The special session on ascites due to liver cirrhosis was ended successfully

Speech by Professor Xu Xiaoyuan

      Esther Fages Contel, Director of East Asia Affairs of Kirifax, mentioned that many patients around the world were affected by cirrhosis and its related complications, which led to a serious decline in the quality of life, with Chinese patients accounting for up to 50%. It is believed that this meeting can promote the development of liver cirrhosis and its related complications in China, bring good news to more patients, provide better treatment plans, and provide good learning and exchange opportunities for experts and scholars.

Speech by Esther Fages Contel

      In the international frontier academic part, Professor Paolo Angeli elaborated on the latest progress of ascites management in patients with liver cirrhosis. He believes that endogenous systemic vasoactive factors and sodium retention molecules increase in cirrhosis. The diagnostic criteria of EASL CLIF were cirrhosis, acute decompensation, progression of organ failure and 28 day mortality>15%. Organ failure often occurs during systemic inflammation, and may also occur when the plasma renin concentration (PRC) is normal.

      The types of decompensated cirrhosis patients: acute chronic liver failure (ACLF), unstable decompensated cirrhosis (UDC) and stable decompensated cirrhosis (SDC). During one year,50%of outpatients with liver cirrhosis may develop chronic acute liver failure. Plasma expander should be used after a large amount of fluid is discharged from abdominal puncture. TIPS and intraperitoneal puncture can be used to treat refractory or recurrent ascites with good safety, but TIPS cannot be used for more than 50% of patients with refractory ascites. Small diameter PTEF covered stent is recommended to reduce the risk of TIPS stent dysfunction and hepatic encephalopathy. Human serum albumin can protect the cells of liver cells. Long term use of albumin can effectively prevent stubborn ascites and other complications, and improve the survival rate of patients with ascites who respond to treatment.

Lecture by Professor Paolo Angeli

      Professor Mauro Bernardi shared the new definition of decompensated cirrhosis. Acute decompensated cirrhosis is a newly defined stage of development in the natural history of the disease. The inducements of acute decompensated cirrhosis include bacterial infection, severe alcoholic infection, gastrointestinal hemorrhage with shock and toxic encephalopathy. CANONIC and PREDICT studies show that about 1/4 of patients with compensatory cirrhosis will suffer from acute decompensation. Diagnostic criteria for acute decompensation: patients with grade 2 or 3 ascites for the first time or relapse within 2 weeks, and patients with normal past consciousness first or repeatedly have hepatic encephalopathy, acute gastrointestinal bleeding, and any type of acute bacterial infection. Diagnostic criteria for non acute decompensation: progressive jaundice in patients with slow ascites formation, mild grade 1 or 2 hepatic encephalopathy and non cholestatic cirrhosis.

      Liver cirrhosis recompensation is a new stage of disease development. At this time, there are no signs related to liver cirrhosis decompensation events. Successful etiological treatment is related to the improvement of liver fibrosis and portal hypertension. No disease correction treatment is required, and new clinical decompensation events may occur. However, no decompensation events occur within at least 1 year after drug withdrawal, so it is necessary to carefully consider discontinuing non β Receptor blockers.

Lecture by Professor Mauro Bernardi

      In the academic part of "Voice of China", Professor Ding Huiguo introduced the AASLD/AISF guidelines on the diagnosis and management of ascites and complications in cirrhotic patients in China in 2017 and 2021 from the perspective of clinical practice. Professor Ding believes that according to the three guidelines, the diagnosis and evaluation of ascites due to cirrhosis, hepatorenal syndrome, acute renal injury and ascites examination are similar. The differences lie in the diuretic dose, initial drug selection, definition of refractory ascites, albumin and LVP, and salt restriction and hyponatremia. Liver cirrhosis is the most common cause of ascites in the world. Other potential causes include malignant tumors, heart failure, pulmonary tuberculosis and pancreatic diseases. SAAG, PMN, Cultures and Protein concentration should be evaluated for patients with initial ascites.

