腹腔置管持续引流腹水治疗肝肾综合征13例报告

目的观察腹腔置管持续引流腹水对终末期肝硬化患者并发肝肾综合征的治疗效果。方法13例终末期肝硬化并发肝肾综合征患者在常规抗感染、利尿、补充血容量、营养、支持等综合治疗基础上,采用腹腔置管持续引流腹水,观察置管前后患者临床表现、肝功能、肾功能、电解质和尿量的变化,5例患者连续3天检测腹水TNF-α浓度。结果治疗组13例病人在术后72小时尿量明显增加、食欲改善,肾功能好转,其中3例患者尿量虽有增加,但病情无明显改善,放弃治疗,5例患者腹水TNF-α浓度均明显下降。结论腹腔置管持续引流腹水治疗终末期肝硬化并发肝肾综合征患者有暂时的治疗效果。     

肝硬化腹水并发HRS和低钠血症患者综合护理干预效果分析

目的评估综合护理干预对肝硬化腹水并发HRS和低钠血症患者的临床效果。方法选取2015年3月至2017年6月在我院住院治疗的肝硬化腹水并发肝肾综合征低钠血症患者88例,随机分为观察组和对照组,各44例。观察组给予综合护理,对照组给予常规护理,对比分析两组患者的临床效果。结果在经过药物治疗和不同的护理干预后,观察组血清钠和GFR水平明显高于对照组(P0.05),但两组的肝功能Child-Pugh分级评分无统计学差异(P0.05)。观察组临床总有效率明显高于对照组(P0.05)。结论综合护理干预提升了肝硬化腹水并发肝肾综合征低钠血症患者的临床疗效,效果确切,值得推广。     

特利加压素治疗肝硬化腹水不伴肝肾综合征的效果

正腹水是肝硬化患者的常见并发症,肝硬化伴腹水患者易发生急性肾损伤或肝肾综合征,并可能在腹腔穿刺术后并发循环功能障碍。目前,特利加压素并非肝硬化腹水的主要治疗选择。本研究旨在系统回顾有关特利加压素在肝硬化腹水不伴肝肾综合征患者中使用的证据。检索了PubMed、EMBASE和Cochrane Library三个数据库中关于特利加压素在肝硬化腹水患者中应用的研究。     

腹水超滤浓缩回输腹腔对肝硬化顽固性腹水患者肾功能的影响

肝硬化顽固性腹水患者,由于大量腹水压迫,影响呼吸及循环,特别是压迫肾脏影响肾功能,使尿量进一步减少,形成恶性循环.长期大量腹水的存在,容易并发自发性细菌性腹膜炎、肝性脑病、肝肾综合征及消化道出血等并发症,预后极差.一般的疗法(包括利尿、输蛋白、放腹水等)疗效差,且长期大量使用利尿剂可加重肝肾综合征、电解质紊乱而危及患者生命.我们采用腹水超滤浓缩回输腹腔治疗肝硬化顽固性腹水62例,结果显示对肾功能有改善作用,现报告如下.     

温肾利水法联合前列地尔治疗肝硬化并发肝肾综合征29例

目的 观察温肾利水法联合前列地尔对肝硬化并发肝肾综合征患者肝、肾功能及尿量的影响.方法 将57例肝硬化并发肝肾综合征患者随机分为治疗组和对照组.对照组28例,常规予限钠、支持、保肝、利尿、补充白蛋白、抗感染、应用血管扩张剂及促肝细胞生长素等对症治疗,前列地尔10 μg静脉滴注.治疗组29例在对照组治疗基础上予自拟温肾利水中药汤剂口服.两组均以三周为一疗程.1疗程后观察比较两组治疗前后临床症状、腹水、肝肾功能及尿量变化.结果 临床疗效比较,治疗组总有效率86.21％,对照组总有效率67.86％.两组总有效率比较差异有统计学意义(P＜0.05).结论 温肾利水法联合前列地尔在肝硬化并发肝肾综合征的治疗上能更好地改善临床症状,缩短腹水消退时间,改善肝、肾功能,延缓和阻止病情的进展.     

