2019歐洲低鈉血癥診療指南解讀2019歐洲1歐洲危重病學會(ES|CM)歐洲內(nèi)分泌學會(ESE)歐洲腎臟最佳臨床實踐(EuropeanRenalBestPracticeERBP)為代表的歐洲腎臟病協(xié)會和歐洲透析與移植協(xié)會(ERA-EDTA)共同制定了歐洲低鈉血癥臨床診療指南歐洲危重病學會(ES|CM)2低鈉血癥Hyponatraemia,definedasa■定義:serumsodiumconcentration<135mmol/isthemost血清鈉低于135mmol/lcommondisorderofbodyfluidandelectrolytebalanceencounteredinclinicalpractice■臨床最常見的水鹽失衡,其Itoccursinupto30%of發(fā)生率約占住院患者的30%hospitalisedpatientsandcleadtoawidespectrumofclinicalsymptoms,fromsubtle癥狀不一,從輕微到致命tosevereorevenlifethreatening(10,11)低鈉血癥36低鈉血癥診斷Diagnosisofhyponatraemia6.1.分類:Classificationofhyponatraemia6.1.1.Definitionofhyponatraemiabasedon■根據(jù)血鈉濃度分類biochemicalseverity616.1.1.1Wedefine'mildhyponatraemiaasabiochemical輕度(mld)低鈉血癥:血鈉:sodiumconcentrationbetween130and135mmo/asmeasuredbyion-specific130~135mmolelectrode6.1.1.2.Wedefinemoderatehyponatraemiaasabio.6112:chemicalfindingofaserumsodiumconcentrationbetween125and129mmoasmeasuredbyion-中度(moderate)低鈉血癥:血鈉:specificelectrode125~129mmol6.1.13.Wedefineprofoundhyponatraemiaasabiochemicalfindingofaserumsodiumconcentration<125mmollasmeasuredbyion-specificelectrode6113重度(profound)低鈉血癥:血鈉:<125mmo/6低鈉血癥診斷Diagnosisofhyponatra4■依據(jù)發(fā)生時間分類6.1.2.Definitionofhyponatraemiabasedontimeofdevelopment■61216.1.21.Wedefineacute'hyponatraemiaashyponatraemia急性低鈉血癥<48hthatisdocumentedtoexist<43h6.1.2.2.Wedefinechronic'hyponatraemiaashyponatraeiathatisdocumentedtoexistforatleast48h6.1.2.3.Ifhyponatraemiacannotbedassified,weconsiderit■慢性低鈉血癥≥48hbeingchronicunlessthereiscinicaloranamnesticevidenceofthecontrary(TableB).6123如果不能對其分類,除非有臨床或回顧性反證(表8),則應認為系慢性低鈉血癥■依據(jù)發(fā)生時間分類56.13.Definitionofhyponatraemiabasedon根據(jù)癥狀分類:6.1.3.1.Wemoderatelysymptomatic'hyponatraemia6131:中度癥狀asamybiochemicaldegreeofhyponatraemiainthepresenceofmoderatelyseveresymptomsofhypo惡心natremia(Table5)意識混亂6.1.3.2Wedefine'sewerelysymptomatic'hyponatraemiaasamybiochemicaldegreeofhyponatraemiainthe頭痛presenceofseveresymptomsofhyponatraemiaTable5)6132:重度癥狀嘔吐Severity心臟呼吸窘迫Moderatelysevereauseawithoutvomit嗜睡癲癇樣發(fā)作spiratorydistress昏迷(G|ashow評分≤8)Coma(GlasgowComaScales8)6.13.Definitionofhyponatra6歐洲低鈉血癥診療指南課件76.2證實低滲性排除非低滲性低鈉血癥6.2.Confirminghypotonicandexcluding■6.2.1.1推薦通過測定血糖,排除non-hypotonichyponatraemia高糖性低鈉血癥。