冠心病患者冠脉介入治疗术后对比剂肾病的相关因素和尿NGAL对对比剂肾病的早期诊断价值
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摘要
目的探讨尿中性粒细胞明胶酶相关载脂蛋白(NGAL)对冠心病患者经皮冠脉介入(PCI)治疗术后对比剂肾病(CIN)的早期诊断意义以及CIN的相关因素。方法选取入院后行PCI的冠心病患者208例,其中并发高血压病118例、并发糖尿病106例、并发慢性心力衰竭28例、慢性肾功能不全24例,检测术前及术后4、24、48和72 h血清肌酐(SCr)、尿NGAL的含量,对CIN进行诊断性评价。观察CIN的发生率,同时观察住院至出院1个月内的主要心血管不良事件(MACE)。结果 208例患者中术后发生CIN 31例,CIN发生率为14. 9%; CIN组糖尿病和慢性心力衰竭的患病率以及MACE发生率显著高于非CIN组(P <0. 05)。CIN组和非CIN组术前尿NGAL含量水平相似,两组比较无统计学意义,CIN组术后4 h尿NGAL开始升高,且逐渐升高至72 h,与术前比较有统计学意义(P <0. 05);非CIN组术后尿NGAL较术前升高不明显;两组术后同时段尿NGAL的含量比较具有统计学意义(P <0. 05)。ROC曲线分析发现,术后尿NGAL各时段4、24、48和72 h的曲线下面积(AUC)分别为0. 932、0. 946、0. 957和0. 975,诊断的敏感性为94%,特异性为100%;术后SCr各时段相应的AUC分别为0. 588、0. 562、0. 842和0. 879,诊断CIN的敏感性、特异性明显低于尿NGAL。Logistic多因素回归分析显示:糖尿病、SCr、肾小球滤过率估算值(e GFR)[<60 ml/(min·1. 73 m2)]、NGAL、慢性心力衰竭(左室射血分数LVEF <35%)、糖化血红蛋白(> 9. 5%)是CIN的危险因素。结论尿NGAL对PCI治疗术后CIN具有一定的早期诊断价值。并发糖尿病、慢性肾功能不全、慢性心力衰竭等为CIN的相关因素。发生CIN后MACE明显增高。
AIM To investigate the significance of urinary neutrophil gelatinase associated apolipoprotein( NGAL) in the early diagnosis of contrast induced nephropathy( CIN) after percutaneous coronary intervention( PCI) and related factors of CIN. METHODS 208 patients with coronary heart disease underwent PCI after admission were selected,including 118 with hypertension,106 with diabetes mellitus,28 with chronic heart failure and 24 with chronic renal insufficiency. Serum creatinine and urinary NGAL content were measured before and at 4,24,48 and 72 hours after PCI and diagnostic evaluation of CIN was carried out. The incidence of contrast induced nephropathy was observed and major cardiovascular adverse events were also observed within one month after hospital discharge. RESULTS After PCI,there were 31 CIN cases out of 208 and the postoperative incidence rate was 14. 9%. The prevalence of diabetes mellitus and chronic heart failure and the incidence of MACE in the CIN group were significantly higher than those in the non-CIN group( P < 0. 05). Preoperative urinary NGAL levels in the CIN group and the non CIN group were similar and there was no significant difference between the two groups( P > 0. 05). Urinary NGAL levels in the CIN group began to increase from 4 hours after the operation and the levels were still rising at72 hours,with statistical significance compared with that before operation( P < 0. 05). The urinary NGAL in the non CIN group was not significantly higher than that before operation. There was statistical difference in the content of urinary NGAL at the same time between the two groups( P < 0. 05). ROC curve analysis revealed that the area under the curve of 4 h,24 h,48 h and 72 h in each period of urinary NGAL( AUC) was respectively,0. 932,0. 946,0. 957 and 0. 975,the sensitivity of diagnosis was 94% and the specificity was100%. The area under the curve of postoperative SCr was 0. 588,0. 562,0. 842,and 0. 879,respectively.The sensitivity and specificity of the diagnosis of CIN were significantly lower than that of urinary NGAL Logistic multivariate regression analysis showed that diabetes mellitus,SCr,e GFR [< 60 ml/( min 1. 73 m2) ],chronic heart failure( LVEF < 35%) and glycosylated hemoglobin( > 9. 5%) were risk factors of CIN.CONCLUSION Urinary NGAL has early diagnostic value for CIN after percutaneous coronary intervention.Diabetes mellitus,chronic renal insufficiency,and chronic heart failure are related factors of CIN. After the occurrence of CIN,adverse cardiovascular events were increased significantly.
