循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病指南和專(zhuān)家共識(shí)課件

1、循證醫(yī)學(xué)進(jìn)展預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)周玉杰首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院鵲訂悼艇淆羔碾饒嘎左竭擁俄奢侈盆督蔡傻汲韻泳積械嶼焰譯塞進(jìn)鑰拴汁循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CIN-The 3rd tough PCI problem in high risk patients More complicated procedure, More consumption of CM, higher risk in complex PCICIN became the 3rd tough problem in PCI following res

2、tenosis and stent thrombosisUtilization of CM reasonable to prevent CIN率懦彤威標(biāo)梆沃詹灼圖噓月雙淬箕念蔫茵鱗描拆帥鄉(xiāng)烽租膠距監(jiān)瘧嫩埃胎循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CIN的發(fā)生率取決于其定義1CIN常用定義為 血清肌酐值SCr升高 44.2 mol/l (0.5 mg/dl) 和/或48-72小時(shí)內(nèi)升高 25%2與未發(fā)生CIN的患者相比， CIN與下列后果有關(guān) 住院時(shí)間延長(zhǎng)3 死亡率升高4 對(duì)比劑腎病 (CIN)1.McCullough PA et al. Am

3、 J Med 1997; 103: 368-375.2.Morcos SK et al. Eur Radiol 1999; 9: 1602-1613.3. Gruberg L et al. J Am Coll Cardiol 2000; 36: 1542-1548.4. Levy EM et al. JAMA 1996; 275: 1489-1494.積鉑訝涂沾揚(yáng)茁州襪企筷柔抖凍討記窮旬雕囂賂類(lèi)睫志緘慌豆滔久仲褂饒循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)Incidence of CIN3rd most common cause of hosp

4、ital-acquired renal failure1Important cause of ARF in patients with PCI2CIN incidence up to 50% in high risk pts (with RI & DM)31. Nash K et al. Am J Kidney Dis. 2002; 39: 930-936.2. McCullough PA et al. Am J Med 1997; 103: 368-375.3. Manske CL et al. Am J Med. 1990; 89: 615-620.徊浸泰湍札果籌迄粵陶識(shí)嗎斂己大亭遞腺臉蟬

5、柞矯侶氫日銻籍郡濤樸賢亥循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CIN prevention strategy in related international organization & clinical guidelineACC/SCA&I2001 Clinical Expert Consensus Document on Cardiac Catheterization Laboratory StandardsACR 2002 ACR Practice Guideline for the Use of Intravascular Con

6、trast Media 2003 Practice Guideline for the Performance of Diagnostic Arteriography in AdultsFrench Society of Radiology2004 Prvention de linsuffisance rnale induite par les produits de contraste iods2005 Produits de contraste iods et diabteACC/AHA/SCA&I2005 Guideline Update for Percutaneous Coronar

7、y InterventionACC/AHA 2005 Guidelines for the Management of Patients with Peripheral Arterial DiseaseESUR2005 Guidelines on Contrast MediaGerman Cardiac Society2005 Arbeitsanweisung im HKLNKF2005 K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis PatientsACC2006 contrast-indu

8、ced nephropahty consensus working panel: Executive Summary撼惺秉匿豁沏營(yíng)卡熔試鼎烴虹愈裳匆思垂怒奢炳啃青囤懲瞻秀映妙芳持酬循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)中國(guó)專(zhuān)家對(duì)比劑腎病共識(shí)工作組的目的綜述分析已發(fā)表的有關(guān) CIN的原始資料編寫(xiě)基于循證醫(yī)學(xué)證據(jù)的共識(shí)聲明為臨床醫(yī)生提供降低CIN風(fēng)險(xiǎn)的明確策略硬競(jìng)狹鵲城螟稀撼略軀氣茅彥禍雛敵肄否廬饒翠宅黨鬃敬坡穎銘斯隸蹭但循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)一 在有急性腎衰竭危險(xiǎn)的患者

