1、,术后肌酐升高一例,哈尔滨医科大学附属第一医院 心血管病医院 心血管内科 李为民 李悦 薛竞宜 盛力,PCI,女，71岁阵发性心前区疼痛3年，加重1周高血压病15年糖尿病史8年心脏超声：左室舒张功能减低，EF：55%SCr： 96.3mol/L,临床资料（2003-2）,CAG 2003-2-12,LAD 近段高度狭窄,The First Affiliated Hospital of Harbin Medical University,The First Affiliated Hospital of Harbin Medical University,TSUNAMI 3.0 x 25 mm,T
2、he First Affiliated Hospital of Harbin Medical University,The First Affiliated Hospital of Harbin Medical University,碘海醇(iohexol):180ml,The First Affiliated Hospital of Harbin Medical University,Scr升高是否考虑造影剂肾病,?,A. 是 B. 否,Def. Of CIN: 0.5 mg/dl or 25% increase Cr at 48 hours,44.3mol/ L,CIN,CIN 预测因子,
3、肾功能损害？ 高龄 (71Y) 糖尿病 (8Y) CHF或围术期血流动力学不稳定（IABP） 有效血容量降低 贫血,对比剂肾病中国专家共识,The First Affiliated Hospital of Harbin Medical University,SCr,A. 肾功能正常,96.3mol/L,女 76106 mol/L 男 44132 mol/L,B. 肾功能异常,The First Affiliated Hospital of Harbin Medical University,C. 肾功能不一定正常,Scr受多种因素影响,年龄 性别 体重 肌肉含量20g = 1mg 种族,The
4、 First Affiliated Hospital of Harbin Medical University,GFR (ml/min1.73m2)=175血肌酐-1.154年龄 -0.203女性0.79(血肌酐:mg/dl；年龄:岁),MDRD 简化公式,=52.9 ml/min1.73m2,对比剂肾病中国专家共识,SCr 正常,肾功能正常,=,(96.3mol/L),96.3 mol/L,肾功能损害 高龄 (71Y) 糖尿病 (8Y) CHF或围术期血流动力学不稳定（IABP） 有效血容量降低 贫血,对比剂肾病中国专家共识,The First Affiliated Hospital of
5、Harbin Medical University,CIN 预测因子,But, occurs in 19.7% of patients with renal insufficiency + DM,Occurs in less than 1% of general population,Am J Med, 1997;103:368-375,Occurs in “only“ 5.7% of patients with renal insufficiency,The First Affiliated Hospital of Harbin Medical University,CIN 预测因子,Meh
6、ran et al. JACC 2004;44:1393-1399.,Hypotension,IABP,CHF,Age 75 years,Anemia,Diabetes,Contrast media volume,Risk Factors,5,5,5,4,3,3,Integer Score,1 for each 100 cc3,Mehrans CIN Risk Score,Serum creatine 1.5mg/dl,4,eGFR 60ml/min/1.73 m2,2 for 40 60 4 for 20 40 6 for 20,Calculate,OR,7分,76岁阵发性心前区疼痛加重10
7、天心脏超声：左室舒张功能减低，EF：47%SCr： 135.3mol/L,GFR（MDRD）,=34.1 ml/min1.73m2,The First Affiliated Hospital of Harbin Medical University,临床资料（2008-5）,Mehran et al. JACC 2004;44:1393-1399.,Hypotension,IABP,CHF,Age 75 years,Anemia,Diabetes,Contrast media volume,Risk Factors,5,5,5,4,3,3,Integer Score,1 for each 10
8、0 cc3,Mehrans CIN Risk Score,Serum creatine 1.5mg/dl,4,eGFR 60ml/min/1.73 m2,2 for 40 60 4 for 20 40 6 for 20,Calculate,OR,13分,如何防治CIN,?,A. 水化 B. 等渗造影剂 C. 造影剂限量 D. 速尿 E. A+B+C,The First Affiliated Hospital of Harbin Medical University,计算GFR（评估CIN风险）,3059mL/min,60mL/min,30mL/min,住院治疗肾内会诊准备透析其他同GFR305
9、9mL/min,水化等渗造影剂限制造影剂量药物治疗,临床预后好,监测血肌酐和电解质,2472h内监测血肌酐,对比剂肾病中国专家共识,口服阿托乏他汀（20mg）,Am J Med,2005,118:843-849 Am J Cardiol,2008,101:279 285,对比剂肾病中国专家共识,The First Affiliated Hospital of Harbin Medical University,防治CIN措施,碱化尿液（NaHCO3),0.9%氯化钠，1ml/Kg/h，术前12小时开始，维持到术后12小时,充分水化,Am J Cardiol 2007;100:781786),防
10、治CIN措施,The First Affiliated Hospital of Harbin Medical University,选用非离子型、等渗造影剂 (威视派克),In chronic kidney disease patients undergoing angiography, isosmolar contrast agents are indicated and are preferred. (Class ; Level of Evidence: A),2007 ACC/AHA, UA/NSTEMI guideline2007 ACC/AHA/SCAI, PCI guideline
11、,减少造影剂用量,防治CIN措施,The First Affiliated Hospital of Harbin Medical University,CAG 2008-5-7,LAD 支架内再狭窄高度狭窄 D1高度狭窄,The First Affiliated Hospital of Harbin Medical University,LCX 高度 狭窄,CAG 2008-5-7,Ryujin balloon 2.5x20mm,The First Affiliated Hospital of Harbin Medical University,D1 Firebird stent 2.5x29
12、mm,剧烈胸痛,The First Affiliated Hospital of Harbin Medical University,Avita 2.5x20mm,The First Affiliated Hospital of Harbin Medical University,TAXUS Liberte 2.75x32mm,The First Affiliated Hospital of Harbin Medical University,Cypher select 2.75x28mm,The First Affiliated Hospital of Harbin Medical Univ
13、ersity,碘克沙醇(iodixanol): 210ml,The First Affiliated Hospital of Harbin Medical University,Def. Of CIN: 0.5 mg/dl or 25% increase Cr at 48 hours,CIN,The First Affiliated Hospital of Harbin Medical University,Prevention is better than cure !,71Y；GFR： 52.9 ml/min；DM,碘海醇,CIN,水化、碱化,碘克沙醇,他汀,CIN,5Y,风险评估 + 有效措施,(180ml),(210ml),76Y；GFR： 34.1 ml/min；DM,
