Tobe S W, Morali G A, Greig P D, Logan A, Blendis L M
Department of Medicine, University of Toronto, Canada.
Gastroenterology. 1993 Jul;105(1):202-7. doi: 10.1016/0016-5085(93)90027-a.
Sodium retention in cirrhosis has been attributed to an imbalance between vasoconstrictive, antinatriuretic forces such as the renin aldosterone angiotensin system and the sympathetic nervous system, and vasodilatory, natriuretic agents such as atrial natriuretic factor (ANF). Patients with diuretic resistant refractory ascites may require peritoneovenous shunting (PVS) to control ascites.
To study the factors responsible for the improvement in sodium homeostasis post-PVS, we compared the response to ANF infusion before and 1 month after PVS in 6 patients with massive ascites.
Before PVS, sodium excretion at baseline and in response to ANF infusion was blunted but became more normal post-PVS. ANF infusion post-PVS induced a significant increase in the glomerular filtration rate and filtration fraction and also in distal delivery of sodium. ANF's distal effect of increasing the fractional excretion of distally delivered sodium was present pre-PVS and was not significantly increased post-PVS. Changes in sodium handling were accompanied by a significant decrease in antinatriuretic forces (baseline aldosterone, 2079 +/- 507 vs. 647 +/- 17 nmol/L; P < 0.04) post-PVS.
The improvement in sodium homeostasis and response to ANF infusion post-PVS appears to be associated with the decrease in antinatriuretic forces with the loss of massive refractory ascites. Thus, PVS restores the balance toward ANF responsiveness.
肝硬化患者的钠潴留被认为是由于血管收缩性、抗利尿因子如肾素-醛固酮-血管紧张素系统和交感神经系统与血管舒张性、利钠因子如心房利钠因子（ANF）之间的失衡所致。利尿剂抵抗的难治性腹水患者可能需要进行腹腔静脉分流术（PVS）来控制腹水。
为了研究PVS后钠稳态改善的相关因素，我们比较了6例大量腹水患者在PVS前及PVS后1个月对ANF输注的反应。
PVS前，基线时及对ANF输注的钠排泄受到抑制，但PVS后变得较为正常。PVS后输注ANF可使肾小球滤过率和滤过分数显著增加，同时钠向远端的输送也增加。PVS前就存在ANF增加远端输送钠的分数排泄的远端效应，PVS后未显著增加。钠处理的变化伴随着PVS后抗利尿因子的显著降低（基线醛固酮，2079±507对647±17 nmol/L；P<0.04）。
PVS后钠稳态的改善及对ANF输注的反应似乎与抗利尿因子的降低以及大量难治性腹水的消失有关。因此，PVS恢复了对ANF反应性的平衡。
