Peritoneovenous shunting restores atrial natriuretic factor responsiveness in refractory hepatic ascites

Effects and safety of natriuretic peptides as treatment of cirrhotic ascites: A systematic review and meta-analysis

BACKGROUND

Natriuretic peptides are involved in the cascade of pathophysiological events occurring in liver cirrhosis, counterbalancing vasoconstriction and anti-natriuretic factors. The effects of natriuretic peptides as treatment of cirrhotic ascites have been investigated only in small studies, and definitive results are lacking.

AIM

To examine the effects and safety of natriuretic peptides in cirrhosis patients with ascites.

METHODS

We searched MEDLINE, Web of Science, Scopus, Cochrane Library and Embase for all available studies applying intravenous administration of any natriuretic peptide to patients suffering from cirrhotic ascites. Inclusion was not limited by treatment duration or dose, or by follow-up duration. Both randomised controlled trials and non-randomised studies were eligible for inclusion. The primary outcome was change in renal sodium excretion. Secondary outcomes included safety measures and changes in renal water excretion, plasma aldosterone concentration, and plasma renin activity.

RESULTS

Twenty-two studies were included. Atrial natriuretic peptide (ANP) was the only intensively studied treatment. Sodium excretion increased in response to continuous ANP infusion and was more pronounced when infusion rates of > 30 ng/kg/min were administered compared with ≤ 30 ng/kg/min (P < 0.01). Moreover, natriuresis was significantly higher in study subgroups with mild/moderate ascites compared with moderate/severe and refractory ascites (P < 0.01). ANP infusions increased renal water excretion, although without reaching a statistically significant dose-response gradient. Plasma aldosterone concentration and plasma renin activity were significantly lower at baseline in study subgroups achieving a negative sodium balance in response to an ANP administration compared with treatment non-responders (P < 0.01). Blood pressure decreases occurred less frequently when ANP doses ≤ 30 ng/kg/min were applied. The quality of evidence for a natriuretic response to ANP was low, mainly due to small sample sizes and considerable between-study heterogeneity. Data were sparse for the other natriuretic peptides; B-type natriuretic peptide and urodilatin.

CONCLUSION

Intravenous ANP infusions increase sodium excretion in patients with cirrhotic ascites. Continuous infusion rates > 30 ng/kg/min are the most effective. However, safety increases with infusion rates ≤ 30 ng/kg/min.

Pathophysiology, diagnosis, and management of pediatric ascites

The pediatric population has a number of unique considerations related to the diagnosis and treatment of ascites. This review summarizes the physiologic mechanisms for cirrhotic and noncirrhotic ascites and provides a comprehensive list of reported etiologies stratified by the patient's age. Characteristic findings on physical examination, diagnostic imaging, and abdominal paracentesis are also reviewed, with particular attention to those aspects that are unique to children. Medical and surgical treatments of ascites are discussed. Both prompt diagnosis and appropriate management of ascites are required to avoid associated morbidity and mortality.

Modified saphenous-peritoneal shunt in refractory ascites: new technique

BACKGROUND

Refractory ascites is a serious complication for patients with decompensated liver cirrhosis. Saphenous-peritoneal shunting is a possible surgical treatment for its relief, but tends to lead to higher groin infections. The purpose of the present paper was to determine whether a modified procedure could resolve the problem and offer potential advantages over a peritoneo-venous shunt.

METHODS

Sixteen patients with refractory ascites who received modified saphenous-peritoneal shunts were studied. Clinical data such as bodyweight, abdominal girth, indocyanine green 15-min retention rate (ICG-15), serum bilirubin concentrations, Child-Pugh Score, creatinine clearance (C(Cr)), daily urinary output, urine sodium (U(Na)) and operative complications were recorded before, and 3 months after, surgery.

RESULTS

Three months after the operation, the urinary output, nutritional status and Child-Pugh scores had improved, but ICG-15 and total bilirubin output had not changed significantly. The C(Cr), U(Na) bodyweight and abdominal girth tended to decrease, but not significantly. No groin infections were noted following this procedure.

CONCLUSIONS

This modified procedure not only improved the nutritional status of cirrhotic patients with refractory ascites but also improved their quality of life. Infections and obstructions decreased in the short term. However, long-term follow up is mandatory. This new technique requires more practice and experience.

The pathophysiologic basis for the treatment of cirrhotic ascites

Advances in the understanding of the pathophysiology of sodium retention and ascites formation in cirrhosis has helped improve the treatment of ascites in these patients. It is likely that further unraveling of these pathophysiologic changes will lead to the development of novel and better treatment options. For example, the development of aquaretic agents for the management of hyponatremia in cirrhosis may allow more effective use of diuretic therapy. The ultimate challenge is to use the understanding of the pathophysiology to develop new strategies to prevent the development of ascites in cirrhosis.