原发性醛固酮增多症研究进展论文

1. APA及PAH：应行腹腔镜手术摘除单侧肾上腺瘤或增生的肾上腺，治愈率70%－90%[26-27]。术前准备包括补钾, 应用安体舒通控制血压，纠正电解质紊乱和酸碱平衡。术后血钾多在1周内恢复。大多数患者的血压可以恢复正常；如血压仍轻度升高，可加用安体舒通及其他降压药控制；血压改善不理想者，可能与长期高血压致肾损害以及动脉硬化有关。术前及后一周，可加用氢化可的松100～200mg/天，一周后逐渐停药。2. IHA：可选用安体舒通治疗，安体舒通为醛固酮拮抗剂，可与肾小管细胞浆以及核内受体结合。用法：120～240mg/天，服药后血钾多于1～2周、血压4～8周内恢复正常。安体舒通在降低原醛患者血压的同时，还能改善由于高醛固酮血症对心肌和血管的毒性，降低心力衰竭和心肌梗死发生率，此作用是独立于降压作用之外；安体舒通治疗有一定的不良反应，主要是由于对孕酮和雄激素受体的部分拮抗作用，临床上可表现为男性乳房发育、阳痿、性欲减退，女性月经紊乱；部分患者难以长期坚持使用。近年来国外应用高选择性的醛固酮受体拮抗剂依普利酮( eplerenone)治疗[28]，剂量为25-50mg，每日2次，避免了上述不良反应。其他药物可选用氨氯吡咪或氨苯蝶啶，钙离子阻断剂、ACEI及ARB等，可用于原醛症患者血压的控制，但无明显拮抗高醛固酮的作用。3. GRA生理剂量的糖皮质激素可使GRA患者血压、血钾恢复正常。对于儿童患者，治疗过程中要考虑到糖皮质激素对其生长发育的影响，应选择短效制剂，采用最低有效剂量(如氢化可的松 10～12 mg/m2 ·天). 也可使用盐皮质激素受体拮抗剂治疗GRA，疗效与糖皮质激素相当，并可避免糖皮质激素导致下丘脑-垂体-肾上腺轴的抑制和医源性副作用。[29]4. 肾上腺醛固酮癌：发现时多已有转移，失去手术时机，可行化疗，用米托坦、氨基导眠能、顺铂等治疗。[30] 参考资料1． Nishimura M，Uzu T，Fujii T，et a1． Cardiovascular complications in patients with primary aldosteronism．Am J Kidney Dis，1999；33(2):261-266．2． 吕朝晖，郑蕾，田 慧。等．原发性醛固酮增多症高血压特点的临床研究．解放军医学杂志，2003，28(5)：419-421．3． 吴景程，汤正义，张 炜，等．原发性醛固酮增多症患者心血管和肾功能指标的改变。上海交通大学学报(医学版)。2006；26：48-504． Funder JW ，Carey RM ，Fardella C，et a1． Case detection，diagnosis，and treatment of patients with primary aldosteronism：an endocrine society clinical practice guideline．Clin Endocrinol M etab，2008；93(9)：5． Milliez P，Girerd X，Plouin PF，et a1．Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism．J Am Coll Cardiol，2005，45(8)：1243—1248．6． William F. Young Jr. Primary aldosteronism, In Kronenberg ed: Williams Textbook of Endocrinology, 11th ed. Saunders, 20087． Fardella CE, Mosso L, Gomez-Sanchez C, et al: Primary hyperaldosteronism in essential hypertensives: prevalence, biochemical profile, and molecular biology. J Clin Endocrinol Metab 2000; 85:1863-1868． Loh KC, Koay ES, Khaw MC, et al: Prevalence of primary aldosteronism among Asian hypertensive patients in Singapore. J Clin Endocrinol Metab 2000; 85:2854-2859.Mulatero P，Stowasser M，Loh KC，et a1．In9． Phillips JL，Wahher MM，Pezzullo JC，et a1．Predictive value of pre．operative tests in discriminating bilateral adrenal hyperplasia from an aldosterone-producing adrenal adenoma． J Clin Endocrinol Metab，210． McMahon GT, Dluhy RG: Glucocorticoid-remediable aldosteronism. Cardiol Rev 2004; 12:44-48.11． Young Jr WF, Klee GG: Primary aldosteronism. Diagnostic evaluation. Endocrinol Metab Clin North Am 1988; 17:367-39512． Blumenfeld JD, Sealey JE, Schlussel Y, et al: Diagnosis and treatment of primary hyperaldosteronism. Ann Intern Med 1994; 121:877-885.13． Ma JT, Wang C, Lam KS, et al: Fifty cases of primary hyperaldosteronism in Hong Kong Chinese with a high frequency of periodic paralysis. Evaluation of techniques for tumour localisation. Q J Med 1914． Holland OB, Brown H, Kuhnert L, et al: Further evaluation of saline infusion for the diagnosis of primary aldosteronism. Hypertension 1984; 6:717-723.15． Schirpenbach C. Seiler L, Maser- Gluth C, et al. Confirmatory testing in normalkalaemic primary aldosteronism: the value of the saline infusion test and urinary aldosterone metabolites. Euro J Endocri16． Young Jr WF, Klee GG: Primary aldosteronism. Diagnostic evaluation. Endocrinol Metab Clin North Am 1988; 17:367-395.17． Young Jr WF, Hogan MJ, Klee GG, et al: Primary aldoster-onism: diagnosis and treatment. Mayo Clinic Proc 1990; 65:96-110.18． Bravo EL, Tarazi RC, Dustan HP, et al: The changing clinical spectrum of primary aldosteronism. Am J Med 1983; 74:641-6519． Lim PO, Farquharson CA, Shiels P, et al: Adverse cardiac effects of salt with fludrocortisone in hypertension. Hypertension 2001; 37:856-861.20． Stowasser M, Gordon RD: Primary aldosteronism—careful investigation is essential and rewarding. Mol Cell Endocrinol 2004; 217:33-39.21． Gordon RD, Stowasser M, Rutherford JC: Primary aldosteronism: are we diagnosing and operating on too few patients?. World J Surg 2001; 25:941-947.22． Young WF, Stanson AW, Thompson GB, et al: Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004; 136:1227-1235.23． Doppman JL, Gill Jr JR: Hyperaldosteronism: sampling the adrenal veins. Radiology. 1996; 198:309-312.24． 张炜，汤正义，王卫庆，等．肾上腺静脉采血在原发性醛固酮增多症分型诊断中的应用．中华内分泌代谢杂志，2006，22(5)：411—413．25． Daunt N: Adrenal vein sampling: how to make it quick, easy, and successful. Radiographics 2005; 25(suppl 1):S143-S158.26． Rossi H, Kim A, Prinz RA: Primary hyperaldosteronism in the era of laparoscopic adrenalectomy. Am Surg 2002; 68:253-256.discussion 256-257.27． Gonzalez R, Smith CD, McClusky 3rd DA, et al: Laparoscopic approach reduces likelihood of perioperative complications in patients undergoing adrenalectomy. Am Surg 2004; 70:668-674.28． Sica DA: Pharmacokinetics and pharmacodynamics of mineralocorticoid blocking agents and their effects on potassium homeostasis. Heart Fail Rev. 2005; 10:23-29.29． Stowasser M, Sharman J, Leano R, et al: Evidence for abnormal left ventricular structure and function in normotensive individuals with familial hyperaldosteronism type I. J Clin Endocrinol Metab. 20030． Katayama Y, Takata N. Tamura T，et al. A case of primary aldosteronism due to unilateral adrenal hyperplasia. Hypertens Res. 2005; 28: 379–384