【正文】 個人的意見是采用更為謹(jǐn)慎的方法。佳樂施(譯者注：含琥珀明膠，平均分子量30000，血容量補充藥)，海脈素(譯者注：尿素交聯(lián)明膠，血漿代用品) ％的白蛋白溶液包含的鈉濃度與生理鹽水相當(dāng)（154mmol/L）。 DiureticsDiuretics have been the mainstay of treatment of ascites since the 1940s when they first became available. Many diuretic agents have been evaluated over the years but in clinical practice in the UK this has been mainly confined to spironolactone, amiloride, frusemide, and bumetanide. These are discussed below.自20世紀(jì)40年代利尿劑首先可用時就一直是腹水治療的主要用藥。螺內(nèi)酯是肝硬化腹水初始治療的首選藥物。6871螺內(nèi)酯在肝硬化中大部分常見的副作用與其抗雄激素活性有關(guān)，如男性性欲降低，陽萎和男性乳腺發(fā)育，而在女性則為月經(jīng)紊亂（雖然大多數(shù)有腹水的女性不來月經(jīng)）。Remendationsl Serum sodium 126–135 mmol/l, normal serum creatinine. Continue diuretic therapy but observe serum electrolytes. Do not water restrict. l Serum sodium 121–125 mmol/l, normal serum creatinine. International opinion is to continue diuretic therapy, our opinion is to stop diuretic therapy or adopt a more cautious approach.l Serum sodium 121–125 mmol/l, serum creatinine elevated (＞150 mmol/l or＞120 mmol/l and rising). Stop diuretics and give volume expansion. l Serum sodium ≤120 mmol/l, stop diuretics. Management of these patients is difficult and controversial. We believe that most patients should undergo volume expansion with colloid (haemaccel, gelofusine, or voluven) or saline. However, avoid increasing serum sodium by .12 mmol/l per 24 hours. (Level of evidence: 5。l 血鈉121～125 mmol/l，血肌酐升高(＞150 mmol/l 或者是＞120 mmol/l并繼續(xù)升高)：停止利尿并予以擴(kuò)容。（證據(jù)水平：5；推薦：D） FrusemideFrusemide is a loop diuretic which causes marked natriuresis and diuresis in normal subjects. It is generally used as an adjunct to spironolactone treatment because of its low efficacy when used alone in The initial dose of frusemide is 40 mg/day and it is generally increased every 2– 3 days up to a dose not exceeding 160 mg/day. High doses of frusemide are associated with severe electrolyte disturbance and metabolic alkalosis, and should be used cautiously. Simultaneous administration of frusemide and spironolactone increases the natriuretic 28（呋塞米）速尿是絆利尿劑，在正常情況下可引起明顯的排鈉和利尿作用。同時應(yīng)用螺內(nèi)酯和速尿會增加排鈉效果。71速尿的初始劑量是40mg/d，一般每23天增加直到不超過160 mg/d的劑量。我們相信大多數(shù)患者應(yīng)該用膠體(海脈素, 佳樂施, 或萬汶voluven)或鹽水進(jìn)行擴(kuò)容。不用限水。他莫昔芬20mg每日兩次在處理男性乳腺發(fā)育中已顯示有益。在應(yīng)用螺內(nèi)酯治療開始和出現(xiàn)尿鈉排泄之間會有35天的延遲。這將在以下進(jìn)行討論。不過我們相信腎功能正常時有腹水要好于發(fā)展為潛在的不可逆性腎衰。該領(lǐng)域所有的專家推薦如果血鈉≤120 mmol/L，停用利尿劑。 Management of hyponatraemia in patients on diuretic therapy Serum sodium ≥126 mmol/lFor patients with ascites who have a serum sodium ≥126 mmol/l, there should be no water restriction, and diuretics can be safely continued, providing that renal function is not deteriorating or has not significantly deteriorated during diuretic therapy.≥126mmol/L 對于血鈉≥126mmol/L的腹水患者，不應(yīng)該限水。61所以，有些肝病專家包括本文作者提倡進(jìn)一步的血漿擴(kuò)容以使ADH釋放的刺激因素正常化和受抑。大多數(shù)肝病專家用嚴(yán)格的限水來治療這些患者。 remendation: B.)推薦 l 飲食中鹽應(yīng)該限制到不再另加食鹽的每天90mmol（）水平（證據(jù)水平：2b，推薦：B） Role of water restrictionThere have been no studies on the benefits or harm of water restriction on the resolution of ascites. Most experts agree that there is no role for water restriction in patients with unplicated ascites. However, water restriction for patients with ascites and hyponatraemia has bee standard clinical practice in many centres. However, there is real controversy about the best management of these patients, and at present we do not know the best approach. Most hepatologists treat these patients with severe water restriction. However, based on our understanding of the pathogenesis of hyponatraemia, this treatment is probably illogical and may exacerbate the severity of effective central hypovolaemia that drives the nonosmotic secretion of antidiuretic hormone (ADH). This may result in further increases in circulating ADH, and a further decline of renal function. Impaired free water clearance is observed in 25– 60% of patients with ascites due to cirrhosis,60 and many develop spontaneous Therefore, some hepatologists, including the authors, advocate further plasma expansion to normalise and inhibit stimulation of ADH release. Studies are needed to determine the best There are data emerging that support the use of specific vasopressin 2 receptor antagonists in the treatment of dilutional hyponatraemia,63–65 but whether this improves overall morbidity and mortality is not yet known. It is important to avoid severe hyponatraemia in patients awaiting liver transplantation as it may increase the risk of central pontine myelinolysis during fluid resuscitation in surgery.還沒有有關(guān)限水對腹水消退益、害的研究。－，而每200ml（400mg）環(huán)丙沙星含30mmol鈉。傳統(tǒng)的英國飲食每天飲食中含鈉約150mmol，其中15％源于加入的食鹽，70％源于食品加工。 remendation: D.)推薦l 臥床休息不推薦用于腹水的治療（證據(jù)水平：5；推薦：D） Dietary salt restrictionDietary salt restriction alone can create a negative sodium balance in 10% of Sodium restriction has been associated with lower diuretic requirement, faster resolution of ascites, and shorter 56 In the past, dietary salt was often restricted to 22 or 50 mmol/day. These diets may lead to protein malnutrition and a similar oute,57 and are no longer remended. A typical UK diet contains about 150 mmol of sodium per day, of which 15% is from added salt and 70% is from manufactured 59 Dietary salt should be restricted to ,90 mmol/day ( g) salt by adopting a noadded salt diet and avoidance of preprepared foodstuffs (for example, pies). Dieticians’ guidance and information leaflets will assist in educating patient and relatives regarding salt restriction. Certain drugs, especially those in the effervescent tablet form, have high sodium contents. Intravenous antibiotics generally contain – mmol of sodium per gram with the exception of ciprofloxacin which contains 30 mmol sodium in 200 ml (400 mg) for intravenous infusion. Although in general it is preferable to avoid infusion of fluids which contain salt in patients with ascites, there are occasions, such as the development of hepatorenal syndrome or renal impairment with severe hyponatraemia, when it may be appropriate and indicated to give volume expansion with a crystalloid or colloid. For patients developing hepatorenal