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Asociación Mexicana de Gastroenterología

2005, Number 3

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Rev Gastroenterol Mex 2005; 70 (3)

Refractory ascites and dilutional hyponatremia: Current management and new aquaretics

Torre DA

Language: Spanish
References: 64
Page: 299-311
PDF size: 80.84 Kb.


ABSTRACT

Ascites is the most common complication of cirrhosis and is associated with 50% mortality at 2 years if patients do not receive orthotopic liver transplantation. Recently the International Ascites Club defined ascites into three groups: In grade I ascites fluid is detected only by ultrasound; in grade II, ascites is moderate with symmetrical distention of the abdomen; and in Grade 3 ascites is large or tense with marked abdominal distention. About 10% of patients with ascites are refractory to treatment with diuretics. In refractory ascites, patients do not respond to highest doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/day) or develop side effects (hyperkalemia, hyponatremia, hepatic encephalopathy, or renal failure) that prohibit thier use. Patients may be treated either by repeated large volume paracentesis plus albumin or transjugular intrahepatic portosystemic shunts (TIPS). Dilutional hyponatremia in cirrhotic patients is defined as serum sodium ≤ 130 mEq/L in the presence of an expanded extracellular fluid volume, as indicated by the presence of ascites and/or edema. This complication of cirrhotic patients with ascites has recently gained attention given that several reports indicate that when serum sodium concentration is combined with the Model for End-Stage liver disease (MELD) it improves the prognostic accuracy of MELD score in patients awaiting orthotopic liver transplant (OLT). The first step in the management of dilutional hyponatremia is fluid restriction and discontinuation of diuretics. Water restriction at 1,000 mL/day helps prevent the progressive decrease in serum sodium concentration but ussually does not correct hyponatremia in most cases. Actually are developing drugs that are active orally and act by selectively antagonizing the specific receptors (V2 receptor) of arginine vasopressin. These agents act in the distal collecting ducts of the kidneys, by increasing solute free water excretion and, thus, improving serum sodium concentration in hyponatremic patients


REFERENCES

  1. Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudates-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117: 215-20.

  2. Arroyo V, Ginés P, Gerbes A, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996; 23: 164-76.

  3. Salerno F, Borroni G, Moser P, et al. Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients. Am J Gastroenterol 1993; 88: 514-19.

  4. Ring-Larsen H, Henriksen JH, Wilken C, et al. Diuretic treatment in decompensated cirrhosis and congestive heart failure: effect of posture. Br Med J 1986; 292: 1351-3.

  5. Reynolds TB. Ascites. Clin Liver Dis 2000; 4: 151-68.

  6. Bernardi M, Laffi G, Salvagnini M, et al. Efficacy and safety of the stepped care medical treatment of ascites in liver cirrhosis: a randomized controlled clinical trial comparing two diets with different sodium content. Liver 1993; 13: 156-62.

  7. Wilkinson SP, Jowett TP, Slater JD, et al. Renal sodium retention in cirrhosis: relation to aldosterone and nephron site. Clin Sci 1979; 56: 169-77.

  8. Fogel MR, Sawhney VK, Neal Ea, et al. Diuresis in the ascitic patient: a randomized controlled trial of three regimens. J Clin Gastroenterol 1981; 3(Suppl. 1): 73-80.

  9. Pérez Ayuso RM, Arroyo V, Planas R, et al. Randomized comparative study of efficacy of furosemide versus spironolactone in patients with liver cirrhosis and ascities. Gastroenterology 1983; 84: 961-8.

  10. Gatta A, Angeli P, Caregaro L, et al. A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients. Hepatology 1991; 14: 231-6.

  11. Angeli P, Dalla Pria M, De Bei E, et al. Randomized clinical study of the efficacy amiloride and potassium canreonate in nonazotemic cirrhotic patients with ascites. Hepatology 1994; 19: 72-9.

  12. Gatta A, Angeli P, Caregaro L, et al. A pathophysiogical interpretation of unresponsiveness to spironolactone in a stepped care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients with liver cirrhosis and ascites. Hepatology 1991; 14: 231-6.

  13. Bernardi M, Laffi G, Salvagnini M, et al. Efficacy and safety of the stepped care medical treatment of ascites in liver cirrhosis: a randomized controlled clinical trail comparing two diets with different sodium content. Liver 1993; 13: 156-62.

  14. Gabow PA, Moore S, Schrider RW. Spironolactone-induced hyperchloremic acidosis in cirrhosis. Ann Intern Med 1979; 90: 338-40.

  15. Pockros PJ, Reynolds TB. Rapid diuresis in patients with ascites from chronic liver disease: the importance of peripheral edema. Gastroenterology 1986; 90: 1827-33.

  16. Angeli P, Albino G, Carraro P, et al. Cirrhosis and muscle cramps: evidence of a causal relantionship. Hepatology 1996; 23: 264-73.

