肝硬化腹水相关实验室检查:从指南到临床实践

Related laboratory detections for liver cirrhosis ascites:from guidelines to clinical practice

腹水是肝硬化最常见的并发症,影响患者的预后及生活质量。早期选择合适的腹水检查指标是临床医生作出最合适的个体化诊疗决策的依据,也是提高肝硬化腹水诊疗效果的重要基础。基于2023年中华医学会肝病学分会修订的《肝硬化腹水诊疗指南(2023年版)》对肝硬化腹水、自发性腹膜炎、急性肾损伤-肝肾综合征的诊断与治疗提出的推荐性意见,该文对腹水相关实验室检查指标进行详细解读,重点叙述了及时腹腔穿刺进行腹水细胞学分析、总蛋白及清蛋白(血清-腹水清蛋白梯度)测定、腹水细菌与真菌培养、肾功能(血清肌酐、估计肾小球滤过率等)实验室检查的重要临床意义,总结了近年来有关腹水检查主要的新技术,如微滴式数字PCR方法、宏基因组二代测序,以及肾损伤新的标志物,如中性粒细胞明胶酶相关载脂蛋白、肾损伤分子1等在肝硬化腹水及相关并发症诊疗中的应用前景。在未来,简便的随机尿Na^(+)/K^(+)测定或联合新的生物标志物在腹水临床管理中的意义值得重视。在临床工作中,仍需要临床医生充分理解与应用该指南推荐的意见,从实际出发:一方面,选择合理的腹水检查指标,为最合适的个体化诊疗决策提供证据;另一方面,也需要临床医生探索及验证新的生物标志物,不断提高对肝硬化腹水的诊疗水平。

Ascites is the most common complication of liver cirrhosis,which affects the patients′prognosis and quality of life.Early selection of reasonable ascites detection indexes is the basis for clinicians to make the most appropriate individual diagnosis and treatment decisions,and is also an important basis for improving the diagnosis and treatment effect of ascites in liver cirrhosis.Based on the Guidelines for the Diagnosis and Treatment of ascites in Cirrhosis 2023 Edition revised by the Hepatology Branch of the Chinese Medical Association in 2023,the recommendations for the diagnosis and treatment of liver cirrhosis ascites,spontaneous peritonitis and acute kidney injury hepatorenal syndrome is proposed.In this paper,the indicators of laboratory tests related to ascites are interpreted in detail,and the important clinical significance of timely abdominal puncture for conducting ascites cytological analysis,total protein and albumin determination(serum-ascites albumin gradient,SAAG),ascites bacteria and fungi culture,and laboratory tests of renal function(serum creatinine,estimated glomerular filtration rate,etc.)were emphasized.It summarizes main new technologies in related ascites detection in recent years,such as droplet digital PCR method,metagenomic next-generation sequencing(mNGS),and new biomarkers for renal injury such as neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 in the diagnosis and treatment of cirrhosis-related ascites and its complications.In the future,the significance of simple random urine Na^(+)/K^(+)determination or combined with new biomarkers in the clinical management of ascites deserves attention.In clinical work,it is still necessary for clinicians to fully understand and apply the opinion recommended by this guideline,from reality,on the one hand,reasonable indicators of ascites examination should be selected to provide the evidence for the most appropriate individual diagnosis and treatment decision.On the other hand,it is also necessary for clinicians to explore and validate the new biomarkers to continuously improve the diagnosis and treatment level of liver cirrhosis ascites.