Marcus R G, Messana J, Swartz R
Department of Internal Medicine, University of Michigan, Ann Arbor.
Am J Med. 1992 Jul;93(1):35-40. doi: 10.1016/0002-9343(92)90677-4.
Hemodialysis in patients with chronic liver disease and ascites may be complicated by intradialytic hypotension, limiting the amount of ultrafiltration and resulting in massive ascites. Successful maintenance peritoneal dialysis (PD) has not been previously reported as an alternative to hemodialysis in this population.
Nine patients with chronic renal failure, chronic liver disease, and tense ascites prior to beginning PD are described. All chronic PD catheters were placed percutaneously by the nephrology staff. Seven patients were maintained primarily on continuous ambulatory peritoneal dialysis, whereas two were on intermittent peritoneal dialysis.
PD catheters were placed without serious hemorrhage or bowel injury. PD provided adequate clearance and volume maintenance for each patient. Fifteen episodes of peritonitis occurred in 18 patient-years of PD. All episodes of peritonitis were successfully treated with intraperitoneal antibiotics without catheter removal. Only one patient had a decline in the serum albumin level of 0.5 g/dL or more during the course of chronic PD. Three of the nine patients are still alive and on PD for durations of 18 to 24 months. One patient insidiously developed sclerosing peritonitis after 8 years on PD and is now on hemodialysis, and another patient switched to hemodialysis because she was no longer able to care for herself or to manage her PD. Four patients died while maintained on PD; three deaths were due to complications of liver failure within the first 4 months of PD and the fourth was due to empyema after 4 years of PD.
PD can be used successfully to treat chronic renal failure in patients with chronic liver disease and ascites when the liver disease itself is not rapidly fatal. PD may be better tolerated than hemodialysis and perhaps should be the renal replacement treatment of choice in these patients.
慢性肝病合并腹水患者进行血液透析时可能并发透析中低血压，限制超滤量并导致大量腹水。此前尚无成功进行维持性腹膜透析（PD）作为该人群血液透析替代方案的报道。
描述了9例在开始PD前患有慢性肾衰竭、慢性肝病和大量腹水的患者。所有慢性PD导管均由肾病科工作人员经皮置入。7例患者主要采用持续性非卧床腹膜透析，2例采用间歇性腹膜透析。
PD导管置入过程中未发生严重出血或肠道损伤。PD为每位患者提供了足够的清除率和容量维持。在18个患者年的PD治疗中发生了15次腹膜炎发作。所有腹膜炎发作均通过腹腔内使用抗生素成功治疗，无需拔除导管。在慢性PD过程中，只有1例患者血清白蛋白水平下降了0.5g/dL或更多。9例患者中有3例仍存活并接受PD治疗，持续时间为18至24个月。1例患者在PD治疗8年后隐匿性发生硬化性腹膜炎，现改为血液透析，另1例患者改为血液透析是因为她无法再照顾自己或管理自己的PD。4例患者在接受PD治疗期间死亡；3例死亡是由于在PD治疗的前4个月内出现肝功能衰竭并发症，第4例是由于PD治疗4年后发生脓胸。
当肝病本身并非迅速致命时，PD可成功用于治疗慢性肝病合并腹水患者的慢性肾衰竭。PD可能比血液透析耐受性更好，或许应成为这些患者肾脏替代治疗的首选。
