Nagler Evi V, Vanmassenhove Jill, van der Veer Sabine N, Nistor Ionut, Van Biesen Wim, Webster Angela C, Vanholder Raymond
European Renal Best Practice (ERBP), guidance body of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), De Pintelaan 185, Ghent 9000, Belgium.
BMC Med. 2014 Dec 11;12:1. doi: 10.1186/s12916-014-0231-1.
Hyponatremia is a common electrolyte disorder. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. We aimed to explore the scope, content, and consistency of these documents.
We searched MEDLINE, EMBASE, and websites of guideline organizations and professional societies to September 2014 without language restriction for Clinical Practice Guidelines (defined as any document providing guidance informed by systematic literature review) and Consensus Statements (any other guidance document) developed specifically to guide differential diagnosis or treatment of hyponatremia. Four reviewers appraised guideline quality using the 23-item AGREE II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Total scores were calculated as standardized averages by domain.
We found ten guidance documents; five clinical practice guidelines and five consensus statements. Overall, quality was mixed: two clinical practice guidelines attained an average score of >50% for all of the domains, three rated the evidence in a systematic way and two graded strength of the recommendations. All five consensus statements received AGREE scores below 60% for each of the specific domains.The guidance documents varied widely in scope. All dealt with therapy and seven included recommendations on diagnosis, using serum osmolality to confirm hypotonic hyponatremia, and volume status, urinary sodium concentration, and urinary osmolality for further classification of the hyponatremia. They differed, however, in classification thresholds, what additional tests to consider, and when to initiate diagnostic work-up. Eight guidance documents advocated hypertonic NaCl in severely symptomatic, acute onset (<48 h) hyponatremia. In chronic (>48 h) or asymptomatic cases, recommended treatments were NaCl 0.9%, fluid restriction, and cause-specific therapy for hypovolemic, euvolemic, and hypervolemic hyponatremia, respectively. Eight guidance documents recommended limits for speed of increase of sodium concentration, but these varied between 8 and 12 mmol/L per 24 h. Inconsistencies also existed in the recommended dose of NaCl, its initial infusion speed, and which second line interventions to consider.
Current guidance documents on the assessment and treatment of hyponatremia vary in methodological rigor and recommendations are not always consistent.
低钠血症是一种常见的电解质紊乱。多个组织已发布指导文件，以协助临床医生管理低钠血症。我们旨在探讨这些文件的范围、内容和一致性。
我们检索了MEDLINE、EMBASE以及指南组织和专业协会的网站，检索至2014年9月，不限语言，查找专门为指导低钠血症的鉴别诊断或治疗而制定的临床实践指南（定义为任何通过系统文献综述提供指导的文件）和共识声明（任何其他指导文件）。四名评审员使用23项AGREE II工具评估指南质量，该工具在六个领域对指导制定过程的报告进行评分：范围和目的、利益相关者参与、制定的严谨性、表述的清晰度、适用性和编辑独立性。总分按领域计算为标准化平均值。
我们找到了十份指导文件；五份临床实践指南和五份共识声明。总体而言，质量参差不齐：两份临床实践指南在所有领域的平均得分均超过50%，三份以系统的方式对证据进行了评级，两份对推荐强度进行了分级。所有五份共识声明在每个特定领域的AGREE得分均低于60%。指导文件的范围差异很大。所有文件都涉及治疗，七份文件包括关于诊断的建议，使用血清渗透压来确认低渗性低钠血症，以及使用容量状态、尿钠浓度和尿渗透压对低钠血症进行进一步分类。然而，它们在分类阈值、应考虑的其他检查以及何时开始诊断性检查方面存在差异。八份指导文件主张在严重症状性、急性发作（<48小时）的低钠血症中使用高渗氯化钠。在慢性（>48小时）或无症状病例中，推荐的治疗方法分别是0.9%氯化钠、液体限制以及针对低血容量性、等血容量性和高血容量性低钠血症的病因特异性治疗。八份指导文件推荐了钠浓度升高速度的限制，但这些限制在每24小时8至12毫摩尔/升之间有所不同。在氯化钠的推荐剂量、其初始输注速度以及应考虑的二线干预措施方面也存在不一致之处。
目前关于低钠血症评估和治疗的指导文件在方法严谨性方面存在差异，推荐意见也并非总是一致。