肝硬化并发自发性细菌性腹膜炎患者腹水病原菌及其耐药分析

自发性细菌性腹膜炎（SBP）是肝硬化常见的严重并发症，住院的肝硬化患者SBP发病率约为10%～30％，一旦发生，常使肝硬化病情加重，腹水难以消退，并促使肝肾综合征的发生，最终危及患者生命。因此，早期诊断和合理治疗至关重要。本研究对我院2005年6月-2007年6月住院的肝硬化并发SBP患者54例（腹水细菌培养均阳性）进行回顾性分析，探讨腹水病原菌的分布及其耐药情况，旨在为临床合理选用抗生素提供参考。     

乙肝肝硬化并发肝肾综合征危险因素Logistic回归分析

目的探讨乙肝肝硬化并发肝肾综合征(HRS)的危险因素。方法 2004年1月～2011年1月本院收治的乙肝肝硬化患者642例(其中发生肝肾综合征46例),收集患者的性别、年龄,发现乙肝病史时程,Child-Pugh评分,丙氨酸氨基转移酶、天门冬氨酸氨基转移酶、碱性磷酸酶、γ-谷氨酰转移酶、胆碱酯酶、血钠、白蛋白、前白蛋白、总胆红素、凝血酶原时间和活化部分凝血活酶时间、腹水程度,是否存在感染、消化道出血、强烈利尿、大量放腹水及应用氨基糖苷类药物等相关资料,进行单因素和多因素非条件Logistic回归模型分析。结果单因素和多因素非条件Logistic回归分析显示,Child-Pugh评分、腹水程度、感染是并发HRS的危险因素(P<0.05),OR值分别为6.21、3.57和4.56。结论Child-Pugh评分C级、大量腹水、伴发感染为乙肝肝硬化并发HRS的独立危险因素,对于该类患者应采取适当的干预措施。     

肝硬化腹水并发低钠血症

低钠血症是肝硬化腹水中常见的并发症,维持电解质平衡仍是最基本的治疗。现将我院肝病科收治的肝硬化腹水并发低钠血症101例进行分析,报告如下。1　临床资料1.1　一般资料　220例肝硬化腹水中并发低钠血症101例(45.91%),其中男87例,女14例,年龄24～73岁。依据1990年上海病毒性肝炎学术会议修订的标准,全部病例为失代偿期肝炎后肝硬化,ＨＢｓＡｇ全部阳性。腹水病程1周至4年。并发肝性脑病27例,上消化道出血14例,肝肾综合征15例,自发性腹膜炎19例,肝源性糖尿病6例,急性低钠血症8例。1.2　电解质测定　101例肝硬化腹水者中,血钠135～131ｍｍｏ…     

肝肾综合征早期诊断和预后评估研究进展

肝硬化晚期严重并发症包括难治性腹水、自发性腹膜炎、肝肾综综合征（HRS）等。国外文献报道肝硬化并发腹腔积液患者1年的肝肾综合征发生率为18％,5年为40％。在肝功能衰竭患者中,肝肾综合征发生率为60％～80％。一旦发生肝肾综合征,治疗相当困难,肝移植是唯一有效的根治方法。肝肾综合征预后差,3个月病死率高达80％～100％。其中肝肾综合征Ⅰ型的预后更差,若无干预治疗,中位生存期不足2周。所以肝肾综合征早期诊断对诊疗方案调整、药物剂量调整及预后评估有重要意义。     

肝硬化失代偿期并低钠血症的临床分析

低钠血症是肝硬化失代偿期常见的并发症，严重的低钠血症可加重肝性脑病、肝肾综合征的发生，并影响腹水的疗效及预后，防治低钠血症的发生是临床治疗和预防肝硬化并发症的重要手段。现将我科2001年1月-2006年3月收治的肝硬化失代偿期患者367例，其中并发低钠血症203例患者的临床资料进行回顾性分析，现报告如下。     

Atrial natriuretic peptide, plasma renin activity, plasma volume, systemic vascular resistance and cardiac output in patients with cirrhosis

