난치성 복수를 동반한 간경변증 환자의 혈장 Aldosterone 치

서정일(Jeong Ill Suh),김영진(Young Jin Kim),이태일(Tae Il Lee),이재성(Jae Sung Lee),김기덕(Ki Duk Kim),권준영(Jun Young Kweon),김병훈(Byeong Hun Kim),김기윤(Ky Yun Kim),박종원(Jong Won Park),이헌주(Heon Ju Lee) 대한내과학회 1994 대한내과학회지 Vol.46 No.5

Objectives: Hyperaldosteronism is the most important factor in sustaining salt and water retention in patients with cirrhosis and aldosterone antagonists or loop natriuretic agents are used for the treatment of ascites. But some patients do not respond to the dietary diuretic regime and the cause or mechanism of refractory ascites complex. To evaluate the difference in response after treatment of ascites and the importance of plasma aldosterone level in refractory ascites, pretreatment plasma aldosterone concentration and the degree of cirrhosis by Child-Pugh classification were investigated among cirrhotic patients. Methods: Plasma renin activity (PRA), plasma aldosterone concentration (PAC) and 24 hour urinary Na+ excretion (Una+V) were tested in 16 normal control (group I), 16 cirrhotic patients without ascites (group II), 29 cirrhotic patients with ascites who responded to aldosterone antagonist (group III) and 12 cirrhotic patients with refractory ascites (group IV). Results: The amount of Una+ in group IV (19.1±13.0 mmol/day) was much lower than that of group I (81.8±42.2mmol/day), group II (75.1±12.5mmol/day), and group III (74.9±47.8 mmol/day) (p<0.01). PRA and PAC in group III (10.8±4.1ng/ml/hr, 359.8±196.8pg/ml) and group IV (12.5±8.7ng/ml/hr, 585.9±323.7pg/ml) were significantly elevated as compared to group I (1.5±0.8ng/ml/hr, 127.0±69.1pg/ml) (p<0.01 and p<0.05, respectively) and group II (4.3±2.1ng/ml/hr, 198.8±50.8pg/ml) (p<0.01 and p<0.05, respectively). But no remarkable differences were noted between group III and group IV in PRA and PAC. No negative correlations were noted between Una+V and PRA, or between Una+V and PAC in cirrhotic patients. According to Child-Pugh classification, the majority of the group IV were in C. Conclusion: Hyperaldosteronism itself is not the main cause of low sodium excretion in cirrhosis with refractory ascites. Some other factors related to the advanced cirrhosis may play a major role in the mechanism of diuretics resistance in refractory ascites.

동시 간전이 직장 구불결장암 환자의 재발성 복수에 대한 SB 복강 주입의 복수 감소 효과 증례

전형준,김종민,조종관,이연월,한균인,유화승,Jeon, Hyung-Joon,Kim, Jong-Min,Cho, Chong-Kwan,Lee, Yeon-Weol,Han, Kyun-In,Yoo, Hwa-Seung 대한한방내과학회 2013 大韓韓方內科學會誌 Vol.34 No.4

Objectives : To report and demonstrate the effect of decreasing ascites volume by SB intraperitoneal injection to a refractory ascites patient with synchronous colorectal liver metastasis and metachronous peritoneal carcinomatosis. Methods : Two cycles of intraperitoneal and intravenous SB injection were conducted. Each injection cycle was made up of 4 days. Nine vials of SB were injected to the patient every day. To compare the volume of ascites between pret- and post-treatment, follow-up computed tomography was done on June 3, 2013. To observe other therapeutic effects of SB injection, laboratory tests were conducted periodically. Results : On the follow-up computed tomography images, the amount of ascites and pleural effusion had decreased compared to the April 30, 2013 computed tomography images. The levels of aspartate transaminase, alanine aminotransferase and lactate dehydrogenase decreased significantly from May 9, to May 30, 2013. The amount of oral intake increased constantly during hospitalization. The patient's symptoms such as abdominal distension, abdominal pain and dyspnea were improving until discharge. Conclusions : Even if thiese results cannot be applied to every synchronous colorectal cancer liver metastasis patient, we demonstrated that SB intraperitoneal injection has ascites-decreasing effect to refractory ascites patients with synchronous colorectal liver metastasis and metachronous peritoneal carcinomatosis.

