2014歐洲低鈉血癥診療指南

1、2014 歐洲低鈉血癥診療指南解讀,山東大學(xué)附屬千佛山醫(yī)院呼吸科張劭夫,,歐洲危重病學(xué)會(huì)（ESICM），歐洲內(nèi)分泌學(xué)會(huì)（ESE）歐洲腎臟最佳臨床實(shí)踐（European Renal Best Practice ERBP)為代表的歐洲腎臟病協(xié)會(huì)和歐洲透析與移植協(xié)會(huì)（ERA-EDTA）共同制定了歐洲低鈉血癥臨床診療指南,低鈉血癥,Hyponatraemia, defined as a serum sodium concentratio

2、n＜135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It occurs in up to 30% of hospitalised patients and can lead to a wide spectrum of clinical symptoms, from

3、 subtle to severe or even life threatening (10, 11),定義： 血清鈉低于135mmol/L臨床最常見(jiàn)的水鹽失衡，其發(fā)生率約占住院患者的30%癥狀不一，從輕微到致命,,In most cases, hyponatraemia reflects low effective osmolality or hypotonicity, which causes symptoms o

4、f cellular oedema. However, hyponatraemia may also (rarely) occur with isotonic or hypertonic serum if the serum contains many additional osmoles, such as glucose or mannitol. Therefore, we discuss not only how hypo-osm

5、olar but also how isosmolar and hyperosmolar states develop.,絕大多數(shù)情況下，低鈉血癥反映了低有效滲透壓狀態(tài)，主要引起細(xì)胞水腫然而，如果血清含有其他滲透性物質(zhì)如葡萄糖和甘露醇，則低鈉血癥在個(gè)別情況下也可發(fā)生于等滲或高滲情況。因此，低鈉血癥不僅見(jiàn)于低滲，也見(jiàn)于等滲和高滲的情況。,,Severe symptoms of hyponatraemia are caused by

6、 brain oedema and increased intracranial pressure. Brain cells start to swell when water moves from the extracellular to the intracellular compartment because of a difference in effective osmolality between brain and pla

7、sma.patients with chronic hyponatraemia and no apparent symptoms can have subtle clinical abnormalities when analysed in more detail. Such abnormalities include gait disturbances, falls, concentration and cognitive def

8、icitspatients with chronic hyponatraemia more often have osteoporosis and more frequently sustain bone fractures than normonatraemic persons,低鈉血癥嚴(yán)重癥狀為腦水腫。低滲的血漿向高滲的腦細(xì)胞進(jìn)行水轉(zhuǎn)移，導(dǎo)致細(xì)胞腫脹慢性和無(wú)明顯癥狀的低鈉血癥患者，可有如下輕微癥狀：步態(tài)不穩(wěn)，跌倒，注意力

9、不集中和認(rèn)知障礙慢性低鈉血癥患者更易發(fā)生骨質(zhì)疏松和骨折,圖示：大腦對(duì)低鈉血癥的適應(yīng)過(guò)程：1即可反應(yīng)2快速適應(yīng)3慢適應(yīng)調(diào)節(jié)4不適當(dāng)糾正（快速升高滲透壓）5適當(dāng)糾正（緩慢提高滲透壓）,6. 低鈉血癥診斷Diagnosis of hyponatraemia6.1. 分類：Classification of hyponatraemia,,根據(jù)血鈉濃度分類：6111：輕度(mild)低鈉血癥：血鈉：

10、 130~135mmol/l6112： 中度（moderate）低鈉血癥：血鈉： 125~129mmol/l6113：重度（profound）低鈉血癥： 血鈉： <125mmol/l,,,依據(jù)發(fā)生時(shí)間分類：6121：急性低鈉血癥<48h61

11、22: 慢性低鈉血癥≥48h6123如果不能對(duì)其分類，除非有臨床或回顧性反證（表8），則應(yīng)認(rèn)為系慢性低鈉血癥,為何以48小時(shí)為界限界定急慢性低鈉血癥？,This usually occurs when hyponatraemia develops rapidly, and the brain has had too little time to adapt to its hypotonic environment.Over t

