等渗或低渗对比剂对急诊经皮冠状动脉介入治疗术后急性肾损伤的影响

Comparison of iodixanol and iohexol on contrast-induced acute kidney injury in acute myocardial infarction patients undergoing emergent percutaneous coronary intervention

目的比较等渗对比剂碘克沙醇与低渗对比剂碘海醇在急性ST段抬高型心肌梗死(STEMI)并行急诊经皮冠状动脉介入治疗(PCI)患者中对比剂致急性肾损伤(CI-AKI)的发生率。方法本研究为前瞻性、随机对照研究,连续入选2015年7月至2016年11月入住广州军区广州总医院胸痛中心并行急诊PCI的患者,根据心肌梗死病变部位区分下壁和前壁心肌梗死作为区组,分配至碘克沙醇组与碘海醇组,检测术后72 h内血清肌酸酐值。CI-AKI定义为:使用对比剂72 h内,血清肌酸酐值较基础值升高>25%或增加>0.5 mg/dl(44μmol/L)。结果 297例进入最终统计分析,碘克沙醇组与碘海醇组分别为149例和148例,其CI-AKI的发生率分别为22.1%和16.9%,按照非劣效界值Δ=10%计算,95%CI–14.2%~3.8%,P<0.002。同时前壁心肌梗死组与下壁心肌梗死组发生率为26.4%和11.6%,两组比较P=0.001,差异有统计学意义。结论在STEMI并行急诊PCI的患者中,低渗对比剂碘海醇非劣效于等渗对比剂碘克沙醇,在未来CI-AKI对比研究中按照心肌梗死病变部位进行分组可以尽可能地避免选择性偏倚。

Objective To compare the incidence of contrast-induced acute kidney injury（CI-AKI）following iso-osmolar iodixanol or low-osmolar iohexol administration in patients with acute myocardial infarction（AMI）undergoing emergent percutaneous coronary intervention（PCI）. Methods The study was a prospectiverandomized controlled study.Consecutive patients with AMI were assigned to either the iodixanol group or the iohexol group randomly after they were categorized in different group according to the infarcted walls（inferior and anterior infarction）indicated by electrocardiogram. The primary end point was the incidence of CI-AKI,which is defined as serum creatinine（sCr）increase25% or 0.5 mg/dl（44 μmol/L）from baseline witin 72 hours. Results Two hundred ninety-seven patients were enrolled and allocated to the iodixanol group（n=149）or the iohexol group（n=148）,and CIAKI occurred in 22.1% of patients in the iodixanol group and 16.9% of patients in the iohexol group（95% confidence interval –14.2% to 3.8%,P for noninferiority0.002）. The incidence of CI-AKI was higher in the anterior infarction group than in the inferior infarction group（21.4% vs. 11.6%,P0.01）. Conclusions In patients with AMI who underwent emergent PCI,iohexol was not inferior to iodixanol on the incidence of CI-AKI,and it is reasonable to avoid selection bias for assigning patients into inferior and anterior infarction group according to the infarcted walls for the future CI-AKI related clinical study.