Splanchnic hemodynamic factors in cirrhosis with refractory ascites.

Splanchnic and systemic hemodynamic observations in eight patients with cirrhosis and refractory ascites were compared to those of 25 patients with cirrhosis and responsive ascites. The refractory ascitic group was characterized by less portasystemic shunting from both the superior mesenteric and splenic vascular beds, a lower cardiac output, a higher systemic vascular resistance, a wider arterial-hepatic venous oxygen difference, and a tendency for a lower HBF and higher postsinusoidal resistance. Portal pressures assessed from hepatic vein catheterization were similar in the two groups. The absence of a well-developed portasystemic collateral bed in patients with refractory ascites could in part be caused by the tense ascites but could also be an important factor in the mechanism of refractory ascites.     

血浆与白蛋白交替输注治疗肝硬化难治性腹腔积液的临床研究

目的：观察血浆与白蛋白交替输注治疗肝硬化难治性腹腔积液的疗效。方法：将122例肝硬化合并难治性腹腔积液患者随机平均分为对照组和观察组。对照组采用常规治疗方法,观察组在常规治疗的基础上应用血浆与白蛋白交替输注进行治疗。结果：观察组总有效率为86．5％,明显比对照组的总有效率高（67．6％）。结论：临床治疗中采用血浆与白蛋白交替输注治疗肝硬化难治性腹腔积液疗效显著,安全性高。     

口服中药合腹水超滤浓缩回输治疗肝硬化顽固性腹水的护理研究

目的 观察口服中药联合腹水超滤浓缩回输护理治疗肝硬化顽固性腹水的疗效.方法 选择肝硬化顽固性腹水住院患者62例,随机分为两组,治疗组32例,采用口服中药+腹水超滤浓缩回输+基础治疗;对照组30例,采用腹水超滤浓缩回输+基础治疗.疗程均为1个月,腹水超滤浓缩回输的频率为2 w 1次,1次超滤的腹水为3 000～8 000 ml,观察治疗前后患者的体重、腹围、24 h尿量、血浆白蛋白、腹水白蛋白、患者血浆和腹水中内毒素水平的变化.结果两组患者的临床症状均有改善,体重及腹围显著下降,24 h尿量增加,血浆及腹水中蛋白量增加,血浆中内毒素水平较治疗前显著下降;治疗组患者腹水Ⅰ级消退者18例,占56.3%,对照组4例,占13.3%,与对照组比较差异有显著性意义(P<0.05).结论 中药口服联合腹水超滤浓缩回输治疗肝硬化顽固性腹水有较好疗效,其作用机制可能与改善患者血浆内毒素水平有关.     

经腹深静脉导管引流治疗肝硬化难治性腹水

目的：探讨经皮腹腔穿刺置入深静脉导管引流在腹腔积液治疗中的效果。方法：130例肝硬化失代偿期患者分为两组，观察组68例行经皮腹腔穿刺置入深静脉导管引流腹腔积液，对照组62例予传统腹腔穿刺抽液，治疗3d后观察治疗效果及不良反应。结果：两组治疗后体重下降，腹围减小，24h尿量增加，且观察组优于对照组。治疗前后血清谷丙转氨酶、总胆红素无明显变化；治疗后血清总蛋白、白蛋白浓度增高，血肌酐及尿素氮水平降低，两组相比差异无统计学意义（P〉0．05）；两组血K^＋，Na^＋，Cl^-等电解质变化差异无统计学意义（P〉0．05）；观察组临床缓解率97％，对照组68％，差异有统计学意义（P〈0．01）；观察组不良反应发生率3％，明显低于对照组29％，差异有统计学意义（P〈0．01）。结论：经皮腹腔穿刺置入深静脉导管引流较腹腔穿刺抽液治疗腹腔积液具有简单、方便、安全、创伤少、不易感染、治疗效果好等优点。     

留置单腔中心静脉导管引流肝硬化顽固性腹水的护理

顽固性腹水是肝硬化终末期表现,经限水、限钠、大剂量利尿剂严格治疗后,腹水持续存在或无明显减少,给患者带来极大的痛苦.     

留置单腔中心静脉导管引流肝硬化顽固性腹水的护理

顽固性腹水是肝硬化终末期表现，经限水、限钠、大剂量利尿剂严格治疗后，腹水持续存在或无明显减少，给患者带来极大的痛苦。我院于2002年2月～2006年12月共为38例肝硬化顽固性腹水的患者采用留置单腔中心静脉导管引流腹水，取得了良好的疗效，现将护理体会总结如下。     

Prostaglandin precursor fatty acids in cirrhosis with ascites: effect of linoleic acid infusion in functional renal failure