12、ime, the brain reduces the number of osmotically active particles within its cells (mostly potassium and organic solutes) in an attempt to restore the brain volume (Fig. 2). This process takes 24–48 h, hence the reason f

13、or using the 48-h threshold to distinguish acute (＜48 h) from chronic (≥48 h) hyponatraemia,當(dāng)?shù)外c血癥發(fā)生快速發(fā)生時(shí)，腦細(xì)胞幾乎沒(méi)有時(shí)間來(lái)適應(yīng)低滲環(huán)境。大腦通過(guò)減少其細(xì)胞內(nèi)滲透活性物質(zhì)如鉀和有機(jī)溶質(zhì)以試圖恢復(fù)腦容量。此過(guò)程需時(shí)24~48小時(shí)。因此，以48小時(shí)作為急性和慢性低鈉血癥的界限,表8 與急性低鈉血癥相關(guān)的藥物和病情,,術(shù)后階段前列

14、腺癌的手術(shù)切除后，內(nèi)鏡下切除后子宮手術(shù)煩渴運(yùn)動(dòng)最近的噻嗪類藥物處方3,4-methylenedioxymethamfetamine（MDMA，XTC）結(jié)腸鏡檢查的準(zhǔn)備工作環(huán)磷酰胺（IV）催產(chǎn)素最近開(kāi)始去氨加壓素治療最近開(kāi)始特利加壓素，加壓素,,根據(jù)癥狀分類：6131：中度癥狀 惡心 意識(shí)混亂

15、 頭痛6132：重度癥狀 嘔吐 心臟呼吸窘迫 嗜睡 癲癇樣發(fā)作 昏迷（Glasgow評(píng)分≤8）,低鈉血癥分類的說(shuō)明,血鈉水平：重度低鈉血癥值為≤125mmol/l，文獻(xiàn)提示110～125mmol/l,患者癥狀明顯且嚴(yán)重進(jìn)展速度：低鈉血癥發(fā)生于＜48h更

16、易腦水腫發(fā)生，且腦需要48h適應(yīng)低鈉環(huán)境，但如果血鈉糾正過(guò)快，則腦可能再損傷癥狀輕重：指南根據(jù)急性低鈉血癥的觀察，將癥狀分為中重度。重度癥狀者病死率增高。指南避免提及“無(wú)癥狀”低鈉血癥，因?yàn)閲?yán)格意義上，患者并非無(wú)癥狀，僅僅是表現(xiàn)為不引人注意的注意力不集中血液滲透壓：指南主要涉及低滲性低鈉血癥，故需首先建立區(qū)分高滲與非高滲的臨床標(biāo)準(zhǔn)（見(jiàn)6.2）測(cè)得的血清滲透壓＜275 mOsm/kg 總提示為低滲性低鈉血癥,因?yàn)橛行B透壓絕不會(huì)高于總

17、或測(cè)得的滲透壓。（as effective osmolality can never be higher than total or measured osmolality.） 如果計(jì)算的滲透壓＜275 mOsm/kg 則低鈉血癥可能是低滲，等滲或高滲，這取決于哪些滲透性活性物質(zhì)的存在和其是否計(jì)入公式。（By contrast, if calculated osmolality is＜275 mOsm/kg, hyponatraemia

18、 can be hypotonic, isotonic or hypertonic, depending on which osmotically active agents are present and whether or not they are incorporated in the formula.）血容量：低鈉血癥患者可以分別是低容、等容或高容。傳統(tǒng)診斷程序是首先評(píng)估患者的容量狀態(tài)，但所謂容量狀態(tài)究系指細(xì)胞外液量、有效

