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Article(id=1207751282434089020, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1207751280789921836, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2022.07.0717, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1637683200000, receivedDateStr=2021-11-24, revisedDate=null, revisedDateStr=null, acceptedDate=1642435200000, acceptedDateStr=2022-01-18, onlineDate=1765879944665, onlineDateStr=2025-12-16, pubDate=1658937600000, pubDateStr=2022-07-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1765879944665, onlineIssueDateStr=2025-12-16, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1765879944665, creator=13701087609, updateTime=1765879944665, updator=13701087609, issue=Issue{id=1207751280789921836, tenantId=1146029695717560320, journalId=1189873630562394117, year='2022', volume='47', issue='7', pageStart='639', pageEnd='744', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1765879944274, creator=13701087609, updateTime=1765879944274, updator=13701087609, preIssue=null, nextIssue=null, ext=null, issueFiles=null}, startPage=717, endPage=722, ext={EN=ArticleExt(id=1207751282744467530, articleId=1207751282434089020, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Prognostic impact of hyponatremia in neurointensive care patients, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To investigate the impact of hyponatremia on the prognosis of neurointensive care patients. Methods A retrospective study of 942 neurointensive care patients admitted to the First Medical Center of PLA General Hospital between August 2010 and May 2020 was performed. We classified these patients into two groups according to serum sodium level within 24 hours of admission: hyponatremia group 233 cases (<135 mmol/L), normonatremia group 709 cases (135-145 mmol/L).The 233 hyponatremia patients were subdivided into two groups: mild hyponatremia group (130-135 mmol/L, n=165) and moderate-severe hyponatremia group (<130 mmol/L, n=68). Primary endpoints were evaluated at 1-month and 6-month respectively with modified Rankin Scale (mRS), mRS scores of 4-6 were defined as poor outcomes. The general clinical data and prognosis were compared between the groups. Logistic regression was used to analyze the influencing factors of patient prognosis. Results Compared with the normonatremia group, the body temperature, blood glucose, urea, and creatinine, diagnosed as cerebrovascular disease, the proportion of poor prognosis at 6 months as well as hospitalization costs in the hyponatremia group were significantly different (P<0.05). There was no significant difference in the prognosis of patients with different degrees of hyponatremia (P>0.05). Multivariate logistic regression showed that hyponatremia, older age, high serum creatinine level, diagnosed as cerebrovascular disease, higher hospitalization costs, and low GCS score were independent risk factor for poor prognosis of NICU patients at 1 month after discharge. And multivariate logistic regression showed that hyponatremia, older age and low GCS score were independent risk factor for poor prognosis of NICU patients at 6 months after discharge. Conclusions Hyponatremia,a common electrolyte disorder in neurointensive care patients, is an independent risk factor influencing prognosis. Even mild hyponatremia may have an impact on outcomes.

, correspAuthors=Jia-Tang Zhang, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 探讨低钠血症对神经重症患者预后的影响。方法 回顾性分析2010年8月－2020年5月解放军总医院第一医学中心神经内科监护室收治的神经重症患者942例。根据入院24 h内血钠检测结果分为低钠血症组233例(<135 mmol/L)，正常血钠组709例(135~145 mmol/L)；根据低钠严重程度将233例患者分为轻度低钠血症组165例(130~135 mmol/L)，中、重度低钠血症组68例(<130 mmol/L)。分别于出院后1个月及6个月采用改良Rankin量表(mRS)对患者的临床结局进行评估，mRS评分4~6分定义为预后不良。比较各组一般临床资料及预后情况；采用广义估计方程(GEE)研究低钠程度与预后的关系，以及出院后不同时间预后的差异；采用二元logistic回归分析患者出院后1个月和6个月预后的影响因素。结果 与正常血钠组比较，低钠血症组的体温及血糖、尿素、肌酐水平，出院诊断为脑血管病、出院6个月预后不良的比例及住院费用差异有统计学意义(P<0.05)。不同程度低钠血症患者预后差异无统计学意义(P>0.05)。Logistic回归分析显示，低钠血症、年龄大、血尿素水平高、出院时诊断为脑血管病、住院费用高及GCS评分低为神经重症患者出院后1个月预后不良的独立危险因素(P<0.05)，低钠血症、年龄大及GCS评分低为出院后6个月预后不良的独立危险因素(P<0.05)。结论 低钠血症是神经重症患者常见的电解质紊乱，是影响患者预后的独立危险因素；即使是轻度低钠血症也可能会对患者预后造成影响。

