Στρογγυλό τραπέζι ΙΙΙ : Υπονατριαιμία Ο εγκέφαλος και...

1

6 ,

, 28 & 29 2012 :

( ) 1 ( [Na] < 136 mmol / L ) Na ( Na : ) 2 ( [Na] < 136 mmol / L ) Na ( Na : )

3 ( [Na] < 136 mmol / L ) Na ( Na : )

[Na] ~ ~ 1/ _4 ( [Na] < 136 mmol / L ) Na ( Na : )

[Na] ~ ~ 1/ _ 5 (ADH,)

6

7Verney EB. Absorption and excretion of water: the antidiuretic hormone. Lancet 1946; 2:781

NaCl8Verney EB. Absorption and excretion of water: the antidiuretic hormone. Lancet 1946; 2:781

NaCl 9Verney EB. Absorption and excretion of water: the antidiuretic hormone. Lancet 1946; 2:781

NaCl

NaCl

10Verney EB. Absorption and excretion of water: the antidiuretic hormone. Lancet 1946; 2:781

NaCl

NaCl

: 11Verney EB. Absorption and excretion of water: the antidiuretic hormone. Lancet 1946; 2:781

NaCl

NaCl

:

;12 O (ADH)

ADH13 Oliver G, Schaefer EA: On the physiological actions of extracts of the pituitary body and certain other glandular organs. J Physiol (Lond) 1895; 18:277-27914 Oliver G, Schaefer EA: On the physiological actions of extracts of the pituitary body and certain other glandular organs. J Physiol (Lond) 1895; 18:277-279

- (AVP) 15 Oliver G, Schaefer EA: On the physiological actions of extracts of the pituitary body and certain other glandular organs. J Physiol (Lond) 1895; 18:277-279

- (AVP) Du Vigneaud V: Hormones of the posterior pituitary gland: Oxytocin and vasopressin. In: DuVigneaud V, Bing RJ, Oncley JL, ed. The Harvey Lectures, 1954-55, New York: Academic Press; 1956:1-28

16 Oliver G, Schaefer EA: On the physiological actions of extracts of the pituitary body and certain other glandular organs. J Physiol (Lond) 1895; 18:277-279

- (AVP) Du Vigneaud V: Hormones of the posterior pituitary gland: Oxytocin and vasopressin. In: DuVigneaud V, Bing RJ, Oncley JL, ed. The Harvey Lectures, 1954-55, New York: Academic Press; 1956:1-28

- AVP = ADH 17 9-

-:

ADH 18 9-

-:

ADH -:

ADH 19 9-

-:

ADH -:

ADH :

,

20 9-

-:

ADH -:

ADH :

,

Vincent du VigneaudNobel 195521 9-

Deamino-d-(dextro-)-:

ADH -:

ADH :

,

DdAVP()

:6 14 22 ADH ADHCOOH-1913105107145

1. 23 ADH ADHCOOH-1913105107145

ADHCOOH-2. 1. 24 ADH ADHCOOH-1913105107145

1. ADHCOOH-2. 3. ADHCOOH-

25 ADH

3. ADHCOOH-

ADH: > 1

: ([ADH] )26 ADH (V2 ) ( ) Na Henle (V1a ) () [ADH] VIII von Willebrand 27 ADH ADH V2 (V2R) c-AMP AQP2 AQP3 AQP2 ( ) Aquaporins

Agre J, Am Soc Nephrol 2000;11:764-777 28

Aquaporins AQP1, AQP2, AQP3, AQP4, AQP6, AQP7, AQP8, AQP1029H ADH

H2O[ADH]V2 :1. 2. 30

ADH : H2O ~ = GFR - 31 , [ADH]. .

32 ADH

:

2. ( )++++33 ADH

:

2. ( )++++ 34

ADH : 1.Brenner & Rector's THE KIDNEY Eighth Edition35

ADH : 1. ( ) [ADH] 36

ADH : 1. ( ) [ADH] 37

ADH : 1.2.38

ADH : 1.2. ( ) [ADH] 39

ADH : 1.2. . ( ) [ADH] 40

ADH : 1.2. ( ) [ADH] . [ADH]. . . . > 10% 41

ADH : 1.2. ( ) [ADH] . [ADH]. . . . > 10% [ADH] >> 42

ADH : ( ) [ADH] [ADH]. . . . > 10% [ADH] >> 43 ADH

(Subfornical organ) - - 44 ADH

ADH () , 45 ADH

ADH () ,

T ADH 46 : , , ,

47 : , , ,

+ 48 : , , ,

GFR +49 : , , ,

GFR + ADH. +50

ADH ADH () ,

T ADH ADHBrenner & Rector's THE KIDNEY Eighth Edition51 ADHAcetylcholineNorepinephrineNicotineFluphenazineApomorphineHaloperidolMorphine (high doses)PromethazineEpinephrineOxilorphanIsoproterenolButorphanolHistamineOpioid agonistsBradykininMorphine (low doses)ProstaglandinEthanol-EndorphinCarbamazepineCyclophosphamide IVGlucocorticoidsVincristineClonidineInsulinMuscimol2-DeoxyglucosePhencyclidineAngiotensin IIPhenytoinLithiumCorticotropin-releasing factorNaloxoneCholecystokininBrenner & Rector's THE KIDNEY Eighth Edition52 ADHDesmopressin acetateOxytocin

ADH

ChlorpropamideClofibrateCarbamazepine, oxycarbazepineVincristineNicotineNarcotics (-opioid receptors)Antipsychotics, antidepressantsIfosfamide