1. Functional renal failure (FRF) in cirrhosis with ascites could be related to an inappropriately low renal prostaglandin (PG) production. To investigate whether the impaired renal PG synthesis in these patients is related to a PG precursor fatty acid deficiency, serum levels of linoleic and arachidonic acids and the urinary excretion of PGE2, 6-keto-PGF1 alpha and thromboxane B2 (TxB2) were measured in 10 normal subjects, 17 non-azotaemic cirrhotic patients with ascites and 10 cirrhotic patients with ascites and FRF. 2. Serum linoleic acid levels were similar in the three groups studied. Both groups of cirrhotic patients showed lower arachidonic acid levels than normal subjects; however, non-azotaemic cirrhotic patients and patients with FRF did not differ in relation to serum arachidonic acid. 3. Non-azotaemic cirrhotic patients had higher urinary PGE2, 6-keto-PGF1 alpha and TxB2 excretion than normal subjects and cirrhotic patients with FRF. Patients with FRF showed similar urinary PGE2 and TxB2 and lower urinary 6-keto-PGF1 alpha than normal subjects. In all cirrhotic patients no significant correlation was found between serum linoleic and arachidonic acid levels and urinary PGs. 4. In seven patients with FRF an acute intravenous infusion of linoleic acid induced a marked increase in serum levels of this fatty acid. However, no increase in serum arachidonic acid levels and urinary PG excretion and no improvement in renal function was observed. 5. This study suggests that an arachidonic acid deficiency is present in cirrhotic patients with ascites but that this abnormality is not a major determinant of renal function and PG production in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous bacterial peritonitis in alcoholic cirrhosis with ascites

Taking part in recreation or tourist pursuits far from medical resources can tax the ingenuity of even the best-prepared wilderness traveler. In part 1 of this three-part article, which appeared in the June issue, means of preventing illness and injury in the “wilds” were discussed. This part outlines the specific management of several illnesses and injuries that might occur on the trail. In part 3, to appear in August, items for inclusion in a medical kit for wilderness travel will be detailed.     

腹水超滤浓缩回输治疗顽固性腹水疗效观察

目的:观察腹水超滤浓缩回输治疗顽固性腹水的临床疗效。方法:用金宝AK95s型血液透析机、14S透析器及透析管路,对8例顽固性腹水患者进行腹水浓缩回输腹腔或静脉治疗,分析患者治疗前后腹围、体重、血浆白蛋白等指标并与9例未经腹水回输患者进行疗效对照。结果:所有患者回输治疗后腹胀、呼吸困难明显减轻,腹围缩小,体重下降、血浆白蛋白较治疗前明显增加(P<0.01),治疗组8例患者中有2例为显效,4例有效,2例无效,治疗总有效率为75%,而对照组9例仅3例有效,6例无效,总有效率为33.3%。两组比较有显著性差异(P<0.01)。结论:腹水超滤浓缩回输治疗顽固性腹水是一种安全有效的方法,值得临床推广应用。     

Management of refractory ascites

Ascites that does not respond or recurs after high-dose diuresis and sodium restriction should be considered refractory ascites. As cirrhosis advances, the escaping fluid overwhelms the lymphatic return. Decrease in renal plasma flow leads to increased sodium reabsorption at the proximal tubule leading to decreased responsiveness to loop diuretics and mineralocorticoid antagonists, which work distally. These complex hemodynamic alterations lead to refractory ascites. In refractory ascites, high-dose diuresis (400 mg of spironolactone and 160 mg of furosemide) and sodium restriction (<90 mmol/d) result in inadequate weight loss and sub optimal sodium excretion (<78 mmol/d). Further use of diuretics is limited by complications such as encephalopathy, azotemia, renal insufficiency, hyponatremia, and hyperkalemia. Therapy for refractory ascites is limited. The available therapies are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, investigational medical therapies, and liver transplantation. LVP with concomitant volume expanders is the initial treatment of choice. Transjugular intrahepatic portosystemic seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life. Several treatments that act at different steps in the pathogenesis of ascites are investigational, and some show promising results. Splanchnic and peripheral vasoconstrictors (Octreotide, Midodrine, and Terlipressin) increase effective arterial volume and decrease activation of the renin-angiotensin system with resultant increase in renal sodium excretion. Clonidine when given with spironolactone has been shown to cause rapid mobilization of ascites by significantly decreasing the sympathetic activity and renin-aldosterone levels. Natural aquaretics and synthetic V2 receptor antagonists (satavaptan) are being evaluated for mobilization of ascites by increasing the excretion of solute-free water. Liver transplantation remains the only definitive therapy for refractory ascites. Because refractory ascites is a poor prognostic sign, liver transplantation should be considered and incorporated early in the treatment plan.     

