从《肝硬化腹水及相关并发症的诊疗指南》探讨肝硬化顽固性腹水诊治“路线图”

丁惠国

doi:10.3969/j.issn.1001-5256.2018.01.006

从《肝硬化腹水及相关并发症的诊疗指南》探讨肝硬化顽固性腹水诊治“路线图”

DOI: 10.3969/j.issn.1001-5256.2018.01.006

丁惠国

首都医科大学附属北京佑安医院肝病消化中心

基金项目:

北京市医院管理局临床医学发展专项(ZYLX201610)；登峰计划专项(DFL20151602)；

详细信息

中图分类号: R575.2
计量
- 文章访问数: 622
- HTML全文浏览量: 48
- PDF下载量: 636
- 被引次数: 0
出版历程
- 出版日期: 2018-01-20

Road map of the diagnosis and treatment of intractable ascites based on guidelines for the diagnosis and treatment of cirrhotic ascites and related complications

Ding HuiGuo

Center of Hepatic and Digestive Diseases, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China

Research funding:

摘要

摘要: 《肝硬化腹水及相关并发症的诊疗指南》提出了肝硬化顽固性腹水（RA）诊治的新标准,其中自发性细菌性腹膜炎为肝硬化RA常见原因。50%89%肝硬化RA患者对特利加压素（28 mg/d）、盐酸米多君（22.5 mg/d）、托伐普坦（7.515 mg/d）有显著的应答反应。静脉补充白蛋白（8 g/1000 ml腹水）与特利加压素（3 mg）预防大量放腹水后循环功能障碍的效果相似。药物治疗应答差或需要频繁进行大量放腹水（>3次/周）或频繁住院（>3次/月）的肝硬化RA患者,应该早期评估肝移植或经颈静脉肝内门体静脉分流术。α晶型利福昔明能够影响肠道-微生物-肝脏轴,是预防肝硬化相关并发症的新策略。因此,探讨适合中国临床实践的肝硬化RA诊治"路线图"具有较重要的意义。
- 肝硬化 /
- 腹水 /
- 腹膜炎 /
- 诊断 /
- 治疗
Abstract: Guidelines for the diagnosis and treatment of cirrhotic ascites and related complications put forward the new criteria for the diagnosis and treatment of intractable cirrhotic ascites, and spontaneous bacterial peritonitis is a common cause of intractable cirrhotic ascites. About 50% -89% of patients with intractable cirrhotic ascites have a significant response to terlipressin ( 2-8 mg/d) , midodrine hydrochloride ( 22. 5 mg/d) , and tolvaptan ( 7. 5-15 mg/d) . Intravenous albumin supplementation ( 8 g/1000 ml ascites) has a similar therapeutic effect as terlipressin ( 3 mg) in preventing posterior circulation dysfunction after large-volume paracentesis. Patients with a poor response to medication or those who need frequent large-volume paracentesis ( more than three times per week) or frequent hospitalization ( more than three times per month) should be evaluated for liver transplantation or transjugular intrahepatic portosystemic shunt. α-Crystal rifaximin may become a new strategy for preventing complications of liver cirrhosis by regulating the intestine-microbe-liver axis. Therefore, it is of great significance to explore the“road map”of the diagnosis and treatment of intractable cirrhotic ascites that is suitable for the clinical practice in China.
- liver cirrhosis /
- ascites /
- peritonitis /
- diagnosis /
- therapy

HTML全文

参考文献(28)

[1]FLEMING KM, AITHAL GP, CARD TR, et al.All-cause mortality in people with cirrhosis compared with the general population:a population-based cohort study[J].Liver Int, 2012, 32 (1) :79-84.

[2]GE PS, RUNYON BA.Treatment of patients with cirrhosis[J].N Engl J Med, 2016, 375 (8) :767-777.

[3]Chinese Society of Hepatology, Chinese Medical Association.Guidelines on the management of ascites and complications in cirrhosis[J].J Clin Hepatol, 2017, 33 (10) :1847-1863. (in Chinese) 中华医学会肝病学分会.肝硬化腹水及相关并发症的诊疗指南[J].临床肝胆病杂志, 2017, 33 (10) :1847-1863.

[4]ARROYO V, GINES P, GERBES AL, et al.Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis.International Ascites Club[J].Hepatology, 1996, 23 (1) :164-176.

[5]European Association for the Study of the Liver.EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis[J].J Hepatol, 2010, 53 (3) :397-417.

[6]RUNYON BA, AASLD.Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012[J].Hepatology, 2013, 57 (4) :1651-1653.

[7]KALAMBOKIS G, TSIANOS EV.Refractory ascites:can it be defined only by the response to furosemide and spironolactone?[J].Liver Int, 2010, 30 (9) :1394.

[8]ZHANG X, WANG SZ, ZHENG JF, et al.Clinical efficacy of tolvaptan for treatment of refractory ascites in liver cirrhosis patients[J].World J Gastroenterol, 2014, 20 (32) :11400-11405.

