摘要
中华医学会肝病学分会于2017年8月颁布了肝硬化腹水及相关并发症的诊疗指南。笔者阅后提出商榷:(1)该指南参考的国外文献在国内已出现很多争议,能否代表国内研究现状;(2)肾素-血管紧张素-醛固酮系统(RAAS)活性增强与血清钠及渗透压下降有关,是对低钠血症的生理性保护反应,并非限钠治疗依据;(3)从一线治疗开始限钠及使用醛固酮拮抗剂,为什么不能解决钠潴留及RAAS活性问题;(4)血清钠<125 mmol/L时病死率明显上升,不建议纠正缺乏充足理论依据;(5)螺内酯与呋塞米联合使用可丢失氯化钠近160 mmol/d,限制钠盐摄入量4~6 g/d是否使利尿剂作用减弱或无应答;(6)低钠血症是影响终末期肝病患者预后主要因素,为什么不提倡从源头上解决低钠血症问题等。该文旨在为制订有中国特色与知识产权的肝硬化腹水诊疗指南努力。
The Guidelines for diagnosis and management of ascites and associated complications were issued by the Chinese Society of Hepatology in August,2017. The following aspects should be re-considered after thoroughly reviewing the new-version guidelines. First,the international references cited in the guidelines are controversial and cannot represent the current research situations in China. Second,the increased activity of renin-angiotensin-aldosterone system( RAAS) is correlated with the decreased serum sodium and osmotic pressure,which is physiological protective response towards hyponatremia rather than the evidence for sodium-limiting therapy. Third,why do sodium-limiting intervention in the first-line treatment and administration of aldosterone antagonists cannot solve the problems of sodium retention and RAAS activity? Fourth,the mortality rate is significantly enhanced when serum sodium < 125 mmol/L. Not recommending increasing the level of serum sodium lacks of theoretical evidence. Fifth,combined use of spironolactone and furosemide can lead to the loss of sodium chloride( NaCl) up to nearly 160 mmol/d. Whether daily limit of sodium intake within 4-6 g weakens or blocks the effect of diuretics remains to be validated. Sixth,hyponatremia is the main factor affecting the prognosis of patients with end-stage liver disease. Why does it not recommend taking measures to treat hyponatremia? The aim is to make guidelines for the treatment of cirrhosis and ascites with Chinese characteristics and intellectual property.
出处
《新医学》
2018年第1期1-5,共5页
Journal of New Medicine
关键词
腹水
发病机制
肾素-血管紧张素-醛固酮系统
钠潴留
诊断
肝肾综合征
限钠治疗
Ascites
Pathogenesis
Renin-angiotensin-aldosterone system
Sodium retention
Diagnosis
Hepatorenal syndrome
Sodium-limiting therapy
