Hoorn E J, Halperin M L, Zietse R
Department of Internal Medicine, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands.
QJM. 2005 Jul;98(7):529-40. doi: 10.1093/qjmed/hci081. Epub 2005 Jun 13.
The usual diagnostic approach to a patient with hyponatraemia is based on the clinical assessment of the extracellular fluid (ECF) volume, and laboratory parameters such as plasma osmolality, urine osmolality and/or urine sodium concentration. Several clinical diagnostic algorithms (CDA) applying these diagnostic parameters are available to the clinician. However, the accuracy and utility of these CDAs has never been tested. Therefore, we performed a survey in which 46 physicians were asked to apply all existing, unique CDAs for hyponatraemia to four selected cases of hyponatraemia. The results of this survey showed that, on average, the CDAs enabled only 10% of physicians to reach a correct diagnosis. Several weaknesses were identified in the CDAs, including a failure to consider acute hyponatraemia, the belief that a modest degree of ECF contraction can be detected by physical examination supported by routine laboratory data, and a tendency to diagnose the syndrome of inappropriate secretion of antidiuretic hormone prior to excluding other causes of hyponatraemia. We conclude that the typical architecture of CDAs for hyponatraemia represents a hierarchical order of isolated clinical and/or laboratory parameters, and that they do not take into account the pathophysiological context, the mechanism by which hyponatraemia developed and the clinical dangers of hyponatraemia. These restrictions are important for physicians confronted with hyponatraemic patients and may require them to choose different approaches. We therefore conclude this review with the presentation of a more physiology-based approach to hyponatraemia, which seeks to overcome some of the limitations of the existing CDAs.
对于低钠血症患者，常用的诊断方法基于细胞外液（ECF）容量的临床评估以及血浆渗透压、尿渗透压和/或尿钠浓度等实验室参数。临床医生可以使用几种应用这些诊断参数的临床诊断算法（CDA）。然而，这些CDA的准确性和实用性从未经过测试。因此，我们进行了一项调查，要求46名医生将所有现有的、独特的低钠血症CDA应用于4例选定的低钠血症病例。这项调查的结果表明，平均而言，CDA仅使10%的医生能够做出正确诊断。在CDA中发现了几个弱点，包括未考虑急性低钠血症、认为通过常规实验室数据支持的体格检查可以检测到适度的ECF收缩，以及在排除低钠血症的其他原因之前倾向于诊断抗利尿激素分泌不当综合征。我们得出结论，低钠血症CDA的典型架构代表了孤立的临床和/或实验室参数的层次顺序，并且它们没有考虑病理生理背景、低钠血症发生的机制以及低钠血症的临床风险。这些限制对于面对低钠血症患者的医生来说很重要，可能需要他们选择不同的方法。因此，我们在本综述结尾介绍一种更基于生理学的低钠血症方法，该方法旨在克服现有CDA的一些局限性。
