造影剂诱导 AKI 的预防
既往研究报告称,静脉用碘化造影剂可引起造影剂性 AKI(contrast induced AKI, CI-AKI)。[5]Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's the kidney. 9th ed. Philadelphia, PA: Saunders; 2012. 然而,这种关联最近受到了一些大型人群研究的质疑,这些研究未能证明存在这种风险。[40]Wilhelm-Leen E, Montez-Rath ME, Chertow G. Estimating the risk of radiocontrast-associated nephropathy. J Am Soc Nephrol. 2017 Feb;28(2):653-9.
https://jasn.asnjournals.org/content/28/2/653.long
http://www.ncbi.nlm.nih.gov/pubmed/27688297?tool=bestpractice.com
[41]Brinjikji W, Demchuk AM, Murad MH, et al. Neurons over nephrons: systematic review and meta-analysis of contrast-induced nephropathy in patients with acute stroke. Stroke. 2017 Jul;48(7):1862-8.
https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.117.016771
http://www.ncbi.nlm.nih.gov/pubmed/28583996?tool=bestpractice.com
[42]Ehrmann S, Quartin A, Hobbs BP, et al. Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis. Intensive Care Med. 2017 Jun;43(6):785-94.
http://www.ncbi.nlm.nih.gov/pubmed/28197679?tool=bestpractice.com
在预防 CI-AKI 方面的证据很薄弱,而且经常结论不一。[57]Barrett BJ, Parfey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006 Jan 26;354(4):379-86.
http://www.ncbi.nlm.nih.gov/pubmed/16436769?tool=bestpractice.com
[58]Nijssen EC, Rennenberg RJ, Nelemans PJ, et al. Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet. 2017 Apr 1;389(10076):1312-22.
http://www.ncbi.nlm.nih.gov/pubmed/28233565?tool=bestpractice.com
如果进行非紧急影像学检查时使用了碘化造影剂,则必须在 3 个月内评估患者的肾脏功能。
2019 年,更新了英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)有关预防 CI-AKI 的建议。[3]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication].
https://www.nice.org.uk/guidance/ng148
CI-AKI 风险增加的患者包括存在以下情况的人群:
慢性肾病 [eGFR <40 mL/(min·1.73m2)]。如果患者 eGFR <40 mL/(min·1.73m2),可考虑暂时停用 ACE 抑制剂和血管紧张素 II 受体拮抗剂
糖尿病,但前提是患者同时存在慢性肾病(eGFR <40 mL/(min·1.73m2))
心衰
肾移植
年龄 ≥ 75 岁
血容量不足
碘化造影剂的用量增加
动脉内给予造影剂且首先通过肾脏暴露(例如,将造影剂注入心脏左侧或直接注入肾动脉)。
然而,强调风险评估不应延误紧急影像学检查很重要。对于使用了碘化造影剂的住院患者,如果他们具有特别强的危险因素,可考虑使用等渗碳酸氢钠或生理盐水(0.9% 氯化钠)进行静脉扩容。这些特别强的危险因素包括:
eGFR <30 mL/(min·1.73m2)
肾移植
使用大量造影剂
动脉内注射造影剂。
对于正在接受肾脏替代治疗或移植了肾脏的患者,在提供碘化造影剂之前可与肾病专科团队进行讨论,但不要延误紧急影像学检查。
请勿使用 N-乙酰半胱氨酸来预防造影剂性 AKI。[59]Weisbord SD, Gallagher M, Jneid H, et al; PRESERVE Trial Group. Outcomes after angiography with sodium bicarbonate and acetylcysteine. N Engl J Med. 2018 Feb 15;378(7):603-14.
https://www.nejm.org/doi/10.1056/NEJMoa1710933
http://www.ncbi.nlm.nih.gov/pubmed/29130810?tool=bestpractice.com
[60]Anderson SM, Park ZH, Patel RV. Intravenous N-acetylcysteine in the prevention of contrast media-induced nephropathy. Ann Pharmacother. 2011 Jan;45(1):101-7.
http://www.ncbi.nlm.nih.gov/pubmed/21205947?tool=bestpractice.com
[61]Mei M, Zhao HW, Pan QG, et al. Efficacy of N-acetylcysteine in preventing acute kidney injury after cardiac surgery: a meta-analysis study. J Invest Surg. 2018 Feb;31(1):14-23.
http://www.ncbi.nlm.nih.gov/pubmed/28060555?tool=bestpractice.com
围手术期 AKI 的预防
手术前确定患者的 AKI 危险因素,包括: