A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites

BACKGROUND: In patients with cirrhosis and ascites, creation of a transjugular intrahepatic portosystemic shunt may reduce the ascites and improve renal function. However, the benefit of this procedure as compared with that of large-volume paracentesis is uncertain. METHODS: We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child-Pugh class B in 42 patients and class C in 18 patients) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (+/-SD) duration of follow-up was 45+/-16 months among those assigned to shunting and 44+/-18 months among those assigned to paracentesis. The primary outcome was survival without liver transplantation. RESULTS: Among the patients in the shunt group, 15 died and 1 underwent liver transplantation during the study period, as compared with 23 patients and 2 patients, respectively, in the paracentesis group. The probability of survival without liver transplantation was 69 percent at one year and 58 percent at two years in the shunt group, as compared with 52 percent and 32 percent in the paracentesis group (P=0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shunting was independently associated with survival without the need for transplantation (P=0.02). At three months, 61 percent of the patients in the shunt group and 18 percent of those in the paracentesis group had no ascites (P=0.006). The frequency of hepatic encephalopathy was similar in the two groups. Of the patients assigned to paracentesis in whom this procedure was unsuccessful, 10 received a transjugular shunt a mean of 5.5+/-4 months after randomization; 4 had a response to this rescue treatment. CONCLUSIONS: In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.     

Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites

The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.     

Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage

Fifty-two patients with severe cirrhosis (Child Class C) and variceal hemorrhage requiring six or more units of blood were randomly assigned to either sclerotherapy or portacaval shunt. Of 38 pretreatment characteristics, only the frequency of active alcoholism differed significantly between the groups. During the initial hospitalization, the patients in the shunt group required significantly more blood (21.5 +/- 3.1 units) than did those in the sclerotherapy group (12.3 +/- 1.3 units), although the latter had significantly more rebleeding during hospitalization after the procedure (14 of 28 vs. 5 of 24 patients). There was no difference in short-term survival, with 13 patients in the sclerotherapy group discharged alive, as compared with 10 patients in the shunt group. Patients were followed for a mean of 263 days after the initial discharge (range, 8 to 1117). The sclerotherapy group required significantly more days of hospitalization for rebleeding, but we failed to demonstrate any significant difference in long-term survival between the sclerotherapy and shunt groups. Total health-care costs per patient were significantly higher for the shunt group (+23,957 +/- +3,111) than for the sclerotherapy group (+15,364 +/- +2,220). We conclude that sclerotherapy is less costly than portacaval shunt and as effective for the treatment of esophageal varices associated with severe cirrhosis.     

Peritoneovenous shunts for palliation of malignant ascites.

BACKGROUND: Malignant ascites may produce a cluster of symptoms that include abdominal distention, early satiety, respiratory embarrassment, impaired mobility, and lethargy, and relief of these symptoms is often difficult to achieve. We report on the placement of peritoneovenous shunts (PVSs) in a group of patients with malignant ascites, with particular reference to the effectiveness and complications of the procedure. PATIENTS AND METHOD: PVSs were inserted in 9 patients with malignant ascites after obtaining their informed consent. The patients were 6 men and 3 women with a median age of 59 years. All had previously been treated with vigorous diuretic therapy or repeated paracentesis or both. Shunt insertion was carried out via a percutaneous approach under local anesthesia. RESULTS: The procedure was well tolerated by all patients. The abdominal distention resolved in all patients, and urine volume increased significantly, demonstrating that the PVS did not affect renal function. The platelet count was reduced, and prothrombin time was prolonged. Two patients had the complication of shunt occlusion, and both patients underwent shunt replacement. There were no lethal complications. Median survival time after PVS placement was 21 days (range, 10 approximately 90 days), and the shunt was functioning at the time of death with good control of ascites in all patients. CONCLUSIONS: Malignant ascites produces troublesome symptoms for patients, who may live for some time. Placement of a PVS is a well-tolerated, relatively minor surgical procedure that can provide excellent control of ascites in most patients selected. The selection of optimal patients requires further study.     

Human atrial natriuretic factor (hANF) in liver cirrhosis

Mean plasma levels of hANF at admission were significantly higher in liver cirrhosis (LC) patients with ascites (93 +/- 11 ng, n = 20; p less than 0.05) than in LC-patients without ascites (32 +/- 14 ng/l, n = 11) or healthy controls (31 +/- 15 ng/l; range: 5-80 ng/l; n = 106). Diuretic treatment of patients with LC and ascites normalised hANF plasma concentrations (44 +/- 14 ng/l; p less than 0.05). Increase of plasma hANF in LC-patients with ascites after acute volume expansion was lower (relative rise: 159%) than in those without ascites (relative rise: 223%). Volume redistribution into the vascular compartment, induced by peritoneovenous shunt implantation in LC-patients with diuretic treatment-refractory ascites, resulted in a sharp increase of plasma hANF levels (344 +/- 87 ng/l = 420% of preoperative concentration). Normal and slightly increased levels of plasma hANF and the appropriate regulation to volume changes suggest an intact control of the hormone in LC-patients. Neither a lack nor an inappropriate secretion of hANF as a cause for sodium retention as postulated by the overflow theory of ascites accumulation could be found in liver cirrhosis.     

Trichosporon beigelii endocarditis as a complication of peritoneovenous shunt

Trichosporon is a common cause of superficial mycotic infection but has rarely been associated with endocarditis. The case of a patient who had a peritoneovenous shunt for chronic intractable ascites due to Laennec liver cirrhosis is described. The shunt was revised on several occasions, and the last procedure was complicated by a draining skin sinus wound. To the authors' knowledge, this is the first reported case of Trichosporon endocarditis complicating a peritoneovenous shunt.     

Transcatheter coil embolization of the inferior epigastric artery in a huge abdominal wall hematoma caused by paracentesis in a patient with liver cirrhosis

Therapeutic paracentesis is considered to be a relatively safe procedure and is performed commonly for the control of massive ascites in patients with liver cirrhosis. The commonest puncture site, approximately 4 or 5 cm medial of left anterior superior iliac spine, can be located across the route of the inferior epigastric artery, which is one of the sites of potential massive bleeding. In a 46-year-old woman with liver cirrhosis and refractory ascites, a huge abdominal wall hematoma developed after therapeutic paracentesis. The patient was not stabilized by conservative treatment, and inferior epigastric artery injury was confirmed on angiography. Angiographic coil embolization of the inferior epigastric artery was conducted, after which the bleeding ceased and the hematoma stopped growing. This case indicates that physicians performing paracentesis should be aware of the possibility of inferior epigastric artery injury and consider early angiographic coil embolization when a life-threatening abdominal wall hematoma develops.     

Surgery for variceal bleeding in cirrhosis: a review of our experience and present concepts.

The major cause of portal hypertension in Western countries is nutritional cirrhosis (parenchymal block) related to alcoholism. A third of those patients die of variceal bleeding when increased pressure within the varices precipitates bleeding. Construction of portal systemic shunts is aimed at reducing the pressure within the varices and thereby decreasing the risk of bleeding. However, it increases the incidence of hepatic encephalopathy and hence should be used only in patients who have bled. The remaining function appears to be the main factor that determines survival and the incidence of encephalopathy in obese individuals. Portacaval shunts almost completely eliminate the risk of bleeding. There is a greater incidence of hepatic encephalopathy with this procedure than with other shunts. The splenorenal shunt and the distal splenorenal shunt appear to work well in selected patients. Technically, it is a more difficult procedure. The interposition mesocaval shunt is technically easier and is also helpful in patients with ascites. Its post-shunt encephalopathy rate, however, is higher than the splenorenal shunt or the distal splenorenal shunt, though less than the portacaval shunts. Experience with the newer arterialized portacaval and coronary caval shunts is limited. A non-shunt procedure, such as the one described by Sugiura, with impressive results and follow-up may become more acceptable as experience grows.     

Surgical disconnection of patent paraumbilical vein in refractory hepatic encephalopathy

BACKGROUND: Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE. PATIENTS: Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE. SURGICAL PROCEDURE: Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery. RESULT: The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE. CONCLUSION: Ligation of the patent PUV is an effective treatment for patients with refractory HE.     