투석식 초여과를 이용한 간경변 환자에서의 저항성 복수의 조절

한상진(Sang Jin Han),정의훈(Eui Hun Jeong),백광호(Gwang Ho Baik),윤동석(Dong Seok Yoon),김명빈(Myung Bin Kim),고문수(Moon Soo Koh),구자룡(Ja Ryong Koo),장웅기(Ung Ki Jang),김동준(Dong Jun Kim) 대한내과학회 1997 대한내과학회지 Vol.53 No.5

Background: Currently the most common treatment modality of refractory ascites in patients with liver cirrhosis was large volume paracentesis, but this procedure usually needed albumin infusion and occasionally developed unwanted complications. By reason of albumin shortage in Korea and occasional unfavorable complications, we studied the usefulness of dialytic ultrafiltration as an another treatment modality of refractory ascites. Methods: Dialytic ultrafiltration was done in 10 patients (total 48 times) with liver cirrhosis or hepatocellular carcinoma. Two drainage conduit (via 16 gauge angio-catheter) of input and output were made by puncture of patient's right and left lower quadrant abdomen. The initial ultrafiltration rate of dialyser was 250mL/min. Ascitic fluid was removed continuously until the filtration rate down at 50mL/min. After ultrafiltration, ascitic fluid contained concentrated albumin and large molecules was reinfused via input conduit. Pre-treatment and post-treatment level of blood chemistry, plasma renin concentration, aldosterone, and electrolytes in serum; total protein and albumin in ascites were measured. During the ultrafiltration, we closely observed the change of blood pressure, heart rates and mental status. Results: The mean ultrafiltration time was 231±28min, ultrafiltrated volume was 5.15±1.41 L. During dialytic ultrafiltration, patient's blood pressure and heart rate were stable and there was no change of mental status. After dialytic ultrafiltration, blood urea nitrogen level significantly decreased from 30.5±23.7㎎/dL to 25.7±20.2㎎/dL; serum aldosterone level decreased from 807.3±301.1pg/ml to 431.1±187.2pg/ml in serum (P<0.01). The albumin level in the ascitic fluid significantly increased from 0.67±0.28g/dL to 1.90±1.16g/dL (P<0.01). Plasma renin concentration level tend to decreased (P=0.06). The patient's serum total protein, albumin, electrolytes, and creatinine were not changed. Complications of dialytic ultrafiltration were peritonitis (one case) and hypotension (one case). But these unwanted complications were readily managed by adequate antibiotics and intravenous fluid therapy. Conclusion: The dialytic ultrafiltration can be used effectively without albumin infusion in the treatment of refrartory ascites in patients with advanced liver cirrhosis.

β-blockers in advanced cirrhosis: More friend than enemy

( Ki Tae Yoon ),( Hongqun Liu ),( Samuel S. Lee ) 대한간학회 2021 Clinical and Molecular Hepatology(대한간학회지) Vol.27 No.3

Nonselective beta-adrenergic blocker (NSBB) therapy for the prevention of initial and recurrent gastrointestinal bleeding in cirrhotic patients with gastroesophageal varices has been used for the past four decades. NSBB therapy is considered the cornerstone of treatment for varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker therapy suggested a detrimental effect of NSBBs in decompensated cirrhosis, especially in patients with refractory ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a “therapeutic window” has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with cirrhosis, not only with respect to bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first bleeding and recurrent bleeding. Furthermore, NSBBs improve congestion/ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in cirrhosis are much more of a friend than enemy. (Clin Mol Hepatol 2021;27:425-436)

LC : Real Clinical Practice on Transjugular Intrahepatic Portosystemic Shunt for the Management of the Refractory Ascites in Korea

( Hyung Ki Kim ),( Young Seok Kim ),( Young Kul Jung ),( Woo Jin Chung ),( Hyun Young Woo ),( Sung Jae Park ),( Do Young Kim ),( Jae Jun Shim ),( Soo Young Park ),( Jae Myung Lee ) 대한간학회 2013 춘·추계 학술대회 (KASL) Vol.2013 No.1

