【正文】 is divided on what is the next best course of action. The international opinion,10 in which a consensus of international experts was sought and reported, is that diuretics should be continued. However, there are no or few data to support the best course of action, and our personal view is to adopt a more cautious approach. We believe that diuretics should be stopped once serum sodium is (125 mmol/l and the patient observed. All experts in the field remend stopping diuretics if serum sodium is (120 mmol/l. If there is a significant increase in serum creatinine or serum creatinine is .150 mmol/l, we would remend volume expansion. Gelofusine, haemaccel, and % albumin solutions contain sodium concentrations equivalent to normal saline (154 mmol/l). This will worsen their salt retention but we take the view that it is better to have ascites with normal renal function than to develop potentially irreversible renal failure. Water restriction should be reserved for those who are clinically euvolaemic with severe hyponatraemia in which free water clearance is decreased, and who are not currently taking diuretics, and in whom serum creatinine is normal.≤125 mmol/L對(duì)于中度低鈉血癥（血鈉121125 mmol/L）患者，意見(jiàn)因下一步最佳course of action不同而不同。國(guó)際上的意見(jiàn)10（尋找及報(bào)告國(guó)際專(zhuān)家共識(shí)）是繼續(xù)使用利尿劑，但是，沒(méi)有或很少有將被支持最佳course of action，我們個(gè)人的意見(jiàn)是采用更為謹(jǐn)慎的方法。我們相信一旦血鈉≤125 mmol/L利尿劑應(yīng)該停用并且要對(duì)患者進(jìn)行觀察。該領(lǐng)域所有的專(zhuān)家推薦如果血鈉≤120 mmol/L，停用利尿劑。如果血肌酐明顯增加或血肌酐＞150 mmol/L，我們推薦進(jìn)行擴(kuò)容。佳樂(lè)施(譯者注：含琥珀明膠，平均分子量30000，血容量補(bǔ)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）。這將會(huì)使鹽的貯留更加惡化。不過(guò)我們相信腎功能正常時(shí)有腹水要好于發(fā)展為潛在的不可逆性腎衰。對(duì)于臨床上are euvolaemic with嚴(yán)重低鈉血癥者，其游離水的清除降低，目前未服用利尿劑，其血肌酐正常，仍然要限水。 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(shí)就一直是腹水治療的主要用藥。在過(guò)去的多年間已對(duì)許多利尿劑進(jìn)行了評(píng)估，不過(guò)英國(guó)的臨床實(shí)踐中，還主要限于螺內(nèi)酯，阿米羅利，速尿和布美他尼。這將在以下進(jìn)行討論。 SpironolactoneSpironolactone is an aldosterone antagonist, acting mainly on the distal tubules to increase natriuresis and conserve potassium. Spironolactone is the drug of choice in the initial treatment of ascites due to The initial daily dose of 100 mg may have to be progressively increased up to 400 mg to achieve adequate natriuresis. There is a lag of 3–5 days between the beginning of spironolactone treatment and the onset of the natriuretic Controlled studies have found that spironolactone achieves a better natriuresis and diuresis than a ‘‘loop diuretic’’ such as –71 Most frequent side effects of spironolactone in cirrhotics are those related to its antiandrogenic activity, such as decreased libido, impotence, and gynaeastia in men and menstrual irregularity in women (although most women with ascites do not menstruate anyway). Gynaeastia can be significantly reduced when the hydrophilic derivative potassium canrenoate is used,72 but this is not readily available in the UK. Tamoxifen at a dose 20 mg twice a day has been shown to be useful in the management of Hyperkalaemia is a significant plication that frequently limits the use of spironolactone in the treatment of ascites.螺內(nèi)酯是醛固酮拮抗劑，主要作用于遠(yuǎn)端小管增加尿鈉排泄和保鉀。螺內(nèi)酯是肝硬化腹水初始治療的首選藥物。66初始每天100mg的量可能需要逐步增加到400mg以達(dá)到適當(dāng)?shù)哪蛞号赔c。在應(yīng)用螺內(nèi)酯治療開(kāi)始和出現(xiàn)尿鈉排泄之間會(huì)有35天的延遲。67對(duì)照研究發(fā)現(xiàn)螺內(nèi)酯較絆利尿劑如速尿能取得更好的排鈉和利尿效果。6871螺內(nèi)酯在肝硬化中大部分常見(jiàn)的副作用與其抗雄激素活性有關(guān)，如男性性欲降低，陽(yáng)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(lái)月經(jīng)）。當(dāng)使用親水性衍生物烯睪丙酸鉀時(shí)男性乳腺發(fā)育可以明顯的減少，72不過(guò)在英國(guó)還不會(huì)很快就能用。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。73高鉀血癥常是腹水治療中限制采用螺內(nèi)酯的一個(gè)重要并發(fā)癥。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。 remendation: D.)推薦l 血清鈉126～135 mmol/l，血肌酐正常：繼續(xù)利尿治療不過(guò)要注意觀察血電解質(zhì)。不用限水。l 血鈉121～125 mmol/l，血肌酐正常：國(guó)際上的意見(jiàn)是繼續(xù)利尿治療，我們的意見(jiàn)是停止利尿治療或采用更加謹(jǐn)慎的方法。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。l 血鈉≤120 mmol/l：停止利尿，這些患者的處理很困難且有爭(zhēng)議。我們相信大多數(shù)患者應(yīng)該用膠體(海脈素, 佳樂(lè)施, 或萬(wàn)汶voluven)或鹽水進(jìn)行擴(kuò)容。但是，要避免每24小時(shí)增加血鈉＞12 mmol/l。（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。一般用做螺內(nèi)酯治療時(shí)的輔助因?yàn)槠鋯为?dú)用于肝硬化時(shí)效能較低。71速尿的初始劑量是40mg/d，一般每23天增加直到不超過(guò)160 mg/d的劑量。大劑量的速尿會(huì)引起嚴(yán)重電解質(zhì)紊亂和代謝性堿中毒，應(yīng)該慎重使用。同時(shí)應(yīng)用螺內(nèi)酯和速尿會(huì)增加排鈉效果。12，28 Other diureticsAmiloride acts on the distal tubule and induces diuresis in 80% of patients at doses of 15–30 mg/ It is less effective pared with spironolactone or potassium 72 Bumetanide is similar to frusemide in its action and Generally, a ‘‘stepped care’’ approach is used in the management of ascites starting with modest dietary salt restriction, together with an increasing dose of spironolactone. Frusemide is only added when 400 mg of spironolactone alone has proved –79 In patients with severe oedema there is no need to slow down the rate of da