Diuretic-resistant ascites in cirrhosis. Mechanism and treatment

Refractory ascites (or diuretic-resistant ascites), i.e. ascites that cannot be mobilized by medical treatment (low sodium diet and high doses of furosemide and spironolactone) is an infrequent phenomenon in cirrhosis. It usually occurs in patients with functional renal failure as a consequence of alteration in both pharmacokinetics and pharmacodynamics of diuretics. Peritoneovenous shunting, a procedure which improves systemic hemodynamics and renal function and suppresses the plasma levels of renin, aldosterone, norepinephrine and antidiuretic hormone in cirrhotics with ascites, has been proposed as the treatment of choice in patients with refractory ascites. Unfortunately it is associated to a high rate of severe complications and does not prolong the survival of these patients. Moreover, in approximately one third of the patients the shunt becomes occluded within the first year after operation. Recent studies have shown that repeated large volume paracentesis (4-64 per day until disappearance of ascites) or total paracentesis (complete mobilization of ascites in only one paracentesis session) associated to i.v. albumin infusion are an effective and safe therapy of ascites. At present, there is only one controlled trial comparing therapeutic paracentesis versus peritoneo-venous shunt in the management of patients with refractory ascites. In this study, there were no significant difference between both therapeutic groups with respect to survival. However, the incidence of readmission to hospital for the treatment of ascites was higher in the paracentesis group. Therefore, both procedures are valid therapeutic alternatives for that type of patients. Future studies are necessary to investigate if there are subsets of cirrhotics with refractory ascites in which one of these two types of treatment is especially indicated.     

Treatment of ascites and renal failure in cirrhosis

Ascites is a frequent complication in patients with liver cirrhosis. The accumulation of fluid in the abdominal cavity is associated with disturbances of systemic and splanchnic haemodynamics and of kidney function, which contribute to the poor prognosis of these patients. Classically, the treatment of ascites in patients with cirrhosis has been based on the combination of a sodium-restricted diet and the administration of diuretics. However, this treatment is not entirely satisfactory, since it is associated with a relatively high incidence of side-effects, and about 20% of patients hospitalized for the treatment of an episode of ascites do not respond to such therapy. In the last two decades, alternative therapies to diuretics have been introduced. PVS is an effective method of treating ascites. The high incidence of complications observed in early studies may be reduced by adequate perioperative management and careful selection of patients. The role of the PVS in the treatment of cirrhotics with ascites, however, still remains to be established. Recently, paracentesis has emerged as an alternative method of treating ascites in patients with cirrhosis. Several studies have shown that therapeutic paracentesis plus i.v. albumin infusion is more effective than conventional diuretic therapy and is associated with a lower incidence of complications. It has also been demonstrated that therapeutic paracentesis without the i.v. administration of albumin is associated with a marked increase in plasma renin activity, suggesting an impairment of effective blood volume, and with the development of hyponatraemia and/or renal failure in 20% of cases. Therefore, the i.v. administration of albumin is an essential measure in preventing the impairment of systemic haemodynamics and renal function that frequently follows the mobilization of ascites by paracentesis.     

Refractory ascites and dilutional hyponatremia: current management and new aquaretics

Ascites is the most common complication of cirrhosis and is associated with 50% mortality at 2 years if patients do not receive orthotopic liver transplantation. Recently the International Ascites Club defined ascites into three groups: In grade I ascites fluid is detected only by ultrasound; in grade II, ascites is moderate with symmetrical distention of the abdomen; and in Grade 3 ascites is large or tense with marked abdominal distention. About 10% of patients with ascites are refractory to treatment with diuretics. In refractory ascites, patients do not respond to highest doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/ day) or develop side effects (hyperkalemia, hyponatremia, hepatic encephalopathy, or renal failure) that prohibit their use. Patients may be treated either by repeated large volume paracentesis plus albumin or transjugular intrahepatic portosystemic shunts (TIPS). Dilutional hyponatremia in cirrhotic patients is defined as serum sodium < or = 130 mEq/L in the presence of an expanded extracellular fluid volume, as indicated by the presence of ascites and/or edema. This complication of cirrhotic patients with ascites has recently gained attention given that several reports indicate that when serum sodium concentration is combined with the Model for End-Stage liver disease (MELD) it improves the prognostic accuracy of MELD score in patients awaiting orthotopic liver transplant (OLT). The first step in the management of dilutional hyponatremia is fluid restriction and discontinuation of diuretics. Water restriction at 1,000 mL/day helps prevent the progressive decrease in serum sodium concentration but usually does not correct hyponatremia in most cases. Actually are developing drugs that are active orally and act by selectively antagonizing the specific receptors (V2 receptor) of arginine vasopressin. These agents act in the distal collecting ducts of the kidneys, by increasing solute free water excretion and, thus, improving serum sodium concentration in hyponatremic patients.     

