日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
〒162-0801東京都新宿区山吹町358-5アカデミーセンター Japanese Society of Pediatric Cardiology and Cardiac Surgery Academy Center, 358-5 Yamabuki-cho, Shinju-ku, Tokyo 162-0801, Japan
Pediatric Cardiology and Cardiac Surgery 36(2): 166-172 (2020)
doi:10.9794/jspccs.36.166

症例報告Case Report

造影剤腎症を発症し持続血液濾過透析を導入した成人チアノーゼ性先天性心疾患の1例Contrast-Induced Nephropathy Requiring Continuous Hemodiafiltration in an Adult Patient with Cyanotic Congenital Heart Disease

1静岡県立こども病院循環器科Department of Cardiology, Shizuoka Children’s Hospital ◇ Shizuoka, Japan

2山形大学医学部小児科学講座Department of Pediatrics, Yamagata University Faculty of Medicine ◇ Yamagata, Japan

受付日:2019年8月1日Received: August 1, 2019
受理日:2020年1月6日Accepted: January 6, 2020
発行日:2020年6月1日Published: June 1, 2020
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造影剤腎症(contrast-induced nephropathy: CIN)は,脱水,重症心不全,造影剤投与前の腎機能障害や利尿薬投与,貧血などがリスクファクターとされている.CINの腎機能障害は可逆的であり,透析を要する例はまれである.一方,チアノーゼ性先天性心疾患(cyanotic congenital heart diseases: CCHD)ではしばしばチアノーゼ腎症(cyanotic nephropathy: CN)や相対的貧血を合併し,さらに難治性心不全に対して利尿薬投与や水分制限を必要とする機会が多い.しかし,CCHD患者でCINの発症リスクや発症時の重症度が高いか否かは明らかではなく,造影剤使用の危険性に関して十分な検討がなされていないのが現状である.症例は30歳女性であった.純型肺動脈閉鎖症,Blalock–Taussig シャント術後でチアノーゼが残存し,15歳時に腎生検でCNと診断された.呼吸器感染症での入院を契機に,慢性心不全の急性増悪で利尿薬やmilrinoneの投与を要した.心不全改善後に血行動態評価のため心臓カテーテル検査を施行した.検査翌日から乏尿となり,血清クレアチニンが検査前の0.79 mg/dLから最大3.86 mg/dLまで上昇し,胸腹水貯留,代謝性アシドーシスが遷延したため,CINの診断で持続血液濾過透析を8日間施行した.成人CCHD患者,特にCN合併例ではCIN発症リスクのみならず,CIN発症時の重症度がより高くなる可能性があり,造影剤使用の際は適応や使用量を含めてより慎重に検討する必要がある.

Renal dysfunction, severe heart failure, anemia, administration of diuretics, and dehydration are risk factors for contrast-induced nephropathy (CIN). The renal dysfunction is reversible in most cases of CIN, and renal replacement therapy is rarely required. Cyanotic nephropathy (CN) and relative anemia often occur in patients with cyanotic congenital heart diseases (CCHD). Although diuretic administration and fluid restriction for refractory heart failure are recommended, the association between the use of contrast media for patients with CCHD and the risk of developing CIN remains unclear. We report the case of a 30-year-old woman who had undergone a Blalock–Taussig shunt procedure at 3 months of age after being diagnosed with pulmonary atresia with intact ventricular septum, and at 15 years of age presented with proteinuria and was diagnosed with CN based on renal biopsy. During hospitalization for management of exacerbated chronic heart failure, we performed cardiac catheterization for hemodynamic evaluation. After catheterization, she developed oliguria, pleural effusion, ascites, and prolonged metabolic acidosis. Her serum creatinine levels increased from 0.79 mg/dL to 3.86 mg/dL. Based on these findings, we diagnosed the patient with CIN and performed continuous hemodiafiltration for 8 days. Patients with CCHD may be at a high risk of developing CIN and the severity may be higher in cases with CN. In these circumstances, it is necessary to carefully consider the indication and amount of contrast agent required.

Key words: cyanotic congenital heart disease; contrast-induced nephropathy; cyanotic nephropathy; continuous hemodiafiltration

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This page was last modified on 2020-06-18T11:35:35.000+09:00


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