-
Categories
-
Pharmaceutical Intermediates
-
Active Pharmaceutical Ingredients
-
Food Additives
- Industrial Coatings
- Agrochemicals
- Dyes and Pigments
- Surfactant
- Flavors and Fragrances
- Chemical Reagents
- Catalyst and Auxiliary
- Natural Products
- Inorganic Chemistry
-
Organic Chemistry
-
Biochemical Engineering
- Analytical Chemistry
- Cosmetic Ingredient
-
Pharmaceutical Intermediates
Promotion
ECHEMI Mall
Wholesale
Weekly Price
Exhibition
News
-
Trade Service
Introduction Ascites is one of the most common complications of liver cirrhosis.
50%-60% of patients with liver cirrhosis will develop ascites within 10 years after diagnosis.
After the first appearance of ascites, 10% of patients will develop refractory ascites.
Refractory ascites is associated with a 65% 2-year mortality rate, poor quality of life, and increased risk of spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS).
Therefore, any patient with refractory ascites should consider liver transplantation (LT).
However, due to the long waiting period for LT, other treatment options must be considered.
The focus of treatment is to improve the patient's quality of life and nutritional status.
The definition of refractory ascites Ascites can not disappear after treatment or drug treatment can not prevent the early recurrence of ascites, it is called refractory ascites.
Refractory ascites includes the following two different conditions: ➤Diuretic-resistant ascites: restrict sodium intake and use the maximum dose of diuretics (spironolactone 400 mg and furosemide 160 mg) to treat ascites that is ineffective.
➤Diuretic refractory ascites: Patients cannot receive diuretic treatment because complications caused by diuretics prevent the use of effective doses.
Pathophysiological mechanism of ascites Ascites is the result of the combined effect of portal hypertension and liver insufficiency.
Ascites generally occurs when the portal pressure gradient exceeds 10 mmHg.
In liver cirrhosis, the portal pressure first increases because the level of the hepatic vascular bed increases the resistance to portal blood flow.
The increase in resistance is due to changes in liver structure, as well as decreased vasodilation and increased vasoconstriction, resulting in increased intrahepatic blood vessel tension.
Secondary portal body collateral formation, visceral vasodilation leads to increased blood flow.
Vasodilatation leads to reduced systemic vascular resistance and insufficient effective arterial blood volume.
The increase in cardiac output, the activation of the sympathetic nervous system, the antidiuretic system and the renin-angiotensin-aldosterone system are designed to correct insufficient effective blood volume, but can cause renal vasoconstriction and water and sodium retention.
Hypoalbuminemia caused by liver insufficiency is the reason for the decrease of colloidal osmotic pressure and the leakage of fluid to the interstitial area.
Advanced liver cirrhosis is an inflammatory state with high levels of pro-inflammatory cytokines, which can increase arterial nitric oxide production, aggravate visceral vasodilation, and then lead to insufficient effective arterial filling.
The effective volume reduction tends to develop into refractory ascites.
Intestinal microecological disorders and bacterial translocation after increased intestinal permeability are common and contribute to the release of pro-inflammatory cytokines.
Management and treatment of refractory ascites One of the most important treatments for refractory ascites is the treatment of underlying liver disease (abstinence of alcohol, antiviral therapy, etc.
), which can cause ascites to subside.
In a randomized study comparing transjugular intrahepatic portosystemic shunt (TIPS) and repeated puncture and aspiration, up to 20% of patients do not require further mass puncture and aspiration, which may be because the cause has been controlled , Portal hypertension and/or liver function have been improved.
Patients with refractory ascites usually stop diuretics.
European guidelines recommend that during diuretic treatment, if the urine sodium is less than 30 mmol per day, it is recommended to stop using diuretics.
Blood pressure and renal function should be closely monitored.
Patients with reduced organ perfusion or hypotension (systolic blood pressure <90 mmHg, mean arterial pressure <65 mmHg, acute kidney injury, SBP) should consider discontinuing or not using β-blockers.
Large-volume puncture and aspiration and albumin infusion.
Large-volume puncture and aspiration plus albumin infusion (LVP+A) are the standard and first-line treatments for tension-induced ascites.
This method can quickly relieve abdominal distension, relieve pain and discomfort, and can be performed in an outpatient clinic.