, correspAuthors=张家堂, authorNote=null, correspAuthorsNote=
张家堂，E-mail：
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谭锐书，医学硕士，主要从事神经内科疾病的相关研究

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谭锐书，医学硕士，主要从事神经内科疾病的相关研究

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谭锐书，医学硕士，主要从事神经内科疾病的相关研究

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Clin J Am Soc Nephrol, 2011, 6(5): 960-965., articleTitle=Mortality and serum sodium: do patients die from or with hyponatremia?, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1207751283444916333, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, xref=1, ext=[AuthorCompanyExt(id=1207751283453304942, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, companyId=1207751283444916333, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Graduate School, Medical School of Chinese PLA, Beijing 100853, China), AuthorCompanyExt(id=1207751283457499247, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, companyId=1207751283444916333, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1解放军医学院研究生院，北京 100853)]), AuthorCompany(id=1207751283532996724, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, xref=2, ext=[AuthorCompanyExt(id=1207751283545579637, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, companyId=1207751283532996724, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Neurology, the First Medical Center, Chinese PLA General Hospital, Beijing 100853, China), AuthorCompanyExt(id=1207751283553968246, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, companyId=1207751283532996724, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2解放军总医院第一医学中心神经内科医学部，北京 100853)])], figs=[ArticleFig(id=1207751287941210500, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=EN, label=Tab. 1, caption=

Comparison of the clinical data of neurointensive care patients in two groups

, figureFileSmall=null, figureFileBig=null, tableContent=
临床指标低钠血症组(n=233)正常血钠组(n=709)χ2/ZP
人口学指标
 男性[例(%)]149(63.9)425(59.9)1.1820.277
 年龄[岁，M(Q1, Q3)]54(41, 70)56(40, 71)–0.3650.715
入院时生命体征[M(Q1, Q3)]
 体温(℃)36.8(36.5, 37.5)36.8(36.5, 37.2)–2.0920.036
 脉搏(次/min)83(76, 96)81(73, 96)–1.4630.143
 呼吸(次/min)18(18, 19)18(18, 19)–1.6070.108
 收缩压(mmHg)135(120, 151)137(122, 156)–1.4640.143
 舒张压(mmHg)78(68, 87)79(69, 88)–1.0310.303
入院GCS评分[分，M(Q1, Q3)]13(8, 15)13(8, 15)–0.5650.572
既往疾病史[例(%)]
 高血压95(40.8)271(38.2)0.2440.621
 糖尿病56(24.0)120(16.9)1.2540.534
 心脏疾病39(16.7)126(17.8)0.7170.397
 脑血管病30(12.9)87(12.3)0.0900.764
入院时实验室指标[M(Q1, Q3)]
 白细胞(×109/L)8.71(6.62, 11.93)9.02(6.96, 12.24)–1.0080.313
 血钾(mmol/L)3.75(3.51, 4.02)3.79(3.52, 4.09)–1.5280.126
 谷丙转氨酶(U/L)20.2(13.6, 35.7)18.75(12.5, 31.58)–1.6470.100
 谷草转氨酶(U/L)20.5(14.4, 32.8)21.1(15.1, 32.2)–0.3940.693
 白蛋白(g/L)39.2(34.7, 43.3)39.4(35.3, 43.3)–1.0740.283
 血糖(mmol/L)6.92(5.96, 8.82)6.70(5.46, 8.13)–3.3320.001
 尿素(mmol/L)4.64(3.65, 6.49)5.13(3.85, 6.86)–1.9770.048
 肌酐(μmol/L)61.5(50.5, 76.1)66.6(54.5, 82.9)–3.3930.001
出院诊断[例(%)]  17.550<0.001
 脑血管病90(38.6)386(54.4)
 非脑血管病143(61.4)323(45.6)
结局[例(%)]
 1个月预后不良139(59.7)385(54.3)2.0370.153
 6个月预后不良118(50.6)295(41.6)5.8160.016
住院费用(万元)7.4(4.3, 14.8)6.5(3.0, 14.0)2.2040.027
), ArticleFig(id=1207751288062845322, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=CN, label=表1, caption=