19、循環(huán)血量還是體內(nèi)液體總量，含義不清。為避免混亂，本指南將其定義為有效循環(huán)血量。,6.2 證實(shí)低滲性排除非低滲性低鈉血癥,6.2.1.1 推薦通過(guò)測(cè)定血糖，排除高糖性低鈉血癥。如果血糖增高，校正血鈉濃度（表9）。6.2.1.2 測(cè)得的滲透壓＜275 mOsm/kg 總提示為低滲性低鈉血癥。6.2.1.3 若無(wú)表10中所列非低滲性低鈉血癥的證據(jù)則接受“低滲性低鈉血癥”。,滲透量表示方法不同：一種是重量滲透克分子濃度(Osmolal

20、ity)，每公斤水中所含的毫滲透粒子數(shù)(mOsm/kg H2O)，冰點(diǎn)滲透計(jì)測(cè)量滲透壓就是用此單位表示的。另一種是容量滲透克分子濃度(Osmolarity)，即每升溶液中所含的毫滲透粒子數(shù)(mOsm/L)，,6.3 區(qū)別低滲性低鈉血癥的參數(shù)？,6.3.1.1 首先檢測(cè)并解釋尿滲透壓6.3.1.2 如果尿滲透壓≤100 mOsm/kg,可認(rèn)為水?dāng)z入相對(duì)過(guò)量是低滲性低鈉血癥的原因。6.3.1.3 如果尿滲透壓＞ 100 mOsm/

21、kg,推薦同時(shí)在采取血液標(biāo)本的基礎(chǔ)上解釋尿鈉濃度。6.3.1.4 如果尿鈉濃度≤30mmol/l,推薦接受有效循環(huán)血量降低為低滲性低鈉血癥的原因6.3.1.5 如果尿鈉濃度＞ 30mmol/l，建議評(píng)估細(xì)胞外液狀況和利尿劑的應(yīng)用，以進(jìn)一步明確低鈉血癥的可能原因。6.3.1.6 不建議檢測(cè)加壓素用于診斷SIADH.,關(guān)于區(qū)別低滲性低鈉血癥的參數(shù)的建議 （G22）,需要同時(shí)采取血和尿標(biāo)本方可對(duì)實(shí)驗(yàn)室結(jié)果做出正確解釋尿鈉濃度和

22、尿滲透壓測(cè)定最好取自同一標(biāo)本如果臨床評(píng)價(jià)表明，細(xì)胞外液量無(wú)明顯增加，尿鈉濃度＞30 mmol/L，在考慮SIAD之前，排除其他原因低滲性低鈉血癥血癥。可考慮根據(jù)表6中列出的診斷標(biāo)準(zhǔn)，尋找SIAD的已知原因。 原發(fā)或繼發(fā)腎上腺皮質(zhì)功能低下可能是低滲性低鈉血癥的潛在原因腎臟疾病使得低鈉血癥鑒別診斷復(fù)雜化。除了導(dǎo)致可能的低鈉血癥外，腎臟調(diào)節(jié)尿滲透壓和尿鈉能力常降低。因而，尿滲透壓和尿鈉可能不再能夠可靠地反映激素對(duì)血鈉的調(diào)節(jié)作用，任何低鈉

23、血癥的診斷程序均應(yīng)慎用于腎臟病患者水負(fù)荷試驗(yàn)無(wú)助于對(duì)低滲性低鈉血癥的鑒別，且存在危險(xiǎn)。,SIAD診斷標(biāo)準(zhǔn),,,基本準(zhǔn)則 有效血漿滲透壓＜275毫滲/公斤 有效滲透壓某種程度的下降,尿滲透壓＞100毫滲/kg, 臨床正常容量 正常的鹽和水?dāng)z入量下，尿鈉濃度＞30 mmol／l， 無(wú)腎上腺，甲狀腺，垂體或腎功能不全 最近沒(méi)有使用利尿劑補(bǔ)充標(biāo)準(zhǔn)血清尿酸＜0.24

