低钠血症鉴别诊断朱大龙.pptVIP

低钠血症（ Hyponatremia ）;水、钠代谢的调节;定 义;分类;根据血钠降低的程度可分为 重度低钠血症＜120mmol/L 中度低钠血症＜130mmol/L 轻度低钠血症＜135mmol/L 此外还有假性低钠血症，见于明显的高脂血症和高蛋白血症。;病 因;;SIADH;低血容量性低钠血症（一）;低血容量性低钠血症（二）;正常容量或高容量性低钠血症（一）;正常容量或高容量性低钠血症（二）;病理生理 ;正常时细胞内渗透压保持稳态平衡。当血浆钠浓度降低，细胞外液渗透压下降，细胞外水流血细胞内，使细胞肿胀，以致细胞功能受损甚至破坏，其中以脑细胞肿胀，可导致低钠血症最严重的临床表现。 血容量缩减如果得不到纠正，则可使血压下降，肾血流量减少，肾小球滤过率降低，可导致肾前性氮质血症。 ;临床表现;;实验室检查;渗透压;诊 断;;;; 低钠血症的治疗应根据病因、低钠血症的类型、低钠血症发生的急慢及伴随疾病而采取不同处理方法，故强调低钠血症的治疗应个别化，但总的治疗措施包括： 　　①去除病因； 　　②纠正低钠血症； 　　③对症处理； 　　④治疗合并症。 ;低钠血症的纠正速度;治 疗;治 疗;治 疗;慢性低钠血症（等容量或高容量性）;抗利尿激素受体（AVPR）拮抗剂;Multi-center, double-blind, placebo controlled, randomly assigned (4days) Conivaptan 30min LD (20mg diluted to 100ml D5W) infusion ? 96hr CIV days 1-4 (diluted to 250ml) 40mg/day 80 mg/day Placebo 100ml D5W as LD ? 250 ml D5W Important Exclusion Criteria: Hypovolemic hyponatremia Cardiac problems: Hyponatremia requiring immediate treatment Medications interacting with CYP4503A4 Other medications ;Time to increase /= 4mEq/L : Conivaptan 40mg/day: 24 hours Conivaptan 80mg/day: 10 hours PBO: no increase within 4 day infusion Change in serum Na from baseline to end of treatment Conivaptan 40mg/day: 6.3 mEq/L Conivaptan 80mg/day: 9.4 mEq/L PBO: 0.8 mEq/L Patients with increase in Na /=6mEq/L or Na /=135 mEq/L Conivaptan 40mg/day: 69% (6.3) Conivaptan 80mg/day: 88.5% (23) PBO: 20.7% (6) Change in serum Na from Baseline to 6-9days post treatment : Conivaptan 40mg/day: 8.1mEq/L (n=13) Conivaptan 80mg/day: 4.7 mEq/L (n=26) PBO: 5.2 mEq/L (n=17) ;Discontinuation was mainly due to Infusion site reactions Other ADRs: hypotension, postural hypotension, pyrexia, hyperkalemia, infusion site thrombosis ;Prospective, multi-center, randomized centrally, double-blind, placebo controlled Conducted 2 trials to assess reproducibility (SALT-1 SALT-2) Tolvaptan 15mg tab 1 tab PO Daily x 30 days OR PBO Important Patient Population Criteria: Inclusion Etiologies: CHF, cirrhosis or SIADH Exclusion Criteria: Other etio