托伐普坦治疗慢性心力衰竭伴低钠血症的疗效及对患者心功能的影响

目的：观察托伐普坦治疗慢性心力衰竭(CHF)伴低钠血症的疗效,并探讨其对患者心功能的影响。方法选取2013年7月至2015年7月在我院住院治疗的80例CHF伴低钠血症患者,采用随机数表法分为观察组(常规治疗+托伐普坦)和对照组(常规治疗),每组各40例,观察并比较治疗前后两组患者的疗效及心功能的变化。结果治疗后,观察组患者的治疗总有效率为87.5%(35/40),明显高于对照组的75.0%(30/40),差异有统计学意义(P<0.05);观察组患者治疗后的24 h尿量[(2645.42±317.46) mL]、血钠[(142.24±1.63) mmol/L]、体质量[(59.55±4.35) kg]、BNP [(946.35±196.63) pg/L]、超声心动图参数[LVEF (50.64±4.32)%、LVEDd (40.36±4.52) mm、LVESd (34.86±3.75) mm]与其自身治疗前[24 h尿量(1451.21±235.35) mL、血钠(127.15±1.85) mmol/L、体质量(69.36±5.63) kg、BNP (2635.43±182.55) pg/L;超声心动图参数：LVEF (35.36±4.52)%、LVEDd (58.25±5.36) mm、LVESd (47.35±5.45) mm]比较均有所改善,差异有统计学意义(P<0.05);观察组患者治疗后的24 h尿量、血钠、体质量、BNP、超声心动图参数(LVEF、LVEDd、LVESd)与对照组患者治疗后[24 h尿量(1326.63±265.52) mL、血钠(128.14±1.52) mmol/L、体质量(68.62±4.52) kg、BNP (2564.45±340.45) pg/L;超声心动图参数：LVEF (36.22±3.36)%、LVEDd (56.35±4.82) mm、LVESd (47.65±5.95) mm]相比亦均有显著改善,两组间差异具有统计学意义(P<0.05);观察组患者的血钾、E/A比值在治疗前后无明显变化(P>0.05),两组患者治疗后血钾、E/A比值相比差异无统计学意义(P>0.05)。治疗后1个月时随访,两组均无严重不良事件。结论托伐普坦治疗慢性心力衰竭伴低钠血症可提高临床疗效,改善心功能。     

醋酸去氨加压素致低钠血症性脑病2例

例1为25岁女性宫外孕患者,于输卵管切开取胚术＋盆腔粘连分离术术后静脉滴注醋酸去氨加压素15μg,1次/12 h。第2天静脉滴注醋酸去氨加压素约30 min 时,患者出现谵妄、神志恍惚、抽搐、牙关紧闭,实验室检查血钠为125 mmol/ L（术前为142 mmol/ L）,考虑为醋酸去氨加压素所致低钠血症性脑病,立即停止输注醋酸去氨加压素并给予补钠等对症治疗,约10 min 后患者症状缓解。第2天患者神志清楚,血钠141 mmol/ L。例2为42岁女性患者,于肛周脓肿根治术后静脉滴注醋酸去氨加压素18μg,1次/12 h。用药第4天患者出现头晕、多汗、双手震颤,畏寒、尿少。第5天出现恶心,双眼上翻,双上肢强直阵挛,实验室检查血钠为124 mmol/ L（术前为141 mmol/ L）,头颅 CT 检查示大脑半球白质区广泛水肿,考虑为醋酸去氨加压素所致低钠血症性脑病。停用醋酸去氨加压素,立即给予补钠等对症治疗,1 d 后患者症状消失,血钠138 mmol/ L。     

以抗利尿激素分泌不当综合征为首发表现的吉兰-巴雷综合征荟萃分析

目的：总结以抗利尿激素分泌不当综合征（SIADH）为首发表现的吉兰-巴雷综合征（GBS）的临床特征和诊治情况。方法检索国内外1980-2014年发表的以SIADH为首发表现的GBS病例报道,对纳入病例进行分析,探讨其临床特点。结果共纳入4例病例,均为女性,发病年龄38-82岁,中位年龄62.5岁。初期表现为精神状态改变（100%）、头痛（50%）、疲乏（50%）、背痛（50%）、呼之不应（25%）、呕吐（25%）等,查体常无明显神经系统损伤定位体征（75%）。发病至GBS典型症状出现时间3-15 d,中位时间5 d。结论该病发病机制尚未明确,病情较重、诊断困难。明确诊断后,治疗反应可,预后好。需行肿瘤筛查,排除副肿瘤综合征可能。     

托伐普坦治疗顽固性心力衰竭合并低钠血症的效果观察

目的：探讨托伐普坦治疗顽固性心力衰竭合并低钠血症的效果。方法选取2014年8~12月河南省人民医院收治的60例心力衰竭患者作为研究对象,随机分为观察组和对照组,各30例。对照组采用常规治疗,观察组在对照组的基础上给予口服托伐普坦治疗。比较两组治疗前后的尿量、血钠、NT-proBNP及左心室射血分数（LVEF）、左室舒张末期内径（LVEDD）及E/A比值。结果观察组治疗后的尿量为（2635依856）ml/24 h,显著多于对照组的（1360依390）ml/24 h,差异有统计学意义（P<0.05）。观察组治疗后的体重下降（0.95依0.65）kg/d,显著多于对照组的（0.30依0.45）kg/d,差异有统计学意义（P<0.05）。观察组治疗后的血钠水平显著高于对照组治疗后,差异有统计学意义（P<0.05）。观察组治疗后的NT-proBNP水平显著低于对照组治疗后,差异有统计学意义（P<0.05）。观察组治疗后的LVEF、E/A比值显著高于对照组治疗后,差异有统计学意义（P<0.05）。观察组治疗后的LVEDD显著低于对照组治疗后,差异有统计学意义（P<0.05）。结论托伐普坦治疗顽固性心力衰竭合并低钠血症的效果显著,能有效增加血钠浓度和增加尿量,改善心功能。     

