原发性醛固酮增多症伴阻塞性睡眠呼吸暂停临床诊治特点(附:两例病例报告和文献回顾)
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摘要
本文回顾性分析我院2例原发性醛固酮增多症(PA)伴阻塞性睡眠呼吸暂停(OSA)患者的临床资料,并进行文献复习。研究中两例中年男性患者均为PA合并中、重度OSA,其醛固酮肾素比值(ARR)均<300,但PA确诊试验阳性。其中病例1,患者甲行肾上腺静脉取血后接受手术治疗,术后恢复良好;病例2,患者乙接受盐皮质激素受体拮抗剂治疗,血压控制平稳。在难治性高血压中,PA与OSA共存较多见,OSA导致的间断性缺氧、睡眠剥夺可能激活交感神经及肾素-血管紧张素(RAS)两大系统,从而除影响血压外,还使筛查PA时呈假阴性结果。故在筛查、诊断PA时,应注意药物、肾脏损伤及OSA等影响肾素-血管紧张素系统而干扰结果判断。醛固酮水平增高可能加重OSA,而PA手术或醛固酮受体拮抗剂治疗可能改善呼吸暂停低通气指数。
Two cases with primary aldosteronism(PA) accompanied with obstructive sleep apnea(OSA) were retrospectively analyzed, literature was also reviewed. Two middle-aged men in our research, both with moderate or severe OSA, had an aldosterone renin ratio(ARR) less than 300, but the confirmatory test of PA was positive. In case 1, patient A underwent adrenalectomy after adrenal vein sampling, and postoperative recovery well. In case 2, patient B was prescribed mineralocorticoid receptor antagonist. His blood pressure was controlled when followed up. PA coexisting with OSA were not seldom in resistant hypertension. OSA could lead to intermittent hypoxia and sleep deprivation, which may activate sympathetic system and renin-angiotensin system(RAS). These effects would not only have impact on blood pressure, but also make results false negative when screening for PA. So when screening and diagnosing PA, attention should be paid to factors, such as drugs, kidney damage and OSA, which may affect renin-angiotensin system, thus interfere the judgment.Increased aldosterone levels may aggravate OSA, whereas therapy including surgery or mineralocorticoid receptor antagonist may improve apnea hypoventilation index.
Two cases with primary aldosteronism(PA) accompanied with obstructive sleep apnea(OSA) were retrospectively analyzed, literature was also reviewed. Two middle-aged men in our research, both with moderate or severe OSA, had an aldosterone renin ratio(ARR) less than 300, but the confirmatory test of PA was positive. In case 1, patient A underwent adrenalectomy after adrenal vein sampling, and postoperative recovery well. In case 2, patient B was prescribed mineralocorticoid receptor antagonist. His blood pressure was controlled when followed up. PA coexisting with OSA were not seldom in resistant hypertension. OSA could lead to intermittent hypoxia and sleep deprivation, which may activate sympathetic system and renin-angiotensin system(RAS). These effects would not only have impact on blood pressure, but also make results false negative when screening for PA. So when screening and diagnosing PA, attention should be paid to factors, such as drugs, kidney damage and OSA, which may affect renin-angiotensin system, thus interfere the judgment.Increased aldosterone levels may aggravate OSA, whereas therapy including surgery or mineralocorticoid receptor antagonist may improve apnea hypoventilation index.
引文
[1]Vongpatanasin W.Resistant hypertension:a review of diagnosis and management[J].J Am Med Assoc,2014,311(21):2216-2224.
[2]Funder JW,Carey RM,Mantero F,et al.The management of primary aldosteronism:case detection,diagnosis,and treatment:an endocrine society clinical practice guideline[J].J Clin Endocrinol Metab,2016,101(5):1889-1916.
[3]Whelton PK,Carey RM,Aronow WS,et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNAguideline for the prevention,detection,evaluation,and management of high blood pressure in adults:a report of the American college of cardiology/American heart association task force on clinical practice guidelines[J].Hypertension,2017,71(6):e13-e115.
[4]Prejbisz A,Florczak E,Klisiewicz A,et al.Relationship between primary aldosteronism and obstructive sleep apnoea,metabolic abnormalities and cardiac structure in patients with resistant hypertension[J].Endokrynol Pol,2013,64(5):363-367.
[5]Ahmad M,Makati D,Akbar S.Review of and updates on hypertension in obstructive sleep apnea[J].Int J Hypertens,2017,doi:10.1155/2017/1848375.
[6]Foster GE,Hanly PJ,Ahmed SB,et al.Intermittent hypoxia increases arterial blood pressure in humans through a reninangiotensin system-dependent mechanism[J].Hypertension,2010,56(3):369-377.
[7]Friedman O,Bradley TD,Chan CT,et al.Relationship between overnight rostral fluid shift and obstructive sleep apnea in drug-resistant hypertension[J].Hypertension,2010,56(6):1077-1082.
[8]Wolley MJ,Pimenta E,Calhoun D,et al.Treatment of primary aldosteronism is associated with a reduction in the severity of obstructive sleep apnoea[J].J Hum Hypertens,2017,31(9):561-567.
[2]Funder JW,Carey RM,Mantero F,et al.The management of primary aldosteronism:case detection,diagnosis,and treatment:an endocrine society clinical practice guideline[J].J Clin Endocrinol Metab,2016,101(5):1889-1916.
[3]Whelton PK,Carey RM,Aronow WS,et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNAguideline for the prevention,detection,evaluation,and management of high blood pressure in adults:a report of the American college of cardiology/American heart association task force on clinical practice guidelines[J].Hypertension,2017,71(6):e13-e115.
[4]Prejbisz A,Florczak E,Klisiewicz A,et al.Relationship between primary aldosteronism and obstructive sleep apnoea,metabolic abnormalities and cardiac structure in patients with resistant hypertension[J].Endokrynol Pol,2013,64(5):363-367.
[5]Ahmad M,Makati D,Akbar S.Review of and updates on hypertension in obstructive sleep apnea[J].Int J Hypertens,2017,doi:10.1155/2017/1848375.
[6]Foster GE,Hanly PJ,Ahmed SB,et al.Intermittent hypoxia increases arterial blood pressure in humans through a reninangiotensin system-dependent mechanism[J].Hypertension,2010,56(3):369-377.
[7]Friedman O,Bradley TD,Chan CT,et al.Relationship between overnight rostral fluid shift and obstructive sleep apnea in drug-resistant hypertension[J].Hypertension,2010,56(6):1077-1082.
[8]Wolley MJ,Pimenta E,Calhoun D,et al.Treatment of primary aldosteronism is associated with a reduction in the severity of obstructive sleep apnoea[J].J Hum Hypertens,2017,31(9):561-567.
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