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Asociación Mexicana de Gastroenterología

2005, Número 3

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Rev Gastroenterol Mex 2005; 70 (3)


Ascitis refractaria e hiponatremia dilucional: tratamiento actual y nuevos acuaréticos

Torre DA

Idioma: Español
Referencias bibliográficas: 64
Paginas: 299-311
Archivo PDF: 80.84 Kb.


RESUMEN

La ascitis es la complicación más común de la cirrosis y se asocia con 50% de mortalidad a dos años si el paciente no recibe un trasplante hepático. Recientemente el Club Internacional de la Ascitis clasificó a la misma en tres grupos: Grado I, en la cual la ascitis es detectada mediante ultrasonografia; grado II, la cual es una ascitis moderada y simétrica a la exploración física, y grado III aquella con ascitis a tensión o marcada distensión abdominal. Cerca de 10% de los pacientes con ascitis son refractarios al tratamiento con diuréticos. En la ascitis refractaria, los pacientes no responden a altas dosis de diuréticos (espironolactona 400 mg/día y furosemida 160 mg/día) o desarrollan efectos colaterales (hiperkalemia, hiponatremia, encefalopatía hepática o insuficiencia renal) lo cual limita su uso. Los pacientes deben ser tratados con paracentesis repetidas de gran volumen + albúmina o con la colocación de TIPS. La hiponatremia dilucional en los pacientes cirróticos se define como un sodio sérico ≤ 130 mEq/L en presencia de un volumen extracelular expandido, manifestado por la presencia de ascitis y/o edema. Esta complicación de los pacientes cirróticos con ascitis recientemente ha ganado mayor atención, ya que hay varios reportes en la literatura que indican que cuando la concentración de sodio sérico se combina con el modelo de enfermedad hepática terminal (MELD) mejora la efectividad pronóstica de los pacientes en lista de espera a un trasplante hepático. El primer paso en el tratamiento de la hiponatremia dilucional es la restricción hídrica y el cese de diuréticos. La restricción de agua a 1,000 mL/día ayuda a prevenir la disminución progresiva en el sodio sérico, pero usualmente no corrige la hiponatremia en la mayoría de los casos. Actualmente están en desarrollo medicamentos que son activos oralmente y actúan por antagonismo selectivo de los receptores específicos de vasopresina (V2). Estos medicamentos actúan en el túbulo colector distal del riñón e incrementan la excreción de agua libre, y por tanto, mejoran la concentración de sodio sérico en los pacientes hiponatrémicos.


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