两组神经重症患者临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
临床指标低钠血症组(n=233)正常血钠组(n=709)χ2/ZP
人口学指标
 男性[例(%)]149(63.9)425(59.9)1.1820.277
 年龄[岁，M(Q1, Q3)]54(41, 70)56(40, 71)–0.3650.715
入院时生命体征[M(Q1, Q3)]
 体温(℃)36.8(36.5, 37.5)36.8(36.5, 37.2)–2.0920.036
 脉搏(次/min)83(76, 96)81(73, 96)–1.4630.143
 呼吸(次/min)18(18, 19)18(18, 19)–1.6070.108
 收缩压(mmHg)135(120, 151)137(122, 156)–1.4640.143
 舒张压(mmHg)78(68, 87)79(69, 88)–1.0310.303
入院GCS评分[分，M(Q1, Q3)]13(8, 15)13(8, 15)–0.5650.572
既往疾病史[例(%)]
 高血压95(40.8)271(38.2)0.2440.621
 糖尿病56(24.0)120(16.9)1.2540.534
 心脏疾病39(16.7)126(17.8)0.7170.397
 脑血管病30(12.9)87(12.3)0.0900.764
入院时实验室指标[M(Q1, Q3)]
 白细胞(×109/L)8.71(6.62, 11.93)9.02(6.96, 12.24)–1.0080.313
 血钾(mmol/L)3.75(3.51, 4.02)3.79(3.52, 4.09)–1.5280.126
 谷丙转氨酶(U/L)20.2(13.6, 35.7)18.75(12.5, 31.58)–1.6470.100
 谷草转氨酶(U/L)20.5(14.4, 32.8)21.1(15.1, 32.2)–0.3940.693
 白蛋白(g/L)39.2(34.7, 43.3)39.4(35.3, 43.3)–1.0740.283
 血糖(mmol/L)6.92(5.96, 8.82)6.70(5.46, 8.13)–3.3320.001
 尿素(mmol/L)4.64(3.65, 6.49)5.13(3.85, 6.86)–1.9770.048
 肌酐(μmol/L)61.5(50.5, 76.1)66.6(54.5, 82.9)–3.3930.001
出院诊断[例(%)]  17.550<0.001
 脑血管病90(38.6)386(54.4)
 非脑血管病143(61.4)323(45.6)
结局[例(%)]
 1个月预后不良139(59.7)385(54.3)2.0370.153
 6个月预后不良118(50.6)295(41.6)5.8160.016
住院费用(万元)7.4(4.3, 14.8)6.5(3.0, 14.0)2.2040.027
), ArticleFig(id=1207751288142537105, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=EN, label=Tab. 2, caption=

Comparison of the prognosis of patients with different degree of hyponatremia with generalized estimation equation models

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βOR (95%CI)P
低钠血症程度0.2991.35(0.78~2.32)0.280
出院后时间0.3671.44(1.21~1.73)＜0.001
), ArticleFig(id=1207751288247394707, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=CN, label=表2, caption=

不同程度低钠血症及出院后不同时间患者预后的GEE比较

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βOR (95%CI)P
低钠血症程度0.2991.35(0.78~2.32)0.280
出院后时间0.3671.44(1.21~1.73)＜0.001
), ArticleFig(id=1207751288343863701, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=EN, label=Tab. 3, caption=

Multivariate logistic regression analysis on the prognosis of NICU patients 1 month and 6 months after discharge