However, recurrence of ascites is the norm, because it is only a local treatment and has no beneficial effect on any mechanism involved in the formation of ascites.
Transjugular intrahepatic portosystemic shunt TIPS is a side-to-side portal vena cava shunt that connects the main branch of the portal vein and the great hepatic vein in the liver.
It reduces the pressure of the portal vein, temporarily increases the effective arterial blood volume, and at the same time reduces the pressure of the portal system and liver microcirculation, reduces the formation of lymph, thereby reducing the formation of ascites.
After TIPS implantation, plasma renin activity, plasma aldosterone and norepinephrine concentrations are reduced, which can improve renal perfusion.
Automatic low-flow ascites pump The automatic low-flow ascites pump (alfapump system) consists of a subcutaneously implantable rechargeable device, which transfers ascites from the peritoneal cavity to the bladder, which can be slowly and continuously discharged every day.
The amount of ascites to be removed every day can be adjusted.
However, the automatic low-flow ascites pump is related to the renal damage caused by the activation of the vasoconstrictor system.
Liver transplantation patients should be evaluated for LT immediately after the diagnosis of refractory ascites, because LT is the only way to treat underlying liver disease and improve long-term prognosis.
For patients with a high MELD score or a high Child-Pugh score, as well as patients with previous relapses or chronic hepatic encephalopathy, LT is the only treatment option.
While waiting for treatment, TIPS or alfapump system should be used.
Other treatment options: Albumin infusion: Albumin can act as a plasma expander, as well as an effective scavenger, anti-inflammatory and antioxidant molecule to maintain homeostasis.
Vasopressors: Vasoconstrictors have been studied in reducing the incidence of circulatory dysfunction (PPCD) after puncture, but the data is controversial.
Vasopressin receptor antagonist: Vaptans is a selective oral vasopressin v2 receptor antagonist for the treatment of isometric or hypovolemic hyponatremia.
Summary Severe refractory ascites has the characteristics of poor prognosis, and LT must be considered first.
If there are contraindications or the waiting time for LT exceeds 6 months, TIPS should be considered for eligible patients.
When TIPS is not feasible, consider the impact of using alfapump or LVP+A on the risk-benefit balance and quality of life.
Regardless of the treatment option chosen, careful selection of patients is essential to avoid further decompensation and complications of each therapy.
Yimaitong compiled from: Larrue H, Vinel JP, Bureau C.
Management of Severe and Refractory Ascites[J].
Clin Liver Dis.
2021 May;25(2):431-440.
Contribution email: tougao@medlive.
cn
50%-60% of patients with liver cirrhosis will develop ascites within 10 years after diagnosis.
After the first appearance of ascites, 10% of patients will develop refractory ascites.
Refractory ascites is associated with a 65% 2-year mortality rate, poor quality of life, and increased risk of spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS).
Therefore, any patient with refractory ascites should consider liver transplantation (LT).
However, due to the long waiting period for LT, other treatment options must be considered.
The focus of treatment is to improve the patient's quality of life and nutritional status.
The definition of refractory ascites Ascites can not disappear after treatment or drug treatment can not prevent the early recurrence of ascites, it is called refractory ascites.
Refractory ascites includes the following two different conditions: ➤Diuretic-resistant ascites: restrict sodium intake and use the maximum dose of diuretics (spironolactone 400 mg and furosemide 160 mg) to treat ascites that is ineffective.
➤Diuretic refractory ascites: Patients cannot receive diuretic treatment because complications caused by diuretics prevent the use of effective doses.
Pathophysiological mechanism of ascites Ascites is the result of the combined effect of portal hypertension and liver insufficiency.
Ascites generally occurs when the portal pressure gradient exceeds 10 mmHg.
In liver cirrhosis, the portal pressure first increases because the level of the hepatic vascular bed increases the resistance to portal blood flow.
The increase in resistance is due to changes in liver structure, as well as decreased vasodilation and increased vasoconstriction, resulting in increased intrahepatic blood vessel tension.
Secondary portal body collateral formation, visceral vasodilation leads to increased blood flow.
Vasodilatation leads to reduced systemic vascular resistance and insufficient effective arterial blood volume.
The increase in cardiac output, the activation of the sympathetic nervous system, the antidiuretic system and the renin-angiotensin-aldosterone system are designed to correct insufficient effective blood volume, but can cause renal vasoconstriction and water and sodium retention.
