心導管手術病人接受預防顯影劑引起急性腎衰竭介入措施之成效評估

Implementation and outcomes of a prevention protocol of contrast-induced acute kidney injury after percutaneous coronary interventions

吳蕙純(Hui-Chun Wu)

指導教授 ： 簡淑真

臺北醫學大學/藥學院/藥學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00164

摘要

研究背景及目的：顯影劑引起之急性腎衰竭(CIAKI)為經皮冠狀動脈介入治療(PCI)的其中一項併發症，且顯影劑引起之急性腎衰竭為住院引起的腎衰竭之原因中的第三位。此外，在許多文獻指出，適當的預防方式可有效降低顯影劑引起之急性腎衰竭的發生，故本研究的目的為評估院內心導管手術病人的顯影劑引起之急性腎衰竭(CIAKI)的發生率及接受「預防顯影劑引起急性腎衰竭介入措施」之成效評估。
研究方法：本研究為一前瞻性、介入性之研究，利用與過去一年內接受心導管手術病人的資料，比較執行「預防顯影劑引起急性腎衰竭介入措施」後的病人及對照組的顯影劑引起之急性腎衰竭(CIAKI)之發生率、腎功能變化及臨床成效(clinical outcomes)。納入條件為年紀大於18歲，且接受經皮冠狀動脈介入治療(PCI)的病人，且病人有執行手術前及後三天內的血清肌肝酸值(serum creatinine)。而病人為末期腎臟疾病並需長期洗腎、住院期間曾執行主動脈瘤之結紮或修補術、罹患敗血症、住院期間曾待過加護病房者及對N-乙醯半胱胺酸(N-acetylcysteine)過敏者均予以排除。「預防顯影劑引起急性腎衰竭介入措施」於99年2月開始執行，實驗組為執行此措施後之四個月內接受心導管手術的病人，對照組為98年1月至12月接受心導管手術的病人。「預防顯影劑引起急性腎衰竭介入措施」包括確認病人的危險因子、停止使用可能具有腎毒性之藥物、預防性使用N-乙醯半胱胺酸(N-acetylcysteine)及水分之補充方式。
研究結果：本研究兩組均各收納57位病人，兩組間的基本資料特性大多相似，包括年齡、性別、並存疾病、腎功能等。在結果中發現，於對照組有11位(19.3%)病人於住院期間發生顯影劑引起之急性腎衰竭(CIAKI)，而實驗組中無病人發生顯影劑引起之急性腎衰竭(CIAKI) (p < 0.001)。其中，病人為執行緊急的心導管手術及顯影劑的劑量為發生顯影劑引起之急性腎衰竭(CIAKI)的危險因子。對照組的平均血中肌酸酐值在給予顯影劑後增加0.09 ± 0.64 mg/dL，實驗組則是減少0.08 ± 0.34 mg/dL，但兩組間沒有顯著差異(p = 0.08)。另外，在對照組的病人其住院天數為17.58 ± 18.4天，而實驗組的病人住院天數為6.23 ± 9.18天 (p < 0.001)。此外，於對照組有三位病人(5.3%)發生手術併發症，實驗組則沒有病人有發生手術併發症(p = 0.24)，而兩組均沒有病人於住院期間死亡。
結論：某醫院心導管手術病人的顯影劑引起之急性腎衰竭(CIAKI)之發生率為19.3%，在執行「預防顯影劑引起急性腎衰竭介入措施」後，顯影劑引起之急性腎衰竭(CIAKI)顯著下降，且可減少腎功能的變化，並且可減少病人的住院天數及手術併發症。故於心導管手術病人執行「預防顯影劑引起急性腎衰竭介入措施」為可行且具有成效的。

關鍵字

顯影劑 ； 顯影劑引起之急性腎衰竭 ； 介入預防措施 ； 發生率

並列摘要

Background and Objective: Contrast-induced acute kidney injury (CIAKI) is one of the recognized complications of percutaneous coronary intervention (PCI) and is associated with prolonged hospitalization and adverse clinical outcomes. Moreover, CIAKI now ranks third in the causes of hospital-acquired acute renal failure. In addition, there was convincing evidence showing that adequate of prevention can significantly decrease the rate of CIAKI. The objectives of the study are to identify the incidence of contrast-induced acute kidney injury (CIAKI) and to assess the effectiveness of “Contrast-induced acute kidney injury prevention protocol”.
Study design: The study is a prospective, interventional study of patients who scheduled for percutaneous coronary interventions (PCI) and underwent the prevention protocol. The outcomes of the implementation of the protocol were compared with a historical control comparison group. The incidence of CIAKI was identified in both two groups.
Patients: Inclusion criteria are patients whose age were over 18 and were scheduled to undergo PCI from January 1, 2009 to May 31st, 2010. If they had both a baseline creatinine value before and within 3 days of the PCI, they would be included. Patients who had end stage renal disease, suprarenal aortic clamping for aortic aneurysm surgery, diagnosis of septicemia, admitted to intensive care unit during the hospitalization and were known allergic to N-acetylcysteine were excluded.
Time period: Protocol group: February 1, 2010 through May 31, 2010; Historical controlled group: January 1, 2009 through December 31, 2009.
Intervention: A prevention protocol incorporating identification of patients’ risk factors, discontinuation of nephrotoxic medications, hydration strategies, use of N-acetylcysteine.
Measurements and results: There were both 57 patients in protocol and historical controlled group. Eleven patients (19.3%) developed CIAKI in the control group and no patients developed CIAKI in protocol group (p < 0.001). The change of renal function in mean serum creatinine value after PCI increased 0.09 ± 0.64 mg/dL in control group and decreased 0.08 ± 0.34 mg/dL in protocol group (p = 0.08). The length of stay was shorter in protocol group, which was 6.23 ± 9.18 days in protocol group and 17.58 ± 18.4 days in control group (p < 0.001). There was decreased rate of complications during the hospitalization in the protocol group (p = 0.24).
Conclusion: Clinical implementation of a prevention protocol of contrast-induced acute kidney injury is effective and is associated with decreased rate of incidence of CIAKI in patients undergoing percutaneous coronary interventions.

並列關鍵字

Contrast media ； contrast-induced acute kidney injury (CIAKI) ； protocol ； prevention ； incidence ； N-acetylcysteine

參考文獻

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