神经外科低钠血症的临床分析

目的：探讨神经外科颅脑损伤患者低钠血症的发病机理、诊断及治疗方法。方法：回顾性分析700例颅脑损伤合并低钠血症患者的实验室检测结果,将患者分为轻-中型组360例,重型组340例,并与对照组比较,分析各组特征。重度颅脑损伤患者中由CSWS所致62例、SIADH所致40例,比较两者各指标的差异。结果：重型组和轻-中型组的血钠、尿钠及尿渗透压与对照组比较差异均有统计学意义（P〈0.05）;且前两组间比较差异均有统计学意义（P〈0.05）。CSWS组与SIADH组的发病时间,红细胞压积及血红蛋白浓度比较差异均有有统计学意义（P〈0.05）。结论：颅脑损伤患者常发生低钠血症。重度颅脑损伤患者的血钠降低、尿钠及尿渗透压升高更明显。重度颅脑损伤可由SIADH和CSWS导致,在治疗上SIADH需要限水,CSWS需要补充血容量及丢失的钠盐。     

Baseline hyponatremia does not predict two-year mortality in patients with chronic peritoneal dialysis

Purpose: Hyponatremia is a common electrolyte abnormality in a variety of medical conditions. Lower predialysis serum sodium concentration is associated with an increased risk of death in oligoanuric patients on hemodialysis. However, whether hyponatremia affects the short-term mortality in chronic peritoneal dialysis (CPD) patients remains unclear. Methods: We conducted a cross-sectional and two-year follow-up review retrospectively, and 318 patients with CPD were enrolled in a medical center. Serum sodium levels were measured at baseline and categorized as quartile of Na: quartile 1 (124–135?mEq/L), quartile 2 (136–139), quartile 3 (140–141) and quartile 4 (142–148). Mortality and cause of death were recorded for longitudinal analyses. Results: The patients with higher quartile (higher serum sodium) had a trend of lower age, peritoneal dialysis (PD) duration, co-morbidity index, D/P Cr and white blood cell counts and higher renal Kt/Vurea (Kt/V) and serum albumin level. Stepwise multiple linear regression analysis showed that serum sodium level was positively associated with albumin, residual renal Kt/V and negatively associated with age and PD duration in CPD patients. After two-year follow-up, stepwise multivariate Cox proportional hazards model demonstrated that age, co-morbidity index and serum albumin were the significant risk factors for all-cause two-year mortality, but not serum sodium levels. Conclusions: Serum sodium level in CPD patients is associated with nutritional status, residual renal function and duration of PD. However, baseline serum sodium level is not an independent predictor of two-year mortality in CPD patients.     

老年慢性心力衰竭合并低钠血症临床防治82例回顾性分析

目的：探讨老年慢性心力衰竭合并低钠血症的临床防治。方法2012年1月～2014年2月期间我院诊治的82例老年慢性心力衰竭合并低钠血症患者,作为观察组研究对象,另选同期82例老年慢性心力衰竭但不合并低钠血症患者,作为对照组研究对象,观察和比较两组病死率、住院时间、LVEF。将82例老年慢性心力衰竭合并低钠血症患者随机分为A组（常规抗心衰）和B组（常规抗心衰基础上,纠正低钠血症）,对两组治疗后血钠水平、临床疗效,进行观察和比较。结果与对照组相比,观察组病死率（29.3% vs 11.0%）、住院时间（15.0±3.0）d vs（10.5±2.5）d明显升高,LVEF明显减少（36.5±0.1）%vs（43.7±0.1）%, P＜0.05;与A组相比,B组治疗后血钠水平（136.7±3.4）mmol/L vs（129.0±2.9）mmol/L及总有效率（73.2%vs 43.9%）明显提高,P＜0.05。结论对于老年慢性心力衰竭合并低钠血症患者,应在抗心衰治疗基础上,积极纠正低钠血症,改善患者的心功能及预后质量。     

Acute intermittent porphyria after right hemi-colectomy

IntroductionAcute intermittent porphyria is a rare autosomal dominant metabolic disease. It is caused by a genetic mutation that results in deficiency of porphobilinogen deaminase enzyme, the third enzyme in heme biosynthesis. Acute intermittent porphyria precipitated by surgery is very rare.Case presentationWe present a 24 year-old woman who developed acute intermittent porphyria five days after right hemi-colectomy. Her presentation included neuro-visceral and psychiatric manifestations, and severe hyponatremia. She received critical care symptomatic management including mechanical ventilation. The diagnosis was based on a positive urine test for porphobilinogen and confirmed by the presence of a heterozygous mutation in the hydroxyrmethylbilane synthase (HMBS) gene (c.760delC p Leu254).DiscussionAcute intermittent porphyria is the most common and life threatining type of acute porphyrias. It is more common in women and usually presents after puberty with acute abdominal pain and diverse neuro-psychiatric manifestations that can be confused with several surgical and medical diseases. Acute intermittent porphyria after surgery is most likely due to postoperative pain and low-calorie intake. Once suspected, prompt ICU management including high calorie intake are necessary to avoid serious complications and mortality before starting definitive treatment with hematin.ConclusionAcute intermittent porphyria should be suspected in any patient, particularly young women, who develop diverse neuro-visceral and psychiatric manifestations and hyponatremia after surgery.