Takaya A, Fukui H, Matsumura M, Uemura M, Kojima H, Okamoto S, Tsujii T
Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan.
J Gastroenterol Hepatol. 1995 Jan-Feb;10(1):30-5. doi: 10.1111/j.1440-1746.1995.tb01043.x.
Thirty-two patients with liver cirrhosis and ascites were treated by stepped care diuretic treatment as follows: step 1, placed on a 35 mEq sodium diet; step 2, given 400 mg/day of potassium canrenoate in addition to step 1 treatment; step 3, given 40-80 mg/day of furosemide in addition to step 2 treatment. Eleven out of 32 patients (34.4%, group 1) and 12 of 21 patients (57.1%, group 2) lost their ascites at step 1 and step 2, respectively. The remaining nine patients (group 3) required step 3 treatment. Basal urinary sodium excretion and creatinine clearance were significantly lower and beta 2-microglobulin was significantly higher in group 3 than those in groups 1 and 2. Elevation of basal plasma renin activity and norepinephrine was evident only in group 3. In group 1, urinary sodium excretion decreased after the treatment. In group 2, plasma alpha-atrial natriuretic polypeptide was lowered and plasma renin activity and norepinephrine were elevated after the treatment. These results suggest that basal renal function and plasma renin activity and norepinephrine levels are useful indices to predict the effect of ascites treatment and that responders to sodium restriction or potassium canrenoate may be in the state of vascular overflow, while non-responders to potassium canrenoate may be in the state of vascular underfilling. In summary, this stepped care treatment is safe without any side effects, although the diuretics themselves may lead to relative vascular underfilling.
32例肝硬化腹水患者接受了如下阶梯式利尿治疗：第一步，采用35毫当量钠饮食；第二步，在第一步治疗基础上加用400毫克/天的螺内酯钾；第三步，在第二步治疗基础上加用40 - 80毫克/天的呋塞米。32例患者中有11例（34.4%，第1组）在第一步治疗时腹水消失，21例患者中有12例（57.1%，第2组）在第二步治疗时腹水消失。其余9例患者（第3组）需要第三步治疗。第3组的基础尿钠排泄和肌酐清除率显著低于第1组和第2组，而β2 -微球蛋白显著高于第1组和第2组。仅在第3组中基础血浆肾素活性和去甲肾上腺素明显升高。在第1组中，治疗后尿钠排泄减少。在第2组中，治疗后血浆α -心房利钠多肽降低，血浆肾素活性和去甲肾上腺素升高。这些结果表明，基础肾功能、血浆肾素活性和去甲肾上腺素水平是预测腹水治疗效果的有用指标，对钠限制或螺内酯钾有反应者可能处于血管充盈过度状态，而对螺内酯钾无反应者可能处于血管充盈不足状态。总之，这种阶梯式治疗是安全的，无任何副作用，尽管利尿剂本身可能导致相对的血管充盈不足。
