肝硬化患者静脉白蛋白输注期间下腔静脉即时超声血管内容量评估

IF 7.5 1区医学 Q1 GASTROENTEROLOGY & HEPATOLOGY

JHEP Reports Pub Date : 2025-08-20 DOI:10.1016/j.jhepr.2025.101559

Daniel Segna , Fabio Brazerol , Pompilia Radu , Gerard Angeles Fite , Jaime Bosch , Annalisa Berzigotti

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引用次数: 0

摘要

背景：目前的指南推荐在失代偿期肝硬化的不同适应症中静脉注射白蛋白，但越来越多的报道称，静脉注射白蛋白后会引起医源性高血容量。我们的目的是利用被动抬腿（PLR）和静脉注射白蛋白期间下腔静脉（IVC）的即时超声（POCUS）来表征血管内容量状态，这可能有助于临床管理和白蛋白剂量的调整。方法该前瞻性先导队列包括需要静脉注射白蛋白的失代偿性肝硬化患者。我们评估了PLR期间和静脉注射白蛋白后最小和最大静脉直径（分别为IVCmin和IVCmax）和溃散性指数（IVCCI）的变化。我们将严重的血管内容量过载定义为IVCmax >；2.1 cm和IVCCI >； 20%。临床结果记录至POCUS后3个月。结果我们纳入了55例患者的81项测量结果（70.9%为男性，中位年龄62岁，58.2%为酒精相关性肝硬化，Child-Pugh中位评分9分，89.1%为穿刺，中位静脉注射白蛋白40 g，腹水5.5 L）。我们发现，在PLR期间（平均[Δ] IVCmin +20.7%， Δ IVCmax +14.1%, p <0.01）和静脉注射白蛋白后（Δ IVCmin +58.8%， Δ IVCmax +48.2%, p <0.01）， IVC直径均显著增加。PLR期间IVCCI（相对Δ -11.1%, p <0.01）和静脉注射白蛋白后IVCCI（相对Δ -18.0%, p <0.01）显著降低。静脉注射白蛋白后发生17次（21%）潜在的严重血管内容量超载，女性比男性更频繁（40%比15.7%,p <0.01）， 1个月后静脉曲张出血的累积发生率更高（16.7%比0%，p = 0.01）和3个月后（18.2%比0%，p = 0.01）。结论1 / 5失代偿期肝硬化患者静脉注射白蛋白后可能出现严重的血管内容量超载。因此，有必要为失代偿肝硬化患者制定个体化容积管理策略。肝硬化患者输注白蛋白后的萎缩性容量过载是一种潜在的有害副作用，但迄今为止还没有建议使用非侵入性工具监测血管内容量过载的政策。在几乎五分之一的男性和十分之四的女性中检测到新发潜在容量过载，并与脑利钠肽n端激素原升高、白蛋白输注期间平均动脉压降低和血清钠水平升高有关。这项概念验证性研究的结果强调需要更大规模的前瞻性队列研究来验证我们的发现，并为失代偿期肝硬化患者引入个体化容积管理策略。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

Point-of-care ultrasound of the inferior vena cava for intravascular volume assessment during intravenous albumin infusion in patients with cirrhosis

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Point-of-care ultrasound of the inferior vena cava for intravascular volume assessment during intravenous albumin infusion in patients with cirrhosis

Background & Aims

Current guidelines recommend intravenous (i.v.) albumin for different indications in decompensated cirrhosis, but iatrogenic hypervolemia following i.v. albumin is increasingly reported. We aimed to characterize intravascular volume status using point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) during passive leg raise (PLR) and i.v. albumin, potentially facilitating clinical management and adjustment of albumin dosage.

Methods

This prospective pilot cohort included patients with decompensated cirrhosis requiring i.v. albumin. We assessed changes in minimal and maximal IVC diameters (IVC^min and IVC^max, respectively) and collapsibility index (IVCCI) during PLR and after i.v. albumin. We defined severe intravascular volume overload as IVC^max >2.1 cm and IVCCI <20%. Clinical outcomes were recorded until 3 months after POCUS.

Results

We included 81 measurements in 55 patients (70.9% men; median age 62 years; 58.2% alcohol-related cirrhosis; median Child-Pugh score 9 points; 89.1% paracentesis; median 40 g i.v. albumin; 5.5 L ascites). We found a significant increase in IVC diameters both during PLR (change in mean [Δ] IVC^min +20.7%, Δ IVC^max +14.1%, p <0.01) and after i.v. albumin (Δ IVC^min +58.8%, Δ IVC^max +48.2%, p <0.01). There was a significant decrease in IVCCI during PLR (relative Δ -11.1%, p <0.01) and after i.v. albumin (relative Δ -18.0%, p <0.01). Potential severe intravascular volume overload occurred on 17 occasions (21%) after i.v. albumin, more frequently in women than in men (40% vs. 15.7%, p <0.01), and showed higher cumulative incidence rates in variceal bleeding after 1 (16.7% vs. 0%, p = 0.01) and 3 months (18.2% vs. 0%, p = 0.01).

Conclusions

Potential severe intravascular volume overload after i.v. albumin was detected in every fifth patient with decompensated cirrhosis. Thus, there is a need to develop strategies for individualizing volume management in patients with decompensated cirrhosis.

Impact and implications

Iatrogenic volume overload after albumin infusions in patients with cirrhosis is a potentially harmful side effect, but no policy for monitoring intravascular volume overload using non-invasive tools has been suggested so far. New-onset potential volume overload was detected in almost one out of five men and four out of 10 women and was associated with increases in N-terminal prohormone of brain natriuretic peptide, lower mean arterial pressure during albumin infusion, and higher serum sodium levels. Our results from this proof-of-concept study emphasize the need for larger prospective cohort studies to validate our findings and introduce strategies for individualizing volume management in patients with decompensated cirrhosis.

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来源期刊

JHEP Reports GASTROENTEROLOGY & HEPATOLOGY-

CiteScore

12.40

自引率

2.40%

发文量

161

审稿时长

36 days

期刊介绍： JHEP Reports is an open access journal that is affiliated with the European Association for the Study of the Liver (EASL). It serves as a companion journal to the highly respected Journal of Hepatology. The primary objective of JHEP Reports is to publish original papers and reviews that contribute to the advancement of knowledge in the field of liver diseases. The journal covers a wide range of topics, including basic, translational, and clinical research. It also focuses on global issues in hepatology, with particular emphasis on areas such as clinical trials, novel diagnostics, precision medicine and therapeutics, cancer research, cellular and molecular studies, artificial intelligence, microbiome research, epidemiology, and cutting-edge technologies. In summary, JHEP Reports is dedicated to promoting scientific discoveries and innovations in liver diseases through the publication of high-quality research papers and reviews covering various aspects of hepatology.