低钠血症临床诊治进展----协和顾峰

1EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHPUMCHClinicalEndocrinologyandMetabolismForumEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低钠血症临床诊治进展顾锋岑晶陈适中国医学科学院&北京协和医学院卫生部重点实验室北京协和医院内分泌科2EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH内容提要低钠血症临床重要性低钠血症发病机制低钠血症临床诊疗常规低钠血症治疗及进展3EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低钠血症临床重要性低钠血症临床重要性低钠血症发病机制低钠血症临床诊疗常规低钠血症治疗及进展4EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH基础疾病复杂，认识不足急、慢性低钠血症临床表现、诊疗原则及预后不同慢性低钠血症非特异临床表现、容易误诊抗利尿激素受体拮抗剂的治疗方案及应用前景低钠血症临床重要性—临床指南及关注问题JosephG.etal.HyponatremiaTreatmentGuidelines2007:ExpertPanelRecommendations.TheAmericanJournalofMedicine,2007.Vol120(11A),S1–S215EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低钠血症—临床最常见的水电解质紊乱•严重急性低钠血症，致死率高•慢性轻度低钠血症，合并多种基础疾病，治疗不当或延误治疗时死亡率增加•低钠血症过度治疗，导致严重的神经系统异常相关死亡率增加•合并低钠血症的患者（包括轻度低钠血症），死亡率是正常人群的3～60倍评价指标/人群发病率血钠浓度135mmol/l15～30%血钠浓度130～131mmol/l1～4%老年患者7～53%医源性/住院患者40～75%•WilliamsTextbookofEndocrinology.11thedition.•GillG,etal.ClinEndo.2006;65:246-249血钠浓度(mmol/l)死亡率125？120-12423%115-11930%11440%低钠血症临床重要性—严重危害6EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH会诊病种糖尿病及其急性并发症甲状腺疾病电解质紊乱内分泌性高血压和肾上腺病垂体和性腺疾病代谢性骨病胰腺内分泌疾病其他内分泌疾病非内分泌疾病全部例数(%)313(46.5)167(24.8)68(10.1)60(8.9)17(2.5)15(2.2)14(2.1)5(0.7)14(2.1)常规例数(%)296(53.4)127(22.9)31(5.6)46(8.3)13(2.3)15(2.7)10(1.8)4(0.7)12(2.2)急诊例数(%)17(14.3)40(33.6)37(31.1)14(11.8)4(3.4)0(0)4(3.4)1(0.8)2(1.7)病房例数(%)50(24.4)16(7.8)10(4.8)56(27.3)32(15.6)20(9.8)11(5.4)10(4.9)123111222333低钠血症临床重要性—PUMCH资料1•北京协和医院总值班—共131天值班(2010年2月10日至2010年11月19日)•673例初会诊患者7EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH所有会诊患者病种分析低钠血症临床重要性—PUMCH资料28EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHDM甲减甲亢肾上腺占位HTN和PA甲亢低钠DKADMHTN和PA•急诊中电解质紊乱十分常见•低钠血症尤该注意低钠血症临床重要性—PUMCH资料39EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH临床表现与血钠相关性临床表现有无P神经系统/14例121±9mmol/l126±10mmol/l0.05肌肉系统/11例121±12mmol/l125±8mmol/l0.05腹部症状(恶心、呕吐)/例121±12mmol/l125±8mmol/l0.05急诊20(59%)重症监护3(9%)平诊11(32%)会诊时表现为低钠血症(共34例)•年龄51±20岁，女性21例，男性13例•会诊时血钠值为123.8±9.7mmol/l明确原发或继发性肾上腺皮质功能减退史患者•急诊15/20•平诊/重症监护4/14低钠血症临床重要性—PUMCH资料410EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低钠血症发病机制低钠血症临床重要性低钠血症发病机制低钠血症临床诊疗常规低钠血症治疗及进展11EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH肾上腺皮质激素甲状腺激素心钠素脑钠素饮食渗透压中枢心、肝、肾脏抗利尿激素低钠血症发病机制—水钠平衡及其影响因素钠钠水水低钠血症水钠平衡影响因素饮食12EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH生理状态下血浆渗透压280～295mOsm/kgH2O测定方法•freezing-pointdepression•vaporpressureofpleasure•Ion-selectiveelectrodes（ISE）低钠血症发病机制—血浆渗透压/有效渗透压2×[Na+](mmol/l)Glu(mg/dl)/18BUN(mg/dl)/2.8血浆总渗透压血浆渗透压有效血浆渗透压13EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低血钠低血浆渗透压假性低钠血症(Pseudohyponatremia)•火焰光度测定法(Flamephotometry)测量•[Na+]↓=Na血浆容量(水93%+蛋白质+脂肪7%）不影响渗透浓度•Ion-selectiveelectrodes（ISE）测量可避免低钠血症低渗性高渗性等渗性高渗性低钠血症—住院患者10-20%•葡萄糖或甘油等渗透性溶质将细胞内液体转移至细胞外•稀释细胞外溶质，即血钠水平降低•直接测定血浆渗透压或校正[Na+]：[Na+]↓(mmol/l)[Glu]↑(mg/dl)参考范围(mg/dl)1.6100100～4002.4100400ReddyPandMooradianAD.Diagnosisandmanagementofhyponatraemiainhospitalisedpatients.IntJClinPract,2009,63(10):1494-1508低钠血症发病机制——低钠血症与血浆渗透压注意问题14EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH低钠血症低渗等/高渗高脂、糖、高渗物质低血容非低血容低钠血症发病机制—低钠血症分类原因：体内有其他增高渗透压的溶质诊断：直接测定血渗透压（280-295mOsm/H2O）治疗：血钠并不真低，不处理低钠胃肠道、汗液、第三间隙丢失肾脏丢失肾上腺皮质功能低减脑耗盐综合症失盐性肾病利尿剂治疗：73%噻嗪，20%联用保钾利尿，8%速尿水摄入过多心、肝脏功能障碍肾水排泄不能SIADH糖皮质激素缺乏甲状腺功能减退尿溶质排泄减少√√√15EndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCHEndocrinologyDepartment&MinistryEndocrineKeyLaboratory,PUMCH等容量或高容量性非低容量性低钠血症心、肝脏功能障碍肾水排泄异常SIADH甲状腺功能减退糖皮质激素缺乏尿溶质排泄减少水摄入过多ADH过量造成肾远端小管重吸收水增多水中毒稀释性低钠血症容量不低细胞外液扩张低钠血症(130mmol/l)低血渗(280mmol/l)高尿钠症(20mmol/l)高尿渗(100mmol/l)心钠素分泌增加，促进排钠肾素-血管紧张素-醛固酮系统受抑制醛固酮保钠作用下降低钠血