Tzamaloukas Antonios H, Ing Todd S, Siamopoulos Kostas C, Raj Dominic S C, Elisaf Moses S, Rohrscheib Mark, Murata Glen H
New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico 87108, USA.
Semin Dial. 2008 Sep-Oct;21(5):431-9. doi: 10.1111/j.1525-139X.2008.00464.x.
The mechanisms of fluid and solute abnormalities that should be considered in any patient with severe hyperglycemia include changes in the total amount of extracellular solute, osmotic diuresis, intake of water driven by thirst, and influences from associated conditions. The absence of osmotic diuresis distinguishes dialysis-associated hyperglycemia (DH) from hyperglycemia with preserved renal function (HPRF). Mainly because of this absence, comparable degrees of hyperglycemia tend to produce less hypertonicity and less severe intracellular volume contraction in DH than in HPRF, while extracellular volume is expanded in DH but contracted in HPRF. Ketoacidosis can develop in both DH and HPRF. Among DH patients, hyperkalemia appears to be more frequent when ketoacidosis is present than when nonketotic hyperglycemia is present. Among HPRF patients, the frequency of hyperkalemia appears to be similar whether ketoacidosis or nonketotic hyperglycemia is present. Usually patients with severe DH have no symptoms or may exhibit a thirst. Infrequent clinical manifestations of DH include coma and seizures from hypertonicity or ketoacidosis and pulmonary edema from extracellular expansion. Insulin infusion is usually the only treatment required to correct the biochemical abnormalities and reverse the clinical manifestations of DH. Monitoring of the clinical manifestations and biochemical parameters during treatment of DH with insulin is needed to determine whether additional measures, such as administration of saline, free water, or potassium salts, as well as emergency hemodialysis (HD) are needed. Emergency HD carries the risk of excessively rapid decline in tonicity; its benefits in the treatment of DH have not been established.
任何严重高血糖患者都应考虑的液体和溶质异常机制包括细胞外溶质总量的变化、渗透性利尿、口渴驱动的水摄入以及相关疾病的影响。无渗透性利尿可将透析相关性高血糖（DH）与肾功能正常的高血糖（HPRF）区分开来。主要由于无渗透性利尿，与HPRF相比，DH中相当程度的高血糖往往产生较低的高渗状态和较轻的细胞内容量收缩，而DH中细胞外容量增加，HPRF中细胞外容量减少。DH和HPRF均可发生酮症酸中毒。在DH患者中，存在酮症酸中毒时高钾血症似乎比非酮症性高血糖时更常见。在HPRF患者中，无论存在酮症酸中毒还是非酮症性高血糖，高钾血症的发生率似乎相似。通常，严重DH患者无症状或可能表现出口渴。DH不常见的临床表现包括高渗或酮症酸中毒引起的昏迷和癫痫发作以及细胞外扩张引起的肺水肿。胰岛素输注通常是纠正生化异常和逆转DH临床表现所需的唯一治疗方法。在用胰岛素治疗DH期间，需要监测临床表现和生化参数，以确定是否需要采取额外措施，如给予生理盐水、游离水或钾盐，以及紧急血液透析（HD）。紧急HD有张力过度快速下降的风险；其在治疗DH中的益处尚未得到证实。