AIM To investigate the significance of urinary neutrophil gelatinase associated apolipoprotein( NGAL) in the early diagnosis of contrast induced nephropathy( CIN) after percutaneous coronary intervention( PCI) and related factors of CIN. METHODS 208 patients with coronary heart disease underwent PCI after admission were selected,including 118 with hypertension,106 with diabetes mellitus,28 with chronic heart failure and 24 with chronic renal insufficiency. Serum creatinine and urinary NGAL content were measured before and at 4,24,48 and 72 hours after PCI and diagnostic evaluation of CIN was carried out. The incidence of contrast induced nephropathy was observed and major cardiovascular adverse events were also observed within one month after hospital discharge. RESULTS After PCI,there were 31 CIN cases out of 208 and the postoperative incidence rate was 14. 9%. The prevalence of diabetes mellitus and chronic heart failure and the incidence of MACE in the CIN group were significantly higher than those in the non-CIN group( P < 0. 05). Preoperative urinary NGAL levels in the CIN group and the non CIN group were similar and there was no significant difference between the two groups( P > 0. 05). Urinary NGAL levels in the CIN group began to increase from 4 hours after the operation and the levels were still rising at72 hours,with statistical significance compared with that before operation( P < 0. 05). The urinary NGAL in the non CIN group was not significantly higher than that before operation. There was statistical difference in the content of urinary NGAL at the same time between the two groups( P < 0. 05). ROC curve analysis revealed that the area under the curve of 4 h,24 h,48 h and 72 h in each period of urinary NGAL( AUC) was respectively,0. 932,0. 946,0. 957 and 0. 975,the sensitivity of diagnosis was 94% and the specificity was100%. The area under the curve of postoperative SCr was 0. 588,0. 562,0. 842,and 0. 879,respectively.The sensitivity and specificity of the diagnosis of CIN were significantly lower than that of urinary NGAL Logistic multivariate regression analysis showed that diabetes mellitus,SCr,e GFR [< 60 ml/( min 1. 73 m2) ],chronic heart failure( LVEF < 35%) and glycosylated hemoglobin( > 9. 5%) were risk factors of CIN.CONCLUSION Urinary NGAL has early diagnostic value for CIN after percutaneous coronary intervention.Diabetes mellitus,chronic renal insufficiency,and chronic heart failure are related factors of CIN. After the occurrence of CIN,adverse cardiovascular events were increased significantly.
引文
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[8]丁琦,欧阳茂.经皮冠状动脉介入治疗患者造影剂肾病的发病率及其相关因素[J].心脏杂志,2015,27(2):142-144.
[9]熊丹,翟红霞,李良,等.对比剂肾病的研究进展[J].心脏杂志,2016,28(1):110-113.
[10]王心镜,刘平玲,曹雪,等.造影剂温度对经皮冠状动脉介入治疗患者造影剂肾病发病率的影响[J].心脏杂志,2017,29(2):198-201.
[11]Li WH,Wang L,He HY,et al. Expression of neutrophil gelatinase-associated lipocalin in low osmolar contrast-induced nephropathy inrats and the effect of N-acetylcysteine[J]. Exp Ther Med,2016,12(5):3175-3180.
[12]Devarajan P. Review:neutrophil gelatinase-associated lipocalin:atroponin-like biomarker for human acute kidney injury[J]. Nephrology(Carlton),2010,15(4):419-428.
[13]Mishra J,Ma Q,Prada A,et al. Identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemicrenal injury[J]. J Am Soc Nephrol,2003,14(10):2534-2543.
[14]Bachorzewska-Gajewska H,Malyszko J,Sitniewska E,et al. Neu-trophil-gelatinase-associated lipocalin and renal function after precu-taneous coronary interventions[J]. Am J Nephrol,2006,26(3):287-292.
