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肝肾综合征|肝肾综合征的治疗进展( 四 )


7. 总结与展望
肝肾综合征是失代偿期肝硬化的严重并发症之一，发病率和病死率均较高 。随着对肝肾综合征病理生理学机制的研究逐步深入，其诊治策略得以不断发展，患者生存率有所改善 。肝肾综合征的治疗主要包括一般支持治疗、药物治疗、RRT、MARS、TIPS和肝移植等 。一般支持治疗主要包括扩容、监测尿量和血流动力学指标、积极去除或减轻诱因等 。目前的药物治疗方案是白蛋白联用血管活性药物，通过扩容和改善内脏动脉血管收缩来改善肾脏血流灌注 。特利加压素是首选的血管活性药物；无法使用特利加压素时可考虑奥曲肽联用米多君、去甲肾上腺素等 。白蛋白联合血管活性药物治疗无效的肝肾综合征患者，尤其是伴有酸中毒、电解质紊乱等情况时，应考虑使用RRT 。MARS及TIPS同样可以作为肝移植术前的过渡期治疗手段 。目前，肝移植仍然是肝肾综合征治疗的最终解决方案，其他治疗方法可作为肝移植术前的过渡期治疗，目的在于改善肾功能，为手术创造条件，降低手术风险 。对于eGFR等于或小于30 ml/min、蛋白尿＞2 g/d或肾活检病理提示间质纤维化或肾小球硬化的肝肾综合征患者，应考虑肝肾联合移植而非单纯的肝移植 。但是，器官来源不足的现象长期存在，严重制约了肝移植的临床应用，未来尚需进一步探索新的替代方案 。
参考文献：
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万十千, 万学发, 朱清静, 等. 高低剂量特利加压素治疗肝硬化合并1型肝肾综合征的比较研究［J］. 中华肝脏病杂志, 2014, 22(5): 349-353.
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