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.

3 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

4 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: 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.

5 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)

6 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. 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.

7 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

8 MRI T2 Parkinsonism MRI FLAIR BMJ 2005;331:829 30 BMC Neurology 2006, 6:33doi:10. 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.]

9 ] Tolvaptan Na ODS Na Na Na