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DETERMINATION OF PHYSICAL AND CHEMICAL PROPERTIES OF BLOOD PLASMA AND ASCETIC FLUID IN PATIENTS WITH LIVER CIRRHOSIS

DETERMINATION OF PHYSICAL AND CHEMICAL PROPERTIES OF BLOOD PLASMA AND ASCETIC FLUID IN PATIENTS WITH LIVER CIRRHOSIS
Alexander Dzygal, candidate of medicine

Odessa National Medical University, Ukraine

Championship participant: the National Research Analytics Championship - "Ukraine";

With the aim of individual treatment strategy selection authors studied proteins content as well as both blood plasma and ascites chemical properties characteristics in patients with liver cirrhosis at different stages of its intensity. 262 patients with liver cirrhosis were divided into 4 groups according to diagnostic examination results which revealed different severity of the pathological process in the liver parenchyma. Proteins level, total bilirubin content, the average mass molecules, the residual nitrogen, urea, creatinine, ALT, AST, alkaline phosphatase, cholesterol and lecithin concentrations were determined in blood plasma and ascites of patients with liver cirrhosis. The data obtained reveal protein homeostasis disturbance, atherogenic lipoproteins levels increase that induce hepatocytes membrane structure failure in patients with liver cirrhosis at all stages. Ascites detected components correlated with the liver parenchyma degree of functional activity disturbances. The authors conclude that homeostasis disorders established in patients with liver cirrhosis complicated by ascites should be taken into account in cases of surgical tactics performing out.

Keywords: liver cirrhosis, ascite, proteins, endotoxicosis, pathogenetic treatment, surgical treatment individual tactic

 

Introduction. Treatment of patients with liver cirrhosis (LC) and its complications remains one of the most difficult problems of surgery, including surgical hepatology and biliary surgery. According to WHO, the LC rate is steadily increasing [1, 2]. As to the results of autopsy, it ranges from 1 to 11% [3-5].

Unfavorable high incidence of LC morbidity as described above, due to rising incidence of acute viral hepatitis, especially due to viral hepatitis types B, C and D, results in marked chronic inflammatory and destructive process in the liver parenchyma [6, 7] with the formation of LC and other complications [7, 8].

It should also be noted that the development of inflammatory and destructive lesions of the liver with the formation of LC is brought about by adverse environmental conditions, contact with hepatotropic poisons, alcoholism as well as drug addiction. Viral hepatites play an important part in increasing the incidence of LC, as it was shown that chronic pathological process in the liver during the first year is 15 - 22.7% in patients with viral hepatitis B and C [2]. In prolongation of the course of viral hepatitis B – for about 3-5 years - the chronic process is observed in 40.9% of patients and in 74.4% of patients with hepatitis C. It is shown that on an average 20-30% of these patients develop liver cirrhosis, and about 20% of the disease is transformed into cancer [2, 3, 9].

Therefore, adverse environmental conditions, consistently high level of alcoholism, drug addiction growth, reinforced by economic difficulties, promote the growth of the liver disease as well as in general organs of the gastro-duodeno-hepatobiliary system, as it is the leader in the maintenance and regulation of homeostasis. A severe course of the disease, prognosis, and - in most cases - failure of treatment makes this disease the most important in modern surgery. It is clear that specific surgical techniques should be used for these patients as well as individual approach, on the basis of which an individual treatment strategy should be devised. Therefore, we made a series of retrospective calculations and traced quantitative content of blood proteins, and a number of other compounds that determine peculiarities of the course of endotoxic reactions in blood and ascetic fluid (AF) in patients with LC in comparative perspective study.

Objective. Investigation of proteins and determination of chemical properties characteristic of blood plasma and AF in patients with LC in different stages of its intensity in the comparative perspective study to select individual tactics of further treatment.

