对肝硬化腹水诊治中若干问题的认识与思考

近年国内对肝硬化腹水发病机制、诊断、治疗有较多研究,与既往相比出现了较大差距,突出问题:(1)根据钠潴留机制限钠、利尿治疗不仅未能抑制肾素-血管紧张素-醛固酮系统(RAAS)活性,反而限钠越严格,RAAS活性就越强。纠正低血钠后RAAS活性受到抑制;(2)肝硬化腹水患者并非因血管活性物质紊乱导致血容量不足而诱发肝肾综合征(HRS),而是限钠、利尿导致血容量不足诱发HRS;(3)国外(美国)肝硬化腹水诊治指南部分条款相互间出现矛盾。根据这些突出问题,应重视对肝硬化腹水的研究。

Current clinical perspectives and implications of cirrhotic ascites in China

In recent years,domestic research efforts have significantly advanced our understanding of the pathogenesis of cirrhotic ascites and led to development of new and improved methods of diagnosis and treatment.Unfortunately,the studies have produced underlying mechanisms remain unknown systematic studies to compare the new and traditional methods are lacking.There is an urgent need to address the following topics and related issues:(1)The mechanism of sodium retention: Sodium restriction treatment regimens and diuretic therapy have not only failed to inhibit activity of the kidney-angiotensin-aldosterone system(RAAS),but stricter salt restriction has produced stronger RAAS activity.However,correcting hyponatremia effectively inhibited the RAAS activity.(2)The causes and effects of hepatorenal syndrome(HRS): The established theory that cirrhotic ascites result from disorders of vasoactive substances leading to hypovolemia and subsequent HRS was not shown in patients.However,cirrhosis ascites were shown to be associated with sodium restriction and diuretic status,which is newly theorized to lead to the hypovolemia-induced HRS.(3)Inconsistencies in established management guidelines: Some rules of the USA guidelines for therapy of cirrhotic ascites lack a theoretical basis,resulting in contradictions in diagnosis and treatment,which may also be explained by ethnic-specific features.Thus,it is necessary to formulate a new set of guidelines for diagnosis and treatment of cirrhotic ascites in Chinese patients based on a comprehensive understanding of the underlying molecular and biological pathogenic mechanisms.