, figureFileSmall=null, figureFileBig=null, tableContent=
临床指标出院后1个月出院后6个月
单因素分析多因素分析单因素分析多因素分析
ORPOR(95%CI)PORPOR(95%CI)P
低钠血症1.2370.1652.080(1.042~4.15)0.0381.4400.0162.081(1.129~3.836)0.019
男性1.2340.118  1.1310.362
年龄1.039＜0.0011.021(1.002~1.040)0.0281.047＜0.0011.052(1.037~1.066)＜0.001
体温1.3930.001  1.2050.059
脉搏1.0120.004  1.0090.033
呼吸0.9690.558  0.9530.369
收缩压1.0070.010  1.0050.072
舒张压1.0050.310  0.9791.000
GCS评分0.613＜0.0010.672(0.605~0.747)＜0.0010.724＜0.0010.725(0.671~0.783)＜0.001
高血压2.963＜0.001  2.910＜0.001
糖尿病2.2730.001  1.8610.004
心脏疾病4.129＜0.001  3.215＜0.001
脑血管病2.4470.002  3.028＜0.001
白细胞1.079＜0.001  1.0430.008
血钾2.019＜0.001  1.789＜0.001
谷丙转氨酶1.0000.836  0.9990.234
谷草转氨酶1.0010.230  1.0010.255
白蛋白0.931＜0.001  0.926＜0.001
血糖1.0010.817  1.0010.887
尿素1.089＜0.0011.113(1.010~1.226)0.0311.073＜0.001
肌酐1.005＜0.001  1.004＜0.001
出院诊断脑血管病3.725＜0.0013.411(1.746~6.664)＜0.0012.800＜0.001
住院费用1.030＜0.0011.067(1.028~1.106)0.0011.069＜0.001  
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NICU患者出院后1个月和6个月预后影响因素的多元logistic回归分析结果

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临床指标出院后1个月出院后6个月
单因素分析多因素分析单因素分析多因素分析
ORPOR(95%CI)PORPOR(95%CI)P
低钠血症1.2370.1652.080(1.042~4.15)0.0381.4400.0162.081(1.129~3.836)0.019
男性1.2340.118  1.1310.362
年龄1.039＜0.0011.021(1.002~1.040)0.0281.047＜0.0011.052(1.037~1.066)＜0.001
体温1.3930.001  1.2050.059
脉搏1.0120.004  1.0090.033
呼吸0.9690.558  0.9530.369
收缩压1.0070.010  1.0050.072
舒张压1.0050.310  0.9791.000
GCS评分0.613＜0.0010.672(0.605~0.747)＜0.0010.724＜0.0010.725(0.671~0.783)＜0.001
高血压2.963＜0.001  2.910＜0.001
糖尿病2.2730.001  1.8610.004
心脏疾病4.129＜0.001  3.215＜0.001
脑血管病2.4470.002  3.028＜0.001
白细胞1.079＜0.001  1.0430.008
血钾2.019＜0.001  1.789＜0.001
谷丙转氨酶1.0000.836  0.9990.234
谷草转氨酶1.0010.230  1.0010.255
白蛋白0.931＜0.001  0.926＜0.001
血糖1.0010.817  1.0010.887
尿素1.089＜0.0011.113(1.010~1.226)0.0311.073＜0.001
肌酐1.005＜0.001  1.004＜0.001
出院诊断脑血管病3.725＜0.0013.411(1.746~6.664)＜0.0012.800＜0.001
住院费用1.030＜0.0011.067(1.028~1.106)0.0011.069＜0.001  
), ArticleFig(id=1207751288545190302, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207751282434089020, language=EN, label=Tab. 4, caption=

The association between hyponatremia and prognosis with generalized estimation equation models

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变量βOR(95%CI)P
无低钠血症+出院1个月预后不良0.0611.06(0.65~1.73)0.805
低钠血症+出院1个月预后不良–0.3010.74(0.53~1.04)0.079
无低钠血症+出院6个月预后不良0.4511.57(0.97~2.54)0.067
低钠血症+出院6个月预后不良01 
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低钠血症与预后的GEE比较