Materials and methods. 262 patients with LC have been treated aged from 36 to 69 For the last 7 years. There were 164 (62.6%) women and 98 (37.4%) men. The age of 67 patients (25.6%) was over 40, the age of 97 patients (37.0%) was over 50, and the age of 56 patients (21.4%) was over 60.

The diagnosis of LC was made on the basis of clinical examination of patients, blood chemistry, ultrasound of the organs of the hepatopancreatoduodenal area, CT, endoscopic retrograde pancreatocholangiography, etc.

As a result of complex diagnostic examination and subsequent treatment, all patients were retrospectively divided into 4 groups: group 1 - patients with LC in the compensation stage (n = 33, 12.6%), the second group - patients with LC in the subcompensation (n = 152, 58.0%), 3 group - patients with LC in the decompensated stage (n = 61, 23.3%) and 4 group - patients with LC in the critical terminal stage (n = 16, 6.1.0%). The control group consisted of 19 healthy individuals without liver disease, having a professional medical examination.

Conventional methods determined the content of proteins (albumin, globulins), and total bilirubin, the molecules of medial weight (MMW), residual nitrogen, urea, creatinine, ALT, AST, alkaline phosphatase, cholesterol and lecithin in the blood plasma and AF of patients with LC. The results obtained in patients at the time of admission to the surgical hospital before treatment have been analyzed. The results were treated statistically. Differences were considered statistically significant in p <0.05.

Results and discussion.

The data are presented in tables. While analyzing quantitative characteristic of blood plasma proteins and AF in patients with LC at different stages of its manifestation, it was clear that the main studied indices did not differ significantly from those we have received in the follow-up studies (Table 1, p> 0.05) in patients of 1 group.  So, considering the figures the number of proteins and other investigated compounds (Table 2), it is clear that the relative compensation of its function is characteristic of patients with the first stage of the pathological process in the hepatic parenchyma in absence of an active destructive (alternating) process, which is expressed predominantly by maintaining protein-synthesizing function, but there is observed lipid metabolism disorder and moderate chronic intoxication.

The patients with LC at the subcompensation stage are characterized by a moderate activation of the liver with a clear decrease in the protein-synthesizing function, mainly due to albumin - globulin imbalance (Table 1), with development of chronic intoxication. AF of these patients is observed to reduction of protein, and decrease in plasma results in significantly greater loss of its concentration in the blood due to extravasation. The content of toxic compounds (bilirubin, nitrogen-containing components) had a tendency to increase, but was statistically identical with the corresponding data in healthy patients.

61 patients with LC in the decompensated stage were clearly traced dysproteinemia. In general, deep dysfunction of the liver accompanied by the development of cholestasis and cytolysis, hypo- and dysproteinemia, nitrogen- and fermentemia, etc is  characteristic of this group of patients (Table. 1 and 2). AF in these patients was characterized by protein reduction - almost 2.5-3.0 times (p <0.01). So this is the consequence of protein-synthetic disorder of the liver.

Data on disorder of homeostasis of cholesterol and related lipid-containing components are of interest as their concentration increased in the patients of the 3rd examined group. We explain this by the fact that accumulation of low-density and very low densitylipoproteids that are responsible for removing cholesterol from the membrane causes the development of destructive changes in the hepatocyte membrane, which is the pathophysiological basis for further progression of the pathological process in LC. It is likely that one of the possible directions of pathogenetically grounded therapy in patients with LC is the use of hypolipid therapy.

Another interesting aspect that can be seen in Tables 1 and 2 is the content of the studied compounds in AF of patients with LC. Thus, the same components of the body homeostasis are in AF, such as blood plasma (sometimes even in bigger amount), making AF an adequate plasma component replacement in LC and in its progression to liver failure. Having a significant antiatherogenic potential AF should be determined before certain complex of hypolipid therapy in its repeated use.

Hypo- and dysproteinemia were marked in the blood of 16 patients in the terminal stage of the disease. The protein content in AF was also significantly reduced. Clinical symptoms were predominant during the examination of such patients - development of edema of the lower extremities, cachexia, severe cardiovascular and pulmonary insufficiency, presence of transsudate in the pleural cavity, etc.

