低Na血症のガイドライン - JSEPTIC

1 Na ICU ESE ERA-EDTA ESICM ESICM 12 ESE 47 ERA-EDTA 39 Na Na Na Na 20-30% popular ICU Na ICU 77 1998-2007 10 ICU 150,000 24 or (135 Na 145 mmol/L: ) Na 130 Na < 135 mmol/L: 125 Na < 130 mmol/L: Na < 125 mmol/L: Na 145 < Na 150 mmol/L: 150 < Na 155 mmol/L: Na > 155 mmol/L: criteria: Borderline, Mild, Severe medical 2 ICU ICU Na Hypo, Hyper borderline acute or chronic Guideline GRADE system Who is this guideline for ?

2 This guideline covers diagnosis and management of true hypotonic hyponatraemia. tonicity effective osmolality Na, glucose urea ineffective osmolality tonicity Isotonic / Hypertonic Isotonic / Hypertonic Na tonicity glucose, mannitol, glycine Na BG 100mg/dL Na 2 mmol/L Pseudohyponatraemia (= laboratory artefact) Na TG, TC, New Engl J Med 2003; 349: 1465-69 Hypotonic hyponatraemia This guideline covers diagnosis and management of true hypotonic hyponatraemia. Na A B Na Na ex SIADH C tonicity Na ex 40% 60% Na K New Engl J Med 2000; 342: 1581-89 E Na Na Na ex F Na Na ex G Na K Na Na K Tolvaptan D Na ex Na K Hypotonic hyponatraemia with decreased extracellular fluid volume Na Vasopressin Non-renal sodium loss Gastrointestinal Transdermal Renal sodium loss Diuretics Primary adrenal insufficiency Cerebral salt wasting Renal salt wasting Chemotherapy, cystic kidney disease Hypotonic hyponatraemia with normal extracellular fluid volume Normal SIADH SIAD, syndrome of inappropriate antidiuresis H.

3 Activity V2 receptor, aquaporin-2 water channel down regulation release Secondary adrenal insufficiency ACTH, cortisol negative feedback Hypothyroidism Urine Osmolality < 100mOsm/kg Anorexia nervosa (1L 50-100mmol ) SIAD SIAD SIAD Hypotonic hyponatraemia with increased extracellular fluid volume Kidney disease Osmolality value: Serum Urine (isosthenuria) Heart failure Na cardiac output RAA vasopressin Na Liver failure Systemic vasodilation, AV shunt Nephrotic syndrome Classification Sodium concentration: < 125mmol/L = profound Rate of development: acute(< 48 hr) or chronic Symptom severity*: moderately severe or severe Serum osmolality: < 275mOsm/kg = hypotonic Volume status: effective circulating volume or extracellular fluid volume acute or chronic Volume status 48hr *Symptom severity Acute (< 48 h) hyponatraemia Na Quality of evidence D cut off 100mOsm/kg Na 30mmol/L SIAD Na assessing volume status Na < 130mmol/L, serum osmolality < 280 mOsm/kg 121 Algorithm (by inexperienced doctor) approach by senior intensive care physician approach by expert endocrinologist (Reference Standard) vs.

4 Vs. primary polydipsia, hypervolemia, hypovolemia, SIADH, diuretic-induced hyponatremia, adrenal insufficiency 6 Na, K, Cl, Cr, Glu, TP, Alb, TG, Osmolality, WBC, RBC, cortisol, ACTH, TSH Algorithm serum-Na serum osmolality Urine osmolality Urine sodium concentration Overall diagnostic agreement: 48% Overall diagnositic agreement: 71% = = Algorithm Pitfall : Use of diuretics 61% ) FE-UA Na A B SIAD Na SIAD FE-UA cut off: 12% volume status SIAD vs. Cerebral Salt Wasting serum ADH SIAD Acute or chronic 3% 500mL 100mL 10%NaCl 120mL 6 150mL 20 Na 5mmol/L 24 10mmol/L 24 8mmol/L 130 mmol/L K Na Osmotic demyelination syndrome Na 1976 1997 ~ 54 case report 87% case 24 12mmol/L 48 20mmol/L MRI T2 Parkinsonism MRI FLAIR BMJ 2005;331:829 30 BMC Neurology 2006, 6:33doi:10.

5 Severe liver disease liver transplant alcoholism severe burns malnutrition anorexia antidepressant accidental overcorrection Severe synptoms Acute hyponatraemia 10mmol/L 3%NaCl Chronic hyponatraemia first-line: Second-line: or NaCl SIAD Vasopressin receptor antagonist Vasopressinn activity Na 15 RCT, N=1619, tolvaptan 4 3-7 1 Na Mean , Osmotic demyelination syndrome ODS Na RR: [95%CI: ] 11 RCT, N=1069, tolvaptan 4 3-5 1 Na Mean , Osmotic demyelination syndrome Na 3 RR: [95%CI: ] Tolvaptan Na ODS Na Na Na