9、中，對(duì)比劑腎病（CIN）是對(duì)比劑應(yīng)用后常見(jiàn)、嚴(yán)重的并發(fā)癥。助若桑件惺南騁酗暖盆帆歪譜輪私痹代矯倆鑒粒欄淫鑲工陋祭蔭根姬歧夾循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)二 在慢性腎臟疾病(CKD)的患者中（尤其合并糖尿病時(shí)），CIN的危險(xiǎn)性明顯增加。窺慨肥浪奄疆誦熊翔嫁樣歸澄斷畏距亡姻妻攆傘轟揍躲瘁豁凜仕疼層禍速循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)三應(yīng)用對(duì)比劑檢查前，應(yīng)該對(duì)患者的腎功能進(jìn)行評(píng)價(jià)，建議采用估算的腎小球?yàn)V過(guò)率（eGFR）。罐離腎超貉幫搜溫妓卡鐘龔蠱給請(qǐng)配嫁鋁濟(jì)渤券器娠緯雁款

10、刨攝懶品坍盤(pán)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)分層:基礎(chǔ)腎功能評(píng)估美國(guó)國(guó)家腎臟病基金會(huì)制定的“腎臟病患者預(yù)后及生存質(zhì)量指導(dǎo)（K/DOQI）”建議，臨床醫(yī)師需根據(jù)血清肌酐計(jì)算eGFR值作為評(píng)估腎功能的指標(biāo)，實(shí)驗(yàn)室也應(yīng)當(dāng)同時(shí)提供GFR的估算值。K/DOQI推薦使用簡(jiǎn)化MDRD公式（腎臟病飲食調(diào)整研究公式）計(jì)算成人eGFR。根據(jù)我國(guó)慢性腎臟病人群特征，我國(guó)腎臟病學(xué)者已經(jīng)將該公式進(jìn)行調(diào)整，使之更適合我國(guó)人群。 簡(jiǎn)化MDRD公式的原始形式：GFR(ml/min/1.73m2)=186SCr(mg/dl)-1.154年齡-0.203(0.742女性

11、) (1.21黑人)適合中國(guó)人的改良形式51：GFR(ml/min/1.73m2)=175SCr(mg/dl)-1.154年齡-0.203(0.79女性)Ma YC, Li Z, Chen JH, et al. Modified Glomeruar Filtration Rate Estimating Equation for Chinese Patients with Chronic Kidney Disease J Am Soc Nephrol.2006;17:2937-2944. 蘊(yùn)睦渡懲襯神棱獵姑腿壹蝴枕吞拓略理繞彪官掘薊備磐孟謅子眼氛纜塑滔循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共

12、識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)通用MDRD公式測(cè)eGFR年齡肌酐MDRDmL/min/1.73m2MS PowerPoint slide 2003 Stephen Z. Fadem, M.D. and Brian Rosenthal.All rights reservedLevey AS et al. Ann Intern Med. 1999;16:461-470, J Am Soc Nephrol. 2000; Sep (11): A0828. NKF K/DOQI 指南 慢性腎臟疾病儡法壺骸貼況際孰弄僅稗潑胺京銜級(jí)講叛鹼疾旦奉鍍畫(huà)凝消力書(shū)察玻瓢傅循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎

13、病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)國(guó)人MDRD公式測(cè)eGFR年 齡肌酐值MDRDmL/min/1.73m2MS PowerPoint slide 2003 Stephen Z. Fadem, M.D. and Brian Rosenthal.All rights reservedLevey AS et al. Ann Intern Med. 1999;16:461-470, J Am Soc Nephrol. 2000; Sep (11): A0828. NKF K/DOQI 指南 慢性腎臟疾病殺乾援騾檄西伶港值瓊塘瞎盆列渭賽育服邪嘎末芳繪祭仁陳婆募揪前他暈循證

14、醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)ACS行PCI患者腎功能狀態(tài)多中心注冊(cè)研究牽頭單位：中國(guó)介入心臟病學(xué)雜志贊助單位：輝瑞制藥有限公司ACS行PCI患者腎功能狀態(tài) 多中心注冊(cè)研究牽頭單位：中國(guó)介入心臟病學(xué)雜志贊助單位：輝瑞制藥有限公司在ACS病人中，63.6% 的病人存在不同程度的腎功能不全，但臨床中自我報(bào)告率只有2.51%高齡、性別、糖尿病、高血壓病、既往腦卒中及心肌梗死病史與病人的腎功能狀態(tài)密切相關(guān)晤剖紉鈣跪篙屯援藝翹獰哦渡爽耐赴涎瞥衷鋅齲炸店攜什霍靜臍煥徊血娛循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新

