冠心病患者短期内两次应用对比剂诱导急性肾损伤临床特点及年龄影响

Clinical characteristics and age effect of patients with coronary atherosclerotic heart disease who are exposed to contrast twice in a short period of time induce acute kidney injury

目的探讨冠心病(CAD)患者住院期间30 d内两次应用对比剂后诱导急性肾损伤(CI⁃AKI)的临床特点及年龄对其的影响,并观察分析远期预后。方法回顾性分析自2010年1月至2015年1月于北部战区总医院心血管内科接受过冠状动脉造影(CAG)或经皮冠状动脉介入治疗(PCI)23444例CAD患者的临床资料,并筛选其中具有完整随访资料的30 d内两次应用对比剂的559例CAD患者为研究对象。按照年龄将患者分为A组(年龄≥75岁,n=83)、B组(年龄60~74岁,n=254)及C组(年龄45~59岁,n=222)。记录并分析各组患者住院期间对比剂诱导CI⁃AKI的临床特点、年龄影响,以及远期随访期间全因死亡及主要不良心血管事件(MACE)的发生情况。结果3组患者的入院舒张压、肾小球滤过率、血尿素氮、SYNTAX评分、基线血清肌酐(Scr)、第1次术后Scr、第2次术后Scr,以及性别、吸烟史、饮酒史、恶性肿瘤、利尿剂使用、左主干病变、主动脉内球囊反搏患者比例及第2次术后CI⁃AKI发生率比较,差异均有统计学意义(P<0.05);且A组第1次术后CI⁃AKI发生率高于B组、C组,差异有统计学意义(P<0.05)。Logistic回归分析结果显示,第1次术后利尿剂(P=0.008)是发生CI⁃AKI的独立相关危险因素,且其与CI⁃AKI发生具有独立相关性;年龄(P<0.001)及利尿剂(P<0.001)是第2次术后发生CI⁃AKI的独立相关危险因素,且年龄、利尿剂与CI⁃AKI发生具有独立相关性。A组全因死亡及MACE发生率均高于B组、C组,差异有统计学意义(P<0.05);对影响终点事件的相关因素进行COX多因素分析发现,均无独立相关性(P>0.05)。结论对于短期(30 d)内两次接触对比剂的不同年龄CAD患者,年龄是第2次PCI术后发生CI⁃AKI的独立危险因素,且高龄(年龄≥75岁)患者CI⁃AKI的发生率更高。在高龄的基础上,女性、恶化的肾功能、复杂的冠状动脉情况可能是导致其高发病率的原因,利尿剂也是发生CI⁃AKI的独立危险因素,因其可增加CI⁃AKI的发生率,在围术期利尿剂的使用上更应谨慎。

Objective To evaluate the clinical features and age of contrast induced acute kidney injury(CI⁃AKI)twice within 30 days of hospitalization in patients with coronary artery disease(CAD),and to observe and analyze the long⁃term prognosis.Methods Clini⁃cal data of 23444 CAD patients who underwent coronary angiography(CAG)or percutaneous coronary intervention(PCI)in the De⁃partment of Cardiovascology of the General Hospital of Northern Theater Command from January 2010 to January 2015 were retrospec⁃tively analyzed,and 559 CAD patients with complete follow⁃up data who received contrast agent twice within 30 days were selected as subjects.According to age,patients were divided into group A(age≥75 years,n=83),group B(age 60 to 74 years,n=254)and group C(age 45 to 59 years,n=222).The clinical characteristics and age effects of contrast agent induced CI⁃AKI during hospitalization,as well as the occurrence of all⁃cause death and major adverse cardiovascular events(MACE)during long⁃term follow⁃up were recorded and analyzed.Results Admission diastolic blood pressure,glomerular filtration rate,blood urea nitrogen,SYNTAX score,baseline ser⁃um creatinine(Scr),Scr after the first surgery,Scr after the second surgery,gender,smoking history,drinking history,malignant tumor,diuretic use,left main disease,proportion of patients with intraaortic balloon counterpulsation and the incidence of CI⁃AKI after the second surgery among three groups were statistically significant(P<0.05).The incidence of CI⁃AKI in group A after the first surgery was higher than that in group B and group C,and the difference was statistically significant(P<0.05).Logistic regression analysis showed that the first postoperative diuretic(P=0.008)was an independent risk factor for the occurrence of CI⁃AKI,and it was inde⁃pendently correlated with the occurrence of CI⁃AKI.Age(P<0.001)and diuretics(P<0.001)were independent risk factors for the occurrence of CI⁃AKI after the second surgery,and age,diuretics and the occurrence of CI⁃AKI were independently correlated.The in⁃cidence of all⁃cause death and MACE in group A was higher than that in group B and C,and the difference was statistically significant(P<0.05).COX multivariate analysis of the related factors affecting the endpoint event found no independent correlation(P>0.05).Conclusion For CAD patients of different ages who are exposed to contrast agents twice within a short period(30 days),age is an in⁃dependent risk factor for CI⁃AKI after the second PCI,and the incidence of CI⁃AKI is higher in older patients(age≥75 years).On the basis of advanced age,female,deteriorating renal function,and complicated coronary artery conditions may be the reasons for the high incidence of CI⁃AKI.Diuretics are also independent risk factors for the occurrence of CI⁃AKI,which may increase the incidence of CI⁃AKI.Therefore,perioperative diuretic use should be more cautious.