Long-term follow-up of Japanese patients with chronic hepatitis B treated with interferon-alpha

The long-term usefulness of interferon-alpha (IFN-alpha) in chronic hepatitis B remains controversial. To investigate the long-term efficacy of IFN-alpha therapy in chronic hepatitis B, 62 Japanese patients, including 27 patients treated with IFN-alpha (IFN group) and 35 patients without antiviral therapy matched by age and sex as controls (control group), were followed up for 2-14 years. At entry, the serum alanine aminotransferase (ALT) level in the IFN group was significantly higher than that in the control group (238.6+/-250.1 vs. 142.3+/-152.1 IU/l, P < 0.05). The prevalence of genotype C was 89%, with no difference between the two groups (93 vs. 86%). There was no significant difference in the presence of the precore mutation or the dual core promoter mutations between the IFN and control groups (37 vs. 46%, 74 vs. 66%). After long-term follow-up, the rate of sustained HBeAg seroconversion was comparable in the two groups (33 vs. 31%). Normalization of serum ALT level was seen in 44% of the IFN group and 51% of the control group, with no difference. There was also no difference in the percentage of cases with loss of serum HBV-DNA by PCR assay between the two groups (33 vs. 29%). During follow-up, two patients of the control group and three patients of the IFN group developed cirrhosis, and one of the IFN- treated patients progressed to hepatocellular carcinoma. The results of this long-term follow-up study showed that no benefit of IFN-alpha treatment was detectable during long-term follow-up in Japanese patients with chronic hepatitis B.     

Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. An analysis of data and prognostic factors in 589 patients from four randomized clinical trials. Franco-Italian Multicenter Study Group.

BACKGROUND. The value of beta-adrenergic-antagonist drug therapy for the prevention of initial episodes of gastrointestinal bleeding in patients with cirrhosis and esophageal varices is uncertain, both positive and negative study results having been reported. METHODS. In this study, we analyzed data on individual patients from four randomized, controlled trials to assess the efficacy of this treatment. Of the 589 patients studied, 286 received a beta-adrenergic-antagonist drug (propranolol in 203 and nadolol in 83) and 303 received placebo. RESULTS. After two years, the mean (+/- SE) percentage of patients who had had no upper gastrointestinal bleeding was 78 +/- 3 percent in the beta-adrenergic-antagonist treatment group and 65 +/- 3 percent in the control group (P = 0.002). The percentage of patients without fatal bleeding was 90 +/- 2 percent in the treatment group and 82 +/- 3 percent in the control group (P = 0.01). The percentage of patients surviving after two years was 71 +/- 3 percent in the treatment group and 68 +/- 3 percent in the control group (P = 0.34). After age and severity of cirrhosis were taken into account, the survival rate was better in the treatment group (P = 0.09). The percentage of surviving patients who had had no bleeding after two years was 62 +/- 3 percent in the treatment group and 53 +/- 3 percent in the control group (P = 0.04). Both propranolol and nadolol prevented a first episode of bleeding. Severe cirrhosis and especially the presence of ascites were associated with bleeding (P less than 0.001) and death (P less than 0.001) in both groups. The efficacy of beta-adrenergic-antagonist therapy in the prevention of bleeding (P less than 0.001) and of fatal bleeding (P = 0.004) and in the prevention of bleeding or death (P = 0.005) was the same after adjustment for cause and severity of cirrhosis, ascites, and size of varices. CONCLUSIONS. Propranolol and nadolol are effective in preventing first bleeding and reducing the mortality rate associated with gastrointestinal bleeding in patients with cirrhosis, regardless of severity.     

Alcohol associated liver cirrhotics have higher mortality after index hospitalization: Long-term data of 5,138 patients

