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Ascites and Renal Dysfunction in Liver Disease: Pathogenesis, Diagnosis, and Treatment
http://www.100md.com 《新英格兰医药杂志》
     The onset of ascites in a patient with cirrhosis signals the beginning of compromised quality and expectancy of life. This common complication of end-stage liver disease results from a complex pathogenesis that leads to marked renal sodium and water retention. The hepatorenal syndrome is characterized by progression of the renal dysfunction of cirrhotic ascites to a more advanced level of functional renal failure. The evolution of our understanding of the pathogenesis of cirrhosis has been beset by chicken-and-egg conundrums, including dueling theories of circulatory "overflow" as compared with "underfill." The almost metaphysical (but ingenious) concept of reduced "effective blood volume," framed by John Peters in 1948, led to a persistent investigation of this complex clinical challenge, and that persistence has paid off. We now have a remarkable — if not complete — understanding of such processes as peripheral arterial vasodilation, activation of the renin–angiotensin–aldosterone system, and activation of the sympathetic nervous system. These processes drive the progression of renal functional compromise in cirrhosis. Most important, this understanding has informed the development of new and effective treatments and preventive strategies.

    The editors of this comprehensive but focused book are recognized leaders in their field. Thanks to them and their assembled cohort of 66 contributors from several countries, the field is presented to the reader with clarity, in detail, and with expertise. Ascites and Renal Dysfunction in Liver Disease is a big book for this specialized topic, but it includes nothing trivial. It opens with a description of the orchestration of normal renal and gastrointestinal circulatory physiology. This discussion forms the logical launching point for a subsequent description of the circulatory derangements in cirrhosis that play a central role in the pathogenesis of renal dysfunction. The reader is treated to an informative discussion of the intensely researched role of humoral vasoregulators (e.g., arachidonic acid metabolites, nitric oxide, endothelin, and carbon monoxide) in cirrhosis and their effect on renal function. Chapters devoted to the role of the hepatic microvascular circulation in ascites formation and to impaired cardiac function in cirrhosis stand out in providing unique overviews of less appreciated but important developments. The basic science of the field is then brought together in a focal-point discussion about the pathogenesis of ascites and the mechanism of sodium retention in cirrhosis. This section includes important information from animal models.

    (Figure)

    Photomicrograph of a Cirrhotic Human Liver.

    From the Carolina Biological Supply Company/Phototake.

    The discussion of basic mechanisms is followed by expert reviews of the treatment of ascites in patients with cirrhosis, including medical management, paracentesis, and the transjugular portosystemic shunt. This information is put into helpful perspective in a chapter that integrates the available options into a practical approach to management. The thoughtful inclusion of a review dedicated to noncirrhotic ascites helps make this book complete in terms of the clinical evaluation and diagnosis of ascites. A full section of Ascites and Renal Dysfunction in Liver Disease is devoted to all relevant aspects of the hepatorenal syndrome, including an appraisal of successful new therapies based on volume expansion and vasoconstrictors. Hyponatremia secondary to nonosmotic release of arginine vasopressin is common in end-stage liver disease as a consequence of the same hemodynamic changes that lead to renal dysfunction. The pertinent chapters include a critical look at new "aquaretic" agents that may be helpful in treating fluid retention in patients with hyponatremia; these drugs are being evaluated in phase 3 trials.

    Certain drugs and the systemic inflammatory response (which commonly arises from spontaneous bacterial peritonitis) often precipitate renal dysfunction in liver disease through the aggravation of existing hemodynamic and renal derangements. The principles of management and prevention of these scenarios are elaborated in the later chapters of the book. Succinct attention is also devoted to less common clinical entities such as renal failure that occurs in patients with acute liver failure and in those with obstructive jaundice.

    As a specialist with a strong interest in the topics covered in this book, I consider it to be the best available book in the field. I also strongly recommend it as the ultimate manual for any physician who is interested in guidance in mastering the art and science of diagnosis and management of ascites and renal dysfunction in cirrhosis.

    Nathan M. Bass, M.D., Ph.D.

    University of California, San Francisco

    San Francisco, CA 94143

    nathan.bass@ucsf.edu(Second edition. Edited by)