腹水超滤浓缩再利用治疗乙型肝炎后肝硬化顽固性腹水的临床价值

The clinical value of re-using ultrafiltrated and concentrated ascites fluid

目的 探讨对乙型肝炎（乙肝）后肝硬化顽固性腹水超滤浓缩再利用的临床价值.方法 采用回顾性研究方法,选择2013年12月至2016年11月在解放军第二五四医院住院接受腹水滤过浓缩腹腔回输治疗的难治性腹水患者113例作为研究组,以同期住院的仅接受常规治疗的难治性腹水患者52例作为对照组.两组均给予保肝、提高血浆渗透压、纠正低蛋白血症（静脉注射白蛋白,每次10 g、每周3次）、降低门脉压（给予奥曲肽0.2 mg、q8 h）、改善微循环、纠正水和电解质平衡紊乱、利尿〔给予呋塞米（速尿）100 mg/d〕等常规治疗;研究组在上述治疗基础上进行腹水浓缩回输.观察研究组患者治疗前后腹胀缓解、意识改变、血压、24 h尿量、内生肌酐清除率（CCr）、血钾离子（K＋）、血钠离子（Na＋）、腹水白蛋白定量和治疗前后1周血白蛋白水平、治疗后1周内腹腔感染情况的变化;比较研究组与对照组治疗12周后腹腔感染发生率的差异.结果 研究组患者治疗后腹胀有不同程度的缓解,24 h尿量较治疗前有所增加（mL：1291.3±123.4比1265.0±61.5,P=0.051）,无病例出现意识改变、血压不稳定;血K＋、Na＋比较差异无统计学意义（均P〉0.05）,腹水白蛋白水平较治疗前明显增加（g/L：19.1±2.9比17.2±4.1,P=0.000）;治疗后1周,CCr较治疗前明显升高（μmol/L：71.2±8.7比56.1±5.4,P=0.000）;3次治疗后1周血白蛋白较治疗前升高（g/L：25.7±4.4比24.6±3.0）,但差异无统计学意义（P=0.054）.研究组治疗后1周内未出现腹腔感染,治疗12周腹腔感染发生率低于对照组〔9.7%（11/113）比13.5%（7/52）〕,但差异亦无统计学意义（P=0.476）.结论 腹水超滤浓缩再利用能有效缓解腹胀症状,提高CCr,有利于腹水白蛋白再利用,未增加12周内腹腔感染的发生,对肝硬化顽固性腹水的治疗有较高价值.

Objective To investigate the clinical value of re-using ultrafiltrated and concentrated ascites fluid for refractory ascites in patients with hepatitis B cirrhosis. Methods A retrospective study was conducted, one hundred and thirteen patients with intractable ascites （all patients received intraperitoneal reinfusion of ultrafiltrated and concentrated ascites fluid therapy） admitted to the Department of Gastroenterology of No.254 Hospital of the Chinese People＇s Liberation Army from December 2013 to November 2016 were enrolled and assigned as the study group, fifty-two patients with intractable ascites admitted in the same period as above group in this hospital without undergoing above ascites fluid reinsfusion were served as the control group. Both groups were given conventional therapies, including measures for hepatoprotection, increase of plasma osmotic pressure, correction of hypoproteinemia （intravenous injection albumin 10 g, 3 times a week）, reduction of portal venous pressure （octreotide 0.2 mg, q8 h）, improvement of microcirculation, correction of water and electrolyte balance disorders, diuresis （furosemide 100 mg/d）, etc. On the basis of the above conventional treatment, the system with ascites ultrafiltration, concentration and reinfusion into abdominal cavity was applied to carry out the concentrated ascites fluid reinfusion therapy in the study group. The relieve of abdominal bloating, conscious, blood pressure, 24-hour urine output, endogenous creatinine clearance rate （CCr）, serum potassium ion （K＋）, serum sodium ion （Na＋）, ascites albumin quantity, serum albumin levels before treatment and after treatment for 1 week, abdominal infection situation after treatment for 1 week were observed in the study group. The difference in incidence of abdominal infection between the study group and control group （at the end of 12 weeks after treatment） was compared. Results In the study group, after treatment, the patients with abdominal bloating had different degrees of relief, 24-hour urine output was increased compared with that before treatment （mL： 1291.3±123.4 vs. 1265.0±61.5, P = 0.051）, no cases with conscious changes, blood pressure instable. There were no statistical significant difference in blood K＋ and Na＋ （P ＆gt; 0.05）. And ascites albumin concentration was increased compared with before treatment （g/L： 19.1±2.9 vs. 17.2±4.1, P = 0.000）; 1 week after treatment, CCr was significantly higher than that before treatment （μmol/L： 71.2±8.7 vs. 56.1±5.4, P = 0.000）; serum albumin was increased after 3 times of treatment in 1 week （g/L： 25.7±4.4 vs. 24.6±3.0）, but the difference was not statistically significant （P = 0.054）. No abdominal infection occurred within 1 week after treatment were observed in patients of study group. There was no statistical significant difference in the incidence of abdominal infection between the study group and control group in 12 weeks after treatment [9.7% （11/113） vs. 13.6% （7/52）, P = 0.476]. Conclusions The re-using of ultrafiltrated and concentrated ascites fluid can effectively relieve the abdominal bloating symptom, improve CCr, be beneficial to the re-use of ascites albumin, and does not increase the incidence of abdominal infection within 12 weeks after the therapy, therefore the treatment has relatively high therapeutic value for intractable ascites in patients with hepatitis B cirrhosis.