不同剂量阿托伐他汀对高水平高敏C反应蛋白患者经皮冠状动脉介入术后发生对比剂肾病的影响

Impact for Different Dose of Atorvastatin on Contrast-induced Nephropathy in Patients With High Level of hs-CRP After Percutaneous Coronary Intervention

目的：探讨不同剂量阿托伐他汀干预对高水平高敏C反应蛋白（hs—CRP）患者经皮冠状动脉介入术（PCI）后发生对比剂肾病（CIN）的影响。方法：人选2011-01至2012—06在我院心内科住院拟行PCI治疗的患者700例，分为强化治疗组（226例）和常规治疗组（474例）。伞部患者入院前3个月内未服用他汀类药物，hs—CRP水平均在3mg／L水平以L，PCI术前24h～术后72h均使用阿托伐他汀治疗。在常规水化治疗基础上，强化治疗组患者给予阿托伐他汀40mg／d，常规治疗组给予阿托伐他汀20mg／d，记录PCI术前及术后48～72h血清肌酐（Scr），尿素氮（BUN）等指标。CIN的诊断标准为：排除其他原因引起的急性肾功能损害，接触对比剂后48～72h内血清肌酐浓度升高〉0．5mg／dl（44．2μmol／L）或者较原基础值升高25％以上。观察入选患者CIN的发生率、危险因素及院内临床不良事件（包括死亡、心肌梗死、心力衰竭及透析等）。结果：100例（14．2％）患者发生了对比剂肾病，强化治疗组对比剂肾病发生率低于常规治疗组（13.3％VS14．8％，x2=0.278，P=O．597），但两组间差异无统计学意义。两组患者死亡率（0．4％比0％，x2=0．96，P=O．327）、需要肾脏替代治疗（RRT，0．9％比0．4％，x2=O．834，P=O．770）、再发心肌梗死（1．1％比0．4％，x2=0．682，P=O．409）、急性心力衰竭（2．7％比2．1％，x20．197，P=0．658）等院内临床不良事件发生率间差异均无统计学意义。对CIN潜在的危险因素进行单因素回归分析，将有统计学差异的变量：强化他汀、术前hs—CRP、年龄〉75岁、糖尿病、基础估计肾小球滤过率（eGFR）〈60ml（min·1．73m2）、急诊PCI、同手术期低血压纳入多因素Logistic回归模型，结果显示术前hs—CRP、急诊PCI、围手术期低血压仍与CIN显著独立相关（分别是OR=1．009，95％CI1．003—1．016，P=O．005；OR=2．133，95％CI 1．532—4．178，P=O．037；OR=3．176，95％CI1．416～7．126，P=O．005）。结论：强化阿托伐他汀治疗对高水平hs—CRP患者PCI后CIN的发生可能无预防作用。

Objective： To explore the impact for different dose ofatorvastatin medication on contrast-induced nephropathy （CIN） in patients with high level of hs-CRP after percutaneous coronary intervention （PCI）. Methods： A total of 700 patients who received PCI in our hospital from 2011-01 to 2012-06 were studied. The patients were divided into 2 groups, Intensive group, n=226, the patients received atorvastatin 40 mg/day at 24 h before to 72 h after PCI, and Routine group, n=474, the patients received atorvastatin 20 rag/day at 24 h before to 72 h after PCI. All patients had pre-operative hs-CRP 〉 3 mg/L and without atorvastatin medication at 3 months before PCI. The serum levels of creatinine （Scr） and urea nitrogen （BUN） were examined at before and 48 h, 72 h after PCI. CIN was defined by elevated Scr 〉 0.5 mg/dl or 25% within 48-72 h after contrast exposure. The CIN occurrence with MACE were compared between 2 groups. Results： CIN occurred in 100/700 （14.3%） patients, the Intensive group and Routine group were similar （13.3% vs 14.8%, Z2=0.278, P=0.597）, and the mortality （0.4% vs 0%, Z2=0. 96, P=0. 327）, the incidence for requiring renal- replacement therapy （0.9% vs 0.4%, Z2=0.834, P=0.770）, re-myocardial infarction （1.1% vs.0.4%, ;~2=0. 682, P=0.409）, acute heart failure （2.7% vs.2.1%, X2=0.197, P=0. 658） were similar between 2 groups. Multivariate logistic regression analysis showed that hs-CRP （OR=1.009, 95% CI 1.003-1.016, P=0.005）, primary PCI （OR=2.133, 95% CI 1.532-4.178, P=0.037） and peri-operative hypotension （OR=3.176, 95%CI 1.416-7.126, P=0.005） were the independent risk factors for CIN. Conclusion： The intensive atorvastatin medication could not prevent CIN in patients with high level of hs-CRP after PCI.