2019精品欧洲低钠血症诊疗指南文档
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Over time, 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 for using the 48-h threshold to distinguish acute (48 h) from chronic (48 h) hyponatraemia
3
2
30mmol/l
Fenske et al. also included hypervolaemicpatients. They assessed the same threshold for distinguishing hypovolaemia from euvolaemia and hypervolaemia but analyzed patients with and without diuretics separately (107)
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 deficits
classifying hyponatraemia as hypovolaemic,
euvolaemic or hypervolaemic (87, 101,
102). However, clinical assessment of volume status is generally not very accurate (90). Hence, we wanted to know which tests are most useful in
24~48 48
8
3,4-methylenedioxymethamfetamine MDMAXTC IV
6131
6132 Glasgow8
125mmol/l110125mmol/l,
48h48h
""
6.2275 mOsm/kg , as effective osmolality can never be higher than total or measured osmolality. 275 mOsm/kg By contrast, if calculated osmolality is275 mOsm/kg,
6.3.1.4 30mmol/l,
6.3.1.5 30mmol/l
6.3.1.6 SIADH.
G22
30 mmol/L SIAD6 SIAD
SIAD
275/ ,100/kg,
30 mmoll
0.24 mmolL 4/ 3.6 mmolL 21.6/ 0.9% 0.5 % 55 % 12 %
Severe symptoms of hyponatraemia are caused by 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 plasma.
hyponatraemia can be hypotonic, isotonic or hypertonic, depending on which osmotically active agents are present and whether or not they are incorporated in the formula.
2
100 mOsm/kg
100 mOsm/kg ""
3
1 5
0.9% 430 mmol/l
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% sodium chloride as the reference standard for diagnosing hypovolaemia (89).
2014
ESICM
ESE
European Renal Best Practice ERBP) ERA-EDTA
Hyponatraemia, defined as a serum sodium concentration 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 subtle to severe or even life threatening (10, 11)
6. Diagnosis of hyponatraemia 6.1. Classification of hyponatraemia
6111 (mild)
130~135mmol/l
6112 moderate 125~129mmol/l
6113 profound
<125mmol/l
SIAD 5.65.8
failure, liver cirrhosis and nephrotic
syndrome (see sections 5.6 and 5.8).
Clinicians have traditionally used the
clinical assessment of `volume status' for
ቤተ መጻሕፍቲ ባይዱ
135mmol/L
30%
In most cases, hyponatraemia reflects low effective osmolality or hypotonicity, which causes symptoms of 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-osmolar but also how isosmolar and hyperosmolar states develop.
Why this question?
Hypotonic hyponatraemia has many possible underlying causes. These include, but are not limited to, non-renal sodium loss, diuretics, third spacing, adrenal insufficiency, SIAD, polydipsia, heart
6.2
6.2.1.1 9
6.2.1.2 275 mOsm/kg
6.2.1.3 10 " "
(Osmolality)(mOsm/kg H2O) (Osmolarity)(mOsm/L)
6.3
6.3.1.1 6.3.1.2 100
mOsm/kg,
6.3.1.3 100 mOsm/kg,
6121 <48h
6122: 48h
6123
8
48
This usually occurs when hyponatraemia develops rapidly, and the brain has had too little time to adapt to its hypotonic environment.
Clinical assessment of fluid status
We found two studies indicating that in patients with hyponatraemia, clinical assessment of volume status has both 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 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
differentiating causes of hypotonic
hyponatraemia, in which order we should
use them and what threshold values have
the highest diagnostic value.
1
Four studies assessed the sensitivity and specificity of a urine sodium concentration 30 mmol/l for diagnosis of euvolaemia vs hypovolaemia
All 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).
patients with chronic hyponatraemia more often have osteoporosis and more frequently sustain bone fractures than normonatraemic persons
1 2 3 4 5
3
2
30mmol/l
Fenske et al. also included hypervolaemicpatients. They assessed the same threshold for distinguishing hypovolaemia from euvolaemia and hypervolaemia but analyzed patients with and without diuretics separately (107)
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 deficits
classifying hyponatraemia as hypovolaemic,
euvolaemic or hypervolaemic (87, 101,
102). However, clinical assessment of volume status is generally not very accurate (90). Hence, we wanted to know which tests are most useful in
24~48 48
8
3,4-methylenedioxymethamfetamine MDMAXTC IV
6131
6132 Glasgow8
125mmol/l110125mmol/l,
48h48h
""
6.2275 mOsm/kg , as effective osmolality can never be higher than total or measured osmolality. 275 mOsm/kg By contrast, if calculated osmolality is275 mOsm/kg,
6.3.1.4 30mmol/l,
6.3.1.5 30mmol/l
6.3.1.6 SIADH.
G22
30 mmol/L SIAD6 SIAD
SIAD
275/ ,100/kg,
30 mmoll
0.24 mmolL 4/ 3.6 mmolL 21.6/ 0.9% 0.5 % 55 % 12 %
Severe symptoms of hyponatraemia are caused by 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 plasma.
hyponatraemia can be hypotonic, isotonic or hypertonic, depending on which osmotically active agents are present and whether or not they are incorporated in the formula.
2
100 mOsm/kg
100 mOsm/kg ""
3
1 5
0.9% 430 mmol/l
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% sodium chloride as the reference standard for diagnosing hypovolaemia (89).
2014
ESICM
ESE
European Renal Best Practice ERBP) ERA-EDTA
Hyponatraemia, defined as a serum sodium concentration 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 subtle to severe or even life threatening (10, 11)
6. Diagnosis of hyponatraemia 6.1. Classification of hyponatraemia
6111 (mild)
130~135mmol/l
6112 moderate 125~129mmol/l
6113 profound
<125mmol/l
SIAD 5.65.8
failure, liver cirrhosis and nephrotic
syndrome (see sections 5.6 and 5.8).
Clinicians have traditionally used the
clinical assessment of `volume status' for
ቤተ መጻሕፍቲ ባይዱ
135mmol/L
30%
In most cases, hyponatraemia reflects low effective osmolality or hypotonicity, which causes symptoms of 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-osmolar but also how isosmolar and hyperosmolar states develop.
Why this question?
Hypotonic hyponatraemia has many possible underlying causes. These include, but are not limited to, non-renal sodium loss, diuretics, third spacing, adrenal insufficiency, SIAD, polydipsia, heart
6.2
6.2.1.1 9
6.2.1.2 275 mOsm/kg
6.2.1.3 10 " "
(Osmolality)(mOsm/kg H2O) (Osmolarity)(mOsm/L)
6.3
6.3.1.1 6.3.1.2 100
mOsm/kg,
6.3.1.3 100 mOsm/kg,
6121 <48h
6122: 48h
6123
8
48
This usually occurs when hyponatraemia develops rapidly, and the brain has had too little time to adapt to its hypotonic environment.
Clinical assessment of fluid status
We found two studies indicating that in patients with hyponatraemia, clinical assessment of volume status has both 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 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
differentiating causes of hypotonic
hyponatraemia, in which order we should
use them and what threshold values have
the highest diagnostic value.
1
Four studies assessed the sensitivity and specificity of a urine sodium concentration 30 mmol/l for diagnosis of euvolaemia vs hypovolaemia
All 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).
patients with chronic hyponatraemia more often have osteoporosis and more frequently sustain bone fractures than normonatraemic persons
1 2 3 4 5