Summarizing these data, it should indicated that all stages of LC, which are complicated by the presence of ascites, are characterized by the disorder of protein homeostasis, increased content of atherogenic lipoproteins in the blood and consequent changes in the structure of hepatocyte membranes. Key studied indices of AF correlated (r = 0.69-0.87) with the degree of functional activity of the liver parenchyma. The above indices of disturbed homeostasis of the corresponding patients should be taken into account in the development of surgical treatment of patients with LC complicated by ascites.

Table 1

Quantitative characteristic of blood plasma proteins and ascetic fluid (АF) in patients with liver cirrhosis in different stages of its manifestation

Manifestationstage of liver cirrhosisin treated patients

Site of determination

General concentration, g/l
M±m

Ratio of albumin /
globulin

General

protein

Albumins

Globulins

Alpha

Beta

Gamma

1

2

 

 

Control indices (blood plasma), n=19

77.7±7.3

48.2±5.6

4.5±0.4

6.5±0.5

12.7±1.4

14.1±1.6

1.4±0.1

Іstage,

n=33

Blood plasma

62.9±6.9

34.8±4.1

6.8±0.9

10.7±1.3

11.3±1.5

19.4±2.0

1.0

АF

44.6±4.5

33.8±3.6

-

-

-

-

-

ІІstage, n=152

Blood plasma

57.1±4.9

28.9±3.2

5.2±0.7

11.3±1.4

12.7±1.7

22.1±2.3

0.9

АF

31.1±2.9

21.9±2.4

-

-

-

-

-

ІІІstage, n=61

Blood plasma

54.7±5.0

20.4±2.4

4.6±0.5

8.9±0.8

12.9±1.7

23.5±2.4

0.8

АF

19,7±2,3

-

-

-

-

-

-

ІV stage,

n= 16

Blood plasma

43.7±4.4

18.3±2.1

5.2±0.5

8.6±0.8

13.1±1.7

30.6±3.1

0.6

АF

3.1±0.4

-

-

-

-

-

-

 

 

Table2

Comparative characteristic of chemical properties of blood plasma and ascetic fluid (АF) in patients with liver cirrhosis in different stages of its manifestation

Manifestationstage of liver cirrhosisin treated patients

Site of determination

Total bilirubin, mcmol/l

МСМ, (од)

Residual nitrogen, mmol/l

Urea, mmol/l

Creatinine, mmol/l

ALT, mcmol/l

AST, mcmol/l

Alkaline phosphatase, U/l

Cholesterol,mmol/l

Lecithin, mmol/l

Control indices (blood plasma), n=19

15.6±±3.3

208±20

16.5±1.8

5.1±0.6

0.08±0.01

0.56±0.04

0.34±0.03

44.7±4.1

5.1±0.5

1.7±0.2

Іstage, n=152

Blood plasma

18.6±2.2

245±25

18.1±1,9

5.1±0.5

0.06±0.01

0.26±0.02

0.30±0.02

62.1±5.7

4.4±0.3

1.4±0.1

АF

5.9±0.6

90±8

6.7±0.7

2.1±0.2

-

0.19±0.02

0.16±0.02

-

3.0±0.3

1.0±0.1

ІІstage, n=152

Blood plasma

33.7±3.4

300±29

26.4±2.3

5.5±0.5

0.08±0.01

0.62±0.05

0.91±0.08

69.8±7.1

3.7±0.4

5.0±0.4

АF

18,.1.2.1

210±19

21.1±2.0

3.0±0.3

-

0.24±0.02

0.21±0.02

-

2,4±0.3

0.7±0.1

ІІІ stage, n=61

Blood plasma

89.4±8.8

600±56

36.7±3.2

9.1±0.8

1.00±0.01

0.56±0.06

0.54±0.05

104.4±9.3

7.6±0.7

3.1±0.2

АF

38.4±4.1

390±40

26.4±2.9

5.9±0.5

-

0.45±0.04

0.31±0.03

-

3.6±0.3

0.8±0.1

ІV stage,

n= 16

Blood plasma

15.1±1.3

-

21.4±2.2

7.3±0.7

0.07±0.01

0.23±0.02

0.37±0.04

109±9.7

3.1±0.3

2.2±0.2

АF

9.1±0.8

-

17.8±1.8

4.6±0.4

-

0.21±0.02

0.16±0.02

-

3.0±0.3

0.6±0.1

 