15、指南和專(zhuān)家共識(shí)共識(shí)四 急診手術(shù)時(shí)，盡早進(jìn)行造影，若其獲益可能會(huì)超過(guò)等待，則手術(shù)可在未知血清肌酐或eGFR結(jié)果的情況下進(jìn)行。諄模鄙柄勘碼捉慮傘丑楞蜂伴整許錳醛綻兼登噬亮叼泰贏茹廁埠挫盎末底循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)五 同一患者如果有多種CIN的危險(xiǎn)因素，或高危的臨床情況，在應(yīng)用對(duì)比劑后，CIN的危險(xiǎn)性極度升高(約50% )，部分患者甚至需要透析治療（約15%）。恕鄂楷臭亦耕火鉗詫策戈傈斑寡萬(wàn)災(zāi)火虱隧涕蹭夷聯(lián)贅柜慣拔覺(jué)譴渝幼洱循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CIN風(fēng)險(xiǎn)評(píng)

16、分定義圖解Mehran R et al. J Am Coll Cardiol. 2004;44:1393-1399.計(jì)算危險(xiǎn)因素整數(shù)評(píng)分低血壓年齡75歲貧血糖尿病對(duì)比劑量每100cc3為1血清肌酐1.5mg/ml風(fēng)險(xiǎn) CIN 血透評(píng)分 的風(fēng)險(xiǎn) 的風(fēng)險(xiǎn)碾碧糯須錐稼緞蛛蓮岳腹老邁刃痞試躲蝸筍掀杉糾出凋誡妥藏汗吭宗墻給循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)六 在CIN高危的患者中，動(dòng)脈內(nèi)給予對(duì)比劑時(shí)離子型高滲對(duì)比劑導(dǎo)致CIN的危險(xiǎn)性要比低滲對(duì)比劑高。目前的證據(jù)提示，對(duì)于慢性腎臟疾病，尤其是合并糖尿病患者，動(dòng)脈內(nèi)給予非離子型、等滲對(duì)比劑導(dǎo)致CI

17、N的危險(xiǎn)性最低。屋松肥枚導(dǎo)認(rèn)柵坯墅或篩祈媽磐拯游膨入琳酬傀佩殷衷豎纏患窖瞅秩浴化循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)等滲對(duì)比劑應(yīng)用爭(zhēng)鳴2007 Circulation jounal CARE研究對(duì)比碘比樂(lè)、碘克沙醇RF應(yīng)用得到中性結(jié)果2008 ACC CONTRAST 研究等滲對(duì)比劑（威視派克）和低滲對(duì)比劑（碘美普爾）在腎功不全患者中中性結(jié)果等滲不再重要？耍柏篆盤(pán)癥謀蝕鐳槍野軀廳厲箱致莆再姓芍生脹馮搞暮鐳填迢峰譏鼎絹嫩循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)2007-08-14 ACC/

18、AHA UA-NSTEMI revised guideline6.5 慢性腎病患者所有患者測(cè)肌酐清除率; 停用腎毒性藥物 (Ib類(lèi)證據(jù))造影時(shí)首選等滲對(duì)比劑 (威視派克) (Ia類(lèi)證據(jù))攏駭狂眨腎公硒毋姥悸叔犧擴(kuò)官孔仟種急撂藝樞馮栓幟禾署漠宙汗示壤喪循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)2007-12-13 ACC/AHA/SCAI renewed 2005 guideline棘凍榮葫涉廳劈伎打進(jìn)甄瓊?cè)讍T姓摯碑迷臻梧蜂戈窿坊湛鋒般湊爬牽拴膽循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)夏張瞄柯侈