24、 mmol／L（ ＜ 4毫克/分升）血清尿素＜ 3.6 mmol／L（ ＜ 21.6毫克/分升）0.9%生理鹽水輸注后未糾正低鈉血癥鈉排泄分?jǐn)?shù)＞0.5 %尿素排泄分?jǐn)?shù)＞55 %尿酸排泄分?jǐn)?shù)＞12 %通過(guò)液體限制低鈉血癥得以校正,為什么提出對(duì)低滲性低鈉血癥進(jìn)行鑒別的參數(shù)？,Why this question?Hypotonic hyponatraemia has many possible underlying

25、 causes. These include, but are not limited to, non-renal sodium loss, diuretics, third spacing, adrenal insufficiency, SIAD, polydipsia, heart failure, liver cirrhosis and nephrotic syndrome (see sections 5.6 and 5.8).

26、Clinicians have traditionally used the clinical assessment of ‘volume status’ for classifying hyponatraemia as hypovolaemic, euvolaemic or hypervolaemic (87, 101, 102). However, clinical assessment of volume status is g

27、enerally not very accurate (90). Hence, we wanted to know which tests are most useful in differentiating causes of hypotonic hyponatraemia, in which order we should use them and what threshold values have the highest dia

28、gnostic value.,多因素：低滲性低鈉血癥見(jiàn)于許多原因：非腎性鈉丟失，利尿劑，第三腔室，腎上腺皮質(zhì)功能低下，SIAD，煩渴，心衰，肝硬化和腎病綜合征（見(jiàn)5.6和5.8）傳統(tǒng)方法評(píng)估缺陷：臨床醫(yī)生以傳統(tǒng)方法對(duì)低鈉血癥的低、等和高血容量狀態(tài)進(jìn)行評(píng)估。但臨床方法失之于精確。因此，本指南復(fù)習(xí)文獻(xiàn)旨在了解哪些試驗(yàn)有助于鑒別低滲性低鈉血癥。什么閾值最具有診斷價(jià)值。,根據(jù)尿滲透壓和尿鈉濃度進(jìn)行容量評(píng)估 1,以尿滲透壓和尿鈉對(duì)患者容

29、量狀態(tài)進(jìn)行評(píng)價(jià)優(yōu)于傳統(tǒng)容量臨床評(píng)估方法，故應(yīng)優(yōu)先考慮。后者的敏感性與特異性均較低。受過(guò)訓(xùn)練的醫(yī)生較之未用該方法的高年資醫(yī)生的診斷水平為優(yōu)。,Clinical assessment of fluid statusWe found two studies indicating that in patients with hyponatraemia, clinical assessment of volume status has b

30、oth low sensitivity (0.5–0.8) and specificity (0.3–0.5)。Similarly, it seems that clinicians often misclassify hyponatraemia when using algorithms that start with a clinical assessment of volume status .Using analgorithm

31、in which urine osmolality and urine sodium concentration are prioritized over assessment of volume status, physicians in training had a better diagnostic performance than senior physicians who did not use the algorithm,根

32、據(jù)尿滲透壓和尿鈉濃度進(jìn)行容量評(píng)估 2,尿滲透壓評(píng)估：尿滲透壓用于對(duì)低鈉血癥的加壓素活性進(jìn)行評(píng)價(jià)。低滲血癥時(shí)，生理學(xué)上應(yīng)使尿液最大限度稀釋，以緩解低滲血癥。除非低滲未能完全抑制抗利尿激素釋放對(duì)于主要因水?dāng)z入過(guò)多的低鈉血癥，抗利尿激素釋放被抑制，致使尿滲透壓＜100 mOsm/kg 。相反，在抗利尿激素未受到抑制的患者，尿滲透壓高于血清滲透壓。這樣在100 mOsm/kg 和血清滲透壓值之間為尿滲透壓留下了一個(gè)“灰色區(qū)域”。在這個(gè)

