急性肾上腺皮质功能减退症伴低钠血症临床分析

目的探讨原发或继发性急性肾上腺皮质功能减退症伴低钠血症的发生和防治。方法收集1970~2006年间急性肾上腺皮质功能减退症伴低钠血症患者的病史资料共48例,分为脑水肿组(n=23)和非脑水肿组(n=25)。回顾两组患者病因和诱因、临床症状、实验室指标以及治疗和预后等情况。分别以慢性肾上腺皮质功能减退症患者(n=48)和健康体检者(n=48)作为慢性疾病对照组和正常对照组。结果48例急性肾上腺皮质功能减退症伴低钠血症的最常见诱因为感染;脑水肿组和非脑水肿组的血钠和尿皮质醇水平均明显低于慢性疾病对照组和正常对照组(P<0.01和P<0.05);48例中死亡7例,均伴休克。脑水肿组中16例使用生理盐水,7例使用3%高渗盐水(血钠<110 mmol/L);非脑水肿组25例患者中5例使用高渗盐水治疗(血钠均在110 mmol/L左右),其中4例发生中心性桥脑脱髓鞘。结论当急性肾上腺皮质功能减退症的低钠血症伴脑水肿时,为迅速提高血浆渗透压及改善脑水肿可酌情使用高渗盐水;无脑水肿则提示脑细胞存在自身代偿,应以治疗基础疾病(激素替代)为主而慎用高渗盐水,以免引起中心性桥脑脱髓鞘。

Clinical analysis of acute adrenocortical hypofunction with hyponatremia

Objective To investigate the development,prevention and treatment of primary or secondary acute adrenal hypofunction with hyponatremia. Methods Forty-eight cases of acute adrenal hypofunction with hyponatremia from 1970 to 2006 were collected and divided into groups of hydrocephalus(n=23) and non-hydrocephalus(n=25).The causes,inducing factors,clinical manifestations,laboratory indexes,treatment and outcomes of the two groups were retrospectively analysed.In addition,another 48 patients with chronic adrenal hypofunction and 48 normal controls were included in the study. Results Infection constituted the most common inducing factor for the 48 cases of acute adrenal hypofunction with hyponatremia.Both natremia and urine cortisone were significantly lower in hydrocephalus and non-hydrocephalus patients than those in chronic adrenal hypofunction and controls(P<0.01 and P<0.05).Seven of the 48 cases of acute adrenal hypofunction with hyponatremia died and all experienced shock.In the hydrocephalus group,16 patients were treated with 0.9% saline,and 7 with 3% saline(natremia,<110 mmol/L in all patients).Five of the 25 cases of non-hydrocephalus were treated with 3% saline(natremia,about 110 mmol/L),and 4 experienced central pontine myelinolysis.Conclusion In patients with acute adrenocortical hypofunction,it is beneficial to use 3% saline with care to increase the plasma osmotic pressure and improve hydrocephalus condition for those with hydrocephalus due to hyponatremia.In non-hydrocephalus condition,brain cells appear to be self adaptive,and even though low natremia persists,the application of 3% saline should be with caution,which could prevent the occurrence of central pontine myelinolysis.