References:

  • 1. Alekseeva I.N., Bruzhyna T.N., Pavlovich S.I., Ylchevych A.B.  The liver and immunologic reactivity. Kiev, 1991. - 150 p.
  • 2. Andreev G.N., Borisov A.E, Ybadyldyn A.S. et al. Pathogenesis, diagnosis and treatment of liver cirrhosis, complicated by refractory ascites.-B. Novgorod, 1999.- 191 p.
  • 3. Eramyshantsev A.S., Manukyan G.V. "Today" and "tomorrow" of surgery of portal hypertension: look at the problem. // Annales of surg. hepatol. -1998.- V., №2.-p. 72-75.
  • 4. Ybadyldyn A.S, Treatment of refractory ascites in patients with portal hypertension // Health protection of Kazakhstan. - 1987. № 6. - p. 40-42.
  • 5. Ybadyldyn A.S., Andreev G.N., Borisov A.E. Polysyndrom of liver cirrhosis. Novgorod, 1999. - 196 p.
  • 6. Abdukadurova M.A. Hepatitis C virus - one of the main ecologic factors of chronic hepatitis // Chronic diseases of the liver from hepatitis to liver cirrhosis - Tashkent, 1996. - p. 4-5.
  • 7. Frolov V.M., Petrunya A.M., Pinskij L.L. State of microhemodynamics and immune status in patients with chronic viral hepatic  affections and their correction // Vrachebnoe delo. 1996. -№ 10-12.-p. 144-146.
  • 8. Chesnokov E.V., Kaszuba E.A.  Chronic hepatitis and liver cirrhosis of viral aetiology. - Tyumen, 2000. - 286 p.
  • 9. Gentilini P., La-Villa G., Romanelli R.C. et al. Pathogenesis and treatment of ascites in hepatic cirrhosis // Cardiology. 1994. - V. 84. - № 2. -p. 68-79.
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Your rating: None Average: 6.3 (6 votes)
Comments: 5

Tegza Alexandra

Hеблагоприятные условия окружающей среды, неизменно высокий уровень алкоголизма, рост наркомании, подкрепленные экономическими трудностями, способствуют росту заболевания печени, а также в общих органах желудочно-дуодено-гепатобилиарной системы, так как она является лидером в техническое обслуживание и регулирование гомеостаза. Серьезные течение болезни, прогноз, и - в большинстве случаев - отказ лечения делает это заболевание наиболее важным в современной хирургии. Вами изучен патогенез социального заболевания. Результаты исследований статистически обработаны. Выводы точны и значимы для клинической практики! Дальнейших Вам научных успехов ! С уважением Александра Тегза

Vashadze Shorena

Dear Alexander Dzygal thank you for enormous work you have done to determine protein imbalance in patients with LC. It was very interesting to read accumulation of LDL and VLDL is a physiological basis for further progression of the pathological process in LC and pathologically grounded therapy in patients with LC is the use of hypo-lipid therapy. Thank you for the extraordinary work you have done. Prof . Shorena Vashadze .

Vacheva Danelina

Уважаемый доктор Дзыгал, тема Вашей статьи относятся к социально значимому заболеванию печени. Вы исследовали большое количество пациентов и параметры плазмы крови, а выводы были сделаны после точной статистической обработки! Я желаю Вам успехов в клинической и научной работе! доц. Данелина Вачева, д.м.