33、灰色地帶，人們不清楚抗利尿激素的活性如何。攝水過(guò)多可能僅僅適度抑制抗利尿激素活性。,根據(jù)尿滲透壓和尿鈉濃度進(jìn)行容量評(píng)估 3,尿鈉濃度（1）：有5項(xiàng)試驗(yàn)對(duì)尿鈉濃度在低血容量與等容量或高容量的鑒別進(jìn)行研究。所有研究均以輸注0.9%氯化鈉后血清鈉升高作為低容量血癥的參考標(biāo)準(zhǔn)。4項(xiàng)研究評(píng)估了尿鈉濃度＞30 mmol/l 作為鑒別等容量與低血容量血癥的診斷標(biāo)準(zhǔn)的特異性和敏感性所有研究均表明：該標(biāo)準(zhǔn)的敏感性較高，但特異性變化范圍較大,

34、five studies assessing diagnostic accuracy of urine sodium concentration for differentiating hypovolaemia from euvolaemia or hypervolaemia. All studies used a rise in serum sodium concentration after the infusion of 0.9%

35、 sodium chloride as the reference standard for diagnosing hypovolaemia (89).Four studies assessed the sensitivity and specificity of a urine sodium concentration ＞30 mmol/l for diagnosis of euvolaemia vs hypovolaemiaA

36、ll found similarly high sensitivity estimates ranging from 0.87 to 1.0 but variable specificity estimates ranging from 0.52 to 0.83(89, 103, 108).,根據(jù)尿滲透壓和尿鈉濃度進(jìn)行容量評(píng)估 3,尿鈉濃度（2）：有試驗(yàn)將高血容量者納入研究，以同樣的閾值（尿鈉濃度 ＞30mmol/l ）作為區(qū)分低

37、容量血癥與等容量和高容量血癥的標(biāo)準(zhǔn)尿鈉濃度＞30mmol/l 對(duì)于用否利尿劑的患者均顯示了高敏感性和低特異性。分別用＞50mmol/l 和 ＞20mmol/l 的尿鈉濃度作為標(biāo)準(zhǔn)，進(jìn)行不同血容量狀態(tài)評(píng)估的結(jié)果均不理想。其敏感性與特異性均較以30mmol/l作為閾值為低。,Fenske et al. also included hypervolaemicpatients. They assessed the same thre

38、shold for distinguishing hypovolaemia from euvolaemia and hypervolaemia but analyzed patients with and without diuretics separately (107)A urine sodium concentration ＞30mmol/l had high estimated sensitivities of 1.0 an

39、d 0.94 respectively in patients off and on diuretics, but low specificities of 0.69 and 0.24 respectively (107). Others evaluated the diagnostic accuracy of a urine sodium concentration ＞50mmol/l (109) and ＞20mmol/l (1

40、09) but found lower sensitivities and specificities respectively than with a threshold of 30mmol/l.,將臨床證據(jù)轉(zhuǎn)化為鑒別診斷方法,尿滲透壓 盡管尚無(wú)理想評(píng)價(jià)加壓素活性的精確的診斷研究，但是尿滲透壓≤100mOsm/kg幾乎總是表明因水?dāng)z入過(guò)多所導(dǎo)致的最大尿液稀釋。由于檢測(cè)尿液滲透壓是一項(xiàng)簡(jiǎn)便易行地證實(shí)過(guò)量水?dāng)z入的方法，指南推薦將

41、測(cè)量尿滲透壓作為低鈉血癥診斷的第一步尿鈉濃度 如果尿滲透壓＞ 100mOsm/kg，則需應(yīng)進(jìn)一步低鈉血癥為高血容量、等容量還是低血容量。由于臨床難以對(duì)患者循環(huán)血量做出準(zhǔn)確評(píng)價(jià)，常使臨床醫(yī)生誤入歧途，因此，指南根據(jù)大量循證醫(yī)學(xué)資料，推薦將尿鈉濃度≤30mmol/l，作為動(dòng)脈有效循環(huán)血量過(guò)低的指標(biāo)，此標(biāo)準(zhǔn)亦可用于應(yīng)用利尿劑的患者。這一閾值對(duì)于在區(qū)分低循環(huán)血量與等容量和高容量上，顯示了高度敏感性和可接受的特異性。,,關(guān)于確定將尿滲

