Y HQC VigT NAM THANG 3 - SO 1/2014
NGHIEN CU'U MOT SO YEU TO NGUY C a LIEN QUAN DEN BENH THAN DO THUOC CAN QUANG TRONG 2 4 GIO" DAU
CAN THIEP DONG MACH VANH QUA DA
T6M TAT
Bddc d^u danh gia mgt sd yeu to nguy cO co lien quan den benh than do thuoc can quang (QN) trong 24 gid dau can thiep dpng mach vanh qua da d 511 bfnh nhan (BN) nam va niT mac benh ddng mach vanh (DMV), nSm dieu tri ndi trii tai Vien Tim Mach Quoc gia Vi?t Nam - Benh vien Bach Mai tir thang 8/2008 den thang 2/2009. Ket qua: cd 40 BN mac CIN (7,8%), nong dp creatinin mau trung binh trong 24 gid dau thii thuat tSng hdn yyde thii thuat ro ret (p < 0,001). Mot so yeu to nguy cd lien quan den CIN bao gom: thuoc can quang (TCQ) ion hda (p < 0,001), tuoi BN > 70 (p
< 0,05), soc bm (p <-0,001), suy tim NYHA III-IV (p <
0,05), phan so tong mau that trai tren sieu am tim (EF) < 29% (p < 0,01), suy than (p < 0,001), tang huyet ap (p < 0,05). Chda thay co mdi lien quan vdi a N trong cac yeu td sau; gidi tinh, the tich TCQ, dai thao dddng.
Tir khoa: Benh than do thudc can quang; Can thi|p OMV qua da; Yeu to nguy cd.
SUMMARY
STUDY ON RISK FACTORS RELATED TO CONTRAST I N D U C E D NEPHROPATHY
DURING THE FIRST 2 4 HOURS OF PERCUTANEOUS CORONARY I N T E R V E N T I O N 511 consecutive patients were monitored senjm creatinine levels before and during the first 24 hours percutaneous coronary intervention at the Vietnam Heart Institute-Bachmai Hospital from 08/2008 to 02/2009. Some risk factors associated with Contrast Induced Nephropathy (QN) has been studied and analyzed.
Results: 40 pabents were idenbfied as CIN (increased serum creatinine levels compared to 44,2 nmol/l before procedures) reached 7,8%. "Hie average serunfi creatinine levels during the first 24 hours procedures w/as higher than average senjm creatinin levels before (p < 0,001). Some risk factors involving:
using Ionizing contrast (p < 0,001), the age of patients a 70 (p < 0,05), cardiogenic shock (p < 0,001), heart failure NYHA level III-IV (p < 0,05), left venbicular ejection fraction < 29% (p < 0,01), renal disease (p <
0,001), hypertension (p < 0,05).
Keywords: Contrast Induced Nephropathy, percutaneous coronary Intervention, risk factors.
Han N h a t L i n h * , Pham Gia K h a i * , Hoang Minh H a n g * *
l . O A T V A N O E
Hien nay, can thiep ddng mach vanh qua da (PCI) la phydng phap dieu trj dieu tn benh OMV rat hieu qua, p^hddng phap nay phal sd dung TCQ de bde Id ton thddng cung nhy danh gia ket qua eua thii thuat. Tuy nhien, sau thii thuat van edn mdt ty le CIN, Qua theo ddi va tim hieu, chiing tdi thay cd mdt so yeu to nguy cd lam tang ty le mac CIN tropg 24 gid dau PCI nhd:
TCQ ion hda, nhdm tuoi > 70, sde tim, suy tim NYHA III-IV, EF < 29%... Vi vay chiing tdi tien hanh nghien eiTu de tai nham muc tieu: "Bddc diu dinh gii va xie dinh mdt sdyiu tdnguy cd iien quan den ty ip mac CIN trong 24 gid dau can thiep dpng mach vinh qua da."
II. OOI TU'ONG VA P H i r a N G PHAP NGHIEN CUIJ 2 . 1 Odi tu'dng nghien cu'u: bao gdm 511 BN nhap vien cap ciTu va nam dieu trj ndi trii tai Vien Tim maeh Viet Nam, ed ehi dinh ean thiep OMV, thdi gian tir thang 8/2008 den thang 2/2009.
2.1.1. Tieu chuan chpn BN: 511 BN cd chi dinh PCI cap ciTu va PCI cd chuan bj dddc theo ddi ndng do creatinin mau trydc va trong 24 gid dau thil thuat can thleia.
2.1.2. Tieu chuan ioai trd: can thiep cho bat thydng ve giai phau OMV. Tien sir dj dng TCQ. Suy^than do I l l b - I V theo phan do suy than ciia Nguyen Van Xang.