Background and Aim: Refractory ascites indicates advanced chronic liver disease and represents a therapeutic challenge. While liver transplantation is the ultimate treatment, for the relief of ascites transjugular intrahepatic portosystemic shunt (TIPS) are well established. We report our experience with TIPS in Korea based on a multicenter retrospective study. Methods: The authors retrospectively reviewed the medical records of 59 patients who underwent TIPS for refractory ascites with liver cirrhosis from 2000 to 2012 in Korea. Results: TIPS was successfully in all 59 patients. Of these, we review medical records of the 55 patients. Complication of the procedure is bleeding (2 patients), hypotension of the unknown origin (1 patient), aggravated heart failure (1 patient). Stent dysfunction happened 5 patients due to stent stenosis (4 patients), stent thrombosis (1 patient) during follow up. Mean follow up period was 326 days. During follow up, 50 (90.9%) patients died and only 2 patients had liver transplantation. 5 (9.1%) patients had shunt revision due to stent dysfunction. The probability of survival without liver transplantation was 26.5% at 1 year. 1-month mortality was 29.1%. The response was assessed in patients who were alive, without transplanstation, at each time point. Either complete or partial response of the ascites was obtained in 68.6%, 75.0 %, 76.4% and 69.2% at 1, 3, 6, 12 months, respectively. Mortality was 29.1%, 48.3%, 58.2% and 70.9% at 1, 3, 6, 12 months, respectively. In 15 patients (30%), a new episode of encephalopathy developed or aggravated and 12 patients (80%) were grade III or IV but most of them (9 patients, 75%) responded quickly to treatment. Conclusions: TIPS is a reliable option or bridge therapy prior to liver transplantation for the management of refractory ascites in patients with liver cirrhosis.

Predictors of Refractory Ascites Development in Patients with Hepatitis B Virus-Related Cirrhosis Hospitalized to Control Ascitic Decompensation

서주희,김승업,박준용,김도영,한광협,전재윤,안상훈 연세대학교의과대학 2013 Yonsei medical journal Vol.54 No.1

Purpose: Refractory ascites (RA) is closely related to a high morbidity and mortality. In this study, we investigated predictors of RA development in patients with hepatitis B virus (HBV)-related cirrhosis who were hospitalized to control ascitic decompensation,and determined predictors for survival in patients who experienced RA. Materials and Methods: We analyzed 199 consecutive patients with HBV-related cirrhosis who were hospitalized to control ascitic decompensation between January 1996 and December 2008. Results: Multivariate analyses showed that only serum potassium at admission predicted RA development independently [p=0.013; hazard ratio (HR), 2.800; 95% confidence interval (CI), 1.166-6.722]. During the follow-up period, 16 (8.0%) patients experienced RA within 4.2 (range, 1.0-39.2) months after admission for controlling ascitic decompensation, and they survived a median of 8.7 (range, 3.9-51.3) months. Child-Pugh class and RA type were identified as independent prognostic factors affecting the survival in patients with RA (p=0.045; HR, 8.079; 95% CI, 1.231-67.984 and p=0.013; HR, 14.510; 95% CI, 1.771-118.874, respectively). Conclusion: Serum potassium was an independent predictor of RA development in patients with HBV-related cirrhosis who were hospitalized to control ascitic decompensation. After RA development, Child-Pugh class and RA type were independent predictors for survival.

Predictors of the development of refractory ascites in patients with hepatitis B virus-related cirrhosis experiencing the first episode of ascitic decompensation

Ju Hee Seo,Seung Up Kim,Jun Yong Park,Do Young Kim,Sang Hoon Ahn,Kwang Hyub Han,Jae Yoon Chon 대한간학회 2009 Clinical and Molecular Hepatology(대한간학회지) Vol.15 No.3(S)

제10차 춘계 학술대회 초록집 : 포스터전시 17 ; Spironolactone과 furosemide의 이제 요법에 난치성인 복수를 동반한 간경변증 환자에서 metolazone병합 삼제 요법의 유용성

서요안,최현희,김대용,구현철,김익근,박인일,한재필,백광호,김진봉,김동준 대한간학회 2004 Clinical and Molecular Hepatology(대한간학회지) Vol.10 No.3(S)