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1、对比剂肾病新进展CASE REPORTn女性，75岁n2-DM，CHF，高血压，CKD（eGFR 40ml/min)n因急性心梗接受急诊PCIn术前口服N-乙酰半胱氨酸600mg，静脉给予 生理盐水150ml/hn术后两天SCr4.8mg/dl，尿量1000ml/day； 术后5天SCr5.6mg/dln诊断：CINCASE REPORTn处理：肾脏科会诊，血透n血透数天直至SCr恢复至基线水平n住院时间延长约8天，花费较其他患者 增加近4倍CIN概述n定义：排除其它原因的情况下，对比剂 （CM）血管内给药后3天内出现的肾功 能损害nSCr相对升高25%或绝对升高44umol （0.5mg/d
2、l）欧洲泌尿生殖放射协会（ESUR）对比剂指南（6.0版）CIN的流行病学nCIN是急性肾衰的第三位病因，10急性肾功能病例是由 CIN导致n几乎所有造影后患者都可能出现轻微、短暂的肾功能受损(Katholi RE,Taylor GJ,Mccamm WP et al Radiology 1995,195:17-22)n大人群研究发现：使用对比剂后，发生肾功能衰竭的危险性 平均为3（Rudnick MR,Bems JS,Cohen RM et al.Semin Nephrol 1997,17:15-26)nMccullough研究发现：1，826例心血管造影的患者中CIN发 生率为14.5%(M
3、ccoullough PA,Wolyn R,Rooher LL et al Am J Med 1997,103:368-375)n肾功能正常者发生率60mL/min/1.73者）高危患者n较严重的肾功能损害（ GFR140mlnGFR75岁n应用肾毒性药物n7天内重复接受对比剂n充血性心力衰竭（LVEF 140 mL contrastP967 (3.5%)6 (2.9%) 操作类型诊断性心血管造影123 (60.3%)128 (61.0%)0.92 PCI（经皮冠状动脉介入术）81 (39.7%)82 (39.0%) 预防性NAC给药n(%)79 (38.7%)89 (42.4%)0.48 单
4、位体重静脉补液量(mL/kg)12.22.311.52.30.32 给药前eGFR (mL/min/1.73 m2)20-3015 (7.4%)17 (8.1%)0.8330-4042 (20.6%)40 (19.1%) 40-5082 (40.1%)78 (37.1%) 50-5965 (31.9%)75 (35.7%)Solomon et al., Circulation 2007;115;3189-3196Variable典比乐-370碘克沙醇-320 P value*Total PopulationN=204N=210Predose SCr (mg / dL)1.460.361.440
5、.410.64Predose eGFR (mL/min / 1.73 m2)49.311.650.213.00.45Pts with Diabetes and Renal FailureN=78N=92Predose SCr (mg / dL)1.560.431.570.470.80Predose eGFR (mL/min / 1.73 m2)47.112.447.513.40.81CARE Study 研究组的可比性Solomon et al., Circulation 2007;115;3189-3196CARE Study CIN Rates终点典比乐-370 (N=204)碘克沙醇-3
6、20 (N=210)P value*Serum creatinine 绝对升高 0.5 mg/dL9 (4.4%)14 (6.7%)0.39Serum creatinine 相对升高 25%20 (9.8%)26 (12.4%)0.44Estimated GFR 降低 25%12 (5.9%)21 (10.0%)0.15* Fishers exact testTotal CIN Population (N=414)Solomon et al., Circulation 2007;115;3189-3196CARE Study vs RECOVER Study终点典比乐370 (N=204)碘克
7、沙醇-320 (N=210)Serum creatinine 升高 0.5 mg/dL9 (4.4%)14 (6.7%)终点海赛显-320 (N=135)碘克沙醇-320 (N=140)Serum creatinine 升高 0.5 mg/dL12 (8.9%)5 (3.6%)Total CIN Rate CARE Study, 25 Centers, North America (Circulation 2007;115;3189-3196) RECOVER Study, 1 Center, Korea (JACC 2006; 48: 924-930)RECOVER Study, 1 Cen
