pci術(shù)后肌酐升高一例李為民

術(shù)后肌酐升高一例哈爾濱醫(yī)科大學(xué)附屬第一醫(yī)院心血管病醫(yī)院

心血管內(nèi)科李為民李悅薛競宜盛力PCI女，71歲陣發(fā)性心前區(qū)疼痛3年，加重1周高血壓病15年糖尿病史8年心臟超聲：左室舒張功能減低，EF：55%

SCr：96.3

mol/L

臨床資料〔2003-2〕CAG2003-2-12LAD近段高度狹窄TheFirstAffiliatedHospitalofHarbinMedicalUniversityTheFirstAffiliatedHospitalofHarbinMedicalUniversityTSUNAMI3.0x25mmTheFirstAffiliatedHospitalofHarbinMedicalUniversityTheFirstAffiliatedHospitalofHarbinMedicalUniversity碘海醇(iohexol):180ml2003-2-11

術(shù)前2003-2-13術(shù)后一天2003-2-14術(shù)后二天2003-2-20術(shù)后一周2003-3-12術(shù)后一月SCr

mol/L96.3

146.6241.2160.8103.8

ΔSCr

mol/L49.3134.963.57.5TheFirstAffiliatedHospitalofHarbinMedicalUniversityScr升高是否考慮造影劑腎病?A.

是B.否Def.OfCIN:

>0.5mg/dl

or

>25%

increaseCrat48hours44.3μmol/LCIN√CIN

預(yù)測因子腎功能損害？高齡(71Y)糖尿病(8Y)CHF或圍術(shù)期血流動力學(xué)不穩(wěn)定〔IABP〕有效血容量降低貧血?比照劑腎病中國專家共識?TheFirstAffiliatedHospitalofHarbinMedicalUniversitySCrA.

腎功能正常96.3

mol/L女76～106

mol/L男

44～132

mol/LB.

腎功能異常TheFirstAffiliatedHospitalofHarbinMedicalUniversityC.

腎功能不一定正常Scr受多種因素影響年齡性別體重肌肉含量

20g=1mg種族TheFirstAffiliatedHospitalofHarbinMedicalUniversityGFR(ml/min·1.73m2)

=175×血肌酐-1.154×年齡-0.203×[女性×0.79]

(血肌酐:mg/dl；年齡:歲)MDRD簡化公式=52.9

ml/min·1.73m2?比照劑腎病中國專家共識?SCr正常腎功能正常=(96.3

mol/L)96.3

mol/L腎功能損害高齡(71Y)糖尿病(8Y)CHF或圍術(shù)期血流動力學(xué)不穩(wěn)定〔IABP〕有效血容量降低貧血?比照劑腎病中國專家共識?TheFirstAffiliatedHospitalofHarbinMedicalUniversityCIN

預(yù)測因子But,occursin19.7%ofpatients

with

renalinsufficiency

+

DMOccursinlessthan1%ofgeneralpopulationAmJMed,1997;103:368-375Occursin"only"5.7%ofpatientswithrenal

insufficiencyTheFirstAffiliatedHospitalofHarbinMedicalUniversityCIN

預(yù)測因子Risk

ScoreRisk

ofCINRiskofDialysis≤57.5%0.04%6to1014.0%0.12%11to1626.1%1.09%≥1657.3%12.6%Mehranetal.JACC2004;44:1393-1399.HypotensionIABPCHFAge>75yearsAnemiaDiabetesContrastmediavolumeRiskFactors555433IntegerScore1foreach100cc3Mehran’sCINRiskScoreSerumcreatine>1.5mg/dl4eGFR<60ml/min/1.73m22for40–604for20–406for<20CalculateOR7分76歲陣發(fā)性心前區(qū)疼痛加重10天心臟超聲：左室舒張功能減低，EF：47%

SCr：135.3

mol/L

GFR〔MDRD〕=34.1

ml/min·1.73m2TheFirstAffiliatedHospitalofHarbinMedicalUniversity臨床資料〔2021-5〕Risk

ScoreRisk

ofCINRiskofDialysis≤57.5%0.04%6to1014.0%0.12%11to1626.1%1.09%≥1657.3%12.6%Mehranetal.JACC2004;44:1393-1399.HypotensionIABPCHFAge>75yearsAnemiaDiabetesContrastmediavolumeRiskFactors555433IntegerScore1foreach100cc3Mehran’sCINRiskScoreSerumcreatine>1.5mg/dl4eGFR<60ml/min/1.73m22for40–604for20–406for<20CalculateOR13分如何防治CIN?A.水化B.等滲造影劑C.造影劑限量D.速尿E.A+B+CTheFirstAffiliatedHospitalofHarbinMedicalUniversity計算GFR〔評估CIN風(fēng)險〕30～59mL/min≥60mL/min<30mL/min

住院治療腎內(nèi)會診準(zhǔn)備透析其他同GFR

30～59mL/min

水化

等滲造影劑

限制造影劑量

藥物治療

臨床預(yù)后好監(jiān)測血肌酐和電解質(zhì)24～72h內(nèi)監(jiān)測血肌酐?比照劑腎病中國專家共識?口服阿托乏他汀〔20mg〕AmJMed,2005,118:843-849AmJCardiol,2021,101:279–285陽性結(jié)果：茶堿、他汀、維生素C、前列腺素E1中間結(jié)果：NAC、非諾多泮、CCB、L-精氨酸陰性結(jié)果：速尿、甘露醇比照劑腎病中國專家共識TheFirstAffiliatedHospitalofHarbinMedicalUniversity防治CIN措施堿化尿液〔NaHCO3)0.9%氯化鈉，1ml/Kg/h，術(shù)前12小時開始，維持到術(shù)后12小時充分水化AmJCardiol2007;100:781–786)防治CIN措施TheFirstAffiliatedHospitalofHarbinMedicalUniversity

選用非離子型、等滲造影劑(威視派克)Inchronickidneydiseasepatientsundergoingangiography,isosmolarcontrastagentsareindicatedandarepreferred.(ClassⅠ;LevelofEvidence:A)2007ACC/AHA,UA/NSTEMIguideline2007ACC/AHA/SCAI,PCIguideline

減少造影劑用量防治CIN措施TheFirstAffiliatedHospitalofHarbinMedicalUniversityCAG2021-5-7LAD支架內(nèi)再狹窄高度狹窄D1高度狹窄TheFirstAffiliatedHospitalofHarbinMedicalUniversityLCX高度狹窄CAG2021-5-7Ryujinballoon2.5x20mmTheFirstAffiliatedHospitalofHarbinMedicalUniversityD1Firebirdstent2.5x29mm劇烈胸痛TheFirstAffiliatedHospitalofHarbinMedicalUniversity

Avita

2.5x20mmTheFirstAffiliatedHospitalofHarbinMedicalUniversityTAXUSLiberte2.75x32mmTheFirstAffiliatedHospitalofHarbinMedicalUniversityCypherselect

2.75x28mmTheFirstAffiliatedHospitalofHarbinMedicalUniversity碘克沙醇(iodixanol):

210mlTheFirstAffiliatedHospitalofHarbinMedicalUniversity2008-5-6術(shù)前2008-5-8術(shù)后一天2008-5-9術(shù)后三天2008-5-15術(shù)后一周2008-6-7術(shù)后一月SCr

mol/L135.3

147.2163.1141.7132.8

ΔSCr

mol/L11.927.85.4-2.5Def.OfCIN:>0.5mg