2.2. Phu'dng phap nghien cii'u:
2.2.1. Thiet ke nghien cdu: Nghien ciru tien eiai, md ta eat ngang, theo ddi dpc trong 24 gid dau ke tir khi bat dhu thii thuat can thiep DMV 2.2.2. Tieu chuan chin doin xie djnh CIN: khi nong do creatinin mau tang 44,2 ^mol/l (0,5 mg/dl) hoae tang 2 5 % so vdi nong dp creatinin mau tru'de khi diing TCQ ma khdng do cae nguyen nhan khac [ 5 ] .
2.2.3. Xd iy sd iieu: bang phan mem SPSS 16.0, thuat toan T-test de so sanh trung binh, kiem dinh gia thiet bang thuat toan x^ va ydc lydng khoang tin cay eiia OR de so sanh cac ty le.
'^ignTim m^ch Vigt Nam
"D^IhgcYH^Npi
Phin bign khoa hpc: PGS.TS L i Vi?t ThSng
Y H O C VIET NAM THAN^ii i - ^..,
. KET QUA NGHIEN CU'U VA BAN LUAN
3.1, Oac diem lam sang va can lam sang tru'de thii thuat can thiep Bang 1. Oae diem lam sang va can lam sang
Oac diem
Tuoi Gi(Si tinh
NMCT
>90 40-89
<40 Nam Nff
< 6 gid 6 - 23 gid 1 - 14 ngay
> 14 nqay Oau tiiat ngu'c on dinii Soc tim trffdc can tiiiep (Killip IV) Suy tim NYHA III-IV Suy tim Kiliip III Tanq tiuyet ap Suy tiian Dai thao dffdng Roi loan lipid mau EF* < 29%
Hcf van hai la vffa - nhieu
ScfBN 2 506
3 395 116 43 92 122
11 243 15 53 28 316 8 66 81 39 41
Ty le "/o 0,4 99,0 0,6 77,3 22,7 8,4 18,0 23,9 2,2 47,6 2,9 10,4
5,5 61,8 1,6 12,9 15,9 7,6 8,0
^ ChLfc nang tam thu that trai tren sieu am tim 3.2. Dac diem vj tri va tinli chat ton thu'Ong DMV
Trong so 511 BN nhap vien, co 268 BN vdi chan doan hpi chffng Of^V cap va du'de tien hanh PQ cap cffu (52,45%), va 243 BN vdl chan doan dau ngu'c on dinh va dffdc tien hanh PCI co chuan bj (47,55%). Tat ca cac BN deu dffdc chup OMV trffdc thu thuat va co l<et qua:
Bang 2. Ket qua chijp DMV Dac diem Than chung DMV OM lien that trffdc OM mu OMV phal Tac hoan toan OMV Ton thffdng 3 than OMV
SoBN 35
Ty le % 6,B
65,6 36,8
3.3. Ty le mac CIN: Theo doi nong do creatinin trffdc va sau 24 gid dau thu thuat can thiep cl 511 BN, dffa theo tieu chuan chan doan xac dinh CIN thi co 40 BN mac CIN, chiem ty le 7,8%.
Bang 3, Nong dp creatinin mau trung binh tai 2 thdi diem thii thuat Creatinin (^mo|/l) Tru'de thii thuat (n = 511) I Sau thii thuat (n = 511)
Nong do trung binh 9,09 ± 29,25 110,18 ± 42,97 < 0,001
Thap nhat - Cao nhat 46 - 292 52 - 407
Nghien c&u cua Hd Van Phudc cho thay ndng do creatinin mau trung binh d nhiihg BN sau khi ding TCQ tang ien rd ret so vdi trudc khi ddng (109,0 ± 47,9 so vdi 90,5 ± 22,9 vdip < 0,001) [2J. Hhil vay so vdi ket qua bang 3, ndng do creatinin mau trung binh sau khi dung TCQ tang ien rd ret so vet trudc khi dung TCQ.
3.4. Oac diem ve gidi tinh va nhom tuoi mac CIN Bang 4. Ty le mac ON theo gidi ti'nh
^^^^PCI Gidi^^-^
Nam Nff
P
Cap cu'u (n = 268) n
19 4
Ty le % 8,7 8,0
>0,05
Co chuan bi (n = 243) n 1 Ty le % 16 1 9,0 1 1 1,5
<0,05
Chung (n = 511) n
35
1 5Ty le % 8,9 4,3
>0,05
Y HQC VigT NAM THANG 3 - SO 1/2014
Gi&i tinh: nghien cijru ciia Roxana Mehran thi nu' gidl co nguy cd mac CIN gap 1,5 lan so vdl nam gidl [7]. Hien nay, theo khuyen cao ciia hoi dien quang Canada Ithong de cap yeu to nguy cd mac CIN ve gidi tinh [5].