Background/AimsLiver cirrhosis is an important cause of morbidity and mortality globally. Every episode of decompensation and hospitalization reduces survival. We studied the clinical profile and long-term outcomes comparing alcohol-related cirrhosis (ALC) and non-ALC.MethodsCirrhosis patients at index hospitalisation (from January 2010 to June 2017), with ≥1 year follow-up were included.ResultsFive thousand and one hundred thirty-eight cirrhosis patients (age, 49.8±14.6 years; male, 79.5%; alcohol, 39.5%; Child-A:B:C, 11.7%:41.6%:46.8%) from their index hospitalization were analysed. The median time from diagnosis of cirrhosis to index hospitalization was 2 years (0.2–10). One thousand and seven hundred seven patients (33.2%) died within a year; 1,248 (24.3%) during index hospitalization. 59.5% (2,316/3,890) of the survivors, required at least one readmission, with additional mortality of 19.8% (459/2,316). ALC compared to non-ALC were more often (P<0.001) male (97.7% vs. 67.7%), younger (40–50 group, 36.2% vs. 20.2%; P<0.001) with higher liver related complications at baseline, (P<0.001 for each), sepsis: 20.3% vs. 14.9%; ascites: 82.2% vs. 65.9%; spontaneous bacterial peritonitis: 21.8% vs. 15.7%; hepatic encephalopathy: 41.0% vs. 25.0%; acute variceal bleeding: 32.0% vs. 23.7%; and acute kidney injury 30.5% vs. 19.6%. ALC patients had higher Child-Pugh (10.6±2.0 vs. 9.0±2.3), model for end-stage liver-disease scores (21.49±8.47 vs. 16.85±7.79), and higher mortality (42.3% vs. 27.3%, P<0.001) compared to non-ALC.ConclusionsOne-third of cirrhosis patients die in index hospitalization. 60% of the survivors require at least one rehospitalization within a year. ALC patients present with higher morbidity and mortality and at a younger age.     

Theophylline pharmacokinetics in patients with liver diseases with reference to estimated hepatic blood flow]

Pharmacokinetics of theophylline were determined in patients with liver cirrhosis and idiopathic portal hypertension with reference to estimated hepatic blood flow assessed by indocyanine green (ICG). Decreased plasma clearance of theophylline was noted in patients with liver cirrhosis and the clearance was significantly lower in Child C group than in Child A, B groups (17.5 +/- 3.4 ml/Kg/hr vs 27.6 +/- 8.7, p less than 0.05). Theophylline has been classified as a drug with a low hepatic extraction ratio and it has been believed that changes in hepatic blood flow have little effect on its clearance. The results of present study indicate that theophylline clearance is basically not related to ICG clearance but to theophylline extraction ratio, supporting the common belief. However, it is noteworthy that the clearance was related to decreased hepatic blood flow rather than extraction ratio in a cirrhotic patient with huge extrahepatic shunt, suggesting that hepatic clearance of this drug could be affected by hepatic blood flow under some circumstances.     

Renal perfusion in dogs with experimental hepatic cirrhosis: role of prostaglandins

Increased renal production of prostaglandins are thought to be important for the maintenance of kidney blood flow in advanced cirrhosis. In alert, unanesthetized dogs with chronic cirrhosis and ascites, produced by bile duct ligation, we measured inulin and p-aminohippurate (PAH) clearance before and after the intravenous administration of 2 mg/kg indomethacin, an inhibitor of prostaglandin production. Inulin and PAH clearance declined by 42 and 43%, respectively. This decline in renal perfusion was not associated with changes in blood pressure or cardiac output. If portal hypertension was prevented by creating an end-side portacaval anastomosis at the time of bile duct ligation, indomethacin was without effect on renal perfusion whether or not the dog had ascites. If ascites was completely mobilized in cirrhotic dogs with portal venous hypertension with the aid of a LeVeen valve, indomethacin depressed inulin and PAH clearance as usual during the steady-state period once all ascites had been removed. An attempt was made to determine some of the factors mediating the apparent increase in renal prostaglandin synthesis by administering various pharmacological antagonists. The inhibition of angiotensin effect with saralasin and the inhibition of kallikrein with aprotinin prevented the usual indomethacin effect. It is concluded that portal hypertension, but not a "sick liver per se, in cirrhosis activates the renin-angiotensin system to both produce renal vasoconstriction and stimulate prostaglandin synthesis, thereby normalizing renal perfusion. Renal kallikrein also appears to play a role, probably by augmenting renin release.     

The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction

Background/Aims

Ascites is a dreadful complication of liver cirrhosis associated with short survival. Large volume paracentesis (LVP) is used to treat tense or refractory ascites. Paracentesis induced circulatory dysfunction (PICD) develops if no plasma expanders are given with ominous complications. To study the effect of ascites flow rate on PICD development.

Methods

Sixty patients with cirrhosis and tense ascites underwent LVP of 8 L were randomized into 3 equal groups of different flow rate extraction; group I (80 mL/minute), group II (180 mL/minute) and group III (270 mL/minute). Plasma renin activity (PRA) was measured baseline and on day six. PICD was defined as increase in PRA >50% of the pretreatment value.

