Torre Delgadillo Aldo
Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, D.F.
Rev Gastroenterol Mex. 2005 Jul-Sep;70(3):299-311.
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.
腹水是肝硬化最常见的并发症，如果患者不接受原位肝移植，2年内死亡率可达50%。最近，国际腹水俱乐部将腹水分为三组：I级腹水仅通过超声检测到；II级腹水为中度，腹部对称膨隆；III级腹水量大或张力高，腹部明显膨隆。约10%的腹水患者对利尿剂治疗无效。在顽固性腹水中，患者对最高剂量的利尿剂（螺内酯400mg/天和呋塞米160mg/天）无反应，或出现禁止使用这些药物的副作用（高钾血症、低钠血症、肝性脑病或肾衰竭）。患者可通过反复大量腹腔穿刺放液加白蛋白或经颈静脉肝内门体分流术（TIPS）进行治疗。肝硬化患者的稀释性低钠血症定义为在细胞外液量增加的情况下血清钠≤130mEq/L，腹水和/或水肿的存在表明了这一点。鉴于一些报告表明，当血清钠浓度与终末期肝病模型（MELD）相结合时，可提高等待原位肝移植（OLT）患者MELD评分的预后准确性，肝硬化腹水患者的这一并发症最近受到了关注。稀释性低钠血症管理的第一步是限制液体摄入并停用利尿剂。每天限制饮水1000mL有助于防止血清钠浓度逐渐下降，但在大多数情况下通常无法纠正低钠血症。实际上正在研发口服活性药物，其作用是选择性拮抗精氨酸加压素的特定受体（V2受体）。这些药物作用于肾脏的远曲小管，通过增加无溶质自由水排泄，从而提高低钠血症患者的血清钠浓度。