Hypoalbuminemia caused by liver insufficiency is the reason for the decrease of colloidal osmotic pressure and the leakage of fluid to the interstitial area.
Advanced liver cirrhosis is an inflammatory state with high levels of pro-inflammatory cytokines, which can increase arterial nitric oxide production, aggravate visceral vasodilation, and then lead to insufficient effective arterial filling.
The effective volume reduction tends to develop into refractory ascites.
Intestinal microecological disorders and bacterial translocation after increased intestinal permeability are common and contribute to the release of pro-inflammatory cytokines.
Management and treatment of refractory ascites One of the most important treatments for refractory ascites is the treatment of underlying liver disease (abstinence of alcohol, antiviral therapy, etc.
), which can cause ascites to subside.
In a randomized study comparing transjugular intrahepatic portosystemic shunt (TIPS) and repeated puncture and aspiration, up to 20% of patients do not require further mass puncture and aspiration, which may be because the cause has been controlled , Portal hypertension and/or liver function have been improved.
Patients with refractory ascites usually stop diuretics.
European guidelines recommend that during diuretic treatment, if the urine sodium is less than 30 mmol per day, it is recommended to stop using diuretics.
Blood pressure and renal function should be closely monitored.
Patients with reduced organ perfusion or hypotension (systolic blood pressure <90 mmHg, mean arterial pressure <65 mmHg, acute kidney injury, SBP) should consider discontinuing or not using β-blockers.
Large-volume puncture and aspiration and albumin infusion.
Large-volume puncture and aspiration plus albumin infusion (LVP+A) are the standard and first-line treatments for tension-induced ascites.
This method can quickly relieve abdominal distension, relieve pain and discomfort, and can be performed in an outpatient clinic.
However, recurrence of ascites is the norm, because it is only a local treatment and has no beneficial effect on any mechanism involved in the formation of ascites.
Transjugular intrahepatic portosystemic shunt TIPS is a side-to-side portal vena cava shunt that connects the main branch of the portal vein and the great hepatic vein in the liver.
It reduces the pressure of the portal vein, temporarily increases the effective arterial blood volume, and at the same time reduces the pressure of the portal system and liver microcirculation, reduces the formation of lymph, thereby reducing the formation of ascites.
After TIPS implantation, plasma renin activity, plasma aldosterone and norepinephrine concentrations are reduced, which can improve renal perfusion.
Automatic low-flow ascites pump The automatic low-flow ascites pump (alfapump system) consists of a subcutaneously implantable rechargeable device, which transfers ascites from the peritoneal cavity to the bladder, which can be slowly and continuously discharged every day.
The amount of ascites to be removed every day can be adjusted.
However, the automatic low-flow ascites pump is related to the renal damage caused by the activation of the vasoconstrictor system.
Liver transplantation patients should be evaluated for LT immediately after the diagnosis of refractory ascites, because LT is the only way to treat underlying liver disease and improve long-term prognosis.
For patients with a high MELD score or a high Child-Pugh score, as well as patients with previous relapses or chronic hepatic encephalopathy, LT is the only treatment option.
While waiting for treatment, TIPS or alfapump system should be used.
Other treatment options: Albumin infusion: Albumin can act as a plasma expander, as well as an effective scavenger, anti-inflammatory and antioxidant molecule to maintain homeostasis.
Vasopressors: Vasoconstrictors have been studied in reducing the incidence of circulatory dysfunction (PPCD) after puncture, but the data is controversial.
Vasopressin receptor antagonist: Vaptans is a selective oral vasopressin v2 receptor antagonist for the treatment of isometric or hypovolemic hyponatremia.
Summary Severe refractory ascites has the characteristics of poor prognosis, and LT must be considered first.
If there are contraindications or the waiting time for LT exceeds 6 months, TIPS should be considered for eligible patients.
When TIPS is not feasible, consider the impact of using alfapump or LVP+A on the risk-benefit balance and quality of life.
Regardless of the treatment option chosen, careful selection of patients is essential to avoid further decompensation and complications of each therapy.
Yimaitong compiled from: Larrue H, Vinel JP, Bureau C.
Management of Severe and Refractory Ascites[J].
Clin Liver Dis.
2021 May;25(2):431-440.
Contribution email: tougao@medlive.
cn