Results

In group I through 3; the mean age was (52.5±9.4 vs. 56.4±8.5 vs. 55.8±7.1 years; P>0.05), mean arterial pressure (81.4±5.6 vs. 81.5±7 vs. 79.5±7.2 mmHg; P>0.05), MELD (17.6±4.1 vs. 15.8±4.1 vs. 14.7±4.5). Baseline PRA was comparable (1,366.0±1244.9 vs. 1,151.3±1,444.8 vs. 951.9±1,088 pg/mL; P>0.05). There was no statistically significant (P>0.05) flow mediated changes (Δ) of creatinine (0.23±0.27 vs. 0.38±0.33 vs. 0.26±0.18 mg/dL), MELD (1.25±5.72 vs. 1.70±2.18 vs. 1.45±2.21) or PRA (450.93±614.10 vs. 394.61±954.64 vs. 629.51±1,116.46 pg/mL). PICD was detected in a similar frequency in the three groups (P>0.05). On univariate logistic analysis only female sex was a fairly significant PICD predictor (Wald 3.85, odds ratio 3.14; P=0.05).

Conclusions

The ascites flow rate does not correlate with PICD development.     

乙肝肝硬化失代偿期腹水患者血钠水平与其并发症及临床预后的关系

目的:探求乙肝肝硬化失代偿期腹水患者血钠水平与其并发症及临床预后的关系.方法:回顾性分析2015年5月至2016年10月年收治的乙型肝炎肝硬化失代偿期伴腹水患者98例病例资料,据血钠水平分为低钠血症组与正常组,通过分层分析,对比不同组别患者入院时肝肾功能、血清白蛋白含量、Child-pugh评分、肝纤维化程度及并发症情况,治疗2周后,对比两组患者腹水疗效及出院后预后.结果:98例患者中血钠水平＜130 mmol/L者41例(41.8％).低钠血症组入院时转氨酶、血肌酐、总胆红素、凝血酶原时间、Child-pugh评分均明显高于正常组,血清白蛋白含量则低于血钠水平正常组,差异均具有统计学意义(P＜0.05).低钠血症组与正常组入院时伴肝性脑病、肝肾综合征、消化道出血、自发性腹膜炎比例差异均具有统计学意义(分别为24.4％ vs.7.0％,19.5％vs.5.3％,26.8％ vs.10.5％及24.4％vs.8.8％;P＜0.05).入院14d,两组腹水治疗效果中显效比例分别为73.2％,89.5％(x2=4.421,P=0.036);出院后12个月随访期间内,两组病死率分别为36.6％,15.8％(x2=5.577,P=0.018).结论:血钠水平与肝硬化失代偿期病情密切相关,低钠血症患者病情较重,疗效与预后较差.     

Ultrafiltration by hemofilter--a new therapeutic measure in intractable ascites

The clinical efficacy of ultrafiltration (UF) of ascitic fluid with hemofilter in the treatment of intractable ascites associated with chronic liver disease or intraabdominal malignancy was studied in fifteen patients. The ascitic fluid was reinfused into the peritoneal cavity after ultrafiltration. An average of 6.2 liters of fluid was removed during 4.4 hours of ultrafiltration with no significant change in blood pressure, central venous pressure, hemoglobin, platelets or plasma creatinine. Ascitic fluid albumin rose significantly immediately after the procedure (from 5.2 +/- 4.3 gm/L to 31.9 +/- 30.0 gm/L, P less than 0.01). The plasma albumin concentration increased significantly at the end of UF (P less than 0.001). Also there was a significant increase in urine output (P less than 0.001), urinary sodium excretion (P less than 0.001), and endogenous creatinine clearance (P less than 0.01) during the 48 hours following UF. There was no evidence of hemodynamic, renal or hematological dysfunction, and other complications, including encephalopathy, peritonitis and variceal bleeding were not experienced. Ultrafiltration of ascitic fluid with hemofilter may be safely used in the temporary relief of refractory ascites due to cirrhosis or intra-abdominal malignancy.     

