Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with nonc...Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.展开更多
Due to the restrictions of liver transplantation,complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis.This article aims to provide a complete overview of pharmacothe...Due to the restrictions of liver transplantation,complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis.This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications,together with discussion of current controversies and potential future directions.PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety,efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis.Non-selective betablockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices,but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation.Recent observational studies suggest protective,haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation.The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy;recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis.Diuretics remain the mainstay of uncomplicated ascites treatment,and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites.Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications.Despite initial hepatotoxicity concerns,safety of statin administration has been demonstrated in compensated cirrhosis.Furthermore,statins are suggested to have protective effects upon fibrosis progression,decompensation and mortality.Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting.Emerging evidence indicates that anticoagulation therapy reduces incidence and increases展开更多
目的观察托伐普坦治疗老年急性失代偿心力衰竭伴轻中度肾功能不全患者临床治疗效果。方法选择急性失代偿心力衰竭伴轻中度肾功能不全患者95例,随机分为对照组49例,观察组46例。对照组给予利尿、强心及纠正水电解质紊乱等常规治疗,观察...目的观察托伐普坦治疗老年急性失代偿心力衰竭伴轻中度肾功能不全患者临床治疗效果。方法选择急性失代偿心力衰竭伴轻中度肾功能不全患者95例,随机分为对照组49例,观察组46例。对照组给予利尿、强心及纠正水电解质紊乱等常规治疗,观察组在此基础上加用托伐普坦治疗。比较2组治疗后利尿效果和心、肾功能及电解质指标变化;随访3个月,比较2组心力衰竭再入院情况。结果与对照组比较,观察组24h尿量明显增加,体质量达稳时间明显提前,呋塞米日均剂量明显减少,出院前男性和女性体质量下降更为明显(P<0.01)。观察组治疗后N末端B型利钠肽前体水平较对照组明显降低(P<0.01);在托伐普坦治疗结束后,观察组血钠水平较对照组明显升高[(139.1±5.3)mmol/L vs (136.4±5.1)mmol/L,P<0.05]。与对照组比较,观察组住院天数明显缩短[(13.0±2.5)d vs (17.3±3.7)d,P<0.01]。结论托伐普坦能快速降低老年急性失代偿心力衰竭伴轻中度肾功能不全患者液体负荷,改善心功能状态,缩短住院天数,对肾功能无明显影响。展开更多
Background Studies have shown that increased levels of serum uric acid （SUA） are associated with atrial fibrillation （AF）. However, less is known about the prognostic value of SUA levels for AF in patients with ch...Background Studies have shown that increased levels of serum uric acid （SUA） are associated with atrial fibrillation （AF）. However, less is known about the prognostic value of SUA levels for AF in patients with chronic heart failure （CHF）. The aim of the study was to examine the prognostic value of SUA levels for AF in patients with CHF. Methods Sixteen thousand six hundred and eighty-one patients diagnosed with CHF from 12 hospitals were analyzed. Patients were categorized into AF group and non-AF group, death group, and survival group according to the results of the patients＇ medical records and follow-up. Univariate and multivariate Cox proportional hazards analyses were performed to examine the risk of AF. The sensitivity and specificity of SUA level in predicting the prognosis were examined by multivariate Cox models and receiver operating characteristic （ROC） curves. Results The results of univariate predictors in overall patients showed that the higher SUA level was associated with AF. SUA level （HR, 1.084; 95% CI, 1.017-1.144; P 〈0.001）, diuretics （HR, 1.549; 95% CI, 1.246-1.854; P 〈0.001）, and New York Heart Association （NYHA） （HR, 1.237; 95% CI, 1.168-1.306; P 〈0.001） function class were the independent risk factors for AF. The sensitivity and specificity of the models were 29.6% and 83.8% respectively for predicting AF. When SUA level was added to these models, it remained significant （Wald Z2, 1494.88; P 〈0.001 for AF）; 58.8% （95% CI, 57.7%-60.0%） of the observed results were concordant with the separate model. Conclusion Higher SUA level is associated strongly with AF in patients with CHF. SUA level can increase the sensitivity and specificity in predicting AF.展开更多