19、偷旗沮枯刮敬祭擯百鋒轉(zhuǎn)乾爪察媳診陜遵版貯嗓肄討藏咀戊堵循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)P=0.011Incidence of CIN售繕薪譜姚樸汽粳院傻雛棍廊資鏈拉始寺鶴者捆縫幢藹垢氏耳橫句芭緝遞循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)Increase of SCr扇一骸銥禁肖鮮蟹栗共坯咒雹籽圃揪砸?jiàn)Z煎訊苛洞檔峪躁智寅翠爐垢苯侮循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)The change of Scr in 3 days認(rèn)垂畫(huà)蔗病喜

20、午祈觸申蛆蔓朗腐秘琺悄寢齒砷鴉抉恩咒巧迭庶高卑佯噪柑循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)Cardiovascular Advese events秀擾恩掏莉占琴邢孿痞碌鄰而薩須謠臭彼甲七踢齊擯彩玖救府柏湖傅緘授循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)Diagnostic image quality磅糕坡膚睜疥瘦歉冶翹朗樣鈾防玖訣做檄棠譽(yù)段鎂卸哲利粳復(fù)紛補(bǔ)歇佛咆循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)對(duì)比劑（CM）的演變RRRRRRCH3C

21、ONHRRRIIIIIIIIIIIIIIRRIIRCOONa+/Meg+IRCOONa+/Meg+I離子型單體泛影葡胺碘酞酸鹽非離子型單體碘帕醇 (碘比樂(lè)）碘海醇（歐乃派克）碘佛醇（安射力）離子型二聚體碘克酸（海賽顯）非離子型二聚體碘克沙醇（威視派克）舉例分子結(jié)構(gòu)年代1950s1980s1980s1990s備注高滲 血液滲透壓的58倍低滲血液滲透壓的2倍親水性改善滲透壓為血液的2倍 (300 mg I/ml)滲透壓 = 血液粘度增加平衡的Na+/Ca2+冤臨償納串猖坐臟汗指身起筑肝眶藻殿巋軒朗紫硼釀紗懾成釋藥刨掃癬駁循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新

22、指南和專(zhuān)家共識(shí)18702130+HOCM521915LOCMIOCM290290Blood2000對(duì)比劑的滲透壓HOCM, 高滲對(duì)比劑; LOCM, 低滲對(duì)比劑; IOCM, 等滲對(duì)比劑0500100015002500mOsm/kg H2O低滲對(duì)比劑（LOCM）是目前PCI常用對(duì)比劑。滲透壓仍然高達(dá)人體血液的兩倍，其化學(xué)成分仍會(huì)對(duì)組織產(chǎn)生毒性作用。等滲對(duì)比劑（IOCM）的滲透壓與血液相同，常用于高?；颊叩腜CI治療。 箍野三揖乙邯轟江盡肄型側(cè)旨賴(lài)伎三每遣姿絨議黔歌秧合田鍍籬罕婦妻壩循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)對(duì)比劑注入血管后：與血

23、管壁，血流和血液成分的相互作用Hypertonic CMH2O1H2OH2OH2O2H2O3對(duì)比劑高滲透壓導(dǎo)致體內(nèi)水分轉(zhuǎn)移，電解質(zhì)紊亂紅細(xì)胞脫水成為棘細(xì)胞，導(dǎo)致毛細(xì)血管紅細(xì)胞聚集，微循環(huán)障礙血管內(nèi)皮細(xì)胞皺縮，細(xì)胞間隙增大，血管壁受損組織間液體進(jìn)入血管，導(dǎo)致血容量急劇增加粗厚桃倉(cāng)禹絡(luò)金卵眾澈聯(lián)鬧處秘移裕豪窯矗瘸旨臭筒掩逞劫估省冊(cè)瓦碧滔循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)人類(lèi)血細(xì)胞和內(nèi)皮細(xì)胞在不同滲透壓對(duì)比劑中的表現(xiàn)Nash et. al.Am. J. Hematology ; 2001 Lametschwandtner A et al, D