  17. Diener HC, Dethlefsen U, Dethlefsen-Gruber S, et al. Effectiveness of quinine in treating muscle cramps: a double blind, placebo controlled, parallel group, multicentre trial. Int Clin J Pract 2002; 56: 243.

  18. Kugelmas M. Preliminary observation: oral zinc sulphate replacement is effective in treating muscle cramps in cirrhotics patients. J Am Coll Nutr 2000; 19: 13-15.

  19. Lee FY, Lee SD, Tsai YT et al. A randomized controlled trial of quinidine in the treatment of cirrhotic patients with muscle cramps. J Hepatol 1991; 12: 236-240.

  20. Moore KP, Wong F, Ginès P, et al. The management of ascites in cirrhosis: report of the Consensus Conference of the International Ascites Club. Hepatology 2003; 38: 258-66.

  21. Fernández-Esparrach G, Guevara M, Sort P, et al. Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double blind trial of spironolactone versus placebo. J Hepatol 1997; 26: 614-20.

  22. Ginès A, Fernández-Esparrach G, Monescillo A, et al. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated with paracentesis. Gastroenterology 1996; 111: 1002-10.

  23. Ginès P, Arroyo V, Quintero E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987; 93: 234-341.

  24. Salerno F, Badalamenti S, Incerti P, et al. Repeated paracentesis and iv albumin infusion to treat tense ascites in cirrhotic patients. A safe alternative therapy. J Hepatol 1987; 5: 102-8.

  25. Sola R, Vila MC, Andreu M, et al. Total paracentesis with dextran 40 vs. diuretics in the treatment of ascites in cirrhosis: a randomized controlled study. J Hepatol 1994; 20: 282-8.

  26. Cotrim HP, Garrido V, Parana R, et al. Paracentesis associated to dextran 40 vs. diuretics in the treatment of ascites in patients with chronic liver disease: a randomized therapeutic study. Arch Gastroenterol 1994; 31: 125-9.

  27. Hagengue H, Ink O, Ducreux M, et al. Treatment of ascites in patients with liver cirrhosis without neither hyponatremia non real renal insufficiency. Results of a randomized study comparing diuretics and punctures compensated by albumin. Gastroenterol Clin Biol 1992; 16: 751-5.

  28. Wong F, Sniderman K, Liu P, et al. The effects of transjugular intrahepatic portosystemic shunt on systemic and renal hemodynamics and sodium homeostasis in cirrhotics patients with refractory ascites. Ann Intern Med 1995; 122: 816-22.

  29. Sanyal AJ, Genning C, Reddy KR, et al. North American Study for the treatment of refractory ascites group. Gastroenterology 2003; 124: 634-41.

  30. Ginès P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002; 123: 1839-47.

  31. Lebrec D, Giuily N, Hadenque A, et al. Transjugular intrahepatic portosystemic shunt: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. J Hepatol 1996, 25: 135-44.

  32. Rossle M, Ochs A, Gulberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Eng J Med 2000; 342: 1701-7.

  33. Saxon RR, Timmermans HA, Uchida BT, et al. Stent grafts for revision of TIPS stenoses and occlusions: a clinical pilot study. J Vasc Interv Radiol 1997; 8: 539-48.

  34. Arroyo V, Ginès P, Planas R, et al. Pathogenesis, diagnosis and treatment of ascites. In: Bircher J, Benhamou JP, McIntyre N, Rizzetto M, Rodés J (eds.). Ed. Oxford textbook of clinical hepatology. 2nd. New York: Oxford Medical Publications; p. 699-731.

  35. Ginés P, Arroyo V, Vargas V, et al. Paracentesis with infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325: 829-35.

  36. Ginés A, Planas R, Angeli P, et al. Treatment of patients with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: comparison with therapeutic paracentesis. Hepatology 1995; 22: 124-31.

  37. Guevara M, Alessandria C, Uriz J. TIPS y ascitis refractaria. Gastroenterol Hepatol 2004; 27(4): 285-91.

  38. Arroyo V, Rodés J, Gutiérrez-Lizarraga MA, et al. Prognostic value of spontaneous hyponatremia in cirrhosis with ascites. Am J Dig Dis 1976; 21: 249-56.

  39. Ishikawa S, Schrier RW. Arginine vasopressin in cirrhosis. In: Arroyo V, Ginès P, Rodés J, Schrier RW (eds.). Ascites and renal dysfunction in liver disease. Pathogenesis, diagnosis and treatment. Malden, MA: Blackwell Science; 1999, p. 220-30.

  40. Ginés P, Rodés J. Clinical disorders of renal function in cirrhosis with ascites. In: Arroyo V, Ginès P, Rodés J, Schrier RW (eds.). Ascites and renal dysfunction in liver disease. Pathogenesis, diagnosis and treatment. Malden, MA: Blackwell Science; 1999, p. 36-62.