8、ter, Korea (JACC 2006; 48: 924-930)Endpoint典比乐 370 (N=204)碘克沙醇-320 Group (N=210) SCr 绝对升高 0.5 mg/dL and/or SCr 相对 升高 25%21 (10.3%)27 (12.9%)Endpoint海赛显 320 (N=135)碘克沙醇-320 (N=140)SCr 绝对升高 0.5 mg/dL and/or SCr 相对 升高 25%23 (17.0%)11 (7.9%)RECOVER Study, 1 Center, Korea (JACC 2006; 48: 924-930)RECOVER
9、Study, 1 Center, Korea (JACC 2006; 48: 924-930)CARE Study vs RECOVER Study CIN Rate Using Multiple EndpointsCARE Study, 25 Centers, North America (Circulation 2007;115;3189-3196) CARE Study CIN RatesEndpoint典比乐乐370 (N=78)碘克沙醇-320 (N=92)P value*Serum creatinine绝对升高 0.5 mg/dL4 (5.1%)12 (13.0%)0.12Seru
10、m creatinine 相对升高 25%8 (10.3%)14 (15.2%)0.37Estimated GFR 降低 25%5 (6.4%)12 (13.0%)0.20* Fishers exact testPatients with Diabetes and Moderate-to-Severe Renal Impairment (N=170)Solomon et al., Circulation 2007;115;3189-3196CARE vs NEPHRIC Study终点典比乐370 (N=78)碘克沙醇-320 (N=92)SCr绝对升高 0.5 mg/dL4 (5.1%)12
11、 (13.0%)终点欧乃派克-350 (N=65)碘克沙醇-320 (N=64)SCr绝对升高 0.5 mg/dL17 (26.1%)2 (3.1%)CIN Rate in Patients with Diabetes and Renal ImpairmentNEPHRIC Study, 17 Centers, Europe (NEJM 2003; 348: 491-499) NEPHRIC Study, 17 Centers, Europe (NEJM 2003; 348: 491-499) CARE Study, 25 Centers, North America (Circulation
12、 2007;115;3189-3196) CARE vs RECOVER StudyEndpoint典比乐370 Group (N=78)碘克沙醇-320 Group (N=92)Serum creatinine 升高 0.5 mg/dL4 (5.1%)12 (13.0%)Endpoint海赛显-320 Group (N=49)碘克沙醇-320 Group (N=48)Serum creatinine 升高 0.5 mg/dL13 (26.5%)5 (10.3%)CIN Rate in Patients with Diabetes and Renal ImpairmentRECOVER Stu
13、dy, 1 Center, Korea (JACC 2006; 48: 924-930)RECOVER Study, 1 Center, Korea (JACC 2006; 48: 924-930)CARE Study, 25 Centers, North America (Circulation 2007;115;3189-3196) PublicationPatient PopulationCIN EndpointContrast agentsResults：CIN发发生率Aspelin et al. (the NEPHRIC Study), New Engl J Med 2003; 34
14、8:491- 499Patients with diabetes mellitus and CKD (N=129) SCr 0.5 mg/dL at 72 hrs post-dose等渗对比剂碘克沙醇与低渗对比剂（LOCM）的对照研究对于前瞻性研究的荟萃分析CARE Study vs Meta-Analysis by Solomon 41: 651-660)Meta-Analysis, 10/22 studies (Invest Radiol 2006; 41: 651-660)在CIN发生率上，低渗对比剂碘帕醇（典比乐）的显著少于低渗对比剂 碘海醇（欧乃派克）低渗对比剂入组病例剂及低渗对比剂入组病例剂及CINCIN发生率发生率: : 海赛显海赛显 (N=789, 58.7%)(N=789, 58.7%) 欧乃派克欧乃派克 (N=381, 28.3%)(N=381, 28.3%) 优维显优维显 (N=106, 7.9%)(N=106, 7.9%) 典比乐典比乐(N=69, 5.1%)(N=69, 5.1%)Iopromide Iopamidol该荟萃分析中98的数据来源于欧 乃派克与海赛显的临床研究. 海赛显 欧乃派克欧乃派克PublicationPatient PopulationCIN Endpoint
