低剂量托伐普坦在2型心肾综合征合并低钠血症超高龄老年患者中应用近期临床评价

目的观察托伐普坦治疗2型心肾综合征合并低钠血症超高龄老年患者的近期疗效及安全性。方法回顾性分析沈阳军区总医院干诊科自2013年1月至2015年12月住院的26例超高龄慢性心肾综合征合并低钠血症老年患者的临床资料,平均年龄(95.2±7.5)岁。所有患者在维持长期治疗方案基础上,予托伐普坦7.5 mg/d口服3 d后,改为(3.75~7.50)mg,qod治疗7 d后停用。随访20 d。主要评估服药第3天、第10天及随访结束时的日均血钠值的变化。同时,观察患者尿量、心衰体征、血压、心率及不良事件,定期检查肝、肾功能,N末端B型脑钠肽前体(N-pro-BNP)及电解质,进行疗效及安全性评估。结果在原治疗基础上,联合托伐普坦治疗后第3天和第10天,日均血钠分别为(134.6±1.5)mmol/L和(141.9±3.5)mmol/L,显著高于治疗前的(130.2±2.4)mmol/L,差异有统计学意义(P<0.05)。所有患者尿量显著增加,治疗第3天尿量(1615.8±643.7)ml较治疗前(678.8±215.9)ml显著增加(P<0.01)。治疗3 d后浮肿缓解明显。治疗结束时N-proBNP为(2 520.3±1421.6)pg/ml,较治疗前(5 865.3±2 031.8)的pg/ml明显下降(P<0.01)。eGFR较前无进一步下降,而第10天eGFR为(41.5±6.7),较治疗前的(38.8±6.2)略有升高(P<0.05)。治疗结束后随访,第10天有1例患者出现高钠血症(156.2 mmol/L),经对症后纠治。有1例出现肝损害。结论低剂量托伐普坦能够有效纠治2型心肾综合征超高龄老年患者的低钠血症,减轻心衰症状,不加重肾脏损害,改善其近期预后,可安全用于超高龄患者,但仍需严密监测不良事件发生。

Short-term effects and prognosis in type 2 cardiorenal syndrom accompanied with hyponatremia of very elderly patients trea-ted with a low dose of Tolvaptan

Objective To evaluate the efficacy of Tolvaptan in very elderly patients with type 2 cardiorenal syndrome ( CRS) accom-panied with hyponatremia. Methods A total of 26 patients with hyponatremia in chronic CRS ( average age 95. 2 ± 7. 5 years) admit-ted in our department from January 2013 to December 2015 were enrolled in this study. At first, both patients were given routine treat-ment, followed by a 3-day treatment period with Tolvaptan ( 7. 5 mg/d ora1 ) in addition, then the administration of Tolvaptan (3. 75~7. 5 mg/d ora1)was changed to intermittent oral for 7 days and then stopped. The primary end points were the serum sodium concentration,blood pressure, heart rate, urine volume, sign of heart failure, the function of liver and kidney, serum levels of N-Pro-BNP and all adverse events were observed. The follow-up period was 20 days. Results Serum sodium concentration was increased sig-nificantly at 3rd day(134. 6 ± 1. 5) mmol/L vs(130. 2 ± 2. 4) mmol/L (P <0. 05), and 10th day (141. 9 ± 3. 5) mmol/L vs (130. 2 ±2. 4) mmol/L (P<0. 01). Urine volume of all patients increased significantly afte combined with Tolvaptan compared to pre-treatment. On the 3rd day, the total urine volume was increased up to the highest (1 615. 8 ± 643. 7) ml vs (678. 8 ± 215. 9) ml (P<0. 01). The changes of sign of heart failure were released significiantly, at the end of the treatment, blood levels of N-pro-BNP were reduced significiantly (2 520. 3 ±1421. 6) pg/ml vs (5 865. 3 ± 2 031. 8) pg/ml (P<0. 01), eGFR was increased slightly (41. 5 ± 6. 7) vs (38. 8 ± 6. 2) (P<0. 05). At 10 th day of the follow-up period, one case of hypernatremia happened. One case of liver dysfunction was reported. Conclusion A low dose of tolvaptan could effectively treat hyponatremia in chronic CRS in the very elderly patients, reduce the symptoms of heart failure, could not aggravate the damage of kidney and improve the prognosis in the near future. It can be safely administered to aged, but its related adverse events should be close monitored.