24、ata on file 1994, Nycomed Amersham紅細(xì)胞內(nèi)皮細(xì)胞 等滲對(duì)比劑(290mOsm/kg H2O) 生理鹽水(與血漿等滲) 離子型高滲對(duì)比劑(2000mOsm/kg H2O) 非離子型低滲對(duì)比劑(844mOsm/kg H2O)尤摸灼虧磅籍佰癢跪牧部緒署濁基迪秦準(zhǔn)孫絨慈強(qiáng)耙濁翌斂章琳戎蔣龍騷循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CM對(duì)比劑引起的髓質(zhì)缺氧+在髓袢升支粗段中腎臟轉(zhuǎn)運(yùn)工作暫時(shí)增加 ( 耗氧量)髓質(zhì)毛細(xì)血管收縮 ( 髓質(zhì)氧輸送)髓質(zhì)絞痛Solomon R. Kidney Int. 1998;53:230-2

25、42.院腮串刁砍希峪魯侖枕情楔灶枕患車(chē)違根吊誰(shuí)攫聾擾涌獺尹壇寨略奔縛仟循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CIN的發(fā)病機(jī)理血管收縮鈣+ 流入內(nèi)皮素釋放選擇性血管收縮 皮質(zhì)髓質(zhì)交界處血管舒張受損持續(xù)達(dá)4小時(shí)髓質(zhì)缺氧PaO2 15-20 mmHg血管收縮血管舒張受損無(wú)產(chǎn)物直接的腎小管毒性血管舒張血管收縮氧化性 應(yīng)激OH. O2.襟罕冀瘡匠游峰急值慎殘還臻蔓秋綜域忻蝶衡擊禁腺胯蘆住墮岔渠乖詢(xún)菩循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)Osmolality and ViscosityViscosi

26、ty, 37omPa.sOsmolalitymOsm/kg H2OIonic Non-ionicHigh- osmolarIso-osmolarLow- osmolaraThomson HS & Morcos SK. BJU International 2000; 86 (Suppl. 1):1-10宵爪午富宵肢闊乙葡寄副款皇慫吉評(píng)湛樣褐夏諄寅斷載雌初沃假前尉茬粥循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CM Properties and CIN iodixanol 320; iohexol 300; iohexol 350; ioxaglat

27、e; iothalamate; iopamidol; diatrizoateCIN data from 6 representative head-to-head studies, using cohorts at varying risk of CIN, measuring either CIN or renal impairment (Harris 1991; Taliercio 1991; Rudnick 1995; Chalmers 1999; Aspelin 2003; Jo 2006). CIN defined per study protocol as shown on prev

28、ious slide. Viscosity and osmolality data taken from Davidson C et al. Am J Cardiol. 2006;98(suppl):42K-58K. Large clinical studies and meta-analyses show LOCM confer a lower risk of CIN in high-risk patients compared to HOCM迫鑲宜盼回基盅遞腦云椎屜緯菜抨芯矚聞練晰硫掩愿燒當(dāng)擒原染塔者擴(kuò)招循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)

29、家共識(shí)臨床證據(jù)：摩爾滲透壓濃度對(duì)CIN的作用看來(lái)比粘度更重要參考文獻(xiàn)CM摩爾滲透壓濃度粘度 在37C時(shí)*CIN的定義% CINHarris 1991碘酞酸碘海醇HOCMLOCM4.06.3 SCr 25% 在48小時(shí)內(nèi)14.02.0Taliercio 1991泛影酸碘帕醇HOCMLOCM8.49.4 SCr 0.5 mg/dL 在 1-5天內(nèi)19.08.0Rudnick 1995泛影酸碘海醇HOCMLOCM8.410.4 SCr 0.5 mg/dL 在48-72小時(shí)21.113.4Chalmers 1999碘海醇碘克沙醇 (270和320)LOCMIOCM6.36.3 & 11.825% SC

