Pose Elisa, Cardenas Andres
GI/Liver Unit, Institut de Malalties Digestives i Metabòliques of Hospital Clínic, and University of Barcelona, Barcelona, Spain.
Dig Dis. 2017;35(4):402-410. doi: 10.1159/000456595. Epub 2017 May 3.
Ascites is the most common complication associated with cirrhosis resulting in poor quality of life, high risk of development of other complications of cirrhosis, increased morbidity and mortality associated with surgical interventions, and poor long-term outcome. Patients with cirrhosis and a first onset of ascites, have a probability of survival of 85% during the first year and 56% at 5 years without liver transplantation. Ascites is caused due to increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation. The practical management of ascites involves the proper evaluation of a patient with a thorough history and physical exam. In addition, complete laboratory, ascitic fluid, and radiological tests should be performed. One of the most important steps in the initial assessment of patients with ascites is to refer the appropriate candidates for liver transplantation, as it offers a definitive cure for cirrhosis and its complications. While the initial management of uncomplicated ascites with low sodium diet and diuretic treatment is straightforward in a majority of patients, approximately 10% of patients fail to respond to diuretics and become a real therapeutic challenge. The initial treatment of choice in patients with refractory ascites is large-volume paracentesis (LVP) associated with intravenous albumin; some patients also benefit from transjugular intrahepatic portosystemic shunts (TIPS). When repeated LVP or TIPS cannot be performed, other approaches using vasoconstrictors such as midodrine can be considered although data are scarce. A newly designed automated low flow pump system (Alfapump), which is designed to move ascites from the peritoneal cavity to the urinary bladder where it is eliminated spontaneously through diuresis is promising, but the data are also limited and safety is still a matter of concern. This article focuses on the practical aspects of the evaluation and treatment of patients with ascites and cirrhosis and also discusses how to translate our current understanding of ascites pathophysiology into new treatment methods for patients with fluid retention.
腹水是肝硬化最常见的并发症，会导致生活质量下降、发生肝硬化其他并发症的风险增加、手术干预相关的发病率和死亡率上升以及长期预后不良。肝硬化并首次出现腹水的患者，在未进行肝移植的情况下，第一年的生存率为85%，5年生存率为56%。腹水是由于肾素 - 血管紧张素 - 醛固酮系统活性增加导致肾钠潴留增加所致，这是对内脏循环明显血管扩张的一种反应。腹水的实际管理包括通过全面的病史和体格检查对患者进行适当评估。此外，还应进行完整的实验室、腹水和影像学检查。对腹水患者进行初始评估时最重要的步骤之一是将合适的候选人转介进行肝移植，因为肝移植可为肝硬化及其并发症提供根治方法。虽然大多数患者通过低钠饮食和利尿剂治疗对单纯性腹水进行初始管理很简单，但约10%的患者对利尿剂无反应，成为真正的治疗挑战。难治性腹水患者的初始治疗选择是大量腹腔穿刺放液（LVP）联合静脉输注白蛋白；一些患者也受益于经颈静脉肝内门体分流术（TIPS）。当无法重复进行LVP或TIPS时，尽管数据稀少，但可以考虑使用如米多君等血管收缩剂的其他方法。一种新设计的自动低流量泵系统（Alfapump），旨在将腹水从腹腔转移到膀胱，然后通过利尿自发排出，前景广阔，但数据也有限，安全性仍是一个令人担忧的问题。本文重点关注腹水和肝硬化患者评估与治疗的实际方面，还讨论了如何将我们目前对腹水病理生理学的理解转化为针对液体潴留患者的新治疗方法。
