原发性醛固酮增多症术后持续性重度高钾血症1例

doi:10.19723/j.issn.1671-167X.2022.02.028

摘要/Abstract

摘要：

高钾血症是原发性醛固酮增多症术后可能发生的并发症之一,但原发性醛固酮增多症术后的高钾血症在临床实践中并不常见,而持续性重度高钾血症更加罕见,临床工作中该并发症也未得到足够的重视。本研究报告1例原发性醛固酮增多症患者肾上腺腺瘤术后出现持续性严重高钾血症的病例,并进行长期随访。患者因原发性醛固酮增多症行经腹腔镜左肾上腺肿物切除术,术后病理学诊断示肾上腺皮质腺瘤。术后1个月随访发现高钾血症,血钾最高7.0 mmol/L,患者自觉皮肤瘙痒、恶心、心悸。复查血浆醛固酮水平由术前35.69 ng/dL降至术后 2.12 ng/dL,24 h尿钾排出明显减少。醛固酮激素的明显下降导致尿钾排出减少可能是引起患者术后高钾血症的原因。予聚磺苯乙烯钠散、呋塞米、复方甘草酸苷降钾治疗,至术后随访14个月患者仍需服用降钾药物来维持血钾水平。用“原发性醛固酮增多症”“高钾血症”“手术治疗”检索2009至2019年发表在PubMed及万方数据库的相关文献,发现原发性醛固酮增多症术后高钾血症的发生率约为6%~29%,大多数以轻中度、一过性高血钾为主,19%~33%的高血钾患者为持续性,影响原发性醛固酮增多症术后高钾的危险因素主要包括肾功能减退、年龄大和高血压病程长等。本研究通过该病例结合文献复习,总结原发性醛固酮增多症手术治疗后出现高钾血症患者的临床特点,以提高临床医生对该严重并发症的认识,尤其对有高危因素的患者,术后更需密切监测血钾。

关键词: 原发性醛固酮增多症, 手术治疗, 高钾血症

Abstract:

Hyperkalemia was one of the complications after primary aldosteronism surgery. Hyperkalemia after primary aldosteronism surgery was uncommon in clinical practice, especially persistent and serious hyperkalemia was rare. This complication was not attached great importance in clinical work. A case about persistent and serious hyperkalemia after primary aldosteronism adrenal adenoma surgery was reported and the patient was followed-up for fourteen months in this study. This patient had a laparoscopic adrenalectomy due to primary aldosteronism. Hyperkalemia was detected one month after surgery of this patient, the highest level of plasma potassium was 7.0 mmol/L. The patient felt skin itchy, nausea, palpitation. Plasma aldosterone concentration fell to 2.12 ng/dL post-operation from 35.69 ng/dL pre-operation, zona glomerulosa insufficiency was confirmed by hormonal tests in this patient after surgery. And levels of 24 hours urinary potassium excretion declined. Decrease of aldosterone levels after surgery might be the cause of hyperkalemia. Hyperkalemia lasted for 14 months after surgery and kalemia-lowering drugs were needed. A systemic search with “primary aldosteronism”, “hyperkalemia”, “surgical treatment” was performed in PubMed and Wanfang Database for articles published between January 2009 and December 2019. Literature review indicated that the incidence of hyperkalemia after primary aldosteronism surgery was 6% to 29%. Most of them was mild to moderator hyperkalemia (plasma potassium 5.5 to 6.0 mmol/L) and transient. 19% to 33% in hyperkalemia patients was persistent hyperkalemia. Previous studies in the levels of plasma potassium reached the level as high as 7 mmol/L in our case were rare. Whether hypoaldosteronemia was the cause of hyperkalemia was not consistent in the published studies. Risk factors of hyperkalemia after primary aldosteronism surgery included kidney dysfunction, old age, long duration of hypertention. This paper aimed to improve doctors’ aweareness of hyperkalemia complication after primary aldosteronism surgery. Plasma potassium should be monitored closely after primary aldosteronism surgery, especially in the patients with risk factors. Some patients could have persistent and serious hyperkalemia, and need medicine treatment.