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变量βOR(95%CI)P
无低钠血症+出院1个月预后不良0.0611.06(0.65~1.73)0.805
低钠血症+出院1个月预后不良–0.3010.74(0.53~1.04)0.079
无低钠血症+出院6个月预后不良0.4511.57(0.97~2.54)0.067
低钠血症+出院6个月预后不良01 
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低钠血症对神经重症患者预后的影响
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谭锐书 1 , 单煜恒 1 , 田成林 2 , 黄德晖 2 , 石强 2 , 杨飞 2 , 崔芳 2 , 马玉宝 2 , 何绵旺 2 , 张家堂 2, *
解放军医学杂志 | 临床研究 2022,47(7): 717-722
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解放军医学杂志 | 临床研究 2022, 47(7): 717-722
低钠血症对神经重症患者预后的影响
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谭锐书1, 单煜恒1, 田成林2, 黄德晖2, 石强2, 杨飞2, 崔芳2, 马玉宝2, 何绵旺2, 张家堂2, *
作者信息
  • 1解放军医学院研究生院，北京 100853
  • 2解放军总医院第一医学中心神经内科医学部，北京 100853

    • 谭锐书，医学硕士，主要从事神经内科疾病的相关研究

通讯作者:

张家堂，E-mail：
Prognostic impact of hyponatremia in neurointensive care patients
Rui-Shu Tan1, Yu-Heng Shan1, Cheng-Lin Tian2, De-Hui Huang2, Qiang Shi2, Fei Yang2, Fang Cui2, Yu-Bao Ma2, Mian-Wang He2, Jia-Tang Zhang2, *
Affiliations
  • 1Graduate School, Medical School of Chinese PLA, Beijing 100853, China
  • 2Department of Neurology, the First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
出版时间: 2022-07-28 doi: 10.11855/j.issn.0577-7402.2022.07.0717
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摘要
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目的 探讨低钠血症对神经重症患者预后的影响。方法 回顾性分析2010年8月－2020年5月解放军总医院第一医学中心神经内科监护室收治的神经重症患者942例。根据入院24 h内血钠检测结果分为低钠血症组233例(<135 mmol/L)，正常血钠组709例(135~145 mmol/L)；根据低钠严重程度将233例患者分为轻度低钠血症组165例(130~135 mmol/L)，中、重度低钠血症组68例(<130 mmol/L)。分别于出院后1个月及6个月采用改良Rankin量表(mRS)对患者的临床结局进行评估，mRS评分4~6分定义为预后不良。比较各组一般临床资料及预后情况；采用广义估计方程(GEE)研究低钠程度与预后的关系，以及出院后不同时间预后的差异；采用二元logistic回归分析患者出院后1个月和6个月预后的影响因素。结果 与正常血钠组比较，低钠血症组的体温及血糖、尿素、肌酐水平，出院诊断为脑血管病、出院6个月预后不良的比例及住院费用差异有统计学意义(P<0.05)。不同程度低钠血症患者预后差异无统计学意义(P>0.05)。Logistic回归分析显示，低钠血症、年龄大、血尿素水平高、出院时诊断为脑血管病、住院费用高及GCS评分低为神经重症患者出院后1个月预后不良的独立危险因素(P<0.05)，低钠血症、年龄大及GCS评分低为出院后6个月预后不良的独立危险因素(P<0.05)。结论 低钠血症是神经重症患者常见的电解质紊乱，是影响患者预后的独立危险因素；即使是轻度低钠血症也可能会对患者预后造成影响。

