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Dandavate V, Bolshette N, Van Drunen R, Manella G, Bueno-Levy H, Zerbib M, Kawano I, Golik M, Adamovich Y, Asher G. Hepatic BMAL1 and HIF1α regulate a time-dependent hypoxic response and prevent hepatopulmonary-like syndrome. Cell Metab 2024; 36:2038-2053.e5. [PMID: 39106859 DOI: 10.1016/j.cmet.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/28/2024] [Accepted: 07/05/2024] [Indexed: 08/09/2024]
Abstract
The transcriptional response to hypoxia is temporally regulated, yet the molecular underpinnings and physiological implications are unknown. We examined the roles of hepatic Bmal1 and Hif1α in the circadian response to hypoxia in mice. We found that the majority of the transcriptional response to hypoxia is dependent on either Bmal1 or Hif1α, through shared and distinct roles that are daytime determined. We further show that hypoxia-inducible factor (HIF)1α accumulation upon hypoxia is temporally regulated and Bmal1 dependent. Unexpectedly, mice lacking both hepatic Bmal1 and Hif1α are hypoxemic and exhibit increased mortality upon hypoxic exposure in a daytime-dependent manner. These mice display mild liver dysfunction with pulmonary vasodilation likely due to extracellular signaling regulated kinase (ERK) activation, endothelial nitric oxide synthase, and nitric oxide accumulation in lungs, suggestive of hepatopulmonary syndrome. Our findings indicate that hepatic BMAL1 and HIF1α are key time-dependent regulators of the hypoxic response and can provide molecular insights into the pathophysiology of hepatopulmonary syndrome.
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Affiliation(s)
- Vaishnavi Dandavate
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Nityanand Bolshette
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Rachel Van Drunen
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Gal Manella
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Hanna Bueno-Levy
- Department of the Veterinary Resources, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Mirie Zerbib
- Department of the Veterinary Resources, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Ippei Kawano
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Marina Golik
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Yaarit Adamovich
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Gad Asher
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel.
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2
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Robert F, Certain MC, Baron A, Thuillet R, Duhaut L, Ottaviani M, Chelgham MK, Normand C, Berrebeh N, Ricard N, Furlan V, Desroches-Castan A, Gonzales E, Jacquemin E, Sitbon O, Humbert M, Bailly S, Coilly A, Guignabert C, Tu L, Savale L. Disrupted BMP-9 Signaling Impairs Pulmonary Vascular Integrity in Hepatopulmonary Syndrome. Am J Respir Crit Care Med 2024; 210:648-661. [PMID: 38626313 DOI: 10.1164/rccm.202307-1289oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/16/2024] [Indexed: 04/18/2024] Open
Abstract
Rationale: Hepatopulmonary syndrome (HPS) is a severe complication of liver diseases characterized by abnormal dilation of pulmonary vessels, resulting in impaired oxygenation. Recent research highlights the pivotal role of liver-produced BMP-9 (bone morphogenetic protein-9) in maintaining pulmonary vascular integrity. Objectives: This study aimed to investigate the involvement of BMP-9 in human and experimental HPS. Methods: Circulating BMP-9 levels were measured in 63 healthy control subjects and 203 patients with cirrhosis with or without HPS. Two animal models of portal hypertension were employed: common bile duct ligation with cirrhosis and long-term partial portal vein ligation without cirrhosis. Additionally, the therapeutic effect of low-dose BMP activator FK506 was investigated, and the pulmonary vascular phenotype of BMP-9-knockout rats was analyzed. Measurements and Main Results: Patients with HPS related to compensated cirrhosis exhibited lower levels of circulating BMP-9 compared with patients without HPS. Patients with severe cirrhosis exhibited consistently low levels of BMP-9. HPS characteristics were observed in animal models, including intrapulmonary vascular dilations and an increase in the alveolar-arterial gradient. HPS development in both rat models correlated with reduced intrahepatic BMP-9 expression, decreased circulating BMP-9 level and activity, and impaired pulmonary BMP-9 endothelial pathway. Daily treatment with FK506 for 2 weeks restored the BMP pathway in the lungs, alleviating intrapulmonary vascular dilations and improving gas exchange impairment. Furthermore, BMP-9-knockout rats displayed a pulmonary HPS phenotype, supporting its role in disease progression. Conclusions: The study findings suggest that portal hypertension-induced loss of BMP-9 signaling contributes to HPS development.
