Clinical management of ascites and complications of liver cirrhosis
With an increased knowledge of the mechanisms of decompensated liver cirrhosis , it is also known that albumin , with its multiple physiological functions , reduces the risk of various complications and improves patients ’ prognoses .
Li Yaping Dang ShuangSuo PhD Department of Infectious Diseases , The Second Affiliated Hospital of Xi ’ an Jiaotong University , Xi ’ an 710004 , China
Ascites is one of the most common and serious complications in patients with decompensated cirrhosis and is also an important sign of the natural progression of liver cirrhosis . Once ascites appears , 1-year case fatality rate is approximately 15 % and 5-year case fatality rate is 44 %– 85 %. 1 Therefore , prevention of ascites is a main goal in clinical practice and a focus of research . In recent years , the role of human albumin in clinical treatment of hepatic ascites has attracted much attention . The pathological mechanism of hypoalbuminaemia in patients with hepatic ascites and use of human albumin in patients with hepatic ascites has been explored . If hypoalbuminaemia is not corrected promptly and effectively , patients with liver cirrhosis may experience circulatory dysfunction after large volume paracentesis ( LVP ). About 5 %– 10 % of patients with liver cirrhosis accompanied by ascites progress to refractory ascites . Some patients experience complications such as spontaneous bacterial peritonitis ( SBP ) and hepatorenal syndrome ( HRS ), which seriously influence their quality of life and lifespan .
Causes of ascites There are three main causes of ascites in liver cirrhosis .
Portal hypertension Portal venous pressure increases in patients with liver cirrhosis , increasing filtration pressure of the capillary bed of the portal system , causing ascites . Peripheral vascular pressure rises , and permeability increases , the distribution of albumin changes , with some leaking into the abdominal cavity and the pleural cavity , forming ascites and pleural effusion .
Secondary hyperaldosteronism Aldosterone is inactivated in patients with liver cirrhosis , leading to secondary hyperaldosteronism , water – sodium retention and ascites .
Hypoalbuminaemia Albumin is the main element in maintaining plasma colloid osmotic pressure . Hypoalbuminaemia leads to a decrease of plasma colloid osmotic pressure , causing water to leak from the tissues into the abdominal cavity , forming ascites . Of the three causes of ascites , hypoalbuminaemia is the most easily corrected . Causes of hypoalbuminaemia in patients with liver cirrhosis accompanied by ascites include : impaired albumin synthesis owing to hepatocyte damage ; decreased level of hepatocytes and weakened hepatocyte function ; and malnutrition and poor appetite , which reduces the raw materials available for albumin synthesis .
Liver cirrhosis is a chronic decline and albumin consumption increases over its course . Some patients also have renal injury , which further increases leakage of albumin .
It is therefore crucial for patients with hepatic ascites to receive albumin infusions . The main benefit is in maintaining the circulatory volume and improving response to loop diuretics . The two effects are not related to patients ’ baseline serum albumin levels . In other words , patients should receive albumin regardless of whether serum albumin levels decrease significantly or not .
Management of ascites and complications Currently the management and treatment of ascites and related complications in patients with liver cirrhosis is carried out in compliance with regionspecific guidelines . Management can be summarised as 1 :
• Nutritional support : Salt restriction ( 4 – 6g / d ), daily caloric intake > 2000 calories mainly from carbohydrate , supplemented with high-quality protein and vitamins , protein 1 – 1.2g /( kg × d ), and 0.5g /( kg × d ) in the event of obvious hepatic encephalopathy
• Aetiological treatment , such as hepatitis B or hepatitis C antivirals
• Rational application of vasoconstrictors and other diuretics
• Avoidance of nephrotoxic drugs
• LVP and human albumin supplementation
• Transjugular intrahepatic portosystemic shunt , etc .
The Chinese , 1 American Association for the Study of Liver Diseases ( AASLD ), 2 European Association for the Study of the Liver ( EASL ), 3 and British Association for Studies of the Liver ( BASL ) guidelines 4 jointly highlight the importance and requirement of human albumin in treating ascites in patients with liver cirrhosis . As emphasised in China ’ s first Guideline for Diagnosis and Treatment of Ascites and relevant Complications of Liver Cirrhosis in 2017 , 1 ‘ human albumin plays an important role in improving the prognosis of patients with liver cirrhosis and efficacy of diuretics and antimicrobial agents in patients with liver cirrhosis and ascites , especially patients with refractory ascites and HRS ’. Table 1 summarises the recommendations of the main clinical guidelines .
Human albumin supplementation is effective in treating ascites Human albumin supplementation is an effective means of treating ascites in liver cirrhosis ,
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