[15]Kafkas N,Liakos C,Zoubouloglou F,et al. Neutrophil Gelatinase-Associated lipocalin as an early marker of Contrast-Inducednephropathy after elective invasive cardiac procedures[J]. ClinCardiol,2016,39(8):464-470.
[16]韩雪晶,林文华,王晓东,等. NGAL在择期冠状动脉介入术后早期肾损伤中临床引用价值的初步探讨[J].中华检验医学杂志,2014,37(7):517-521.
[17]Malyszko J,Bachorzewska-Gajewska H,Poniatowski B,et al.Urinary and serum biomarkers after cardiac catheterization in diabeticpatients with stable angina and without severe chronic kidney disease[J]. Ren Fail,2009,31(10):910-919.
[2]Munir MU,Khan DA,Khan FA,et al. Rapid detection of acutekidney injury by urinary neutrophil gelatinase-associated lipocalinafter cardiopulmonary bypass surgery[J]. J Coll Physicians SurgPak,2013,23(2):103-106.
[3]Khatami MR,Sabbagh MR,Nikravan N,et al. The role of neutro-phil-gelatinase-associated lipocalin in early diagnosis of contrastnephropathy[J]. Indian J Nephrol,2015,25(5):292-296.
[4]王蔚,葛均波.急性冠脉综合征治疗指南解读[J].中国处方药,2006,5(11):6-9.
[5]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.慢性稳定性心绞痛诊断与治疗指南[J].中华心血管病杂志,2007,35(3):195-206.
[6] Stacul F,van der Molen AJ,Reimer P,et al. Contrast inducednephropathy:updated ESUR Contrast Media Safety Committeeguidelines[J]. Eur Radiol,2011,21(12):2527-2541.
[7] Ong AT,Serruys PW,Mohr FW,et al. The SYNergy betweenpercutaneous coronary intervention with TAXus and cardiac surgery(SYNTAX)study:design,rationale,and run-in phase[J]. AmHeart J,2006,151(6):1194-1204.
[8]丁琦,欧阳茂.经皮冠状动脉介入治疗患者造影剂肾病的发病率及其相关因素[J].心脏杂志,2015,27(2):142-144.
[9]熊丹,翟红霞,李良,等.对比剂肾病的研究进展[J].心脏杂志,2016,28(1):110-113.
[10]王心镜,刘平玲,曹雪,等.造影剂温度对经皮冠状动脉介入治疗患者造影剂肾病发病率的影响[J].心脏杂志,2017,29(2):198-201.
[11]Li WH,Wang L,He HY,et al. Expression of neutrophil gelatinase-associated lipocalin in low osmolar contrast-induced nephropathy inrats and the effect of N-acetylcysteine[J]. Exp Ther Med,2016,12(5):3175-3180.
[12]Devarajan P. Review:neutrophil gelatinase-associated lipocalin:atroponin-like biomarker for human acute kidney injury[J]. Nephrology(Carlton),2010,15(4):419-428.
[13]Mishra J,Ma Q,Prada A,et al. Identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemicrenal injury[J]. J Am Soc Nephrol,2003,14(10):2534-2543.
[14]Bachorzewska-Gajewska H,Malyszko J,Sitniewska E,et al. Neu-trophil-gelatinase-associated lipocalin and renal function after precu-taneous coronary interventions[J]. Am J Nephrol,2006,26(3):287-292.
[15]Kafkas N,Liakos C,Zoubouloglou F,et al. Neutrophil Gelatinase-Associated lipocalin as an early marker of Contrast-Inducednephropathy after elective invasive cardiac procedures[J]. ClinCardiol,2016,39(8):464-470.
[16]韩雪晶,林文华,王晓东,等. NGAL在择期冠状动脉介入术后早期肾损伤中临床引用价值的初步探讨[J].中华检验医学杂志,2014,37(7):517-521.
[17]Malyszko J,Bachorzewska-Gajewska H,Poniatowski B,et al.Urinary and serum biomarkers after cardiac catheterization in diabeticpatients with stable angina and without severe chronic kidney disease[J]. Ren Fail,2009,31(10):910-919.