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1、术后肌酐升高一例术后肌酐升高一例哈尔滨医科大学附属第一医院哈尔滨医科大学附属第一医院哈尔滨医科大学附属第一医院哈尔滨医科大学附属第一医院 心血管病医院心血管病医院心血管病医院心血管病医院 心血管内科心血管内科心血管内科心血管内科 李为民李为民李为民李为民 李悦李悦李悦李悦 薛竞宜薛竞宜薛竞宜薛竞宜 盛力盛力盛力盛力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（2003-22003-2）CAG 2003-2-12LAD LAD 近段高度狭窄The First Affiliated
2、 Hospital of Harbin Medical UniversityThe First Affiliated Hospital of Harbin Medical UniversityTSUNAMI TSUNAMI 3.0 x 25 mmThe First Affiliated Hospital of Harbin Medical UniversityThe First Affiliated Hospital of Harbin Medical University碘海醇碘海醇(iohexol):180ml2003-2-11 术前2003-2-13术后一天2003-2-14术后二天20
3、03-2-20术后一周2003-3-12术后一月SCr mol/L96.3 146.6241.2160.8103.8 SCr mol/L49.3134.963.57.5The First Affiliated Hospital of Harbin Medical UniversityScr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 hours44.3mol/ LCINCIN 预测因子肾功能损害？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
4、家共识The First Affiliated Hospital of Harbin Medical UniversitySCrA. 肾功能正常96.3mol/L女 76106 mol/L男 44132 mol/LB. 肾功能异常The First Affiliated Hospital of Harbin Medical UniversityC. 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 2020g = 1mgg = 1mg种族The First Affiliated Hospital of Harbin Medical UniversityGFR (ml/min1.73m2
5、) =175血肌酐-1.154年龄 -0.203女性0.79 (血肌酐:mg/dl；年龄:岁)MDRD MDRD 简化公式简化公式=52.9 ml/min1.73m2对比剂肾病中国专家共识对比剂肾病中国专家共识对比剂肾病中国专家共识对比剂肾病中国专家共识SCr 正常肾功能正常=(96.3mol/L)96.3 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 Harbin Medical UniversityCIN 预测因子But, oc
6、curs in 19.7% of patients with renal insufficiency + DMOccurs in less than 1% of general populationAm J Med, 1997;103:368-375Am J Med, 1997;103:368-375Occurs in only 5.7% of patients with renal insufficiencyThe First Affiliated Hospital of Harbin Medical UniversityCIN 预测因子RiskScoreRiskof CINRisk ofD
7、ialysis 57.5%0.04%6 to 1014.0%0.12%11 to 1626.1%1.09% 1657.3%12.6%Mehran et al. JACC 2004;44:1393-1399.HypotensionIABPCHFAge 75 yearsAnemiaDiabetesContrast media volumeRisk Factors555433Integer Score1 for each 100 cc3Mehrans CIN Risk ScoreSerum creatine 1.5mg/dl4eGFR 60ml/min/1.73 m22 for 40 604 for
8、 20 406 for 75 yearsAnemiaDiabetesContrast media volumeRisk Factors555433Integer Score1 for each 100 cc3Mehrans CIN Risk ScoreSerum creatine 1.5mg/dl4eGFR 60ml/min/1.73 m22 for 40 604 for 20 406 for 20CalculateOR13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+CThe First Affiliated Hospital of Harbin Medical University计算GFR（评估CIN风险）3059mL/min60mL/min0.5 mg/dl0.5 mg/dl or or 25%25% increase Cr at 48 hours increase Cr at 48 hoursCINThe First Affiliated Hospital of Harbin Medical University71Y；GFR： 52.9 ml/min；DM碘海醇CIN水化、碱化碘克沙醇他汀CIN5Y风险评估 + 有效措施(180ml)(210ml)76Y；GFR： 34.1 ml/min；DM