Dextran-70 versus albumin as plasma expanders in cirrhotic patients with tense ascites treated with total paracentesis. Results of a randomized study.

To investigate whether albumin can be substituted by less expensive plasma expanders in cirrhotic patients with tense ascites treated with total paracentesis, 88 patients (16 with renal failure) submitted to this therapeutic procedure were randomly assigned to receive IV albumin (43 patients) or dextran-70. Both substances were given at a dose of 8 g/L of ascitic fluid removed. Patients were discharged from the hospital with diuretics, and cases developing tense ascites during follow-up were treated according to their initial schedule. Total paracentesis was effective in eliminating the ascites in all but two cases in each group. Neither paracentesis plus IV albumin infusion nor paracentesis plus IV dextran-70 infusion was associated with significant changes in renal and hepatic function or serum electrolytes. The incidence of renal impairment (one case in each group), hyponatremia (three and four cases, respectively), and other complications (hepatic encephalopathy, gastrointestinal hemorrhage, bacterial infections) after paracentesis, and the clinical course of the disease as estimated by the probability of readmission to hospital during follow-up, causes of readmission, probability of survival, and causes of death were similar in the two groups of patients. The effect of paracentesis on effective intravascular volume was indirectly assessed by measuring plasma renin activity and aldosterone concentration before and 2 and 6 days after treatment, the patients being without diuretics. In patients treated with albumin, no significant changes in renin and aldosterone were observed during the entire period of observation. In contrast, both parameters increased significantly on the 6th day of treatment in patients receiving dextran-70. A significant increase in plasma renin activity and aldosterone concentration (30% over baseline values) was observed in 51% of patients treated with dextran-70 and in only 15% of those treated with albumin (x2 = 10.4; P = 0.0012). These results indicate that although dextran-70 is less efficacious than albumin in protecting cirrhotic patients treated with total paracentesis from the decrease in effective intravascular volume, it appears to be capable of preventing the renal and electrolyte complications induced by this therapeutic procedure.     

Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study

To investigate whether paracentesis could be an alternative therapy for ascites, 117 cirrhotics with tense ascites were randomly allocated into two groups. Fifty-eight patients (group 1) were treated with paracentesis (4-6 L/day until disappearance of ascites) and intravenous albumin infusion (40 g after each tap). Fifty-nine patients (group 2) were treated with spironolactone (200-400 mg/day) plus furosemide (40-240 mg/day). Patients from group 2 not responding to diuretics were treated with a LeVeen shunt. After disappearance of ascites, patients from both groups were discharged from hospital and were instructed to take diuretics. Patients developing tense ascites during follow-up were readmitted to hospital and treated according to their initial schedule. Paracentesis was effective in eliminating the ascites in 56 patients from group 1 (96.5%) and did not induce significant changes in renal and hepatic function, plasma volume, cardiac index, peripheral resistance, plasma renin activity, plasma norepinephrine and antidiuretic hormone concentration, and urinary excretion of prostaglandin E2 and 6-keto-prostaglandin F1 alpha. Diuretics were effective in eliminating the ascites in 43 patients from group 2 (72.8%) (p less than 0.05). Ten patients in group 1 and 36 in group 2 developed complications during their first hospital stay (p less than 0.001). This difference was due to the significantly higher incidence of hepatic encephalopathy, renal impairment, and electrolyte disturbances occurring in patients treated with diuretics. The duration of hospital stay was 11.7 +/- 1.5 days for patients from group 1 and 31 +/- 2.8 days for patients from group 2 (p less than 0.001). The two groups did not differ significantly with respect to the probability of requiring readmission to hospital during follow-up, reasons for readmission, survival probability after entry into the study, and causes of death. These results indicate that paracentesis associated with intravenous albumin infusion is a fast, effective, and safe therapy for ascites in patients with cirrhosis.     

Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis

It has recently been shown that repeated large-volume paracentesis associated with intravenous albumin infusion is a rapid, effective, and safe therapy of ascites in cirrhosis. To investigate whether intravenous albumin infusion is necessary in the treatment of cirrhotics with large-volume paracentesis, 105 patients with tense ascites were randomly allocated into two groups. Fifty-two patients (group 1) were treated with paracentesis (4-6 L/day until disappearance of ascites) plus intravenous albumin infusion (40 g after each tap), and 53 (group 2) with paracentesis without albumin infusion. After disappearance of ascites, patients were discharged from the hospital with diuretics. Patients developing tense ascites during follow-up were treated according to their initial schedule. Paracentesis was effective in eliminating the ascites in 50 patients from group 1 and in 48 from group 2, with the duration of the hospital stay being approximately 11 days in both groups. Paracentesis plus intravenous albumin did not induce significant changes in standard renal function tests, plasma renin activity, and plasma aldosterone. In contrast, paracentesis without albumin was associated with a significant increase in blood urea nitrogen, a marked elevation in plasma renin activity and plasma aldosterone concentration, and a significant reduction in serum sodium concentration. One patient from group 1 and 11 from group 2 developed renal impairment or severe hyponatremia after treatment, or both (chi 2 = 9.19; p less than 0.01). The development of these complications could not be predicted by clinical and laboratory data before treatment. Although the probability of survival after entry into the study was similar in patients from both groups, a multivariate analysis identified the development of hyponatremia or renal impairment, or both, following the first paracentesis treatment and the occurrence of other complications during the first hospitalization (encephalopathy, gastrointestinal bleeding, and severe infection) as being the only independent predictors of mortality. These results indicate that intravenous albumin infusion is important in avoiding renal and electrolyte complications and activation of endogenous vasoactive systems in cirrhotics with ascites who are treated with repeated large-volume paracentesis. The development of such complications may impair survival in these patients.     

Large volume paracentesis and intravenous dextran to treat tense ascites.

Forty patients with cirrhosis of the liver and tense ascites were randomized to receive either aldactone 400 mg/day and furosemide 80 mg/day (n = 20) or repeated large volume paracentesis (LVP) and infusion of low molecular weight dextran (n = 20). Both treatment groups were similar in clinical and laboratory parameters. Complete mobilization of the ascitic fluid was achieved in all receiving LVP and dextran therapy within 1 week of the treatment, in contrast to the minimal mobilization of the ascitic fluid in patients receiving diuretics even after 2 weeks of therapy. Renal function, the clinical parameters of systemic hemodynamics, serum electrolytes, and hepatic function remained stable in patients receiving LVP and dextran and were similar to those in the diuretic-treated patients. We found no deterioration of these functions in the nonedematous patients treated by LVP and dextran even though the protective effect of edema against LVP was lacking in them. Plasma volume estimation in six nonedematous cirrhotic patients treated by LVP and dextran did not reveal any hypovolemia after complete mobilization of ascites. The frequency of complications and death were similar in the two groups. Dextran infusion is a safe, effective, and low-cost replacement therapy in patients with cirrhotic ascites treated by LVP.     

Prospective study comparing human albumin vs. reinfusion of ultrafiltrate-ascitic fluid after total paracentesis in cirrhotic patients with tense ascites

Although, total paracentesis associated with human albumin substitution has shown to be a rapid, effective and safe treatment of diuretic refractory ascites in advanced liver cirrhosis, it implies high costs and has a limited availability. Therefore an alternative procedure the reinfusion of concentrated ascites has gained popularity in recent years (Smart et al. 1990; Grazioto et al. 1997). It was the aim of the study to compare human albumin substitution vs. reinfusion of ascitic-ultrafiltrate after total paracentesis. 35 patients with cirrhosis and tense ascites received total paracentesis associated with either human albumin (5-8 g/l ascites) (= group A) or reinfusion of an ascitic-ultrafiltrate fluid by means of hemofiltration technique (= group B). The mean volume of ascites removed was 9.41 (2.1-20.0) in group A and 11.41 (6.5-21.0) in group B. No significant differences in serum electrolytes, liver and renal function, coagulation profiles and hormones of the renin-angiotensin-aldosterone system were observed during hospitalization. In both groups sodium excretion increased significantly. 43% of the patients in group B developed pyrexia and chill after reinfusion of the ascitic-ultrafiltrate fluid. In one patient an anaphylactic bronchospasm occurred requiring IUC-treatment. The treatment cost in case of human albumin were 326.-DM vs. 290.-DM for each patient treated with ascitic-ultrafiltrate fluid reinfusion. The probabilities of hospital readmission and survival were similar in both groups during follow-up. The results indicate that i.v. infusion of ascitic-ultrafiltrate fluid is as effective as total paracentesis and albumin infusion in case of diuretic refractory ascites. However, according to the costs of instruments and staff and due to the significant allergic reactions caused by ascitic fluid it cannot be considered as a real alternative to albumin substitution.     

