Arroyo V
Liver Unit, Hospital Clinic i Provincial, University of Barcelona.
Acta Gastroenterol Belg. 1990 Mar-Apr;53(2):249-55.
Refractory ascites (or diuretic-resistant ascites), i.e. ascites that cannot be mobilized by medical treatment (low sodium diet and high doses of furosemide and spironolactone) is an infrequent phenomenon in cirrhosis. It usually occurs in patients with functional renal failure as a consequence of alteration in both pharmacokinetics and pharmacodynamics of diuretics. Peritoneovenous shunting, a procedure which improves systemic hemodynamics and renal function and suppresses the plasma levels of renin, aldosterone, norepinephrine and antidiuretic hormone in cirrhotics with ascites, has been proposed as the treatment of choice in patients with refractory ascites. Unfortunately it is associated to a high rate of severe complications and does not prolong the survival of these patients. Moreover, in approximately one third of the patients the shunt becomes occluded within the first year after operation. Recent studies have shown that repeated large volume paracentesis (4-64 per day until disappearance of ascites) or total paracentesis (complete mobilization of ascites in only one paracentesis session) associated to i.v. albumin infusion are an effective and safe therapy of ascites. At present, there is only one controlled trial comparing therapeutic paracentesis versus peritoneo-venous shunt in the management of patients with refractory ascites. In this study, there were no significant difference between both therapeutic groups with respect to survival. However, the incidence of readmission to hospital for the treatment of ascites was higher in the paracentesis group. Therefore, both procedures are valid therapeutic alternatives for that type of patients. Future studies are necessary to investigate if there are subsets of cirrhotics with refractory ascites in which one of these two types of treatment is especially indicated.
难治性腹水（或利尿抵抗性腹水），即无法通过内科治疗（低钠饮食及大剂量呋塞米和螺内酯）消除的腹水，在肝硬化患者中并不常见。它通常发生于功能性肾衰竭患者，这是利尿剂的药代动力学和药效学改变所致。腹腔静脉分流术可改善全身血流动力学和肾功能，并抑制腹水肝硬化患者的血浆肾素、醛固酮、去甲肾上腺素和抗利尿激素水平，该手术已被提议作为难治性腹水患者的首选治疗方法。不幸的是，它与高发生率的严重并发症相关，且不能延长这些患者的生存期。此外，在大约三分之一的患者中，分流管在术后第一年内会发生堵塞。最近的研究表明，反复大量放腹水（每天4 - 6次直至腹水消失）或一次性完全放腹水（仅一次放腹水操作就使腹水完全消除）联合静脉输注白蛋白是一种有效且安全的腹水治疗方法。目前，仅有一项对照试验比较了治疗性放腹水与腹腔静脉分流术在难治性腹水患者管理中的效果。在这项研究中，两个治疗组在生存期方面无显著差异。然而，放腹水组因腹水治疗再次入院的发生率更高。因此，这两种方法都是这类患者有效的治疗选择。未来有必要进行研究，以确定是否存在难治性腹水肝硬化患者的亚组，针对这些亚组，这两种治疗方法中的某一种特别适用。
