Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
J Am Coll Cardiol. 2015 Feb 10;65(5):480-92. doi: 10.1016/j.jacc.2014.12.010.
Hyponatremia frequently poses a therapeutic challenge in acute decompensated heart failure (ADHF). Treating physicians should differentiate between depletional versus dilutional hyponatremia. The former is caused by diuretic agents, which enhance sodium excretion, often with concomitant potassium/magnesium losses. This can be treated with isotonic saline, whereas potassium/magnesium administration may be helpful if plasma concentrations are low. In contrast, as impaired water excretion, rather than sodium deficiency, is the culprit in dilutional hyponatremia, isotonic saline administration may further depress the serum sodium concentration. Because free water excretion is achieved by continuous sodium reabsorption in distal nephron segments with low water permeability, diuretic agents that impair this mechanism (e.g., thiazide-type diuretic agents and mineralocorticoid receptor antagonists) should be avoided, and proximally acting agents (e.g., acetazolamide and loop diuretic agents) are preferred. Vasopressin antagonists, which promote low water permeability in the collecting ducts and, hence, free water excretion, remain under investigation for dilutional hyponatremia in ADHF.
低钠血症在急性失代偿性心力衰竭（ADHF）中经常带来治疗挑战。治疗医生应区分耗竭性与稀释性低钠血症。前者由利尿剂引起，这些利尿剂增强了钠排泄，常伴有钾/镁丢失。可使用等渗盐水治疗，而如果血浆浓度较低，则可给予钾/镁治疗。相反，由于水排泄受损而不是钠缺乏是稀释性低钠血症的罪魁祸首，因此给予等渗盐水可能会进一步降低血清钠浓度。因为自由水排泄是通过远端肾单位中低水通透性的连续钠再吸收来实现的，所以应避免损害该机制的利尿剂（例如噻嗪类利尿剂和盐皮质激素受体拮抗剂），并优选近端作用的药物（例如乙酰唑胺和袢利尿剂）。加压素拮抗剂可促进集合管中的低水通透性，从而促进自由水排泄，它们仍在研究中，以用于治疗 ADHF 中的稀释性低钠血症。