双重腹水超滤浓缩腹腔回输治疗肝硬化合并自发性细菌性腹膜炎患者的临床疗效观察

目的观察应用双重腹水超滤浓缩腹腔回输术治疗肝硬化合并自发性细菌性腹膜炎腹水的临床效果及安全性。方法选择60例肝硬化合并自发性细菌性腹膜炎患者,其中男性54例,女性6例;年龄36～76岁,平均年龄53.4岁。在内科药物治疗基础上增加双重腹水超滤回输治疗,分别于治疗前后观察患者临床症状、腹围、治疗当天尿量、24h尿量、血清尿素和肌酐、血清电解质、血清蛋白等指标的变化及治疗前后患者并发症发生情况。结果患者治疗后乏力、纳差、腹胀不适症状明显改善56例（56/60）,腹围均明显缩小;同治疗前比较,治疗当天尿量及24h尿量均增加（P〈0.05）;治疗后患者血清尿素和肌酐有所下降,但与治疗前比较均无统计学意义（P〉0.05）,治疗前后血清电解质差异亦无统计学意义（P〉0.05）;治疗结束后腹水蛋白浓度[（16.4±5.6）g/L]明显高于治疗前[（8.4±3.2）g/L],差异有统计学意义（t=27.2,P〈0.01）;60例患者出院时的转归中,好转42例,无效12例,死亡6例,总有效率70.0%。并发症发生情况：术后出现头晕、乏力明显2例,肝区隐痛不适2例,无肝性脑病、消化道出血等严重并发症发生。结论双重腹水超滤浓缩腹腔回输治疗肝硬化合并自发性细菌性腹膜炎患者是安全有效的,且简便易行。     

Spontaneous dialytic ultrafiltration with intraperitoneal reinfusion of the concentrate versus large paracentesis in cirrhotic patients with intractable ascites: a randomized study.

Dialytic ultrafiltration of ascites through a hemofilter associated with peritoneal reinfusion (DUF) of the concentrate has been proposed for the treatment of refractory ascites. In five cirrhotic patients, 18 ascites evacuation procedures were randomized either to DUF (n = 8) or to large paracenteses (LP) (n = 10). The effects of these two methods on hemodynamic and renal function were assessed. After DUF, the protein concentration in ascites increased transiently from 28 +/- 7 g/l to 64.8 +/- 8 g/l (p less than 0.04); urinary output increased from day 1 to day 4 (1000 +/- 100) VS 1430 +/- 140 ml/24h; p less than 0.02). After LP, ascitic protein concentration and urinary output were unchanged. No side effects were observed with the two methods. The mean amount of albumin infused was 20 +/- 15 g after DUF and 15 +/- 5 after LP (ns).     

Natural history of compensated viral cirrhosis in a cohort of patients with HIV infection

BACKGROUND: The natural history of initially compensated cirrhosis in patients with HIV and concurrent hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection is poorly defined. This study was designed to investigate the incidence and type of liver-related complications and mortality in coinfected cirrhotic patients. METHODS: We retrospectively identified a cohort of patients coinfected with HIV and HCV or HBV and initially compensated viral cirrhosis. Time to decompensation and mortality from liver-related causes were recorded. RESULTS: Between 1999 and 2004, 392 HIV-infected patients underwent a follow-up of > or =6 months. Sixty-nine patients (17.6%) with initially compensated cirrhosis were identified (7 HBV positive, 59 HCV positive, and 3 positive for both HBV and HCV). The most frequent complication was ascites. The mortality was 71.3 per 1000 person-years (95% confidence interval [CI], 47 to 108) in HIV-infected patients with HBV and/or HCV compensated cirrhosis, 8 (95% CI, 4 to 16) in HIV/HCV-coinfected patients without cirrhosis, and 6.5 (95% CI, 2.7 to 15.5) in HIV-monoinfected patients. After the first event of decompensation, the survival rate was 48% at 1 year and 18.1% at 3 years. Treatment with HAART after the first event of decompensation was associated with an increased survival rate (61.1% and 26.2% at 1 and 3 years, respectively, vs. 26.7% and 0%; P < 0.0001). CONCLUSIONS: These results indicate significant morbidity and mortality during the 6 years after the diagnosis of compensated cirrhosis due to HBV and/or HCV in HIV-infected patients, identifying ascites as the most frequent complication.