engleski

Effect of posture, physical exercise and treatment algorithm on endogenous neurohumoral system in cirrhotic patients with ascites

In Child-Pugh C cirrhosis of the liver, ascites may become refractory to medical treatment. In many centers paracentesis is considered as the treatment of choice for tense ascites. However, the mechanism of postparacentesis effective hypovolemia, the main cause of postparacentesis circulatory dysfunction syndrome remains unknown. The aim of the study was to assess postparacentesis neurohumoral changes in patients with refractory tense ascites with and without volume replacement and bed rest 24 hours before and after the procedure. 40 patients with Child-Pugh C liver cirrhosis and tense ascites were randomly allocated into 4 groups. 30 patients were treated with paracentesis (6 L) associated with plasma volume expansion (200 mL 20% human albumin, 600 mL fresh frosen plasma, 900 mL solution of synthetic gelatin, which were doses with comparable oncotic power) and bed rest 24 hours before and after the procedure, versus 10 patients treated with paracentesis of 6 L of ascites without volume replacement and no bed rest. Mean arterial pressure, pulse rate, plasma renin activity, plasma aldosteron concentration, plasma atrial natriuretic peptide levels, urine flow rate, creatinine clearance and daily sodium balance were measured before, 6 hours after start of the trial and on the 2nd, 3rd, and 6th day. Paracentesis of 6 L of ascites without plasma volume expansion and no bed rest 24 hours before and after the procedure was associated with statistically significant hypotension (p=0.000), tachycardia (p=0.000), insufficient weight loss (p=0.007), increase in plasma renin activity (p=0.024) and plasma aldosteron concentration (p=0.000), decrease in plasma atrial natriuretic peptide levels (NS) and creatinine clearance (p=0.046). Albumin was superior to the other plasma expanders with exception of cost. Comparison between groups 1, 2, 3 did not provide significant differences at any time except for the amount of needed volume of each substitute, daily sodium balance on the first day of the treatment, increase in aldosteron plasma level in group 3 on the sixth day and cost. Therapeutic paracentesis of 6 L of ascites, bed rest 24 hours before and after the procedure and intravenous substitution of volume with albumin, fresh frosen plasma and solution of synthetic gelatin were safe, rapid and effective therapy, if intravascular volume was substituted simultaneously.

liver cirrhosis; therapy; ascites; therapy; paracentesis; neurohumoral changes; volume replacement

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