42、透壓和尿鈉作為鑒別診斷的有關(guān)文獻(xiàn),53 Thaler SM, Teitelbaum I & Berl T. “Beer potomania” in non-beer drinkers: effect of low dietary solute intake. American Journal of Kidney Diseases 1998 31 1028–1031. (doi:10.1053/ajkd.1998.v31. pm9

43、631849)113 Joyce SM & Potter R. Beer potomania: an unusual cause of symptomatic hyponatremia. Annals of Emergency Medicine 1986 15745–747. (doi:10.1016/S0196-0644(86)80442-5)103 Musch W, Thimpont J, Vandervelde D,

44、Verhaeverbeke I, Berghmans T& Decaux G. Combined fractional excretion of sodium and urea betterpredicts response to saline in hyponatremia than do usual clinicaland biochemical parameters. American Journal of Medicin

45、e 1995 99，348–355. (doi:10.1016/S0002-9343(99)80180-6)107 Fenske W, Stork S, Koschker AC, Blechschmidt A, Lorenz D,Wortmann S & Allolio B. Value of fractional uric acid excretion in differential diagnosis of hyponat

46、remic patients on diuretics. Journal of Clinical Endocrinology and Metabolism 2008 93 2991–2997. (doi:10.1210/jc.2008-0330)108 Musch W & Decaux G. Utility and limitations of biochemical parameters in the evaluation

47、of hyponatremia in the elderly. International Urology and Nephrology 2001 32 475–493. (doi:10.1023/A:1017586004688,1假性低鈉血癥,2非低滲性低鈉血癥,3低滲性低鈉血癥,等滲性低鈉血癥,高滲性低鈉血癥,低滲低容量低鈉血癥,低滲等容量低鈉血癥,低滲高容量低鈉血癥,,,,,,,,,,低鈉血癥的病理生理分

48、類 pathophysiology of hyponatraemia,1假性低鈉血癥（pseudohyponatraemia）,為實(shí)驗(yàn)室的人為現(xiàn)象血液中高濃度脂肪和蛋白干擾血鈉測(cè)定火焰光度測(cè)量法比離子選擇性電極更常見(jiàn)假性低鈉血癥在未經(jīng)稀釋的標(biāo)本中測(cè)量滲透壓，所測(cè)血鈉結(jié)果可信，可避免假性低鈉血癥。直接用血?dú)夥治龅碾娢粶y(cè)定法測(cè)定，血鈉真實(shí)，因?yàn)殡娢环ㄒ膊槐叵♂寴?biāo)本假性低鈉血癥的血滲透壓正常妊娠期間，血清鈉可能降低4~5m

49、mol/l,2 非低滲性低鈉血癥（Non-hypotonic hyponatraemia）,等滲性低鈉血癥 Isotonic hyponatraemia高滲性低鈉血癥 Hypertonic hyponatraemia,等滲性低鈉血癥 Isotonic hyponatraemia,大多數(shù)低鈉血癥患者，血液低滲狀態(tài)，即鈉和有效滲透壓均降低當(dāng)血清含有其他滲透性物質(zhì)增加有效滲透壓，并由于吸引細(xì)胞內(nèi)的水而導(dǎo)致低鈉血癥這些滲透性物質(zhì)主

50、要包括： 控制欠佳糖尿病的高血糖，泌尿外科和婦科沖洗液甘露醇和甘氨酸的吸收由此而產(chǎn)生的所謂“移位”性低鈉血癥常被誤判為假性低鈉血癥，但假性低鈉血癥血液滲透壓正常且不發(fā)生水移位（The resulting ‘translocational’ hyponatraemia is often wrongly considered a form of pseudohyponatraemia. However, as described ear