Treatment of ascites in patients with liver cirrhosis without neither hyponatremia nor renal insufficiency. Results of a randomized study comparing diuretics and punctures compensated by albumin]

Previous studies have suggested that treatment of ascites in cirrhotic patients by repeated paracenteses and albumin infusion is fast, effective and safe. In one of these studies including patients with hyponatremia or renal impairment, this treatment was associated with a reduction of duration of hospital stay in comparison with large dose diuretics. The aim of this randomized study was to compare paracentesis with albumin perfusion and low dose diuretics in cirrhotic patients with ascites, but without hyponatremia or renal impairment. Twenty-six patients (group 1) were treated with paracentesis (4 L/day) and 27 patients (group 2) were treated with spironolactone (225 to 300 mg/day), associated with furosemide (40 to 80 mg/day), when inefficient alone. Ascites and peripheric edema disappeared more rapidly in group 1 than in group 2, 8.6 +/- 9.6 vs 13.5 +/- 6.7 days (P = 0.001) and 4.1 +/- 2.6 vs 10.5 +/- 6.5 days (P = 0.001) respectively. During hospitalisation, the incidence of complications was higher in group 2 than in group 1: 56 vs 26% (P = 0.03). Hyponatremia occurred in 30% of patients in group 2 and 4% of patients in group 1 (P = 0.04). The duration of hospital stay was shorter in group 1 (15.0 +/- 10.4 days) than in group 2 (21.0 +/- 11.7 days) (P = 0.007). During follow-up, ascites reappeared in 32% of patients in group 1 and 57% of patients in group 2 (P = 0.09). At 3 months, one patient in group 1 and 2 patients in group 2 developed spontaneous peritonitis whereas survival was similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

肝硬化腹水治疗的研究现状与展望

腹水是肝硬化最常见的并发症,并与发生感染、稀释性低钠血症、肾功能衰竭和病死率增加密切相关。无并发症的少量腹水患者早期处理原则是,休息加上低钠饮食。中等量腹水患者,一般选择低剂量利尿剂就能达到利尿效果。大量腹水患者,可大量放腹水＋静点白蛋白（8g/每放腹水1000ml）。顽固性腹水患者,可用重复多次大量放腹水＋血浆扩容治疗或用经颈静脉肝内门体分流术（TIPS）治疗。新药（如V2受拮抗剂和血管收缩剂等）对肝硬化腹水的治疗可能带来希望。     

Treatment of cirrhotic ascites

Cirrhosis is the most common cause of ascites and accounts for almost 85% of all cases. It is the most common complication of cirrhosis, after development of ascites only 50% of patients will survive for 2 to 5 years. Successful treatment is dependent on accurate diagnosis of the cause of ascites. Because sodium and water retention is the basic abnormality leading to ascites formation, restriction of sodium intake and enhancing sodium excretion is the mainstay of the treatment of ascites. Patients with cirrhosis and ascites must limit sodium intake to 2 gram per day. Enhancement of sodium excretion can be accomplished by usage of oral diuretics. The recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d. usual maximum doses are 400 mg/d of spironolactone and 160 mg/d of furosemide. The recommended weight loss in patients without peripheral edema is 300 to 500 g/d. There is no limit to the daily weight loss of patients who have edema. About 90% of patients respond well to medical therapy for ascites. Refractory ascites is defined as fluid overload that is unresponsive to sodium restricted diet and high dose diuretic treatment (diuretic resistant) or when there is an inability to reach maximal dose of diuretics because of adverse effects (diuretic-intractable). It has a poor prognosis. Treatment options for patients with refractory ascites are serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS) or peritoneovenous shunt and liver transplantation. TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions. Liver transplantation is the only modality that is associated with improved survival.     

Advances in therapy for ascites and hepatorenal syndrome

Sequential diuretic treatment of ascites with spironolactone and furosemide is equivalent to initial combination therapy. Orally applicable vasopressin-V2-receptor antagonists are an interesting novel therapeutic approach for the elimination of free water. The therapeutic efficacy for patients with cirrhosis and ascites is currently being investigated in phase II trials. Following paracentesis of up to 6 liters volume, infusion of 3.5 % saline is as effective as 20 % albumin. Another trial confirms the superiority of TIPS for the treatment of massive ascites, also demonstrating survival benefit. Determination of leukocyte esterase activity with a simple stix method may be helpful for the rapid and easy diagnosis of spontaneous bacterial peritonitis. Patients with hepatorenal syndrome seem to benefit from a combination of terlipressin and albumin whereas the effect of albumin dialysis on survival remains to be proven.     

