2020 年第 4 期 第 15 卷

二甲双胍对行直接经皮冠状动脉介入治疗患者造影剂肾病发病率的影响

Effect of metformin on the incidence of contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention

作者：于琪朱佳佳刘文娴

英文作者：Yu Qi Zhu Jiajia Liu Wenxian

单位：首都医科大学附属北京安贞医院心内科100029

英文单位：Department of Cardiology Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：急性心肌梗死；2型糖尿病；造影剂肾病；二甲双胍；直接经皮冠状动脉介入

英文关键词：Acutemyocardialinfarction;Type2diabetesmellitus;Contrast-inducednephropathy;Metformin;Primarypercutaneouscoronaryintervention

• 摘要：

• 【摘要】目的    探讨直接经皮冠状动脉介入(PPCI)围术期不停用二甲双胍对急性心肌梗死（AMI）合并2型糖尿病（T2DM）患者造影剂肾病(CIN)发病率的影响。方法    选择2008年1月至2017年12月于首都医科大学附属北京安贞医院诊断为AMI伴T2DM并行PPCI治疗患者共283例，其中PPCI围术期未停用二甲双胍组119例、在术后中断二甲双胍≥72 h组(停用二甲双胍组)共164例。比较2组患者心血管危险因素（年龄≥65岁、性别、糖尿病史≥5年、高脂血症、吸烟史、高血压史、外周血管疾病、陈旧性心肌梗死史），左心室射血分数≤40%、术中使用造影剂剂量≥300 ml、估算肾小球滤过率≤60 ml/（min·1.73 m2）、相对肌酐改变≥25%、绝对肌酐改变≥44.2 μmol/L比例，院内用药和CIN、乳酸酸中毒发生率，以及各实验室指标(糖化血红蛋白、血红蛋白、肌钙蛋白峰值、基线估算肾小球滤过率、基线肌酐、术后肌酐、相对肌酐改变和绝对肌酐改变)水平。应用Logistic回归分析CIN发生的危险因素。结果    PPCI围术期未停用二甲双胍组患者院内使用β受体阻滞剂比例高于停用二甲双胍组［79.8%(95/119)比59.8%（98/164）］，术后肌酐水平低于停用二甲双胍组［76.3(63.7，96.0)μmol/L比82.6(72.4，97.6)μmol/L］（均P<0.05）。2组患者住院期间均无乳酸酸中毒发生，心血管危险因素、院内用药情况和CIN发生率和其他实验室指标水平比较差异均无统计学意义（均P＞0.05）。Logistic回归分析结果表明，造影剂剂量≥300 ml、高血压史是CIN发生的危险因素（比值比=3.552、4.704,95%置信区间：1.653~7.631、1.165~18.994，P=0.001、0.030），而PPCI围术期持续应用二甲双胍不是CIN发生的独立危险因素（比值比=1.113,95%置信区间：0.608~2.036，P=0.728）。结论    AMI合并T2DM患者行PPCI治疗围术期持续应用二甲双胍不会增加CIN的发病率，但PPCI术中应用造影剂剂量≥300 ml和伴高血压史可能引起CIN，应引起临床关注。

• 【Abstract】Objective    To investigate the effect of metformin during perioperative period of primary percutaneous coronary intervention(PPCI) on contrast-induced nephropathy(CIN) in patients with acute myocardial infarction(AMI) and type 2 diabetes mellitus(T2DM). Methods    A total of 283 patients with AMI and T2DM undergoing PPCI from January 2008 to December 2017 in Beijing Anzhen Hospital, Capital Medical University were included. Among them, 119 cases were treated with metformin routinely during perioperative period（group A）; 164 cases stopped taking metformin 72 h after operation（group B）. Cardiovascular risk factors（age≥65 years, gender, course of diabetes≥5 years, hyperlipidemia, smoking, hypertension, peripheral arterial disease, prior myocardial infarction）, rates of left ventricular ejection fraction≤40%, contrast media volume≥300 ml, estimated glomerular filtration rate （eGFR）≤60 ml/（min·1.73 m2）, postoperative relative creatinine difference≥25% and absolute creatinine difference≥44.2 μmol/L, medication during hospital stay, incidences of CIN and lactic acidosis, laboratory indicators（glycosylated hemoglobin, hemoglobin, peak cardiac troponin, baseline eGFR, baseline creatinine, postoperative creatinine, relative creatinine difference and absolute creatinine difference） were recorded. Risk factors of CIN were analyzed by logistic regression. Results    Use rate of β-blockers in group A was higher and postoperative creatinine level was lower than those in group B［79.8%(95/119) vs 59.8%（98/164）, 76.3(63.7，96.0)μmol/L vs 82.6(72.4，97.6)μmol/L］（both P<0.05）. No case of lactic acidosis was observed during hospitalization. No statistical significance was found between groups in cardiovascular risk factors, medication, incidence of CIN and other laboratory indicators(all P>0.05). Logistic regression analysis showed that contrast media volume≥300 ml(odds ratio=3.552, 95%CI: 1.653-7.631, P=0.001) and hypertension(odds ratio=4.704, 95%CI: 1.165-18.994, P=0.030) were the risk factors of CIN. Conclusion    In T2DM patients undergoing PPCI for AMI, continuous use of metformin dose not increase the incidence of CIN. However; patients with hypertension and using contrast media volume≥300 ml are associated with higher risk of CIN.