51、lier, in pseudohyponatraemia, serum osmolality is normal and no shifts of water occur.）,高滲性低鈉血癥 Hypertonic hyponatraemia,高血糖誘導(dǎo)的低鈉血癥，低鈉血癥系因高滲稀釋造成。對(duì)測(cè)量的滲透壓和有效滲透壓進(jìn)行識(shí)別十分重要有效滲透壓通過(guò)以下公式 （血鈉校正公式）計(jì)算：無(wú)效滲透分子（Ineffective

52、osmoles） 腎臟疾病時(shí)，尿素增加，但尿素 可通過(guò)細(xì)胞膜，故 不產(chǎn)生有效滲透壓效應(yīng)， 不吸收水到細(xì)胞外， 不產(chǎn)生低鈉血癥。,,,,3低滲性低鈉血癥 Hypotonic hyponatraemia,5.7. 低容量低滲性低鈉血癥（Hypotonic hyponatraemia with decreased extracellular fluid volume）,循環(huán)血量不足，無(wú)論是否失鈉

53、均刺激加壓素（抗利尿素）分泌雖此時(shí)血液低張，但仍會(huì)繼續(xù)吸收水以補(bǔ)容量不足。因血容量不足刺激加壓素釋放的利弊： 1 對(duì)于低鈉、低滲不利 2 對(duì)于維持循環(huán)血量有利,消化道丟失腎保鈉：尿鈉減少,皮膚丟失多汗,利尿劑,原發(fā)性腎上腺皮質(zhì)功能減退： 醛固酮↓,,鈉的非腎源性丟失,鈉的腎源性丟失,腦耗鹽：需要容量補(bǔ)充,腎疾病,,,,,,,,,第三腔室丟失,,腸梗阻、急性胰腺炎、 sepsis、肌

54、肉大面積損傷 血管內(nèi)液體滲漏 循環(huán)血量顯著減少 刺激壓力感受器而釋放加壓素 低鈉血癥。 若再給予低張液體灌注則會(huì)使低鈉血癥惡化,,,,,,低容量低滲性低鈉血癥示意圖,5.8. 正常（等）容量低滲

55、性低鈉血癥Hypotonic hyponatraemia with normal extracellular fluid volume,Euvolaemic hyponatraemia is caused by an absolute increase in body water, which results from an excessive fluid intake in the presence of an impaired f

56、ree water excretion, either due to inappropriate release of vasopressin or due to a low intake of solutes,在游離水排泄機(jī)制①或因加壓素不當(dāng)釋放②或因低容質(zhì)攝入而受損時(shí)，攝入液體過(guò)量可導(dǎo)致等容量低鈉血癥,正常（等）容量低滲性低鈉血癥,低滲液體攝入過(guò)多：加壓素?zé)o變化，尿呈低滲＜100 mOsm/kg。見(jiàn)于原發(fā)性煩渴患者飲水量大于

57、腎排量,甲狀腺功能低下,繼發(fā)性腎上腺皮質(zhì)功能不全,syndrome of inappropriate antidiuresis (SIAD)與血液有效滲透壓和循環(huán)血量無(wú)關(guān)來(lái)自垂體或異位產(chǎn)生由于ADH活性增高，尿滲透壓增高 ＞100 mOsm/l,,,,,5.9.,高容量低滲性低鈉血癥（水腫、水中毒）Hypotonic hyponatraemia with increased extracellular fluid volume

58、,心衰,腎病綜合征,肝病,腎病,,,,,,,低鈉血癥,排除高血糖和其他原因的非低滲性低鈉血癥,低滲性低鈉血癥,＞30mmol/l利尿劑腎臟疾病 ？,尿鈉濃度,>100mOsm/kg,尿滲透壓,急性或嚴(yán)重癥狀？,≤100mOsm/kg:原發(fā)性煩渴鹽攝入不足、嗜酒,≤30mmol,,,,,,,,,Y,N,有效動(dòng)脈血容量不足,,,,,考慮：利尿劑腎臟疾病,,如果ECF減少：嘔吐，腎耗鹽，腦耗鹽隱匿性利尿，原發(fā)性腎上腺功能