[9]MORI T, OHSAKI Y, OBA-YABANA I, et al.Diuretic usage for protection against end-organ damage in liver cirrhosis and heart failure[J].Hepatol Res, 2017, 47 (1) :11-22.

[10]SANTOS J, PLANAS R, PARDO A, et al.Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis.A randomized comparative study of efficacy and safety[J].J Hepatol, 2003, 39 (2) :187-192.

[11]PEREZ-AYUSO RM, ARROYO V, PLANAS R, et al.Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites.Relationship between the diuretic response and the activity of the renin-aldosterone system[J].Gastroenterology, 1983, 84 (5 Pt 1) :961-968.

[12]PIANO S, TONON M, ANGELI P.Management of ascites and hepatorenal syndrome[J].Hepatol Int, 2017.[Epub ahead of print]

[13]FIMIANI B, GUARDIA DD, PUOTI C, et al.The use of terlipressin in cirrhotic patients with refractory ascites and normal renal function:a multicentric study[J].Eur J Intern Med, 2011, 22 (6) :587-590.

[14]ACEVEDO JG, CRAMP ME.Hepatorenal syndrome:update on diagnosis and therapy[J].World J Hepatol, 2017, 9 (6) :293-299.

[15]SANYAL AJ, BOYER TD, FREDERICK RT, et al.Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs.placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies[J].Aliment Pharmacol Ther, 2017, 45 (11) :1390-1402.

[16]CAVALLIN M, PIANO S, ROMANO A, et al.Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome:a randomized controlled study[J].Hepatology, 2016, 63 (3) :983-992.

[17]SINGH V, DHUNGANA SP, SINGH B, et al.Midodrine in patients with cirrhosis and refractory or recurrent ascites:a randomized pilot study[J].J Hepatol, 2012, 56 (2) :348-354.

[18]GINES P, WONG F, WATSON H, et al.Clinical trial:shortterm effects of combination of satavaptan, a selective vasopressin V2receptor antagonist, and diuretics on ascites in patients with cirrhosis without hyponatraemia——a randomized, double-blind, placebo-controlled study[J].Aliment Pharmacol Ther, 2010, 31 (8) :834-845.

[19]RAI N, SINGH B, SINGH A, et al.Midodrine and tolvaptan in patients with cirrhosis and refractory or recurrent ascites:a randomised pilot study[J].Liver Int, 2017, 37 (3) :406-414.

[20]BERNARDI M, CARACENI P, NAVICKIS RJ.Does the evidence support a survival benefit of albumin infusion in patients with cirrhosis undergoing large-volume paracentesis?[J].Expert Rev Gastroenterol Hepatol, 2017, 11 (3) :191-192.

[21]ALLESANDRIA C, ELLA C, MEZZABITTA L, et al.Prevention of paracentesis-induced circulatory dysfunction in cirrhosis:standard vs half albumin doses.A prospective, randomized, unblinded pilot study[J].Dig Liver Dis, 2011, 43 (11) :881-886.

[22]JOHNSON KB, MUELLER JL, SIMON TG, et al.Reduced albumin dosing during large-volume paracentesis is not associated with adverse clinical outcomes[J].Dig Dis Sci, 2015, 60 (7) :2190-2195.

[23]SINGH V, KUMAR R, NAIN CK, et al.Terlipressin versus albumin in paracentesis-induced circulatory dysfunction in cirrhosis:a randomized study[J].J Gastroenterol Hepatol, 2006, 21 (1 Pt 2) :303-307.

[24]CAI ZH, FAN CL, ZHENG JF, et al.Measurement of serum procalcitonin levels for the early diagnosis of spontaneous bacterial peritonitis in patients with decompensated liver cirrhosis[J].BMC Infect Dis, 2015, 15:55.

[25]USAMI M, MIYOSHI M, YAMASHITA H, et al.Gut microbiota and host metabolism in liver cirrhosis[J].World J Gastroenterol, 2015, 21 (41) :11597-11608.

[26]BAJAJ JS, KASSAM Z, FAGAN A, et al.Fecal microbiota transplant from a rational stool donor improves hepatic encephalopathy:a randomized clinical trial[J].Hepatology, 2017, 66 (6) :1727-1738.

[27]GRAT M, WRONKA KM, KRASNODEBSKI M, et al.Profile of gut microbiota associated with the presence of hepatocellular cancer in patients with liver cirrhosis[J].Transplant Proc, 2016, 48 (5) :1687-1691.

[28]IBRAHIM ES, ALSEBAEY A, ZAGHLA H, et al.Long-term rifaximin therapy as a primary prevention of hepatorenal syndrome[J].Eur J Gastroenterol Hepatol, 2017, 29 (11) :1247-1250.

施引文献

资源附件(0)

访问统计