远端缺血预适应对开通慢性完全闭塞病变时造影剂诱导急性肾损伤的影响

Effects of remote ischemic preconditioning on contrast-induced acute kidney injury after percutaneous coronary intervention in patients with chronic total occlusion

目的探讨远端缺血预适应(RIPC)对慢性完全闭塞病变(CTO)患者行冠状动脉介入治疗(PCI)后造影剂诱导急性肾损伤(CI-AKI)发生的影响。方法前瞻性入选2017年6月至2019年1月在东南大学附属中大医院进行择期开通CTO病变的冠心病患者282例,按随机数字表法分为RIPC组(n=142)和对照组(n=140)。采用胱抑素C(CysC)水平变化作为CI-AKI诊断的标准:应用造影剂后24 h CysC水平高于基线水平≥10%。分析两组患者间的基线资料和CI-AKI发生率差异。采用多因素logistic回归分析评价CI-AKI的影响因素。结果两组患者的年龄、性别、合并吸烟、高血压、糖尿病、卒中及陈旧性心肌梗死、既往冠状动脉外科搭桥术、PCI术史及实验室检测指标、CTO病变靶血管及病变特征、造影剂用量、日本多中心CTO注册研究(J-CTO)评分、SYNTAX评分、PCI成功率及植入支架数等方面差异均无统计学意义(均P>0.05)。根据CysC水平变化,RIPC组CI-AKI发生率明显低于对照组(18.3%比29.3%,P=0.036)。Logistic分析显示,术前肌酐(OR=1.018,95%CI:1.006~1.030,P=0.003)、CysC(OR=5.200,95%CI:2.714~9.963,P<0.001)、造影剂用量(OR=1.013,95%CI:1.007~1.019,P<0.001)及J-CTO评分(OR=1.834,95%CI:1.145~2.939,P=0.012)是CI-AKI发生的独立危险因素,而RIPC(OR=0.391,95%CI:0.199~0.765,P=0.006)是其保护因素。结论CTO病变患者PCI术前采用RIPC干预可减少术后CI-AKI的发生。

Objective To investigate the effect of remote ischemic preconditioning(RIPC)on contrast-induced acute kidney injury(CI-AKI)in patients with chronic total occlusion(CTO)after percutaneous coronary intervention(PCI).Methods A total of 282 patients undergoing PCI at Zhongda Hospital Affiliated to Southeast University between June 2017 and January 2019 were prospectively enrolled.The patients were randomly divided into RIPC group(n=142)and control group(n=140).CI-AKI was defined as an increase in level of cystatin C(CysC)≥10%above baseline at 24 h after contrast administration.Baseline characteristics and the incidence of CI-AKI were compared between the two groups.The multivariate logistic regression analysis was further used to analyze the independent risk factors of CI-AKI.Results There were no significant differences in age,gender,smoking,hypertension,diabetes,stroke and old myocardial infarction,coronary artery bypass graft surgery,previous PCI history and laboratory test indicators,target vessel and pathological characteristics of CTO lesions,contrast agent dosage,J-CTO(Multicenter CTO Registry in Japan)score,SYNTAX(Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery)score,PCI success rate and stent number between the two groups(P>0.05).The incidence of CI-AKI was significantly lower(18.3%vs 29.3%,P=0.036)in RIPC group than that of control group.Multivariate logistic analysis found that creatinine[odds ratio(OR)=1.018,95%CI:1.006-1.030,P=0.003],CysC(OR=5.200,95%CI:2.714-9.963,P<0.001),contrast agent dosage(OR=1.013,95%CI:1.007-1.019,P<0.001)and J-CTO score(OR=1.834,95%CI:1.145-2.939,P=0.012)were independent risk factors of CI-AKI.However,RIPC was an independent protective factor of CI-AKI(OR=0.391,95%CI:0.199-0.765,P=0.006).Conclusion RIPC before contrast agent administration prevents CI-AKI in CTO patients undergoing PCI.