Key words: Primary aldosteronism, Surgery, Hyperkalemia

中图分类号:

R589.4

王薇,蔡林,高莹,郭晓蕙,张俊清. 原发性醛固酮增多症术后持续性重度高钾血症1例[J]. 北京大学学报（医学版）, 2022, 54(2): 376-380.

WANG Wei,CAI Lin,GAO Ying,GUO Xiao-hui,ZHANG Jun-qing. Persistent and serious hyperkalemia after surgery of primary aldosteronism: A case report[J]. Journal of Peking University (Health Sciences), 2022, 54(2): 376-380.

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参考文献 11

[1]	Huang WT, Chau T, Wu ST, et al. Prolonged hyperkalemia following unilateral adrenalectomy for primary hyperaldosteronism[J]. Clin Nephrol, 2010, 73(5):392-397. pmid: 20420801
[2]	Fischer E, Hanslik G, Pallauf A, et al. Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy[J]. J Clin Endocrinol Metab, 2012, 97(11):3965-3973. doi: 10.1210/jc.2012-2234 pmid: 22893716
[3]	Chiang WF, Cheng CJ, Wu ST, et al. Incidence and factors of post-adrenalectomy hyperkalemia in patients with aldosterone producing adenoma[J]. Clin Chim Acta, 2013, 424(9):114-118. doi: 10.1016/j.cca.2013.05.017
[4]	Hibi Y, Hayakawa N, Hasegawa M, et al. Unmasked renal impairment and prolonged hyperkalemia after unilateral adrenalectomy for primary aldosteronism coexisting with primary hyper-parathyroidism: Report of a case[J]. Surg Today, 2015, 45(2):241-246. doi: 10.1007/s00595-013-0813-0
[5]	Tahir A, McLaughlin K, Kline G. Severe hyperkalemia following adrenalectomy for aldosteronoma: Prediction, pathogenesis and approach to clinical management: A case series[J]. BMC Endocr Disord, 2016, 16(1):43. doi: 10.1186/s12902-016-0121-y pmid: 27460219
[6]	Park KS, Kim JH, Yang YS, et al. Outcomes analysis of surgical and medical treatments for patients with primary aldosteronism[J]. Endocr J, 2017, 64(6):623-632. doi: 10.1507/endocrj.EJ16-0530
[7]	Wada N, Shibayama Y, Umakoshi H, et al. Hyperkalemia in both surgically and medically treated patients with primary aldosteronism[J]. J Hum Hypertens, 2017, 31(10):627-632. doi: 10.1038/jhh.2017.38 pmid: 28540931
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[9]	丁韶丽, 阎文军, 赫曼, 等. 原发性醛固酮增多症患者肾上腺切除术中并发严重高钾血症1例[J]. 中华麻醉学杂志, 2018, 38(4):509-510.
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Items	Pre-op	1 month post-op	3 months post-op	7 months post-op	9 months post-op	14 months post-op	Normal range
ACTH/(ng/L)	9.33	-	39.53	33.23	-	-	7.2-63.3
Serum cortisol/(μg/dL)	10.06	-	20.82	14.95	-	-	6.2-19.4
Renin activity/[ng/(mL·h)]	1.32	-	-	-	-	-	0.13-2.5
Renin concentration/(mU/L)	-	-	9.7	24.8	8.6	21.2	4.4-46.1
Plasma aldosterone/(ng/dL)	35.69	-	2.12	8.47	3.96	11.3	3.0-35.3
ARR	-	-	0.22	0.34	0.46	0.53	<3.7
Creatinine/(μmol/L)	178.23	257.00	206.00	237.00	223.00	226	44-133
eGFR/[mL/(min·1.73 m²)]	33.92	21.79	28.47	24.04	25.87	25.28	>90
Plasma sodium/(mmol/L)	142.08	137.00	138.00	138.00	139.0	137.0	137-147
Plasma potassium/(mmol/L)	3.61	7.00	4.70	6.70	5.10	6.5	3.5-5.3
Plasma chlorine/(mmol/L)	107.6	109.0	106.0	108.0	104.0	108	99-110
CO₂/(mmol/L)	27.45	18.80	20.20	17.50	19.50	15	22-30
24 hour urine potassium/(mmol/24 h)	-	-	23.1	-	52.8	-	25-125
24 hour urine sodium/(mmol/24 h)	-	-	304.5	-	283.8	-	130-260