摘要
目的回顾性总结低钾血症的病因、临床表现及常规诊断方法,重点分析内分泌相关性低钾血症的特征、诊断与鉴别诊断,探讨低钾血症在诊治过程中的常见误区,提出低钾血症在临床与护理方面的防治对策。
方法收集2009年1月至2010年12月间,以“低钾血症”收住我院内分泌科的患者155例,其中男性87例,女性68例,年龄14～84岁,平均42.43±13.73岁,病程16小时～20年。统计患者的一般资料信息、临床表现及检查结果；重点分析患者的肾素活性-血管紧张素Ⅱ-醛固酮系统(RAS)速尿激发及立卧位试验、安体舒通试验、氯化钙负荷试验、过夜地塞米松(1mg,8rmg)抑制试验,以及肾上腺薄层CT增强扫描、垂体磁共振成像(MRI)平扫加增强、肾动脉CTA、肾穿刺活检和手术病理报告等特殊检查的结果。
结果低钾血症的病因,以原发性醛固酮增多症最为常见(55例,占35.48%),其后依次为低钾性周期性麻痹(41例,占26.45%)、Bartter综合征(16例,占10.32%)、肾小管酸中毒(11例,占7.10%)、药物性低钾血症(10例,占6.45%)、惊恐障碍所致(6例,占3.87%)、Gitelman综合征(3例,占1.94%)、消化道失钾(2例,占1.29%)；摄入不足、异位ACTH综合征、库欣综合征、嗜铬细胞瘤、糖尿病酮症酸中毒(各1例,分别占0.65%)；不明原因者(6例,占3.87%)。
在诊断为原发性醛固酮增多症患者中,RAS立卧位试验的立位醛固酮与肾素比值(ARR)平均为48.83±40.12ng.ml-2h-1,其中ARR>20ng.ml-1h-1者63.89%,ARR>50ng.ml-1h-1者47.22%；血钾范围2.46±0.52mmol/L;血压范围：收缩压181.11±23.97mmHg,舒张压106.86±11.87mmHg。
存在肾上腺占位的患者共40例,其中32例进行了手术切除(女性19例,男性13例)。在上述手术患者中,29例伴有高血压,其病理报告左侧肾上腺腺瘤15例,右侧肾上腺腺瘤9例,腺瘤样增生2例,双侧腺瘤2例,嗜铬细胞瘤1例。
结论低钾血症的病因很多,主要是原发性醛固酮增多症和周期性麻痹。典型病例通过系统的检查、特殊的激发试验以及影像学分析,再结合临床表现后,做出准确诊断和治疗并不太难。但在临床上,还需要特别注意非典型病例及少见的病因,如Bartter综合征、药物性低钾血症、干燥综合征、惊恐障碍、Gitelman综合征以及不明原因患者的诊断与治疗。对于低钾血症应针对病因个体化治疗,以免误诊误治。
Objective
To sumrhary the etiology, clinical manifestations and conventional diagnostic methods of hypokalemia retrospectively;
To analyze the features and diagnosis of endocrine related hypokalemia;
To discuss Diagnostic errors of Hypokalemia;
To propose the control measures of hypokalemia in clinical and nursing.
Methods
Collected155patients of hypokalemia from January2009to December2010(Male87,female68, aged14to84years,mean age42.43±13.73,duration from16hours to20years);
Statistic the patient's general information, clinical presentation and examination results;
Focus on analysis of the results of patient's activity of rennin-angiotensin Ⅱ-aldosterone system (RAS),stimulated furosemide experiment, vertical and horizontal tests,spironolactone experiments,calcium chloride load test,overnight dexamethasone (lmg,8mg) inhibition test,Thin-enhanced CT scan of adrenal,pituitary magnetic resonance imaging (MRI),CTA of renal artery,renal biopsy and surgical pathology report.
Results
Primary aldosteronism is a major cause of hypokalemia (55,35.48%); Followed by Hypokalemic periodic paralysis (41,26.45%), Bartter syndrome (16,10.32%), renal tubular acidosis (11,7.10%), drug-induced hypokalemia (10,6.45%), panic disorder induced(6,3.87%), Gitelman syndrome (3,1.94%), gastrointestinal loss of potassium (2,1.29%); intake, ectopic ACTH syndrome, Cushing syndrome, pheochromocytoma, diabetic ketoacidosis (1,0.65%, respectively); unknown person (6,3.87%). In patients with primary aldosteronism, ARR average of48.83±40.12ng.ml-1h-1, which ARR>20were63.89%, ARR>50were47.22%; potassium range of2.46±0.52mmol/L; blood pressure range:systolic blood pressure181.11±23.97mmHg, diastolic blood pressure106.86±11.87mmHg. There were40cases of adrenal masses in patients, of which32patients were resected (19females,13males). In the surgical patients,29patients with hypertension, of which left adrenal adenoma in15cases, the right adrenal gland adenoma in9cases, adenomatous hyperplasia in2cases, bilateral adenoma in2cases, pheochromocytoma in1case.
Conclusion
Many causes led to hypokalemia, mainly of primary aldosteronism and periodic paralysis. Through the systematic Inspection, special stimulation test, imaging analysis, and clinical manifestations, to make an accurate diagnosis and treatment of typical cases is not too difficult. However, in clinical practice, also need to pay special attention to the cause of atypical cases, such as Bartter syndrome, drug-induced hypokalemia, Sjogren's syndrome, panic disorder, Gitelman syndrome and unexplained diagnosis and treatment of patients.
引文
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