Low-dose dopamine infusion, renal haemodynamics and urinary albumin excretion rate in insulin-dependent diabetics and in normal man

The effect of experimental renal vasodilatation by means of low-dose (2.0 micrograms/kg/min) intravenous dopamine infusion was investigated in 28 insulin-dependent diabetes mellitus (IDDM) patients with normal basal urinary albumin excretion rate (UAE) (less than 15 micrograms/min), 9 IDDM patients with UAE between 15-200 micrograms/min (microalbuminuria), and 7 normal subjects. Glomerular filtration rate (GFR) (thalamate clearance) showed a small increase with dopamine infusion, in the normoalbuminuric IDDM patients from 140 +/- 20 to 146 +/- 20 ml/min (2p less than 0.01), in the microalbuminuric IDDM patients from 146 to 151 ml/min (NS), and in normal subjects from 115 +/- 16 to 122 +/- 15 (2p less than 0.05). A marked increase in renal plasma flow (RPF) (hippuran clearance) was seen in all three groups--533 +/- 82 to 724 +/- 120 ml/min (2p less than 0.01), 574 +/- 69 to 777 +/- 140 ml/min (2p less than 0.01) and 523 +/- 87 to 749 +/- 145 ml/min (2p less than 0.05), respectively. Urinary albumin excretion rate (radioimmunoassay) increased from 5.3 x/divide 1.5 (tolerance factor) to 6.5 x/divide 1.8 micrograms/min (2p less than 0.05) in the normoalbuminuric IDDM patients and from 6.1 x/divide 2.1 to 7.8 x/divide 2.3 micrograms/min (2p less than 0.05) in the normal subjects, while no significant change was seen in the microalbuminuric group of diabetics. Kidney volume (ultrasonic scanning) was significantly enhanced in IDDM patients (294 +/- 73 ml vs. 196 +/- 49 ml). There was no significant correlation between kidney volume and the renal haemodynamic response to dopamine.(ABSTRACT TRUNCATED AT 250 WORDS)     

改良式腹水枕在肝硬化大量腹水患者中的应用

目的探讨改良式腹水枕在肝硬化大量腹水患者中的应用效果。方法选取2018年1-12月入院的肝硬化大量腹水患者120例,将其随机等分为对照组及试验组。两组均给予常规护理,对照组根据患者体位需要使用传统护理枕,试验组根据患者需要使用改良式腹水枕拆卸组装适应患者体位需求,且提供音乐播放功能。比较两组患者生活质量评分。结果试验组患者躯体、角色、认知、社会和总体健康评分高于对照组(P<0.05),疲倦、疼痛、气促、失眠、情绪、食欲丧失、经济困难评分低于对照组(P<0.05),两组恶心呕吐、便秘、腹泻评分比较差异无统计学意义(P>0.05)。结论改良式腹水枕能缓解患者呼吸困难、腹部不适症状,提供合适腰部支撑,解除腰部肌肉痉挛,减轻疼痛、气促症状,纠正睡姿,提高睡眠质量。改良式腹水枕成本低,使用方便,值得临床推广应用。     

Prognostic value of spontaneous hyponatremia in cirrhosis with ascites.

Spontaneous hyponatremia in cirrhosis with ascites is generally considered to be due to an impaired renal ability to excrete free water, to be a contraindication of diuretics, and to be a bad prognostic sign. These concepts are reviewed in this paper. 55 cirrhotics with ascites were divided into three groups. Group I consisted of 13 patients with hyponatremia and very low free-water clearance CH2O, 0.07 +/- 0.26 ml/min). These patients also had poor renal function: low inulin clearance (CINU, 40.6 +/- 25.9 ml/min) and paraaminohippurate clearance (CPAH, 383 +/- 275 ml/min). Group II consisted of 8 patients who also had hyponatremia. CH2O, CINU, and CPAH in these patients were fairly high: 5.85 +/- 1.53 ml/min, 85.7 +/- 26.2 ml/min, and 651 +/- 294 ml/min. These values are similar to those o7 +/- 4.27 ml/min, 94.7 +/- 33.1 ml/min, and 598 +/- 199 ml/min. Hyponatremia in Group I could be related to the impaired free-water clearance. The mechanism of hyponatremia in Group II patients is not clear. Patients with hyponatremia and low CINU and CPAH had a negative response to diuretics and a poor prognosis. Patients with hyponatremia but with relatively good renal function had a good prognosis, similar to Group III patients. They responded to diuretics with no worsening of their hyponatremia.     

Renin, aldosterone and renal haemodynamics in cirrhosis with ascites

The interrelationships between the renin-angiotensin-aldosterone system, renal haemodynamics and urinary sodium excretion were investigated in fifty-six non-azotaemic cirrhotics with ascites. In twelve additional patients the renal renin secretion rate was also studied. Plasma renin activity and concentration and plasma aldosterone ranged from normal to very high values. There was a significant inverse relationship between plasma aldosterone and the urinary sodium excretion. Plasma aldosterone showed a highly significant direct correlation with plasma renin activity, and plasma renin concentration was closely and directly related to the estimated renin secretion rate. Neither plasma renin activity, plasma renin concnetration nor the estimated renin secretion rate correlated with the renal plasma flow or the glomerular filtration rate. These results suggest that in non-azotaemic cirrhosis with ascites the renin-angiotensin-aldosterone system is an important factor influencing sodium excretion, increased plasma renin and aldosterone concentrations are mainly due to an increased secretion rate, and total renal perfusion is not a major factor influencing renin secretion.