Naslov
Postparacentesis neurohumoral changes and impairment of renal water excretion in Child-Pugh C cirrhosis with and without volume replacement

Autori
Degoricija, Vesna ; Zjačić-Rotkvić, Vanja ; Troskot, Branko ; Šefer, Siniša

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, sažetak, znanstveni

Izvornik
Acta Medica Croatica 2001 ; 55 (suppl 4) / Duvnjak, Marko - Zagreb : Akademija medicinskih znanosti Hrvatske, 2001, 112-113

Skup
Treći kongres Hrvatskog gastroenetrološkog društva

Mjesto i datum
Zagreb, Hrvatska, 23.09.2001. - 26.09.2001

Vrsta sudjelovanja
Predavanje

Vrsta recenzije
Međunarodna recenzija

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

Sažetak
Introduction. 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. The pathogenesis of renal sodium and water retention in liver cirrhosis involves a relative underfilling of the arterial vascular compartment with activation of RAA axis, sympathetic system and non osmotic release of ADH, failure of escape from the sodium retaining effect of aldosteron and renal resistance to the atrial natriuretic peptide. 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 and impairment of renal water excretion in patients with refractory tense ascites with and without volume replacement and bed rest 24 hours before and after the procedure. Methods. 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, hepatic encephalopathy, plasma renin activity, plasma aldosteron concentration, plasma atrial natriuretic peptide levels, urine flow rate, serum creatinine, creatinine clearance, osmolality clearance and free water clearance were measured before, 6 hours after start of the trial and on the 2nd, 3rd, and 6th day. Results. Paracentesis of 6 L of ascites without plasma volume expansion and no bed rest 24 hours before and after the procedure is associated with statistically significant hypotension (p=0.000), tachycardia (p=0.000), insufficient weight loss (p=0.007), worsening of hepatic encephalopathy (p=0.007), increase in plasma renin activity (p=0.024), increase of plasma aldosteron concentration (p=0.000), decrease in plasma atrial natriuretic peptide levels (NS), renal impairment measured with creatinine clearance (p=0.046), and greater risk of development of hepatorenal syndrome. 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 are safe, rapid and effective therapy, if intravascular volume is substituted simultaneously. Albumin is superior to the other plasma expanders with exception of cost. However, comparison between groups did not provide significant differences at any time in negative free water clearance. CONCLUSION. None of the protocols did have aquaretic efficacy. The inability to excrete solute free water is one of the strongest predictors for developing hepatorenal syndrome. The pathogenesis is primarily related to the non-osmotic hypersecretion of vasopressin, whereas additional factors such as release of renal prostaglandins and distal sodium delivery are contributing factors. Patients with liver cirrhosis should be observed at least for 6 days after the large volume paracentesis for evidence of progressively deteriorating renal function, worsening electrolyte imbalance or development or worsening of hepatic encephalopathy.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

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