6.2.1.1.Werecommendexcludinghyp6.2.1.2測得的滲透壓<275traemiabymeasuringtheserumOsm/kg提示為低滲性低鈉血6.2.1.2.Hyponatraemiawithameasuredosmolality<275mOsm/kgalwaysreflectshypotonichypona-aemia(notgradedaemiaahyponatraehyponatraemiaaslistedinTable10Inotgraded)滲透量表示方法不同:種是重量滲透克分子濃度(Osmolality),每公斤水中所含的毫滲透粒子數(shù)(mOsm/kgH2O)冰點滲透計測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,6.2證實低滲性排除非低滲性低鈉血癥863區(qū)別低滲性低鈉血癥的參數(shù)?631.1首先檢測尿滲透壓63Whichparameterstobeusedfordifferentiating■6.3.1.2如果尿滲透壓≤100causesofhypotonichyponatraemia?mOsm/kg,可認為水攝入相對過量是低滲性低鈉血癥的原因。commendinterpretingurineosmolalityofa■63.13如果尿滲透壓>10063.12mOsm/kg,推薦同時在采取血液標本的基礎上解釋尿鈉濃度6.3.1.3Ifurineomanc■6314如果尿鈉濃度≤30mmoM,推薦接受有效循環(huán)血量降低為低滲性6.3.1.4.Ifurineso低鈉血癥的原因ichyponatraemia(2D)■6.3.1.5如果尿鈉濃度>30mmoW,6.3.1.5.Ifurinesodiumcond建議評估細胞外液狀況和利尿劑的應用,以進一步明確低鈉血癥的可6.3.1.6.Wesuggestagainstmeasuringvasopressinfor能原因confirmingthediagnosisofSIADH(2D)■6.3.16不建議檢測加壓素用于診斷SIADH63區(qū)別低滲性低鈉血癥的參數(shù)?9關于區(qū)別低滲性低鈉血癥的參數(shù)的建議(G22)需要同時采取血和尿標本方可對實驗室結(jié)果做出正確解釋尿鈉濃度和尿滲透壓測定最好取自同一標本如果臨床評價表明,細胞外液量無明顯增加,尿鈉濃度>30mmoL,在考慮SADH(抗利尿激素分泌失調(diào)綜合癥)之前,排除其他原因低滲性低鈉血癥血癥?？煽紤]根據(jù)表6中列出的診斷標準,尋找S|ADH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雜化。除了導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血鈉的調(diào)節(jié)作用,任何低鈉血癥的診斷程序均應慎用于腎臟病患者■水負荷試驗無助于對低滲性低鈉血癥的鑒別,且存在危險。關于區(qū)別低滲性低鈉血癥的參數(shù)的建議10歐洲低鈉血癥診療指南課件11歐洲低鈉血癥診療指南課件12歐洲低鈉血癥診療指南課件13歐洲低鈉血癥診療指南課件14歐洲低鈉血癥診療指南課件15歐洲低鈉血癥診療指南課件16歐洲低鈉血癥診療指南課件17歐洲低鈉血癥診療指南課件18歐洲低鈉血癥診療指南課件19歐洲低鈉血癥診療指南課件20歐洲低鈉血癥診療指南課件21歐洲低鈉血癥診療指南課件22歐洲低鈉血癥診療指南課件23歐洲低鈉血癥診療指南課件24歐洲低鈉血癥診療指南課件25歐洲低鈉血癥診療指南課件262019歐洲低鈉血癥診療指南解讀2019歐洲27歐洲危重病學會(ES|CM)歐洲內(nèi)分泌學會(ESE)歐洲腎臟最佳臨床實踐(EuropeanRenalBestPracticeERBP)為代表的歐洲腎臟病協(xié)會和歐洲透析與移植協(xié)會(ERA-EDTA)共同制定了歐洲低鈉血癥臨床診療指南歐洲危重病學會(ES|CM)28低鈉血癥Hyponatraemia,definedasa■定義:serumsodiumconcentration<135mmol/isthemost血清鈉低于135mmol/lcommondisorderofbodyfluidandelectrolytebalanceencounteredinclinicalpractice■臨床最常見的水鹽失衡,其Itoccursinupto30%of發(fā)生率約占住院患者的30%hospitalisedpatientsandcleadtoawidespectrumofclinicalsymptoms,fromsubtle癥狀不一,從輕微到致命tosevereorevenlifethreatening(10,11)低鈉血癥296低鈉血癥診斷Diagnosisofhyponatraemia6.1.