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Affiliation(s)
- Fabien Robert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Marie-Caroline Certain
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Audrey Baron
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Raphaël Thuillet
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Léa Duhaut
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
| | - Mina Ottaviani
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Mustapha Kamel Chelgham
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Corinne Normand
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Nihel Berrebeh
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Nicolas Ricard
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Valerie Furlan
- Service de pharmacologie-toxicologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Agnès Desroches-Castan
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Emmanuel Gonzales
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Emmanuel Jacquemin
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabine Bailly
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Audrey Coilly
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
| | - Christophe Guignabert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Ly Tu
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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3
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Qasim A, Jyala A, Shrivastava S, Allena N, Ghazanfar H, Bhatt V, Ali HR, Vakde T, Patel H. Hepatopulmonary Syndrome: A Comprehensive Review. Cureus 2024; 16:e65204. [PMID: 39176346 PMCID: PMC11340781 DOI: 10.7759/cureus.65204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 08/24/2024] Open
Abstract
Hepatopulmonary syndrome (HPS) is defined by abnormally dilated blood vessels and shunts within the lungs, leading to impaired oxygen exchange. This condition results from intricate interactions between the liver, the gastrointestinal system, and the lungs. This complex system primarily affects pulmonary endothelial, immunomodulatory, and respiratory epithelial cells. Consequently, this contributes to pathological pulmonary changes characteristic of HPS. A classification system based on the severity of oxygen deficiency has been proposed for grading the physiological dysfunction of HPS. Contrast-enhanced echocardiography is considered the primary radiological evaluation for identifying abnormal blood vessel dilations within the lungs, which, combined with an elevated alveolar-arterial gradient, is essential for making the diagnosis. Liver transplantation is the sole effective definitive treatment that can reverse the course of the condition. Despite often being symptomless, HPS carries a significant risk of mortality before transplantation, regardless of the severity of liver disease. Meanwhile, there is varying data regarding survival rates following liver transplantation. The adoption of the model for end-stage liver disease (MELD) standard exception policy has notably improved the results for individuals with HPS compared to the period before MELD was introduced. This review offers a summary of the present understanding, highlighting recent advancements in the diagnosis and treatment of HPS. Furthermore, it aims to augment comprehension of the condition's fundamental mechanisms through insights derived from experimental models and translational research.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, New York, USA
| | | | | | - Nishant Allena
- Pulmonary Medicine, BronxCare Health System, New York, USA
| | | | | | - Husnain R Ali
- Medicine, American University of the Caribbean School of Medicine, Miramar, USA
| | - Trupti Vakde
- Pulmonary and Critical Care, BronxCare Health System, New York, USA
| | - Harish Patel
- Internal Medicine, BronxCare Health System, New York, USA
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4
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Zhao X, Kotha S, Nayyar D, Ma X, Lilly L, Castel H, Gupta S. Physiologic changes in the hepatopulmonary syndrome before and after liver transplant: A longitudinal and predictor analysis. Hepatology 2024; 79:636-649. [PMID: 37732952 PMCID: PMC10871618 DOI: 10.1097/hep.0000000000000605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. APPROACH AND RESULTS This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: -3.7 (-6.4, -0.96) mm Hg/year for partial pressure of arterial oxygen (PaO 2 ); -26 (-96, 44) m/year for 6-minute walk distance, and 3.3% (-6.6, -0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO 2 decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO 2 deterioration classes-"very severe disease, slow decliners" (PaO 2 45.0 mm Hg; -1.0 mm Hg/year); and "moderate disease, steady decliners" (PaO 2 65.5 mm Hg; -2.5 mm Hg/year). PaO 2 increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO 2 was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. CONCLUSIONS We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO 2 decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, McGill University, Montreal, Canada
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Dhruv Nayyar
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xiayi Ma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hélène Castel
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
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5
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Sayadi A, Duhaut L, Robert F, Savale L, Coilly A. [Hepatopulmonary syndrome]. Rev Med Interne 2024; 45:156-165. [PMID: 37005097 DOI: 10.1016/j.revmed.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
The hepatopulmonary syndrome (HPS) is one of the lung diseases associated with cirrhosis and portal hypertension. It should be discussed for any dyspnea in cirrhotic patients. HPS is a pulmonary vascular disease characterized by intrapulmonary vascular dilatations (IPVD). The pathogenesis is complex and seems to rely on communications between the portal and pulmonary circulations. The diagnosis is based on a triad of liver disease and portal hypertension, evidence of IPVDs, and impaired gas exchange (alveolar-arterial oxygen difference [A-aO2]≥15mmHg). HPS impairs prognosis (23% survival at 5years) and patients' quality of life. Liver transplantation (LT) allows regression of IPDVD in almost 100% of cases, normalization of gas exchange and improves survival with a 5-year post-LT survival between 76 and 87%. It is the only curative treatment, indicated in patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60mmHg. When LT is not indicated or feasible, long-term oxygen therapy may be proposed as a palliative treatment. A better understanding of the pathophysiological mechanisms is needed to improve the therapeutic possibilities in a near future.