  41. Roberstson GL, Berl T. Pathophysiology of water metabolism. In: Brenner BM, Rector FC (eds.). The Kidney. Philadelphia: Saunders Company; 1991, p. 677-736.

  42. Skirecki KL, Brown D, Ercolani L, et al. Molecular mechanism of vasopressin action in the kidney. In: Windhager EE (ed.). Handbook of physiology. Section 8, renal physiology. New York: Oxford University Press; 1992, p. 1185-218.

  43. Arroyo V, Clària J, Saló J, et al. Antidiuretic hormone and the pathogenesis of water retention in cirrhosis with ascites. Sem Liver Dis 1994; 14: 44-58.

  44. Ginès P, Berl T, Bernardi M, et al. Hyponatremia in cirrhosis: from pathogenesis to treatment. Hepatology 1998; 28: 851-64.

  45. Palm C, Reimann D, Gross P. The role of V2 vasopressin antagonists in hyponatremia. Cardiovascular Res 2001; 51: 403-8.

  46. Gross P, Palm C. The treatment of hyponatremia using vasopressin antagonists. Exp Physiol 200; 85S: 253S-257S.

  47. Wong LL, Verbalis JG. Vasopressin V2 receptor antagonists. Cardiovascular Res 2001; 51: 391-402.

  48. Torre A, Martín-Llahi M, Ginès P. Hiponatremia dilucional, ascitis refractaria y síndrome hepatorenal. Tratamiento actual. Gastroenterol Hepatol 2004; 4(Suppl 4): 26-39.

  49. Carrilho F, Bosch J, Arroyo V, et al. Renal failure associated with demeclocycline in cirrhosis. Ann Int Med 1977; 87: 195-7.

  50. Bosch-Marcé M, Jiménez W, Angeli P, et al. Aquaretic effect of the kappa-opioid agonist RU 51599 in cirrhotic rats with ascites and water retention. Gastroenterology 1995; 109: 217-33.

  51. Bosch-Marcé M, Poo JL, Jiménez W, et al. Comparison of two aquaretic drugs (Niravoline and OPC-31260) in cirrhotic rats with ascites and water retention. J Pharmacol Exp Ther 1999; 289; 194-201.

  52. Gadano A, Moreau R, Passione F, et al. Aquaretic effects of niravoline, a k- opioid agonist, in patients with cirrhosis. J Hepatol 2000; 32: 38-42.

  53. Sawyer WH, Pang PK, Seto J, et al. Vasopressin analogs that antagonize antiudiuretic responses by rats to the antidiuretic hormone. Science 1981; 212: 49-51.

  54. Manning M, Sawyer WH. Discovery, development and some uses of vasopressin and oxytocin antagonists. J Lab Clin Med 1989; 114: 617-32.

  55. Clària J, Jiménez W, Arroyo V, et al. Blockade of the hydroosmotic effect of vasopressin normalizes water excretion in cirrhotic rats. Gastoenterology 1989; 97: 1294-9.

  56. Tsuboi Y, Ishikawa SE, Fujisawa G, et al. Therapeutic efficacy of the non-peptide AVP antagonist OPC-31260 in cirrhotic rats. Kidney Int 1994; 46: 237-44.

  57. Inoue T, Ohnishi A, Matsuo A, et al. Therapeutic and diagnostic potential of a vasopressin-2 antagonist for impaired water handling in cirrhosis. Clin Pharmacol Ther 1998; 63: 561-70.

  58. Yamamura Y, Ogawa H, Chihara T, et al. OPC-21268, an orally effective, nonpeptide vasopressin V1 receptor antagonist. Science 1991; 252: 572-4.

  59. Yamamura Y, Ogawa H, Yamashita H, et al. Characterization of a novel aquaretic agent, OPC-31260, as an orally effective, nonpeptide vasopressin V2 receptor antagonist. Brit J Pharmacol 1992; 105: 787-91.

  60. Jiménez W, Serradeil-Le Gal C, Ros J, et al. Long-term aquaretic efficacy of a selective nonpeptide V2 vasopressin receptor antagonist, SR 121463, in cirrhotic rats. J Pharmacol Exp Ther 2000; 295: 83-90.

  61. González FX, Rimola A, Grande L, et al. Predictive factors of early postoperative graft function in human liver transplantation. Hepatology 1994; 20: 565-73.

  62. Rimola A. Indications of liver transplantation in patients with portal hypertension. In: Arroyo V, Bosch J, Bruix J, Ginès P, Navasa M, Rodés J (eds.). Therapy in hepatology. Barcelona: Medicina STM Editores, S.L.; 2001, p, 73-9.

  63. Guyader D, Patat A, Ellis-Grosse EJ, et al. Pharmacodynamic effect of a non peptide antidiuretic hormone V2 antagonist in cirrhotic patients with ascites. Hepatology 2002; 36: 1197-205.

  64. Arroyo V, Jiménez W. Clinical need for antidiuretic hormone antagonists in cirrhosis. Hepatology 2003; 37: 13-5.




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