Umgelter Andreas, Wagner Katrin, Reindl Wolfgang, Nurtsch Nils, Huber Wolfgang, Schmid Roland M
II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, D-81675 München, Germany.
BMC Gastroenterol. 2008 Aug 27;8:39. doi: 10.1186/1471-230X-8-39.
Patients with advanced cirrhosis of the liver typically display circulatory disturbance. Haemodynamic management may be critical for avoiding and treating functional renal failure in such patients. This study investigated the effects of plasma expansion with hyperoncotic albumin solution and the role of static haemodynamic parameters in predicting volume responsiveness in patients with advanced cirrhosis.
Patients with advanced cirrhosis (Child B and C) of the liver receiving albumin substitution because of renal compromise were studied using trans-pulmonary thermodilution. Paired measurements before and after two infusions of 200 ml of 20% albumin per patient were recorded and standard haemodynamic parameters such as central venous pressure (CVP), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), cardiac index (CI) and derived variables were assessed, including global end-diastolic blood volume index (GEDVI), a parameter that reflects central blood volume
100 measurements in 50 patients (33 m/17 w; age 56 years (+/- 8); Child-Pugh-score 12 (+/- 2), serum creatinine 256 micromol (+/- 150) were analyzed. Baseline values suggested decreased central blood volumes GEDVI = 675 ml/m2 (+/- 138) despite CVP within the normal range (11 mmHg (+/- 5). After infusion, GEDVI, CI and CVP increased (682 ml/m2 (+/- 128) vs. 744 ml/m2 (+/- 171), p < 0.001; 4.3 L/min/m2 (+/- 1.1) vs. 4.7 L/min/m2 (+/- 1.1), p < 0.001; 12 mmHg (+/- 6) vs. 14 mmHg (+/- 6), p < 0.001 respectively) and systemic vascular resistance decreased (1760 dyn s/cm5/m2 (+/- 1144) vs. 1490 dyn s/cm5/m2 (+/- 837); p < 0.001). Changes in GEDVI, but not CVP, correlated with changes in CI (r2 = 0.51; p < 0.001). To assess the value of static haemodynamic parameters at baseline in predicting an increase in CI of 10%, receiver-operating-characteristic curves were constructed. The areas under the curve were 0.766 (p < 0.001) for SVRI, 0.723 (p < 0.001) for CI, 0.652 (p = 0.010) for CVP and 0.616 (p = 0.050) for GEDVI.
In a substantial proportion of patients with advanced cirrhosis, plasma expansion results in an increase in central blood volume. GEDVI but not CVP behaves as an indicator of cardiac preload, whereas high baseline SVRI is predictive of fluid responsiveness.
晚期肝硬化患者通常会出现循环障碍。血流动力学管理对于避免和治疗此类患者的功能性肾衰竭可能至关重要。本研究调查了使用高渗白蛋白溶液进行血浆扩容的效果以及静态血流动力学参数在预测晚期肝硬化患者容量反应性中的作用。
对因肾功能损害而接受白蛋白替代治疗的晚期肝硬化（Child B级和C级）患者采用经肺热稀释法进行研究。记录每位患者两次输注200 ml 20%白蛋白前后的配对测量值，并评估标准血流动力学参数，如中心静脉压（CVP）、平均动脉压（MAP）、全身血管阻力指数（SVRI）、心脏指数（CI）以及衍生变量，包括反映中心血容量的参数——全心舒张末期血容量指数（GEDVI）。
分析了50例患者（33例男性/17例女性；年龄56岁（±8岁）；Child-Pugh评分12（±2），血清肌酐256 μmol（±150））的100次测量值。基线值提示中心血容量降低，GEDVI = 675 ml/m²（±138），尽管CVP在正常范围内（11 mmHg（±5））。输注后，GEDVI、CI和CVP均升高（682 ml/m²（±128）对744 ml/m²（±171），p < 0.001；4.3 L/min/m²（±1.1）对4.7 L/min/m²（±1.1），p < 0.001；12 mmHg（±6）对14 mmHg（±6），p < 0.001），全身血管阻力降低（1760 dyn s/cm⁵/m²（±1144）对1490 dyn s/cm⁵/m²（±837）；p < 0.001）。GEDVI的变化而非CVP的变化与CI的变化相关（r² = 0.51；p < 0.001）。为评估基线静态血流动力学参数预测CI增加10%的价值，绘制了受试者工作特征曲线。曲线下面积分别为：SVRI为0.766（p < 0.001），CI为0.723（p < 0.001），CVP为0.652（p = 0.010），GEDVI为0.616（p = 0.050）。
在相当一部分晚期肝硬化患者中，血浆扩容导致中心血容量增加。GEDVI而非CVP可作为心脏前负荷的指标，而高基线SVRI可预测液体反应性。
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