神经重症监护  /  低钠血症  /  回顾性研究  /  改良Rankin评分  /  预后

Objective To investigate the impact of hyponatremia on the prognosis of neurointensive care patients. Methods A retrospective study of 942 neurointensive care patients admitted to the First Medical Center of PLA General Hospital between August 2010 and May 2020 was performed. We classified these patients into two groups according to serum sodium level within 24 hours of admission: hyponatremia group 233 cases (<135 mmol/L), normonatremia group 709 cases (135-145 mmol/L).The 233 hyponatremia patients were subdivided into two groups: mild hyponatremia group (130-135 mmol/L, n=165) and moderate-severe hyponatremia group (<130 mmol/L, n=68). Primary endpoints were evaluated at 1-month and 6-month respectively with modified Rankin Scale (mRS), mRS scores of 4-6 were defined as poor outcomes. The general clinical data and prognosis were compared between the groups. Logistic regression was used to analyze the influencing factors of patient prognosis. Results Compared with the normonatremia group, the body temperature, blood glucose, urea, and creatinine, diagnosed as cerebrovascular disease, the proportion of poor prognosis at 6 months as well as hospitalization costs in the hyponatremia group were significantly different (P<0.05). There was no significant difference in the prognosis of patients with different degrees of hyponatremia (P>0.05). Multivariate logistic regression showed that hyponatremia, older age, high serum creatinine level, diagnosed as cerebrovascular disease, higher hospitalization costs, and low GCS score were independent risk factor for poor prognosis of NICU patients at 1 month after discharge. And multivariate logistic regression showed that hyponatremia, older age and low GCS score were independent risk factor for poor prognosis of NICU patients at 6 months after discharge. Conclusions Hyponatremia,a common electrolyte disorder in neurointensive care patients, is an independent risk factor influencing prognosis. Even mild hyponatremia may have an impact on outcomes.