分類:Classificationofhyponatraemia6.1.1.Definitionofhyponatraemiabasedon■根據(jù)血鈉濃度分類biochemicalseverity616.1.1.1Wedefine'mildhyponatraemiaasabiochemical輕度(mld)低鈉血癥:血鈉:sodiumconcentrationbetween130and135mmo/asmeasuredbyion-specific130~135mmolelectrode6.1.1.2.Wedefinemoderatehyponatraemiaasabio.6112:chemicalfindingofaserumsodiumconcentrationbetween125and129mmoasmeasuredbyion-中度(moderate)低鈉血癥:血鈉:specificelectrode125~129mmol6.1.13.Wedefineprofoundhyponatraemiaasabiochemicalfindingofaserumsodiumconcentration<125mmollasmeasuredbyion-specificelectrode6113重度(profound)低鈉血癥:血鈉:<125mmo/6低鈉血癥診斷Diagnosisofhyponatra30■依據(jù)發(fā)生時間分類6.1.2.Definitionofhyponatraemiabasedontimeofdevelopment■61216.1.21.Wedefineacute'hyponatraemiaashyponatraemia急性低鈉血癥<48hthatisdocumentedtoexist<43h6.1.2.2.Wedefinechronic'hyponatraemiaashyponatraeiathatisdocumentedtoexistforatleast48h6.1.2.3.Ifhyponatraemiacannotbedassified,weconsiderit■慢性低鈉血癥≥48hbeingchronicunlessthereiscinicaloranamnesticevidenceofthecontrary(TableB).6123如果不能對其分類,除非有臨床或回顧性反證(表8),則應認為系慢性低鈉血癥■依據(jù)發(fā)生時間分類316.13.Definitionofhyponatraemiabasedon根據(jù)癥狀分類:6.1.3.1.Wemoderatelysymptomatic'hyponatraemia6131:中度癥狀asamybiochemicaldegreeofhyponatraemiainthepresenceofmoderatelyseveresymptomsofhypo惡心natremia(Table5)意識混亂6.1.3.2Wedefine'sewerelysymptomatic'hyponatraemiaasamybiochemicaldegreeofhyponatraemiainthe頭痛presenceofseveresymptomsofhyponatraemiaTable5)6132:重度癥狀嘔吐Severity心臟呼吸窘迫Moderatelysevereauseawithoutvomit嗜睡癲癇樣發(fā)作spiratorydistress昏迷(G|ashow評分≤8)Coma(GlasgowComaScales8)6.13.Definitionofhyponatra32歐洲低鈉血癥診療指南課件336.2證實低滲性排除非低滲性低鈉血癥6.2.Confirminghypotonicandexcluding■6.2.1.1推薦通過測定血糖,排除non-hypotonichyponatraemia高糖性低鈉血癥。6.2.1.1.Werecommendexcludinghyp6.2.1.2測得的滲透壓<275traemiabymeasuringtheserumOsm/kg提示為低滲性低鈉血6.2.1.2.Hyponatraemiawithameasuredosmolality<275mOsm/kgalwaysreflectshypotonichypona-aemia(notgradedaemiaahyponatraehyponatraemiaaslistedinTable10Inotgraded)滲透量表示方法不同:種是重量滲透克分子濃度(Osmolality),每公斤水中所含的毫滲透粒子數(shù)(mOsm/kgH2O)冰點滲透計測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,6.2證實低滲性排除非低滲性低鈉血癥3463區(qū)別低滲性低鈉血癥的參數(shù)?631.1首先檢測尿滲透壓63Whichparameterstobeusedfordifferentiating■6.3.1.2如果尿滲透壓≤100causesofhypotonichyponatraemia?mOsm/kg,可認為水攝入相對過量是低滲性低鈉血癥的原因。commendinterpretingurineosmolalityofa■63.13如果尿滲透壓>10063.12mOsm/kg,推薦同時在采取血液標本的基礎上解釋尿鈉濃度6.3.1.3Ifurineomanc■6314如果尿鈉濃度≤30mmoM,推薦接受有效循環(huán)血量降低為低滲性6.3.1.4.Ifurineso低鈉血癥的原因ichyponatraemia(2D)■6.3.1