59、不全,如果ECF正常:SIAD,甲減，隱匿性利尿繼發(fā)性腎上腺功能不全,,,,,如果ECF減少：嘔吐，第三腔室，遠(yuǎn)程利尿劑,如果ECF增加：心衰，肝硬化，腎病綜合征,,,其他疾病,,,,,,,,,,,Y,,立即開(kāi)始低鈉血癥治療,N,低鈉血癥診斷程序圖示,,,A urine osmolality ＞100 mOsm/kg should trigger additional diagnostic testing to de

60、termine the underlying cause of hyponatraemia: ultimately classified into hyponatraemia with increased, normal or redu extracellular fluid volume.Because clinical assessment of fluid status is often difficult and may l

61、ead clinicians down the wrong path, we have consciously steered away from the traditional approach of including it in the algorithm here. Instead, we recommend determining urine sodium concentration on a spot urine sampl

62、e. It is important to collect the serum and urine sample around the same time to allow correct interpretation of the values. We have selected a urine sodium concentration threshold of 30 mmol/l because several studies in

63、dicated good sensitivity and acceptable specificity in distinguishing hypovolaemia from euvolaemia or hypervolaemia (89, 103, 107, 108). This means that a urine sodium concentration ≤30 mmol/l suggests low effective arte

64、rial blood volume, even in patients on diuretics.,尿滲透壓＞100 mOsm/kg 時(shí)，應(yīng)進(jìn)一步明確低鈉血癥的原因，最終將其分為高、正常，低細(xì)胞外液容量低鈉血癥。由于臨床常常難于評(píng)價(jià)液體狀況，致使醫(yī)生做出錯(cuò)誤判斷。指南推薦檢查尿鈉含量。應(yīng)同時(shí)采集血液和尿液標(biāo)本進(jìn)行檢測(cè)。指南選擇30mmol/l尿鈉濃度作為閾值以區(qū)分低容量血癥和等容量血癥或高容量血癥。幾項(xiàng)研究均表明30mmol/l

65、是區(qū)分低容與等容和高容的閾值。如尿鈉濃度≤30 mmol/l 提示動(dòng)脈血容量過(guò)低,,低滲性低鈉血癥的治療—如何應(yīng)用治療推薦7. Treatment of hypotonic hyponatraemia How to use the treatment recommendations （26）,癥狀嚴(yán)重程度？,中重度癥狀？,急性低鈉血癥,循環(huán)血量不足？,細(xì)胞外液量增多？,癥狀嚴(yán)重的低鈉血癥7.1,中重度癥狀的低鈉血癥7.2,無(wú)

66、嚴(yán)重或中重度癥狀的低鈉血癥7.3,低容量的慢性低鈉血癥7.4.4,高容量慢性低鈉血癥7.4.2,是,否,是,否,Y,N,Y,N,Y,N,,,,,,,慢性低鈉血癥7.4,,,,,,,SIAD7.4.3,低滲性低鈉血癥處理流程圖,7.1.1:嚴(yán)重低鈉血癥患者（慢或急性）第1小時(shí)處理First-hour management, regardless of whether hyponatraemia is acute or chr

67、onic,7.1.1.1. We recommend prompt i.v. infusion of 150 ml 3% hypertonic over 20 min (1D).7.1.1.2. We suggest checking the serum sodium concentration after 20 min while repeating an infusion of 150 ml 3% hypertonic salin

68、e for the next 20 min (2D).7.1.1.3. We suggest repeating therapeuticrecommendations7.1.1.1 and 7.1.1.2 twice or until a target of 5 mmol/l increase in serum sodium concentration is achieved(2D).7.1.1.4. Manage patients