ADH

ChlorpropamideCyclophosphamideNonsteroidal anti-inflammatory drugsAcetaminophen

HaloperidolFluphenazineAmitriptylineThioridazineSelective serotonin reuptake inhibitorsEcstasy (amphetamine-related)Data from Berl T, Schrier RW: Disorders of water metabolism. In Schrier RW (ed): Renal and Electrolyte Disorders, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2003.Brenner & Rector's THE KIDNEY Eighth Edition53 ADH stress

Robertson GL: The regulation of vasopressin function in health and disease. Rec Prog Horm Res 1976; 33:333-385.Brenner & Rector's THE KIDNEY Eighth Edition54 + + stress+ + 55 + + stress+ + ADH + (D/W 5%) .. 56 + + stress+ + ADH N/S 0,9% 1L

150 mmol/L NaCl

1L

150 mmol/L NaCl

++57 + + stress+ + ADH N/S 0,9% 1L

150 mmol/L NaCl

1L

150 mmol/L NaCl

1L

300 mmol/L NaCl

NaCl 1 L ++58 + + stress+ + ADH N/S 0,9% 1L

150 mmol/L NaCl

1L

150 mmol/L NaCl

1L

0 mmol/L NaCl

1L

300 mmol/L NaCl

NaCl 1 L +++59 : ADH [Na] < , ADH[ADH] 60 : ADH [Na] < , ADH[ADH] + 61 ADH (SIADH) Schwartz 1957 ADH : 1. ( ADH ) 2. ( ADH) 3. ( ADH)

62 ADH Data from Berl T, Schrier RW: Disorders of water metabolism. In Schrier RW (ed): Renal and Electrolyte Disorders, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2003.Brenner & Rector's THE KIDNEY Eighth Edition

63 SIADH ADH + [Na]

( ;)64 SIADH ADH + [Na]

Na ( ;)65 SIADH ADH + [Na]

Na ( ;) Na Brenner & Rector's THE KIDNEY Eighth Edition66 : GFR : > 100 mOsm/kg ( > ), [Na] > 30 mmol/L [] [ ] ADH (SIADH) 67 SIADH 1957 : ( ) (. NaCl ) SIADH 1957 , >20 1981- 2008: 119 MedlineRichard H. Sterns and Stephen M. Silver: Cerebral Salt Wasting Versus SIADH: What Difference ? J Am Soc Nephrol 19: 194196, 2008.68 : SIADH NaCl: ( BNP digitalis like sub.)

ADH ;69 : SIADH NaCl: ( BNP digitalis like sub.)

ADH ADH

( )

NaCl: ( NaCl, );70 : SIADH NaCl: ( BNP digitalis like sub.)

ADH ADH

( )

NaCl: ( NaCl, ); 71 : SIADH NaCl: ( BNP digitalis like sub.)

ADH ADH

( )

NaCl: ( NaCl, ); ;;72 : SIADH Na(-150 mmol)

Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L73 : SIADH Na(-150 mmol)

Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol


Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L H2O(0 mmol)

Na

H2O

(+1 L)

Na+K150 mmol

2L

Na+K300 mmol


Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L H2O(0 mmol)

Na

H2O

(+1 L)

Na+K150 mmol

2L

Na+K300 mmol


Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L H2O(0 mmol)

Na

H2O

(+1 L)

Na+K150 mmol

2L

Na+K300 mmol

1L IV 77 : SIADH Na(-150 mmol)

Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L H2O(0 mmol)

Na

H2O

(+1 L)

Na+K150 mmol

2L

Na+K300 mmol

1L[Na] (0 mmol)

Na

H2O

(0 L)

Na+K300 mmol

1L

Na+K300 mmol


Na

H2O

(0 L)

Na+K150 mmol

1L

Na+K300 mmol

1L H2O(0 mmol)

Na

H2O

(+1 L)

Na+K150 mmol

2L

Na+K300 mmol

1L[Na] (0 mmol)

Na

H2O

(0 L)

Na+K300 mmol

1L

Na+K300 mmol

1L ( ) . . SIADH 79 [Na] [Na] : (< 48 ) 80 [Na] [Na] : (< 48 )

Stupor / arrest

81 [Na] [Na] : (< 48 ) Stupor / arrest

15% . 82 Stupor / arrest

[Na] [Na] : (< 48 ) 15% . [Na]Halperein, Kamel and Goldstein. Fluid, Electrolyte and Acid-Base Physiology, 4th ed. 201083 [Na] (< 48 )

. ( ) Ecstasy

. 84 [Na] [Na] 85 [Na] [Na] 1L/min 1L/min [Na] 86 [Na] [Na] 1L/min 1L/min [Na]

= 20 87 [Na] [Na] 1L/min 1L/min [Na]

= 20 88 [Na] [Na] 1L/min 1L/min [Na] [Na]

= 20 89 [Na] 20ml/kg . , 15 min

=

=

Halperein, Kamel and Goldstein: Fluid, Electrolyte and Acid-Base Physiology, fourth edition, 201090 [Na] [Na]+ + -2 91 [Na] [Na]+ + -2 92 [Na] (> 48 ) [Na]+ + -2 2 4 93 [Na] (> 48 ) [Na]+ + -2 2 4 ( ) 94 [Na] (> 48 ) [Na]+ + - [Na] 95 [Na] (> 48 ) [Na]+ + - [Na] . 96 [Na] (> 48 ) [Na]+ + - [Na] [Na] ( ) . 97 [Na] (> 48 ) [Na]+ + - [Na] [Na] ( ) . , 98 (> 48 ) [Na] :

: , , ,

99 (> 48 ) [Na] :

: , , ,

MRI

100 ADH . , ADH, . ( , ), .101

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