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Affiliation(s)
- A Sayadi
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - L Duhaut
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - F Robert
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France
| | - L Savale
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France; Service de pneumologie, hôpital Bicêtre, université Paris-Saclay, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - A Coilly
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France.
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6
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Harden Waibel B, Kamien AJ. Resuscitation and Preparation of the Emergency General Surgery Patient. Surg Clin North Am 2023; 103:1061-1084. [PMID: 37838456 DOI: 10.1016/j.suc.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.
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Affiliation(s)
- Brett Harden Waibel
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
| | - Andrew James Kamien
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
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7
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Han SK, Baik SK, Kim MY. [Pulmonary Complications in Patients with Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:213-223. [PMID: 37997217 DOI: 10.4166/kjg.2023.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023]
Abstract
Portal hypertension is a clinical syndrome defined by an increased portal venous pressure. The most frequent cause of portal hypertension is liver cirrhosis, and many of the complications of cirrhosis, such as ascites and gastroesophageal variceal bleeding, are related to portal hypertension. Portal hypertension is a pathological condition caused by the accumulation of blood flow in the portal system. This blood flow retention reduces the effective circulation volume. To compensate for these changes, neurotransmitter hormone changes and metabolic abnormalities occur, which cause complications in organs other than the liver. A hepatic hydrothorax is fluid accumulation in the pleural space resulting from increased portal pressure. Hepatopulmonary syndrome and portopulmonary hypertension are the pulmonary complications in cirrhosis by deforming the vascular structure. Symptoms, such as dyspnea and hypoxia, affect the survival and the quality of life of patients. These lung complications are usually underestimated in the management of cirrhosis. This review briefly introduces the type of lung complications of cirrhosis.
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Affiliation(s)
- Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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8
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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9
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Igata S, Kono Y, Van Houten T, Hang CT, Cotter BR, Strachan MG, Morikawa N, DeMaria AN. Role of Quantitation of Saline Bubble Studies in Patients with Liver Cirrhosis. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1804-1810. [PMID: 37198087 DOI: 10.1016/j.ultrasmedbio.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Microbubble contrast echocardiography with a late positive signal enables the detection of intrapulmonary vascular dilation, including hepatopulmonary syndrome, in patients with end-stage liver disease. We assessed the relationship between the severity of bubble study and clinical outcome. METHODS We retrospectively analyzed 163 consecutive patients with liver cirrhosis who underwent an echocardiogram with bubble study from 2018 to 2021. Patients who were diagnosed with a late positive signal were divided into three groups: grade 1 (1-9 bubbles), grade 2 (10-30 bubbles) and grade 3 (>30 bubbles). RESULTS Fifty-six percent of the patients had a late positive bubble study (grade 1: 31%, grade 2: 23%, grade 3: 46%). Patients with grade 3 had a significantly higher international normalized ratio, model for end-stage liver disease score and Child-Pugh score and a lower peripheral oxygen saturation compared with patients with a negative study. In patients undergoing liver transplant (LT), survival rates were similar among the groups (3-mo: >87%, 1-y: >87%, 2-y: >83%). However, survival rate was lower in grade 3 patients without LT (3-mo: 81%, 1-y: 64%, 2-y: 39%). CONCLUSION Patients with grade 3 had much worse mortality without LT compared with other groups. However, after LT, all grades had equal survival. Therefore, patients with grade 3 may be considered as higher priority for LT.
