儿童淋巴造血系统肿瘤化疗后继发性肾上腺皮质功能不全致顽固性低钠血症4例

Four cases of refractory hyponatremia caused by secondary adrenal cortical insufficiency after chemotherapy in children with tumors of lymphoid hematopoietic system

目的探讨淋巴造血系统肿瘤化疗后继发性肾上腺皮质功能不全(SACI)所致顽固性低钠血症患儿的临床特点、治疗及预后。方法回顾性病例总结。收集2020年1月至2023年6月郑州大学第一附属医院收治的3例急性淋巴细胞白血病(ALL)和1例淋巴母细胞淋巴瘤(LBL)发生SACI致顽固性低钠血症患儿的年龄、性别、血清钠水平、出现低钠血症的时间、低钠血症持续时间、皮质醇水平、24 h尿钠水平、血尿渗透压、治疗及转归等资料,并进行总结。结果4例患儿均为男童,化疗方案均包含地塞米松;临床首要表现为乏力,中度低钠血症3例,轻度低钠血症1例;低钠血症在激素治疗1周后出现,持续时间10~20 d,平均14.25 d;24 h尿钠增高,血浆渗透压轻度降低或处于正常值低限,尿渗透压大于血浆渗透压;1例LBL早8点血皮质醇降低,1例ALL早8点血皮质醇升高、2例ALL正常,用氢化可的松[10 mg/(m^(2)·d),分2次口服]治疗后,低钠血症得以迅速纠正,纠正时间为3~5 d。结论儿童淋巴造血系统肿瘤在接受激素治疗过程中,可能出现SACI,其所致低钠血症一般出现在激素治疗1周后,持续时间长,实验室检查与抗利尿激素分泌异常综合征类似,但对静脉/口服补充浓钠、限水治疗反应欠佳,加用氢化可的松治疗可迅速纠正,预后良好。

Objective To explore the clinical features,treatment and prognosis of refractory hyponatremia caused by secondary adrenal cortical insufficiency(SACI)after chemotherapy in children with tumors of the lymphoid hematopoietic system.Methods Clinical data including age,sex,serum sodium level,time of onset of hyponatremia,duration of hyponatremia,cortisol level,24 h urinary sodium level,plasma/urine osmotic pressure,treatment and prognosis of 3 acute lymphoblastic leukemia(ALL)children and 1 lymphoblastic lymphoma(LBL)child with SACI-caused refractory hyponatremia treated at the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2023 were analyzed retrospectively.Results The 4 patients were all boys,and they received Dexamethasone chemotherapy.The primary clinical manifestations were fatigue,moderate hyponatremia in 3 cases,and mild hyponatremia in 1 case.Hyponatremia occurred after 1 week of glucocorticoid therapy and persisted for 10-20 days(mean 14.25 days).The 24 h urinary sodium level increased,plasma osmotic pressure slightly decreased or was at the low limit of the normal range,and urine osmotic pressure was greater than plasma osmotic pressure.The serum cortisol level at 8∶00 AM.decreased in 1 LBL case,increased in 1 ALL case,and remained normal in 2 ALL cases.After treatment with Hydrocortisone[10 mg/(m^(2)·d),taken orally in 2 doses],hyponatremia was quickly corrected within 3-5 days.Conclusions When receiving glucocorticoid therapy,children with tumors of the lymphoid hematopoietic system may have SACI,and the hyponatremia caused by it generally appears 1 week after glucocorticoid therapy and persists for a long time.Laboratory tests are similar to the syndrome of inappropriate antidiuretic hormone secretion,but the response to intravenous/oral supplementation of concentrated sodium and water restriction treatment is poor.The addition of Hydrocortisone can quickly correct hyponatremia,and the prognosis is excellent.