Nhff vay so vdl cac nghien cffu tren, ket qua nghien cffu ciia chung toi khong cho thay moi tffdng quan glu^ gidl tinh vdi ty le mac QN.
Bang 5. Ty le mac CIN theo gidl tinh va nhdm tuoi
Nhom tuoi < 70 (n = 343) I Nhom tuoi > 70 (n = 168F 19 (6,9%)
1 (1,4%)
16 (13,2%) 4 (8,5%)
<0,05
>0,05 . Ca 2 gidl 20(5,8%) _ | 20(11,9%) I < 0,05 .
Nhdm tuoi: theo Rich MW va Crecelius CA, tuoi > 70 la yeu to nguy ai doc lap tien Iffdng mac CIN [6]. Nghien cffu ciia Ho Van Phffdc so sanh 2 nhdm tudi cho thay tuoi > 70 cd ty le mac CIN cao hdn tuoi < 70 vdi p = 0,045 [2].
Phan ti'ch ket qua bang 4: ty le mac CIN d nhdm > 70 tud'i cao hdn ty le mac CIN d nhdm < 70 tuoi (p < 0,05).
3.5. Dac diem ve the tich va dac tinh hoa hoc cua thudc can quang:
Bang 6. Ty le mac CIN theo the tich va dac tinh hda hgc ciia TCQ CIN (n = 40) Khong (n = 471) The tich
m > 200 - 300
39 (7,8%) 1 (10%)
462 (92,2%) 9 (90%)
>0,05 03c tinh
hoa hoc
Ion hoa Khong lon hoa
22 (15,4%) OR (95% CI)
18 (4,9%)
121 (84,6%) 3,53 (2,53 - 4,94)
350 (95,1%)
< 0,001
* The tich TCQ: nghien cffu ciia Roxana Mehran va cong sff cho thay cd moi tffdng quan giii'a the tich TCQ vdi CIN (p = 0,045; OR = 1,24) [7].The tfch TCQ trong cac nghien cffu tren rat ldn so vdi the tich TCQ trong nghien cffu ciia chung toi (nhieu nhat la 300 ml, ft nhat la 100 mlj. Do vay, ket qua da phan tichkhong cho thay moi tffdng quan giffa CIN vdl the tfch TCQ diing cho BN trong thii thuat.
* DSiC tinh hda hgc cua TCQ: trong thff nghiem RECOVER so sanh tac dung TCQ loai lon hda (hexabrix) vdl loai khdng lon hda cho thay:
ty 1$ mSc QN d nhdm lon hda cao hdn ty le mac
CIN d nhdm khdng ion hda, theo Sang-Ho Jo va cdng sff dac tfnh hda hoc ciia TCQ la yeu td nguy cd mac CIN [8].
Trong nghien cffu ciia chiing tdi cd 3 loai TCQ Q\S^c sff dung trong thii thuat: hexabrix 320, xenetic 300 va ultravis 300, ca 3 loai TCQ nay deu ap Iffc tham thau thap. Trong dd, hexabrix la loai ion hda, xenetic va ultravis la ioai khdng ion hda. Qua phan tich ket qua: ty le mac CIN d nhffng BN dffdc diing TCQ loai ion hda cao hdn ty le mac CIN d nhffng BN dffdc diing TCQ loai khdng lon hda (OR = 3,53; 95% CI tff 2,53 den 4,94; p < 0,001).
3.6, Ty \% va dac diem mot so yeu to nguy cd Men qu Bang 7. Ty le mot so yeu td lam sang va can lam sane
Yeu tef Sdc tim Khonq NYHA III-IV
NYHA I-II EF < 29%
EF > 29%
Suy than Khdng Oai thao dffdng
Khdng T3nq huyet ap
Khdnq
CIN (n = 40)
6 (40%) 34 (6,9%) 8(15%) 32 (7%) 9(23,1%) 31^6,6%) 8 (100%) 32 (6,4) 9 (13,6%)
31 (7%) 32(10,1%) 8 (4,1%)
Khong (n = 471)
9 (60%) 462(93,1%)
45 (85%) 426 (93%) 30 (76,9%) 441 (93,4%) 0 (0%) 471 (93,6%)
57 (84,6%) 414 (93%) 284 (89,9%) 187 (95,9%)
an den CIN lien quan den CIN
OR ( 9 5 % CI) 9,06 (3,9 - 15,8) 2,37 (1,55 - 3,62) 4,27 (2,8 - 6,52)
•
2,110,96-4,66 2,63 (1,75 - 3,95)
P
< 0,001
<0,05
<0,01
< 0,001
>0,05
<0,05
Do CO ty le bang 0 nen khong tmh OR.