The present study aimed to assess relationships between plasma levels of atrial natriuretic peptide (ANP) and plasma volume, systemic vascular resistances, cardiac output and plasma renin activity in patients with cirrhosis. Thirty patients were included: eight with no history of liver disease were used as controls; 22 patients had biopsy-proven alcoholic cirrhosis without ascites (n = 11) and with ascites (n = 11). Mean ANP plasma level was significantly higher in both groups of cirrhotic patients than in controls (P less than 0.05). In the control group, ANP and plasma renin activity were inversely correlated (P less than 0.05) but no correlation was found in cirrhotic patients. In the group of patients with ascites, ANP plasma levels were inversely correlated to plasma volume (P less than 0.05) and to cardiac output (P less than 0.01) and directly correlated to systemic vascular resistances (P less than 0.01). Using multiple regression analysis, ANP remained correlated only with systemic vascular resistances (P less than 0.05). These results suggest that cirrhotic patients have high plasma levels of ANP whether or not they have ascites. In the light of current knowledge of ANP actions, the relationships between ANP plasma levels and plasma volume, cardiac output, and systemic vascular resistances are paradoxical in cirrhotic patients with ascites. ANP does not seem to play a critical role in the pathogenesis of sodium and water retention observed in these patients.     

经肝动脉自体骨髓干细胞移植联合奥曲肽治疗肝硬化顽固性腹水14例

目的:研究经肝动脉自体骨髓干细胞移植联合奥曲肽治疗肝硬化顽固性腹水的临床疗效.方法:33例肝硬化顽固性腹水患者被随机分为两组,治疗组(14例)在常规治疗药物治疗上行经肝动脉自体骨髓干细胞移植后,再加用奥曲肽,对照组(19例)在常规治疗药物治疗上加奥曲肽.观察患者治疗后的腹围、食欲、尿量、双下肢浮肿、腹水消退情况及血清A...     

Nadolol is superior to isosorbide mononitrate for the prevention of the first variceal bleeding in cirrhotic patients with ascites

BACKGROUND/AIMS: beta-blockers effectively prevent first variceal bleeding (FVB) in cirrhotic patients. In patients with ascites, however, their use might be precluded by a high rate of contraindications and side effects. We compared the efficacy and applicability of nadolol and isosorbide-mononitrate (IsMn) in preventing FVB in a population of cirrhotic patients at high risk of variceal bleeding with ascites, who can be frequently intolerant to beta-blockers. METHODS: A total of 80 consecutive cirrhotic patients with ascites and esophageal varices (25% average risk of bleeding at 1 year) were considered, 28 were excluded due to contraindications and 52 were randomly assigned to receive nadolol (n=25) or IsMn (n=27). RESULTS: Frequency of contraindications was greater for beta-blockers than IsMn (35 versus 0%, P=0.001). During 21.3+/-11.6 months of follow-up, side effects forced six patients taking nadolol and four taking IsMn to stop treatment. Bleeding occurred in two patients taking nadolol and ten taking IsMn. The probability of bleeding was significantly lower in the nadolol group (P<0.05), whereas overall survival was similar (seven patients on IsMn and eight on nadolol died, P=0.3). CONCLUSIONS: In patients with ascites IsMn is tolerated but ineffective while nadolol is effective but less tolerated.     

Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites

The diagnosis of refractory ascites in cirrhotic patients carries a poor prognosis and liver transplantation should always be considered in this situation. Identification of patients who will not respond to diuretic therapy usually requires several weeks of observation during which a trial of diuretics is instituted using stepwise increases in dosage in order to classify ascites as refractory. In the present study we evaluated the effect of a single dose of 80 mg intravenous furosemide on urinary sodium excretion over 8 hours in cirrhotic patients with ascites responsive to diuretic treatment (group 1; n = 14) and patients with refractory ascites (group 2; n = 15). The test was performed after 3 days without diuretics and patients were on a 80 mEq sodium/day diet. Refractory ascites was defined by the absence of response after 3 months of high doses of diuretics (spironolactone 200 mg/d + furosemide 80 mg/d + metolazone 2.5 mg/d) and the need for repeated paracentesis. The two groups had similar degrees of liver and renal dysfunction as assessed by the Pugh score and creatinine clearance. The effects of furosemide on 8-hour natriuresis was much higher in patients with responsive ascites as compared with patients with refractory ascites (125 +/- 46 vs. 30 +/- 16 mEq; mean +/- SD; P <.0001). A natriuresis lower than 50 mEq/8 hours was observed in all group-2 patients as compared with none from group 1. The present study shows that patients with refractory ascites can be identified quickly and accurately by using this simple furosemide-induced natriuresis test, which could be very useful to select patients for liver transplantation.     