Repeated paracentesis and i.v. albumin infusion to treat 'tense' ascites in cirrhotic patients. A safe alternative therapy

To investigate the usefulness of paracentesis as an alternative treatment for ascites, 41 cirrhotic patients with 'tense' ascites were randomly assigned to treatment with either repeated paracenteses plus i.v. albumin infusion (n = 20) or diuretics (n = 21). Satisfactory mobilization of ascites was obtained with paracentesis in all but one case and with diuretics in all but two cases. Ascites disappeared within 3 or 4 days with paracentesis, but only after 15 days with diuretics. The rate of reaccumulation of ascites following paracentesis, without diuretic administration, exceeded 300 g/day in only 5 patients. The incidence of complications and the mortality rate were similar in both groups of patients during hospital stay and during follow-up. This was corroborated by the evidence that no negative changes were induced in clinical and laboratory parameters of hemodynamic, hepatic and renal function after evacuation of the ascites. These results confirm that repeated paracenteses combined with human albumin replacement are safe and effective for treating 'tense' ascites, and more rapid than traditional diuretic therapy.     

Management of cirrhotic ascites: Seven-step treatment protocol based on the Japanese evidence-based clinical practice guidelines for liver cirrhosis 2020

Liver cirrhosis is a severe illness, associated with multiple complications, which can lead to liver failure. One of the major complications of cirrhosis is ascites. This review describes a stepped treatment approach for the management of ascites in Japanese patients with cirrhosis. It is broadly based on the 2020 update of the Japanese clinical practice guidelines for liver cirrhosis, which is briefly compared with guidelines from Europe and the United States. Step 1 is sodium restriction at a level suitable for Japanese individuals (5–7 g/day), Step 2 is albumin treatment to counteract underlying hypoalbuminemia, Step 3 is initiation of diuretic treatment with spironolactone, followed by add-on loop diuretic treatment at Step 4. Patients that are refractory to sodium restriction and sodium diuretics can be treated with tolvaptan (Step 5) – a vasopressin V2 receptor antagonist that is available in Japan. Patients at Steps 6 and 7 have refractory ascites and are treated with large volume paracentesis in combination with an albumin infusion. High-dose albumin infusion (6–8 g/L) at the time of large volume paracentesis has recently become possible in Japan. Cell-free and concentrated ascites reinfusion therapy is also an option at Step 6. Two of the treatment options at Step 7 are limited in Japan (transjugular intrahepatic portosystemic shunts are not approved, and access to liver donors is very limited), but patients can undergo a peritoneovenous shunt if no other options are available. While challenges remain in the treatment of ascites, adopting this stepwise treatment approach may improve patient outcomes.     

Treatment of ascites

Opinion statement Ascites is the most common complication of cirrhosis and occurs in more than half of all patients with cirrhosis. The development of ascites indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate. Conventional therapies used for the treatment of ascites include sodium restriction (<88 mmol/d), diuretics, and large volume paracentesis (LVP) (>5 L). The most effective diuretic combination is that of a potassium-sparing, distal-acting diuretic (eg, spironolactone) with a loop diuretic (eg, furosemide). LVP provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients. Post-paracentesis circulatory dysfunction (PPCD) may occur after LVP and is characterized by hyponatremia, azotemia, and an increase in plasma renin activity. PPCD is associated with an increased mortality and may be prevented by administration of albumin intravenously (6 to 8 g/L of ascites removed) along with LVP. The development of either diuretic-resistant or diuretic-intractable ascites occurs in approximately 5% to 10 % of all cases of ascites. This is a poor prognostic sign, as 50% of such patients die within 6 months of its development. The only definitive therapy for refractory ascites with cirrhosis is orthotopic liver transplantation. The other options that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portosystemic shunts (TIPS). The TIPS procedure has not been shown to have any influence on survival in patients with cirrhosis and refractory ascites, and TIPS is contraindicated in patients who have advanced liver failure because it can hasten death in such individuals. Peritoneovenous shunts are associated with a high incidence of complications and frequent occlusion. They are, therefore, rarely used for refractory ascites. Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites. It may precipitate hepatorenal syndrome. The overall mortality rate from an episode of SBP is approximately 20%. Following an episode of SBP, the 1-year mortality rate approaches 70%. Hospitalized patients should be treated with intravenous third-generation cephalosporins (eg, cefotaxime), and patients at risk should receive prophylaxis with either orally administered quinolones (eg, norfloxacin) or cotrimoxazole.     