Hryhorenko Liubov Victorovna

Уважаемый Александр! Работа очень актуальная, своевременная и показательная в условиях нашего региона. Изучались ли вами факторы риска и проводилась ли кореляционная связь между возрастом и полом и частотой заболеваемости циррозом печени. Мне как гигиенисту а не хирургу понятно что женщины больше пьют в вашей когорте пациентов и чаще болеют циррозом печени, чем мужчины. Наличие абсцесса усложняет течение заболевания, следовательно большой процент осложнений свидетельствует в первую очередь о плохих показателях работы стационара, если брать Возовские показатели.Что с этим делать, как улучшать ппоказатели и проводить первичную профилактику.С уважением Григоренко Любовь Викторовна

Kokolova Luidmila

В научном исследовании авторы изучении белка в плазме крови у больных с циррозом печени на различных стадиях его интенсивности. Полученные данные показывают, белок анормального гомеостаза, уровни атерогенных липопротеинов, которые вызывают увеличение гепатоцитов мембран недостаточность структуры у больных с циррозом печени на всех этапах. Авторы пришли к выводу, что нарушения гомеостаза, установленные у пациентов с циррозом печени, осложненным асцитом следует принимать во внимание в случаях хирургической тактики выполнения вне.
Comments: 5

Tegza Alexandra

Hеблагоприятные условия окружающей среды, неизменно высокий уровень алкоголизма, рост наркомании, подкрепленные экономическими трудностями, способствуют росту заболевания печени, а также в общих органах желудочно-дуодено-гепатобилиарной системы, так как она является лидером в техническое обслуживание и регулирование гомеостаза. Серьезные течение болезни, прогноз, и - в большинстве случаев - отказ лечения делает это заболевание наиболее важным в современной хирургии. Вами изучен патогенез социального заболевания. Результаты исследований статистически обработаны. Выводы точны и значимы для клинической практики! Дальнейших Вам научных успехов ! С уважением Александра Тегза

Vashadze Shorena

Dear Alexander Dzygal thank you for enormous work you have done to determine protein imbalance in patients with LC. It was very interesting to read accumulation of LDL and VLDL is a physiological basis for further progression of the pathological process in LC and pathologically grounded therapy in patients with LC is the use of hypo-lipid therapy. Thank you for the extraordinary work you have done. Prof . Shorena Vashadze .

Vacheva Danelina

Уважаемый доктор Дзыгал, тема Вашей статьи относятся к социально значимому заболеванию печени. Вы исследовали большое количество пациентов и параметры плазмы крови, а выводы были сделаны после точной статистической обработки! Я желаю Вам успехов в клинической и научной работе! доц. Данелина Вачева, д.м.

Hryhorenko Liubov Victorovna

Уважаемый Александр! Работа очень актуальная, своевременная и показательная в условиях нашего региона. Изучались ли вами факторы риска и проводилась ли кореляционная связь между возрастом и полом и частотой заболеваемости циррозом печени. Мне как гигиенисту а не хирургу понятно что женщины больше пьют в вашей когорте пациентов и чаще болеют циррозом печени, чем мужчины. Наличие абсцесса усложняет течение заболевания, следовательно большой процент осложнений свидетельствует в первую очередь о плохих показателях работы стационара, если брать Возовские показатели.Что с этим делать, как улучшать ппоказатели и проводить первичную профилактику.С уважением Григоренко Любовь Викторовна

Kokolova Luidmila

В научном исследовании авторы изучении белка в плазме крови у больных с циррозом печени на различных стадиях его интенсивности. Полученные данные показывают, белок анормального гомеостаза, уровни атерогенных липопротеинов, которые вызывают увеличение гепатоцитов мембран недостаточность структуры у больных с циррозом печени на всех этапах. Авторы пришли к выводу, что нарушения гомеостаза, установленные у пациентов с циррозом печени, осложненным асцитом следует принимать во внимание в случаях хирургической тактики выполнения вне.
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