组患者存在统计学差异(P<0.05)。多元逐步logistic回归显示袢利尿剂使用、术前肾功能水平(e-GFR<60ml/min)、造影剂用量≥200ml和CKD独立影响CIN的发生,其优势比(OR)值分别为：6.07、3.27、3.26、2.80,P值分别为：0.001、0.024、0.015、0.048。CIN病情严重度相关因素分析发现CKD发生率、术前肾功能水平(e-GFR)、糖尿病肾病和视网膜病变发生率及左室射血分数(LVEF%值)在CIN病情轻度和中重度两组间存在统计学差异(P<0.05)。结论老年糖尿病患者CIN发生率随着肾功能下降而升高。围手术期袢利尿剂的使用、术前肾功能水平(e-GFR<60ml/min)、造影剂用量≥200ml和CKD是老年糖尿病患者CIN的独立危险因素；CKD、术前肾功能水平(e-GFR<45ml/min)、糖尿病肾病和视网膜病变是此类患者CIN病情严重程度的危险因素。更多还原

【Abstract】 OBJECTIVE To understand the clinic feature of the elderly patients with diabetes during coronary angiography, analyze risk factors and severity of illness of contrast-induced nephropathy (CIN) in the patients.METHODS We studied and analyzed retrospectively the risk factors and severity of illness of CIN. The study involved 269 elderly patients who had coronary angiography and percutaneous coronary intervention (PCI) from January 2007 to December 2009 in our hospital. The patients were divided into two groups according to the presence of CIN. The possible risk factors for CIN, such as glycemic control, diabetic complication, renal function, volume of contrast medium, inflammatory state, therapy of perioperative period, past medical history, were analyzed and compared between the two groups. Moreover, we divided the patients with CIN into two groups in the light of severity of illness in order to determine the possible factors aggravating CIN.RESULTS In 269 elderly patients with diabetes, the incidence of CIN was 9.3% (25/269). According to estimated glomerular filtration rate (e-GFR),we separate the patients into four subgroup:≥90ml/min,90-60ml/min,60-30ml/min,<30ml/min; then we found the incidence of CIN for subgroup is 2.2%(1/45),4.4%(6/135),17.3% (14/81),50%(4/8) respectively. In the patients, the prevalence of hypertension was 80.7%, the prevalence of chronic kidney disease (CKD) was 29.7%, the prevalence of myocardial infarction was 24.2%, the incidence of diabetic nephropathy and retinopathy was 25.7% and 21.9%, separately.The mean of preoperative e-GFR was 70.14±21.55ml/min, the mean volume of contrast medium (iohexol) was 176.83±71.75ml. Weight, incidence of CKD, diabetic complication, preoperative e-GFR, RBC, albumin, inflammatory state, urine PH, volume of contrast medium, multiple coronary artery disease, intravenous hydration prevention, coronary angiography complication, creatinine concentration, angiotensin-converting enzyme inhibitor (ACEI)(?) and loop diuretic use, hospital day in CIN group were significantly higher than those in the control group (P<0.01 or 0.05). Multivariate logistic gradual regressive analysis showed that loop diuretic use, preoperative e-GFR (<60ml/min), volume of contrast medium (≥200ml), CKD were independent risk factors of CIN.Their odds ratio (OR) was 6.07,3.27,3.26,2.80, respectively, P value was 0.001,0.024,0.015, 0.048, respectively.In analysis for severity of CIN, CKD, preoperative e-GFR, diabetic nephropathy and retinopathy, left ventricular ejection fraction (LVEF) between two groups were significantly different (P<0.05)CONCLUSION Loop diuretic use, preoperative GFR (<60ml/min), volume of contrast medium (≥200ml), CKD are independent risk factors of CIN. CKD, preoperative GFR (<45ml/min), diabetic nephropathy and retinopathy have an effect on the severity of CIN.更多还原