腹水引流術後補充白蛋白效用之實證醫學回顧

Therapeutic Paracentesis with and Without Intravenous Albumin Supplement in Cirrhotic Patients: An Evidence-Based Medicine Review

翁珮瑄(Pei-Hsuan Weng) ； 郭斐然(Fei-Ran Guo)

《臺灣家庭醫學研究》 6卷2期 (2008/04) Pp. 95-104

https://doi.org/10.29475/TFMR.200804.0005

摘要

背景：肝硬化的病人接受腹水引流術後，臨床醫師常建議給予靜脈白蛋白製劑，以避免產生血行動力學惡化或腎功能衰竭。這種作法的效果究竟如何？
目的：探討肝硬化病人接受腹水引流術後，給予靜脈白蛋白的優點，以及若不補充是否會造成臨床上的惡化。
文獻選擇及資料來源：使用PubMed尋找肝硬化病人接受腹水引流術後，補充靜脈白蛋白的相關研究。文獻分析：我們找到的前三篇文章均為隨機對照實驗(randomized control trial, RCT)，三篇都有提到大量腹水引流術後（一般定義為單次引流大於5公升）如果沒有補充白蛋白，會引起血行動力學的惡化，及活化「腎素－血管張力素－醛固酮系統(renin-angiotensin-aldosterone system)」（表示產生paracentesis induced circulatory dysfunction，PICD）。其中一篇研究提到補充白蛋白可降低腹水引流術後腎功能惡化的機率，兩篇研究提到可減少腹水引流術後低血鈉發生的機率。
但上述三篇研究中腹水引流的量均大於8公升，遠高於我們臨床經驗的量（大多小於5公升）。故進行第二部分文獻搜索，尋找關於腹水引流小於5公升的研究，結果找到四篇。一篇病例回顧發現腹水引流量平均2.9±1.3公升的情況下，不補充白蛋白並不會增加腎衰竭的機率。一篇前瞻性研究發現單一次腹水引流5公升不補充白蛋白，不會造成血行動力學的惡化或「腎素－血管張力素－醛固酮系統」的活化。一篇RCT發現腹水引流術後補充dextran 70或polygeline比起補充白蛋白，更易產生PICD，但只有在腹水引流量大於5公升時才有統計學顯著差異。PICD的產生與較短時間內再住院以及存活率的下降有關。另一篇RCT研究發現抽腹水後補充saline比起補充白蛋白，更易產生PICD，但在腹水引流量小於6公升時即無統計學顯著差異。
結論：大量腹水引流（大於5公升）術後應補充白蛋白，以預防血行動力學惡化、低血鈉、腎衰竭及PICD的產生（證據等級為2b）。但若腹水引流量小於5公升，目前並沒有證據顯示不補充白蛋白會導致惡化（證據等級為2b）。目前並沒有研究可直接證明不補充白蛋白會造成死亡率或再住院率等臨床指標有意義的上升。

並列摘要

Context: It is a common practice for physicians to give intravenous albumin infusion to cirrhotic patients after therapeutic paracentesis. However, the effect of giving albumin after paracentesis for the prevention of complications and mortality have not been proved
Objective: Whether intravenous albumin infusion after therapeutic paracentesis decreases complications or mortality.
Data Sources and Study Selection: A systematic review was performed by searching PubMed for articles related to intravenous albumin infusion after therapeutic paracentesis in cirrhotic patients.
Articles analysis: There were three randomized control trials which showed that largevolume paracentesis without albumin was associated with hemodynamic compromise and the activation of renin-angiotensin-aldosterone system (indicating the development of paracentesisinduced circulatory dysfunction, PICD). A higher risk of acute renal failure was observed in one trial, and a higher risk of hyponatremia was observed in other two trials. These complications could be prevented by intravenous albumin infusion.
However, the amount of paracentesis in all these trials exceeded 8 liters, which was quite different from the clinical practice in Taiwan (usually less than 5 liters). Thus, further literature search for studies aiming at paracentesis of less than 5 liters was conducted, and four more studies were included for analysis. A mean paracentesis volume of 2.9±1.3L failed to demonstrate advantage of the administration of albumin in a retrospective chart review. A single 5-liter paracentesis without albumin was not associated with disturbances in systemic and renal hemodynamics 48 hours after the procedure in a prospective trial. In a randomized control trial, researchers found that PICD occurred more frequently in patients treated with dextran-70 or polygeline than those receiving albumin. PICD was observed only when the paracentesis volume exceeded 5 liters. PICD was associated with a shorter duration for readmission and shorter survival. In another randomized control trial, saline infusion was associated with increased incidence of PICD than albumin infusion after paracentesis in cirrhotic participants. However, no significant differences were found when less than 6 liters of ascite was evacuated.
Conclusion: Intravenous albumin should be administered after large-volume paracentesis (more than 5 liters) in cirrhotic patients for the prevention of hemodynamic compromise, hyponatremia, acute renal failure, and PICD (Evidence level IIb). However, there was no evidence demonstrating any differences in surrogate outcomes when albumin was not given after paracentesis with volume less than 5 liters (Evidence level IIb). Up to the present, no studies have proven a direct survival benefit or a decrease in readmission rate with intravenous albumin infusion after therapeutic paracentesis.

並列關鍵字

albumin ； paracentesis ； cirrhosis ； systemic review