Y HOC VIET NAM T H A H V . O •
- Sdc tim: ty le mac CIN d nhu'ng BN soc tim eao hdn ty le mac CIN d nhii'ng BN khong soc t i m . Nguy Cd mac CIN d nhii'ng BN soc tim cao gap 9 lan so vdi nhii'ng BN khong soc tim (p < 0,001).
- EF < 29%: ty le mac CIN d nhij'ng BN c6 EF <
2 9 % cao hdn ty le mac CIN d nhii'ng BN co EF >
29%. Nguy cO mac CIN d nhii'ng BN eo EF <
2 9 % eao gap 4 lan so vdl nhutig BN eo EF >
2 9 % (p < 0,01).
- Suy tim NYHA III, IV: nghien cifu ciia Roxana Mehran va cpng SLT cho thay co 3 8 , 5 % NYHA I I I , IV trUdc thil thuat ed nguy eO mac CIN eao hdn so vcfi NYHA I, I I vcfi p < 0,0001 [ 7 ] . Nghien cii'u CLia Charanjit S. Rihal va eong su'cung cd ket qua tu'dng tu', vcfi 35,4% BN co NYHA I I I , IV tru'de thil thuat bj mac CIN [ 1 ] .
Trong soc tim, EF < 2 9 % va suy tim NYHA I I I , IV eung lu'ong tim giam do do lu'u lu'cfng mau den than giam, TCQ lam tang hoat tinh co maeh than dan den thieu oxy nhu mo than lam tang nguy cd mac CIN.
- Ting huyit ip: tang huyet ap eo moi lien quan den chu'c nang than, Ilan Goldenberg va Shlomi Matetzky cho rang THA la yeu to nguy cd tien lu'dng mac CIN (OR = 1,20, 9 5 % CI tir 1,06 den 1,36) [ 3 ] ,
- Suy thin: nghien eiru ciia Luis Gruberg va cong sir cho thay CIN chiem 1/3 trong so 439 BN du'de PCI CO nong do creatinine mau > 177 jimol/l, va cho thay ty le mac CIN trong suy than man tinh rat cao (55%) [ 4 ] . Trong nghien ciru eiia chiing toi CO 8 BN suy th$n mac CIN (100%) va 32 BN khong suy than mac CIN (6,4%). Nhu' vay cho thay suy than tru'de thii thuat la nguy cd rat cao doi vdi CIN, hay noi each khac suy than la yeu to tien lu'dng doc lap mac CIN.
IV. KET LUAN
Qua theo doi va nghien ciTu 511 BN du'de can thiep DMV qua da tai Vien Tim maeh Viet Nam, bu'de dau chiing toi nhan thay:
- Ty le mac CIN sau 24 gid dau PCI ehiem 7,8%.
Nong do creatinin mau trung binh trong 24 gid dau t h i l thuat can thiep tang hdn tru'de thii thuat r 6 r e t ( p < 6,001).
- Mot SO yeu to nguy cd lien quan den ty le mac CIN, bao g o m :
+ TCQ Ion hoa Nhom tuoi Sde tim Suy tim NYHA I I I - I V
- EF < 2 9 % - Suy than - Tang huyet ap
TAI UEU T H A M KHAO
1 . Charanjit S. Rihal, Stephen C. Textor, et al (2002), "Incidence and Prognostic Importance of Acute Renal Failure After Percutaneous Coronary Intervention", Circulation, 105: 2259-2264.
2. H'6 Van Phu'dc (2006), "Nghien ciili mgt so yeu to anh hu'dng den chirc nang than sau can thiep (Jong maeh vanh qua da", Luin van Thac sy Y hgc- Dai hpc Y Ha Npi, Tr. 34-53.
3. Ilan Goldenberg, Shlomi Matetzky (2005),
"Nephropathy induced by contrast media;
pathogenesis, risk factors and preventive strategies", CMAJ; 172(11): 1461-1459.
4. Luis Gruberg, Gary S. Mintz, Roxana Mehran, et al (2000), "The Prognostic Implications of Further Renal Function Deterioration Within 48 h of Inten/entional Coronary Proeedures in Patients With Pre-existent Chronic Renal Insufficiency", J Am Coll Cardiol, 36: 1542-1548.
5. Owen RJ, Hiremath S, Myers A, Fraser-HIII M, Barrett B. (2011), "Consensus Guidelines for the Prevention of Contrast Induced Nephropathy", Canadian Association ot Radiologists, 2-12.
6. Rich MW, Crecelius CA, (1990), "Incidence, risk factors, and clinical course of acute renal insufficieney after cardiac catheterization In patients 70 years of age or older. A prospective study". Arch Intern Med, 150(6); 1237-1242, 7. Roxana Mehran, Eve D. Aymong, Eugenia
Nikolsky, et al (2004), "A Simple Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention Development and Initial Validation", J Am Q)S Cardiol, 44: 1393-1399.