This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the C...This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords:“liver cirrhosis,”“portal hypertension,”“ascites,”“pathogenesis,”“diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.展开更多
文摘Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
基金Supported by The Division of Integrative Systems Medicine and Digestive Disease at Imperial College London receives financial support from the National Institute for Health Research(NIHR)Imperial Biomedical Research Centre(BRC)based at Imperial College Healthcare NHS Trust and Imperial College Londonfunded by the NIHR BRC
文摘Due to the restrictions of liver transplantation,complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis.This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications,together with discussion of current controversies and potential future directions.PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety,efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis.Non-selective betablockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices,but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation.Recent observational studies suggest protective,haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation.The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy;recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis.Diuretics remain the mainstay of uncomplicated ascites treatment,and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites.Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications.Despite initial hepatotoxicity concerns,safety of statin administration has been demonstrated in compensated cirrhosis.Furthermore,statins are suggested to have protective effects upon fibrosis progression,decompensation and mortality.Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting.Emerging evidence indicates that anticoagulation therapy reduces incidence and increases
文摘目的观察托伐普坦治疗老年急性失代偿心力衰竭伴轻中度肾功能不全患者临床治疗效果。方法选择急性失代偿心力衰竭伴轻中度肾功能不全患者95例,随机分为对照组49例,观察组46例。对照组给予利尿、强心及纠正水电解质紊乱等常规治疗,观察组在此基础上加用托伐普坦治疗。比较2组治疗后利尿效果和心、肾功能及电解质指标变化;随访3个月,比较2组心力衰竭再入院情况。结果与对照组比较,观察组24h尿量明显增加,体质量达稳时间明显提前,呋塞米日均剂量明显减少,出院前男性和女性体质量下降更为明显(P<0.01)。观察组治疗后N末端B型利钠肽前体水平较对照组明显降低(P<0.01);在托伐普坦治疗结束后,观察组血钠水平较对照组明显升高[(139.1±5.3)mmol/L vs (136.4±5.1)mmol/L,P<0.05]。与对照组比较,观察组住院天数明显缩短[(13.0±2.5)d vs (17.3±3.7)d,P<0.01]。结论托伐普坦能快速降低老年急性失代偿心力衰竭伴轻中度肾功能不全患者液体负荷,改善心功能状态,缩短住院天数,对肾功能无明显影响。
文摘Background Studies have shown that increased levels of serum uric acid （SUA） are associated with atrial fibrillation （AF）. However, less is known about the prognostic value of SUA levels for AF in patients with chronic heart failure （CHF）. The aim of the study was to examine the prognostic value of SUA levels for AF in patients with CHF. Methods Sixteen thousand six hundred and eighty-one patients diagnosed with CHF from 12 hospitals were analyzed. Patients were categorized into AF group and non-AF group, death group, and survival group according to the results of the patients＇ medical records and follow-up. Univariate and multivariate Cox proportional hazards analyses were performed to examine the risk of AF. The sensitivity and specificity of SUA level in predicting the prognosis were examined by multivariate Cox models and receiver operating characteristic （ROC） curves. Results The results of univariate predictors in overall patients showed that the higher SUA level was associated with AF. SUA level （HR, 1.084; 95% CI, 1.017-1.144; P 〈0.001）, diuretics （HR, 1.549; 95% CI, 1.246-1.854; P 〈0.001）, and New York Heart Association （NYHA） （HR, 1.237; 95% CI, 1.168-1.306; P 〈0.001） function class were the independent risk factors for AF. The sensitivity and specificity of the models were 29.6% and 83.8% respectively for predicting AF. When SUA level was added to these models, it remained significant （Wald Z2, 1494.88; P 〈0.001 for AF）; 58.8% （95% CI, 57.7%-60.0%） of the observed results were concordant with the separate model. Conclusion Higher SUA level is associated strongly with AF in patients with CHF. SUA level can increase the sensitivity and specificity in predicting AF.
文摘This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords:“liver cirrhosis,”“portal hypertension,”“ascites,”“pathogenesis,”“diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.
