原醛讲课101104.ppt

正常人、高血压病及原醛患者盐水输注后的醛固酮水平 Schirpenbach C. Euro J Endocrinol (2006) 154 865–873 Schirpenbach C. Euro J Endocrinol (2006) 154 865–873 高血压病及原醛患者盐水输注前后的醛固酮水平 氟氢可的松抑制试验 Procedure 患者口服0.1mg氟氢可的松，每6小时1次，共4天，同时应用KCL缓释片进行补充（每6小时1次使血钾保持接近4.0mmol/L）,应用缓释NaCl（30mmol 每日3次与餐同服）以及保持足够的食物盐摄取，以保证尿钠排泄率至少为3mmol/kg体重. 第4日上午10点取血醛固酮和PRA, 患者应取坐位，血浆皮质醇应测上午7点和10点值。 Interpretation 第4日晨10点立位血浆醛固酮6 ng/dL 同时PRA1ng/mL/h，血浆皮质醇在10点的值小于7点的值（排除ACTH混杂的影响）则确诊 PA Linear regression analysis of PAC post iv SLT and PAC post FST. There was a strong association between PAC after SLT and PAC after FST both in patients with EH and PA (P 0.0001; r0.784). Mulatero et al. J Clin Endocrinol Metab, 2006, 91(7):2618 卡托普利试验 卡托普利为ACEI，可降低肾素调节的Aldo分泌 清晨卧位抽血测Aldo及PRA，予巯甲丙脯酸25－50mg口服，2h后予坐位抽血测Aldo和PRA。 正常人服药后血Aldo水平降低，通常降低20%, 或416pmol/L（15 ng/dl）而PRA增加，原醛症患者无明显变化。 敏感性：90%-100%，特异性：50%-80% 安全性、耐受性好，可用于门诊患者。 体位试验 平卧过夜，次日8:00时卧位采血，立位活动4小时再次采血测定PRA及醛固酮水平。 结果：正常人立位后PRA和醛固酮水平明显升高。原醛患者卧位时PRA受抑制，醛固酮升高，立位时醛固酮瘤者醛固酮水平多无明显升高（增幅小于30％）甚至反而下降，而特醛症者醛固酮水平上升明显，并超过正常人。 同时测定血浆皮质醇以排除其他应激因素干扰 速尿激发试验 方法及结果判定同体位试验 清晨卧位抽血测PRA、ATII、Aldo 肌注速尿0.7mg/kg，总量不超过40mg 站立走动2h，再抽血测PRA、ATII、Aldo 原醛患者血浆醛固酮对体位刺激的反应 醛固酮瘤 特醛症 卧位 立位 卧位 立位 APA和IHA的鉴别诊断 地塞米松抑制醛固酮试验 原醛症者如发病年龄小，有高血压，低血钾家族史，体位试验中立位醛固酮无升高或反常性下降，肾上腺CT, MRI(－) 方法：每日地米2mg，共3－4周，血醛固酮在服药后抑制80％以上有意义。 特醛症和APA者服药后可呈一过性抑制（2周后复又升高） CT检查患侧定位的局限性 Adrenal CT is not accurate in distinguishing between APA and IHA. In one study, CT contributed to lateralization in only 59 of 111 patients with surgically proven APA; CT detected fewer than 25% of the APAs that were smaller than 1 cm in diameter. 203 patients with PA who were evaluated with both CT and adrenal vein sampling, CT was accurate in only 53% of patients; based on CT findings, 42 patients (22%) would have been incorrectly excluded as candidates for adrenalectomy and 48 (25%) might have had unnecessary or inappropriate surgery Adrenal venous sampling is essential to direct appropriate therapy in patients with PA who have a high probability of