Atrial natriuretic factor in cirrhotic patients with tense ascites. Effect of large-volume paracentesis

The plasma levels of atrial natriuretic factor in liver cirrhosis can be affected by various factors, such as ascites, renal function, use of diuretics drugs and dietary sodium intake. Moreover, the influence of high intra-abdominal pressure on cardiac atrial natriuretic factor release in patients with tense ascites has not been investigated. The aim of the present study was to evaluate the circulating levels of atrial natriuretic factor and their relationships to plasma renin activity, aldosterone concentration, and urinary sodium excretion in 45 cirrhotic patients divided into 4 groups: (a) cirrhotics without ascites; (b) nonazotemic cirrhotics with ascites; (c) cirrhotics with ascites and functional renal failure; and (d) cirrhotics with ascites taking diuretics. In some patients with tense ascites, atrial natriuretic factor was also measured after rapid abdominal relaxation by large volume paracentesis. Plasma levels of atrial natriuretic factor obtained in 13 healthy control subjects after 5 days on a 40-50 mEq sodium daily intake were 22.8 +/- 3.3 pg/ml. Mean plasma atrial natriuretic factor levels were normal in patients without ascites (35.1 +/- 11.4 pg/ml) and in those with ascites taking diuretics (27 +/- 9.2 pg/ml), but elevated in patients with ascites not taking diuretics (59.6 +/- 12 pg/ml) and in those with ascites and functional renal failure (58.5 +/- 16.6 pg/ml). These data show that plasma atrial natriuretic factor levels are elevated only in cirrhotic patients who are ascitic and not taking diuretics. In these patients atrial natriuretic factor levels were directly correlated with urinary sodium excretion, even though sodium balance was positive. This could be the consequence of the contrasting effects of antinatriuretic factors, as suggested by the inverse relationships between atrial natriuretic factor and urinary sodium on the one hand and plasma renin activity and plasma aldosterone concentration on the other. Twenty-six patients with tense ascites (12 taking diuretics and 14 not) were treated with rapid large-volume paracentesis (6500 +/- 330 ml of ascitic fluid removed in 168 +/- 16 min). At the end of the procedure, plasma atrial natriuretic factor levels had increased in all patients (from 45.5 +/- 10.1 to 100 +/- 17 pg/ml), whereas plasma renin activity and plasma aldosterone concentration had decreased (from 10.3 +/- 1.6 to 7 +/- 1.3 ng/ml/h, and 1160 +/- 197 to 781 +/- 155 pg/ml, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)     

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, ...     

Albumin administration in patients with cirrhosis: Current role and novel perspectives

Mortality in cirrhosis is mostly associated with the development of clinical decompensation, characterized by ascites, hepatic encephalopathy, variceal bleeding, or jaundice. Therefore, it is important to prevent and manage such complications. Traditionally, the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis, but it is currently understood that decompensation might also be driven by a systemic inflammatory state (the systemic inflammation hypothesis). Considering its oncotic and nononcotic properties, albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events. There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis, patients with spontaneous bacterial peritonitis, those with acute kidney injury (even before the etiological diagnosis), and those with hepatorenal syndrome. Moreover, there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites (long-term albumin administration), individuals with hepatic encephalopathy, and those with acute-on-chronic liver failure undergoing modest-volume paracentesis. Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications, such as individuals with extraperitoneal infections, those hospitalized with decompensated cirrhosis and hypoalbuminemia, and patients with hyponatremia.     

腹水超滤浓缩回输腹腔术治疗肝硬化顽固性腹水疗效分析

目的 探讨腹水超滤浓缩回输腹腔术治疗肝硬化顽固性腹水的疗效。方法 将56例肝硬化顽固性腹水患者随机分为2组,均给予保肝、利尿及抗病毒治疗。在此基础上,对治疗组行腹水超滤浓缩回输腹腔术加小剂量人血白蛋白静脉滴注(静滴)(每滤出1000ml腹水,静滴人血白蛋白4g),对对照组行大量放腹水加大剂量人血白蛋白静滴(每抽出1000ml腹水,静滴人血白蛋白8g)。结果 术后第14天,治疗组患者24h尿量、血清ALB水平均高于对照组(P均<0.05),且治疗组总有效率高于对照组(P<0.05)。结论 腹水超滤浓缩回输腹腔术是一种安全有效的治疗肝硬化顽固性腹水的方法。