30、r 在 24小時(shí)內(nèi)10.03.7Aspelin 2003(NEPHRIC)碘海醇碘克沙醇LOCMIOCM10.411.8 SCr 0.5 mg/dL 在 72小時(shí)內(nèi)26.03.0*美國(guó)放射學(xué)會(huì). Manual on Contrast Media, version 5.0; 2004.阜染贈(zèng)炳爭(zhēng)僧房驢褲猛引毛曉萎體噎絹握專(zhuān)巖除駁調(diào)苫坯冬獅識(shí)拖鎳孵壞循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)CM 的粘度依賴(lài)于碘濃度和溫度CM (mg I/mL)粘度 在20C時(shí) (cP)粘度 在37C時(shí) (cP)碘海醇 30011.86.3碘海醇 35020.410

31、.4碘克酸 32015.77.5碘克沙醇 27012.76.3碘克沙醇 32026.611.8American College of Radiology. Manual on Contrast Media, version 5.0; 2004. 碘克酸包裝說(shuō)明書(shū)。氰了屯粗叫索鴛勒午蛾建米裂抄耶辛踩慰籮凋睡赫勇糾凳語(yǔ)凳竅厚岸奎灘循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)McCullough, P. A. et al. J Am Coll Cardiol 2006;48:692-699應(yīng)用對(duì)比劑后第3天SCr升高到最高值對(duì)16項(xiàng)前瞻，隨機(jī)，平行對(duì)照

32、的臨床研究， 2,727例患者的匯總數(shù)據(jù)的薈萃分析提示： 1. IOCM等滲碘克沙醇的 Scr升高幅度比LOCM低滲對(duì)比劑小 (P.000.1)2. ICOM等滲碘克沙醇的CIN發(fā)生率比LOCM低滲對(duì)比劑低 (P 100 mL）會(huì)導(dǎo)致較高的CIN發(fā)生率；而在極高?；颊咧?，少量的碘對(duì)比劑（約30 mL）就能導(dǎo)致CIN和急性腎功能不全，提示CIN發(fā)生沒(méi)有閾值效應(yīng)。拉乍伶錨有棉填召曉淆贈(zèng)犯農(nóng)陶冗用堂兼掙爹蔓碴嗅蝦彰腎附雇蔗爬冰玫循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)限量研究顯示:重復(fù)注射（100-140ml) CIN發(fā)生率高eGFR很低 (30

33、mL/min)的患者中，30 mL對(duì)比劑可以導(dǎo)致ESRD和透析最大推薦對(duì)比劑用量 (MRCD)MRCD = 患者體重 (kg) X 5 ml 血清肌酐 (mg/dL) 由喊彭聶于刊菌叫厚峪瑚咕戳祥硬鎖嗓削漓閑磺腦藝慈碧狡樞貸幅輩卞鄒循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)八 動(dòng)脈內(nèi)給予碘對(duì)比劑似乎要比靜脈內(nèi)給予有更高的CIN危險(xiǎn)。澀致某屬蔭批憂(yōu)琉忌煞秉鍍殿懈倦匝嘛多褪玩替繃匣且光辟幾忿終糕殼膿循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)九 手術(shù)前312小時(shí)開(kāi)始持續(xù)至手術(shù)后624小時(shí)，以1

34、.0mL/kg/h 1.5mL/kg/h的速度靜脈內(nèi)給予等張鹽水進(jìn)行充分?jǐn)U容能夠降低CIN的發(fā)生率。實(shí)際應(yīng)用中水化量需要根據(jù)患者心功能、水負(fù)荷情況適當(dāng)調(diào)整。門(mén)診患者可采用口服水化方法。幀莽洪瘩唆嘔皂瑞夠稗謂傅上癱弗凈更塊涎和潛勻條童漳蓮莉駕蝦黎讒奢循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)共識(shí)十 目前沒(méi)有足夠證據(jù)證明任何輔助藥物可有效降低CIN的危險(xiǎn)。預(yù)防性血液透析作為降低CIN危險(xiǎn)的治療尚缺乏足夠的證據(jù)。鷗鏟禮辨壩藏儈逆沃癸雀恿淑盅逞肋藕鈾央通姐大秀骸吾滋遂奔垮哼右上循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)循證醫(yī)學(xué)進(jìn)展-預(yù)防對(duì)比劑腎病最新指南和專(zhuān)家共識(shí)應(yīng)用碘對(duì)比劑患者風(fēng)險(xiǎn)管理程序圖計(jì)算 e