neurointensive care  /  hyponatremia  /  retrospective study  /  modified Rankin scale score  /  prognosis
谭锐书, 单煜恒, 田成林, 黄德晖, 石强, 杨飞, 崔芳, 马玉宝, 何绵旺, 张家堂. 低钠血症对神经重症患者预后的影响. 解放军医学杂志, 2022 , 47 (7) : 717 -722 . DOI: 10.11855/j.issn.0577-7402.2022.07.0717
Rui-Shu Tan, Yu-Heng Shan, Cheng-Lin Tian, De-Hui Huang, Qiang Shi, Fei Yang, Fang Cui, Yu-Bao Ma, Mian-Wang He, Jia-Tang Zhang. Prognostic impact of hyponatremia in neurointensive care patients[J]. Medical Journal of Chinese People’s Liberation Army, 2022 , 47 (7) : 717 -722 . DOI: 10.11855/j.issn.0577-7402.2022.07.0717
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低钠血症一般指血清钠低于135 mmol/L，是住院患者特别是ICU患者最常见的电解质紊乱[1-2]。低钠血症与抗利尿激素异常分泌、脑利钠肽及交感神经功能异常密切相关。中枢神经系统疾病(如卒中、感染)可影响下丘脑及垂体功能而增加抗利尿激素的释放，同时可导致脑利钠肽异常升高及交感神经系统失调[3-4]。因此，神经重症监护病房(neurocritical care unit，NICU)中的重症患者更易发生低钠血症。低钠血症可使NICU患者的原有症状加重，并可能导致一系列严重的神经系统并发症如癫痫、脑疝等。为避免脑水肿、意识障碍等潜在的严重并发症发生，美国及欧洲指南均建议要积极、适当地纠正低钠血症[5-6]。低钠血症是否为NICU重症患者预后的危险因素仍存在争议。有研究认为低钠血症与重症患者的不良结局相关[7-9]，而有的研究则认为低钠血症与患者的预后无关[10-14]。目前仅有两项较小规模的研究探讨了NICU患者低钠血症对预后的影响且均未得出可靠结论[12-13]。本研究分析了NICU患者低钠血症与预后的关系，以期为临床工作提供指导。
1 资料与方法
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1.1 一般资料
回顾性收集2010年8月－2020年5月解放军总医院第一医学中心NICU收治的神经重症患者942例，其中男573例，女369例；年龄(55.4±20.3)岁。纳入标准：(1)符合2014年制定的《神经重症监护病房建设中国专家共识》收治标准[15]；(2)年龄>18岁；(3)入院时血钠≤145 mmol/L[16-17]。排除标准：(1)住院时间<24 h；(2)基线资料不全；(3)失访。对于多次入院患者，只记录其第1次入院的数据。
1.2 分组及研究方法
根据入院24 h内首次测量的血钠值将患者分为低钠血症组(<135 mmol/L，n=233)和正常血钠组(135~145 mmol/L，n=709)。记录患者的性别、年龄、入院时生命体征、格拉斯哥昏迷评分(Glasgow coma scale，GCS评分)、既往疾病(高血压、糖尿病、心脏疾病、脑血管病)、入院时实验室检查、出院诊断(脑血管病或非脑血管病)、结局及住院费用等。出院后采取门诊复诊或电话问询的方式对患者随访6个月。分别于出院后1个月和6个月采用改良Rankin量表(mRS)对患者的临床结局进行评估。mRS评分为0~3分定义为预后良好，4~6分定义为预后不良。对于死亡患者记录其死亡日期及死亡原因。
低钠血症组患者按病情程度分为轻度低钠血症组(130~135 mmol/L，n=165)和中重度低钠血症组(<130 mmol/L，n=68)两组(根据文献[6]对低钠血症病情程度的分类，将中、重度患者合并处理)。采用广义估计方程(GEE)研究低钠程度与预后的关系，以及出院后不同时间预后的差异；采用二元logistic回归分析患者出院后1个月和6个月预后的影响因素。
1.3 统计学处理
采用SPSS 26.0软件进行统计分析。分类变量以例(%)表示，两组比较采用χ2检验或Fisher精确概率法。连续变量若服从正态分布以$\bar{x}±s$表示，两组比较采用t检验；若不服从正态分布，以M(Q1，Q3)表示，两组比较采用秩和检验。P<0.05为差异有统计学意义。
2 结果
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2.1 两组临床资料比较
与正常血钠组比较，低钠血症组的体温及血糖、尿素、肌酐水平，出院诊断为脑血管病、6个月预后不良的比例及住院费用差异有统计学意义(P<0.05，表1)。
2.2 不同程度低钠血症及出院后时间对预后的影响
不同低钠程度对预后无明显影响(P>0.05)。出院后1个月预后不良的比例高于出院后6个月(P<0.001)(表2)。
2.3 影响神经重症患者预后的多元logistic回归分析结果
分别以患者出院后1个月和6个月的预后为因变量(预后不良=1，预后良好=0)，以是否低钠血症，是否有高血压病史、糖尿病病史、心脏疾病病史、脑血管病史，出院诊断是否为脑血管病(赋值均为是=1，否=0)，以及年龄、性别、体温、脉搏、收缩压、GCS评分、白细胞、血钾、白蛋白、肌酐、尿素和住院费用为自变量进行多因素logistic回归分析，结果显示低钠血症、年龄大、血尿素水平高、出院时诊断为脑血管病、住院费用高及GCS评分低为神经重症患者出院后1个月预后不良的独立危险因素，而低钠血症、年龄大及GCS评分低为神经重症患者出院后6个月预后不良的独立危险因素(表3)。