An analysis of hospital bacterial infections in cirrhotic patients undergoing selective intestinal decontamination

Cirrhotic patients with ascites and low levels of ascitic fluid C3 and total protein and cirrhotic patients with gastrointestinal hemorrhage are at high risk of infection. Selective intestinal decontamination with oral norfloxacin is useful to decrease the incidence of infections in cirrhotic patients at high risk. This study analyzes hospital acquired bacterial infections in cirrhotic patients with ascites and low levels of total protein in ascitic fluid (n = 53) and cirrhotic patients with gastrointestinal hemorrhage (n = 26), both submitted to selective intestinal decontamination with norfloxacin during the hospitalization. Seven patients developed eight infections (8.8%): three patients with ascites and low levels of total protein in ascitic fluid and four patients with gastrointestinal hemorrhage (5.6% vs 15.3%, pNS). Gram negative bacilli were not isolated in any case, but Gram positive cocci were isolated in seven cases. These results suggest that Gram positive cocci must be empirically covered when infection is suspected in cirrhotic patients submitted to selective intestinal decontamination. The analysis of antibiograms in these infections showed a high sensitivity of Gram positive cocci to amoxycillin and clavulanic acid, which could be used as empirical treatment when infection is suspected in these patients.     

Parenteral antibiotic prophylaxis of bacterial infections does not improve cost-efficacy of oral norfloxacin in cirrhotic patients with gastrointestinal bleeding

Objective: Selective intestinal decontamination with norfloxacin is useful in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding. However, bleeding cirrhotic patients with ascites, encephalopathy, or shock are at high risk to develop bacterial infections in spite of prophylactic norfloxacin. The aim of this study was to assess whether the addition of intravenous ceftriaxone could improve the efficacy of prophylaxis with norfloxacin in these patients.
Methods: Fifty-six cirrhotic patients with gastrointestinal hemorrhage and ascites, encephalopathy, or shock were randomized into two groups: Group 1 (  n = 28  ) received oral norfloxacin 400 mg/12 h for 7 days, and group 2 (  n = 28  ) received norfloxacin plus intravenous ceftriaxone 2 g daily during the first 3 days of admission.
Results: Ten patients were excluded because of community-acquired infection, surgery, or death within the first 24 h. The incidence of bacterial infections during hospitalization was 18.1% in group 1 and 12.5% in group 2 (   p = NS  ). The incidence of severe infections (spontaneous bacterial peritonitis, bacteremia, or pneumonia) was also similar in both groups: 9% in group 1 versus 8.3% in group 2 (   p = NS  ). There were no statistical differences between the two groups with respect to duration of hospitalization or mortality. The cost of antibiotic therapy (including prophylaxis and treatment of infections) was significantly higher in group 2.
Conclusions: These results suggest that the addition of intravenous ceftriaxone during the first 3 days of hospitalization does not improve the cost-efficacy of oral norfloxacin in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding and high risk of infection.     

Variability of atrial natriuretic peptide plasma levels in ascitic cirrhotics: pathophysiological and clinical implications.

