Tan Hiang Keat, James Paul Damien, Wong Florence
Division of Gastroenterology, Department of Medicine, Toronto General Hospital, 9EN/222, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
Dig Dis Sci. 2016 Oct;61(10):3084-3092. doi: 10.1007/s10620-016-4140-3. Epub 2016 Apr 5.
Large-volume total paracentesis may result in paracentesis-induced circulatory dysfunction, which is associated with poor outcomes.
To explore the short- and long-term effects of paracentesis-induced circulatory dysfunction on systemic hemodynamics, renal function and other cirrhosis-related complications in patients with refractory ascites, following subtotal large-volume paracentesis.
Patients with cirrhosis and refractory ascites without renal dysfunction had systemic hemodynamics, renal function, and neurohormones (plasma active renin, aldosterone, norepinephrine and angiotensin II) measured pre- and 6 days post-paracentesis. Paracentesis was limited to ≤8 L with 6-8 g of albumin per liter ascites drained. Patients were followed up until transjugular intrahepatic portosystemic shunt insertion, liver transplantation, or death. Paracentesis-induced circulatory dysfunction was defined as >50 % increase in plasma active renin 6 days post-paracentesis.
Fifty-seven patients (mean age 59.0 ± 9.4 years) had mean 6.8 ± 1.8 L of ascites removed with 9 ± 3 g of albumin given/L of ascites drained. Patients were followed up for 715 ± 104 days. Twenty-three patients (40.4 %) developed paracentesis-induced circulatory dysfunction with unchanged serum creatinine on day six, despite worsening of hemodynamics (mean arterial pressure 90 ± 10 mmHg at baseline vs. 84 ± 8 mmHg on day six, p < 0.05). Similar hemodynamic changes were observed among patients without paracentesis-induced circulatory dysfunction. There was no significant difference in the long-term renal function or cirrhosis-related complications between the groups.
The occurrence of paracentesis-induced circulatory dysfunction, as defined by plasma active renin, may not have a significant short- and long-term impact on renal function or cirrhosis-related complications in patients with refractory ascites who undergo subtotal paracentesis with albumin infusion.
大量腹腔穿刺放液可能导致穿刺诱导的循环功能障碍，这与不良预后相关。
探讨在大量腹腔穿刺放液术后，穿刺诱导的循环功能障碍对顽固性腹水患者全身血流动力学、肾功能及其他肝硬化相关并发症的短期和长期影响。
对无肾功能不全的肝硬化顽固性腹水患者，在腹腔穿刺放液术前及术后6天测量其全身血流动力学、肾功能及神经激素（血浆活性肾素、醛固酮、去甲肾上腺素和血管紧张素II）。腹腔穿刺放液量限制在≤8L，每排出1L腹水补充6 - 8g白蛋白。对患者进行随访，直至行经颈静脉肝内门体分流术、肝移植或死亡。穿刺诱导的循环功能障碍定义为腹腔穿刺放液术后6天血浆活性肾素升高>50%。
57例患者（平均年龄59.0±9.4岁）平均排出腹水6.8±1.8L，每排出1L腹水给予9±3g白蛋白。患者随访715±104天。23例患者（40.4%）出现穿刺诱导的循环功能障碍，尽管血流动力学恶化（基线时平均动脉压为90±10mmHg，术后第6天为84±8mmHg，p<0.05），但术后第6天血清肌酐未改变。在未发生穿刺诱导的循环功能障碍的患者中也观察到类似的血流动力学变化。两组患者的长期肾功能或肝硬化相关并发症无显著差异。
以血浆活性肾素定义的穿刺诱导的循环功能障碍的发生，可能对接受补充白蛋白的部分腹腔穿刺放液术的顽固性腹水患者的肾功能或肝硬化相关并发症没有显著的短期和长期影响。