      Tovaptan and terlipressin are recommended as second-line drugs. In 2017, Chinese guidelines recommended the treatment of HRS-AKI: continuous intravenous drip of terlipressin, with an initial dose of 2 mg/d to 12 mg/d; Human serum albumin (20-40g/d) improves the prognosis of patients with cirrhosis ascites and AKI-HRS. Clinical practice has proved that terlipressin has better efficacy and less response to kidney than other active drugs, but the data is limited. For refractory ascites, the maximum dose of spironolactone (160 mg/d)+furosemide (80 mg/d) is recommended in the Chinese guidelines in 2017. Albumin (20-40g/d) is used for patients with refractory ascites and spontaneous peritonitis, and the ascites is removed by puncture (4-5L) at the dose of 4g/L albumin. In patients with decompensated liver cirrhosis, there was no difference in the end point (such as death) between the use of more than 30g albumin and conventional treatment.

      In 2017, the Chinese guidelines recommended that patients with refractory ascites should limit their salt intake, which was 4-6 g/d per day. Tovaptan can improve the survival rate of patients with cirrhosis ascites and hyponatremia, and is an effective drainage drug for the treatment of cirrhosis ascites, especially hyponatremia. The initial dose was 15 mg/day, and the dose was adjusted according to the blood sodium level to avoid excessive aggravation of edema. The minimum dose is 3.75mg/day, and the maximum dose is 60mg/day.

Professor Ding Huiguo gives lectures

      During the symposium, Professor Xie Qing from Ruijin Hospital affiliated to Shanghai Jiaotong University Medical College and Professor You Hong from Beijing Friendship Hospital affiliated to Capital Medical University raised questions about the treatment of patients with liver cirrhosis based on their clinical experience and this expert lecture. Professor Fan Jiangao of Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine proposed the possible benefits and safety of statin in patients with cirrhosis ascites. Professor Xu Jinghang from the First Hospital of Peking University raised his doubts about the connection between liver cirrhosis and the heart.

      Professor Paolo Angeli believes that there are two points for attention in the use of albumin: first, sufficient amount to reach the blood concentration required by patients; Second, it needs to be used consistently for a long time. Simvastatin can prevent decompensation and bleeding of liver ascites.

      Professor Mauro Bernardi said that the dosage and duration of albumin are different for different patients. In the process of long-term use of albumin, complications, bacterial infections and other situations should be considered. Level 2 or 3 ascites due to liver cirrhosis needs to be treated with diuretics. The recommended dosage of albumin is 80g/week, divided into two times, lasting for at least 3-4 months. If the condition is stable, the dosage can be adjusted, but the condition needs to be carefully observed. In the course of treatment, only by eliminating the causes can we truly achieve recompensation and improve the patient's condition.

      Professor Dou Xiaoguang from Shengjing Hospital affiliated to China Medical University said that acute decompensation rarely occurs in hepatitis B decompensated patients after etiological treatment, and the most critical factor for recurrence is infection, which should be paid attention to by clinicians. After recompensation, it is recommended that the amount of albumin used should be maintained at about 30g and checked once every 2-3 months to reduce the readmission rate of patients.

      Professor Nan Yuemin, from the Third Hospital of Hebei Medical University, stressed that we should pay attention to eliminating the causes of disease in clinical practice, such as alcohol, infection, drugs and drug withdrawal of hepatitis B virus, so as to manage, correct and use drugs in time. For recurrent ascites and intractable ascites, in addition to the use of albumin and diuretics, electrolyte, hepatic encephalopathy, infection and kidney injury type should also be considered. For elderly patients with cardiac or renal insufficiency, the use of albumin and fluid should be strictly controlled.

      Professor Yu Yanyan, the First Hospital of Peking University, said that through this meeting, the cognition related to liver cirrhosis was gradually accurate, which would also help clinicians to personalize and accurately control the progress of liver cirrhosis patients.

      Finally, Professor Jia Jidong, the chairman of the conference, summarized the wonderful contents of the conference. It is hoped that more experts and scholars will summarize their experience into evidence in the future, and then turn it into a clinical guide to better provide doctors with professional guidance and help more patients control their illness.