Ascitic cirrhotic patients are a heterogenous population with respect to factors that may affect plasma human atrial natriuretic peptide levels (such as degree of plasma volume and plasma levels of angiotensin II, vasopressin and norepinephrine). Thus the proven variability of plasma human atrial natriuretic peptide values in ascitic cirrhotic patients may be due also to the selection of patients, not only to the study conditions. The response to standardized stepped-care medical treatment of ascites makes it possible to characterize ascitic cirrhotic patients with different patterns of renal sodium excretion, intrarenal sodium handling, plasma renin activity, plasma aldosterone and thus, probably, effective circulating volume. Consequently, we evaluated human atrial natriuretic peptide plasma levels in controls (n = 23), in ascitic cirrhotic patients who underwent spontaneous diuresis (group A, n = 7) and in cirrhotic patients who required diuretic treatment (group B, n = 44). The last group was then divided into two subgroups. Subgroup B-R (n = 25) included patients who responded to spironolactone alone, whereas subgroup B-NR (n = 19) included patients who did not respond to 500 mg/day spironolactone. All patients were maintained on identical normocaloric restricted sodium intake (80 mEq/day) throughout the study. Ascitic cirrhotic patients, as a whole, had higher values of human atrial natriuretic peptide than did controls (70.8 +/- 46.6 pg/ml vs. 41.7 +/- 16.3 pg/ml, p < 0.025). No difference was found in human atrial natriuretic peptide/plasma renin activity between the two groups (87 +/- 160 pg/ng/hr vs. 44 +/- 73 pg/ng/hr, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)     

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation

BACKGROUND/AIMS: In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyon's criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis. METHODS: Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis. RESULTS: The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyon's criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results. CONCLUSIONS: Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.     

Paracentesis with Dextran 70 vs. paracentesis with albumin in cirrhosis with tense ascites : Results of a randomized study

Forty-one patients with cirrhosis and tense ascites were randomized to receive daily paracentesis of 5 liters associated with Dextran 70 as volume expander (6 g for each 1000 ml of ascites removed) (group I = 20 patients) or paracentesis with albumin (6 g for each 1000 ml of ascites) (group II = 21 patients). The basal clinical features, laboratory data, and plasma renin activity were similar in both groups. The volume of ascites removed was 12.9 +/- 4.4 and 10.9 +/- 3.7 liters in group I and II, respectively (n.s.). No significant changes were observed in liver and renal function tests, KPTT, platelet count, factor VIII, serum electrolytes or plasma renin activity 24 and 96 h after the last paracentesis in both groups, except for a decrease in bilirubin in group I and a transient increase of serum albumin in group II. Four patients developed complications in each group, mainly hyponatremia, while one patient in each group developed renal impairment. One patient from group I died with hepatic encephalopathy. Moreover, the probability of survival and readmission to the hospital because of tense ascites were similar in both groups of patients during the follow-up. The treatment cost with Dextran 70 was 15.50 dollars vs. 364.30 dollars with albumin for each patient treated. These results indicate that repeated large volume paracentesis associated with Dextran 70 is as effective and safe as paracentesis associated with albumin in cirrhotic patients with tense ascites. However, due to its reduced cost, paracentesis with Dextran 70 may be considered the treatment of choice in cirrhotic patients with tense ascites without liver cancer and renal failure.     

High circulating D-dimers are associated with ascites and hepatocellular carcinoma in liver cirrhosis

AIM： To measure plasma D-dimer levels in cirrhotic patients with and without ascites, assessing the effect of ascites resolution in D-dimer concentration. METHODS： Seventy consecutive cirrhotic patients （M = 44, F = 26, mean age 65 years, SD ± 13）, observed from October 2005 to March 2006 were enrolled. Circulating D-dimer levels were measured using a latex-enhanced, immunoturbidimetric test. In patients with ascites （n = 42） the test was repeated after ascites resolution. RESULTS： Ascites was present in 42 patients （group A） and absent in 28 （group B）. Group A patients had more advanced liver disease. Hepatocellular carcinoma （HCC） was diagnosed in 14 patients and was more frequent in group B. Above normal range D-dimers were found in 45/70 patients. High D-dimers were more frequent in group A than in group B （P = 0.001）. High D-dimers were associated with presence of HCC （P = 0.048） only in group B. After ascites resolution, obtained in all patients, mean D-dimer values decreased in those 34 patients with high basal levels （P = 0.007）, returning to normal in 17. CONCLUSION： In patients with liver cirrhosis, ascites and HCC are the main factors associated with increased fibrinolytic activity.