肝硬化难治性腹水的诊治进展

摘要/Abstract

摘要： 内脏血管舒张、门静脉高压激活肾素-血管紧张素-醛固酮系统(RAAS系统)是引起肝硬化患者出现水钠潴留的关键因素。当患者严格限钠饮食且使用最大剂量利尿剂(400 mg/d螺内酯联合160 mg/d呋塞米)1周后仍无应答,或患者因服用利尿剂后会出现并发症,而不能使用有效剂量的利尿剂导致腹水时,可被诊断为难治性腹水。目前,腹腔穿刺大量放液联合白蛋白、经颈静脉肝内门体静脉分流术及肝脏移植是治疗难治性腹水的有效方法。随着对难治性腹水的进一步研究,血管收缩剂、高选择性血管加压素V2受体拮抗剂、自动低流量腹水泵等新的治疗方式也逐渐应用于临床。这些新的治疗方式的应用,有望进一步提高难治性腹水的治疗效果。

饶晨怡, 李锋. 肝硬化难治性腹水的诊治进展[J]. 肝脏, 2023, 28(8): 987-989.

参考文献

[1] Caly W R, Abreu R M, Bitelman B, et al. Clinical features of refractory ascites in outpatients . Clinics (Sao Paulo), 2017, 72(7): 405-410.
[2] D'amico G, Morabito A, D'amico M, et al. Clinical states of cirrhosis and competing risks . J Hepatol, 2018, 68(3): 563-576.
[3] Larrue H, Vinel J P, Bureau C. Management of severe and refractory ascites . Clin Liver Dis, 2021, 25(2): 431-440.
[4] Claria J, Stauber R E, Coenraad M J, et al. Systemic inflammation in decompensated cirrhosis: characterization and role in acute-on-chronic liver failure . Hepatology, 2016, 64(4): 1249-1264.
[5] Fortune B, Cardenas A. Ascites, refractory ascites and hyponatremia in cirrhosis . Gastroenterol Rep (Oxf), 2017, 5(2): 104-112.
[6] Aithal G P, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis . Gut, 2021, 70(1): 9-29.
[7] Morando F, Rosi S, Gola E, et al. Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: a real-life cross-sectional study . Liver Int, 2015, 35(5): 1508-1515.
[8] Gow PJ, Ardalan ZS, Vasudevan A, et al. Outpatient terlipressin infusion for the treatment of refractory ascites . Am J Gastroenterol, 2016, 111(7): 1041-1042.
[9] Facciorusso A, Chandar AK, Murad MH, et al. Comparative efficacy of pharmacological strategies for management of type 1 hepatorenal syndrome: a systematic review and network meta-analysis . Lancet Gastroenterol Hepatol, 2017, 2(2): 94-102.
[10] Kulkarni AV, Kumar P, Rao NP, et al. Terlipressin-induced ischaemic skin necrosis . BMJ Case Rep, 2020, 13(1).
[11] Israelsen M, Dahl EK, Madsen BS, et al. Dobutamine reverses the cardio-suppressive effects of terlipressin without improving renal function in cirrhosis and ascites: a randomized controlled trial . Am J Physiol Gastrointest Liver Physiol, 2020, 318(2): G313-G321.
[12] Kalambokis G, Fotopoulos A, Economou M, et al. Effects of a 7-day treatment with midodrine in non-azotemic cirrhotic patients with and without ascites . J Hepatol, 2007, 46(2): 213-221.
[13] Sola E, Sole C, Simon-talero M, et al. Midodrine and albumin for prevention of complications in patients with cirrhosis awaiting liver transplantation. A randomized placebo-controlled trial . J Hepatol, 2018, 69(6): 1250-1259.
[14] Wang H, Liu A, Bo W, et al. Terlipressin in the treatment of hepatorenal syndrome: a systematic review and meta-analysis . Medicine (Baltimore), 2018, 97(16): e0431.
[15] Angeli P, Garcia-tsao G, Nadim MK, et al. News in pathophysiology, definition and classification of hepatorenal syndrome: a step beyond the International Club of Ascites (ICA) consensus document . J Hepatol, 2019, 71(4): 811-822.
[16] Sansoe G, Aragno M, Mastrocola R, et al. Dose-dependency of clonidine's effects in ascitic cirrhotic rats: comparison with alpha1-adrenergic agonist midodrine . Liver Int, 2016, 36(2): 205-211.
[17] Tripathy A, Maiti R, Jena M, et al. Effect of alpha agonists on the prevention of postparacentesis circulatory dysfunction in patients with refractory or recurrent ascites: a meta-analysis . Eur J Gastroenterol Hepatol, 2020, 32(3): 303-311.
[18] Sansoe G, Aragno M, Mastrocola R, et al. Alpha-2A adrenoceptor agonist guanfacine restores diuretic efficiency in experimental cirrhotic ascites: comparison with clonidine . PLoS One, 2016, 11(7): e0158486.
[19] Cavallin M, Kamath PS, Merli M, et al. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: a randomized trial . Hepatology, 2015, 62(2): 567-574.
[20] Iwasa M, Ishihara T, Kato M, et al. Cell-free and concentrated ascites reinfusion therapy for refractory ascites in cirrhosis in post-marketing surveillance and the role of tolvaptan. Intern Med, 2019, 58(21): 3069-3075.
[21] Rai N, Singh B, Singh A, et al. Midodrine and tolvaptan in patients with cirrhosis and refractory or recurrent ascites: a randomised pilot study . Liver Int, 2017, 37(3): 406-414.
[22] Rudler M, Mallet M, Sultanik P, et al. Optimal management of ascites . Liver Int, 2020, 40 Suppl 1: 128-135.
[23] Bureau C, Thabut D, Oberti F, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites . Gastroenterology, 2017, 152(1): 157-163.
[24] Dembinski J, Aranovich D, Banz V, et al. Surgical technique for placement of the automated low flow ascites pump (alfapump) . Langenbecks Arch Surg, 2020, 405(1): 117-123.
[25] Bureau C, Adebayo D, Chalret de rieu M, et al. Alfapump(R) system vs. large volume paracentesis for refractory ascites: a multicenter randomized controlled study . J Hepatol, 2017, 67(5): 940-949.
[26] Stirnimann G, Berg T, Spahr L, et al. Treatment of refractory ascites with an automated low-flow ascites pump in patients with cirrhosis . Aliment Pharmacol Ther, 2017, 46(10): 981-991.
[27] Lepida A, Marot A, Trepo E, et al. Systematic review with meta-analysis: automated low-flow ascites pump therapy for refractory ascites . Aliment Pharmacol Ther, 2019, 50(9): 978-987.