采用GEE分析低钠血症与出院后1个月及6个月预后的关系，将低钠血症、年龄、性别、体温、脉搏、收缩压、GCS评分、高血压病史、糖尿病病史、心脏疾病病史、脑血管病史、白细胞、血钾、白蛋白、肌酐、尿素、出院诊断是否为脑血管病及住院费用为自变量分别纳入，研究低钠血症及预后的交互效应，结果显示，低钠血症患者出院后1个月预后不良的发生率与出院后6个月比较差异无统计学意义(P>0.05)(表4)。
3 讨论
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早期研究发现，心脏重症监护室(CICU)、儿科重症监护室(PICU)患者的病死率与低钠血症存在相关性[7, 9]，但目前针对神经重症患者的研究较少，且未确定二者的相关性[12-13]。既往针对ICU的研究多关注特定疾病，如Palmer[8]对ICU中常见的疾病进行了综述，Luu等[9]对细支气管炎患儿低钠血症与预后的关系进行了研究。笔者认为，对于NICU患者而言，低钠血症引起的疾病可能不是单一的，除了神经系统疾病外，内科疾病如肺炎、心力衰竭在NICU患者中也较为常见。此外，饮食、补液等问题也可能会导致低钠血症。因此按疾病分析可能不能反映低钠血症对NICU患者影响的全貌，特别是在合并其他易出现低钠血症疾病的患者中。本研究将收治的所有神经重症患者纳入分析，以避免疾病差异带来的偏倚。
在不同的研究中，低钠血症的发生率不尽相同(4%~22%)，可能与原发疾病、研究对象(普通病房、综合ICU、专科ICU)有关[1, 7, 9, 18]。本研究中，24.7%(233/942)的患者入院时存在低钠血症，高于上述文献报道[1, 7, 9, 18]，原因可能包括以下几方面：(1)NICU疾病谱决定了神经重症患者易出现低钠血症，如结核性脑膜炎、自身免疫性脑炎、蛛网膜下腔出血等NICU常见疾病均易导致较高的低钠血症发生率[14, 19-20]。本研究中，中枢神经系统感染患者的低钠血症发生率为41.8%(76/182)，这可能导致了本研究的低钠血症发生率较高。(2)本研究是关于神经重症患者的研究，相比综合ICU的患者更易出现意识障碍、吞咽障碍，因此可能存在较高的低钠血症发生率。(3)人种间的差异可能也是本研究低钠血症发生率较高的原因。在美国开展的一项全国性调查发现，非西班牙裔的白种人及黑种人低钠血症发生率较西班牙裔高[21]。两项针对神经重症患者的研究发现，中国的NICU低钠血症发生率高于捷克(20.4% vs. 17.0%)[12-13]。
本研究对低钠血症与预后的单因素及多因素分析证实，神经重症患者出院1个月及6个月后，低钠血症均是其预后不良的独立危险因素，考虑其原因可能包括：(1)对于内外科系统疾病而言，低钠血症是多种疾病预后不良的危险因素，如肺部感染、心力衰竭、心肌梗死、肝肾综合征及骨折等[7, 22-25]，神经重症患者常合并多系统疾病，在低钠血症的影响下，可能会进一步加重患者的不良预后。(2)对于神经系统疾病而言，缺血性脑卒中[26]、脑出血[27]及吉兰-巴雷综合征[28]在神经重症病房中较常见，病情要比普通病房更严重，因此神经重症低钠血症患者出现不良预后的可能性大。此外，对低钠血症与预后的重复测量分析显示低钠血症的预后并未随着随访时间的变化而变化，但此结论可能存在样本量不足的原因，因本研究中P值为0.079，进一步扩大样本量或许能得出阳性结论。
有研究发现，血钠水平越低，脑组织肿胀越明显，可能引起神经损伤、癫痫甚至死亡，而快速地纠正这种状态可能会导致严重的细胞萎缩，出现脑桥中央髓鞘溶解等神经系统损伤[29-30]，因此，中、重度低钠血症组预后不良发生率可能较高。还有研究认为，即使是轻度低钠血症也会对患者的预后产生影响[2, 31]。一项涉及45 693例患者病死率与血钠关系的研究发现，血钠在120~134 mmol/L时，病死率随着血钠水平下降而升高，但血钠<120 mmol/L时，病死率反而随着血钠水平下降而下降[32]。本研究对低钠血症进行亚组分析发现，中、重度低钠血症组预后不良发生率与轻度低钠血症组差异无统计学意义，考虑低钠程度对预后的影响可能并不成比例，而是“0”或“1”的关系，提示轻度低钠血症也会对患者预后产生影响，需积极纠正。
本研究尚存在以下局限性：(1)为单中心研究，更加可靠的结论需要进一步多中心研究来证实；(2)为回顾性研究，许多病例不能进一步用于低钠血症病因的探究，如抗利尿激素分泌异常综合征及脑耗盐综合征等，因此尚不能得出病因分层方面的结论；(3)纠正低钠血症是否可以改善预后，本研究尚未涉及。应对低钠血症进行前瞻性干预，以进一步明确是否存在相关性。
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2022年第47卷第7期
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doi: 10.11855/j.issn.0577-7402.2022.07.0717
  • 接收时间：2021-11-24
  • 首发时间：2025-12-16
  • 出版时间：2022-07-28
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  • 收稿日期：2021-11-24
  • 录用日期：2022-01-18
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    1解放军医学院研究生院，北京 100853
    2解放军总医院第一医学中心神经内科医学部，北京 100853

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
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