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Affiliation(s)
- Sachiyo Igata
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA.
| | - Yuko Kono
- Division of Hepatology, Department of Medicine, University of California, San Diego, CA, USA
| | - Thomas Van Houten
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Calvin T Hang
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Bruno R Cotter
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Monet G Strachan
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Nagisa Morikawa
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Anthony N DeMaria
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
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10
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Arora GS, Javed H, Kaur P, Singh S. Hepatopulmonary Syndrome in a Patient With Autoimmune Hepatitis and Chronic Hepatitis C: A Case Report Highlighting Typical Echo Findings. Cureus 2023; 15:e41491. [PMID: 37484786 PMCID: PMC10359196 DOI: 10.7759/cureus.41491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 07/25/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is a rare complication of liver disease characterized by intrapulmonary vascular dilatations leading to arterial hypoxemia. We present the case of a 59-year-old female with a past medical history of bilateral breast cancer status post mastectomy who presented with progressive dyspnea on exertion and fatigue. A comprehensive diagnostic workup was conducted to exclude other cardiac, pulmonary, and systemic etiologies. She was diagnosed with autoimmune hepatitis along with chronic hepatitis C. Echocardiography revealed characteristic findings of intrapulmonary shunting characteristic of HPS. The patient showed improvement in pulmonary symptoms and oxygenation status following the initiation of steroid therapy. Although corticosteroids are not the definitive treatment for HPS, they were considered a supportive measure in this case. However, it is important to note that liver transplantation remains the definitive treatment for HPS. This case underscores the importance of echocardiography and the potential role of supportive measures, like corticosteroids, in managing HPS-related symptoms, particularly in patients with autoimmune hepatitis, as a bridging therapy while awaiting liver transplantation.
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Affiliation(s)
| | - Hamna Javed
- Internal Medicine, Saint Agnes Medical Center, Fresno, USA
| | - Parneet Kaur
- Internal Medicine, Suburban Community Hospital, Philadelphia, USA
| | - Simran Singh
- Internal Medicine, Jinnah Sindh Medical University (SMC), Karachi, PAK
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11
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Douschan P, Kovacs G, Sassmann T, Stadlbauer V, Avian A, Foris V, Tatscher E, Durchschein F, Rainer F, Spindelboeck W, Wagner M, Kniepeiss D, Zollner G, Bachmaier G, Fickert P, Olschewski H, Stauber RE. Pulmonary vascular disease and exercise hemodynamics in chronic liver disease. Respir Med 2022; 202:106987. [PMID: 36115317 DOI: 10.1016/j.rmed.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are severe pulmonary vascular complications of chronic liver disease and strongly associated with morbidity and mortality. The prevalence of these complications is relatively high in patients evaluated for liver transplantation, however it is virtually unknown in patients with stable chronic liver disease. METHODS We assessed the pulmonary hypertension (PH) and HPS prevalence in a prospective registry study of our liver out-patient clinic in a tertiary center. Between 2011 and 2016, consecutive patients with cirrhosis or non-cirrhotic portal hypertension were prospectively enrolled after written informed consent. We excluded patients with acute decompensation of liver disease and other causes of PH like severe chronic heart or lung diseases and chronic thromboembolic PH. HPS was diagnosed using contrast enhanced echocardiography and blood gas analysis. Patients were screened for PH using an algorithm implementing severity of dyspnea, echocardiography, cardiopulmonary exercise testing and exercise echocardiography employing a threshold of systolic pulmonary arterial pressure (SPAP) = 50 mmHg at peak exercise. If the algorithm indicated an increased PH risk, patients were invited for invasive investigations by means of right heart and hepatic vein catheter. We defined POPH as resting mPAP≥21 mmHg and PVR>3WU and PAWP<15 mmHg, mild PH as resting mPAP = 21-24 mmHg, and exercise PH as mPAP>30 mmHg and TPR >3 WU at peak exercise. RESULTS Two-hundred-five patients were enrolled (male 75%; cirrhosis 96%; median age 57 yrs). Sixty-seven patients (33%) fulfilled HPS criteria but only two (1.0%) for severe (PaO2:50-60 mmHg) or very severe HPS (PaO2<50 mmHg). In 18/77 patients (23%) undergoing exercise echocardiography, SPAP at peak exercise exceeded 50 mmHg. Finally, n = 3 (1.5%) patients were invasively diagnosed with POPH, n = 4 (2.9%) with mild PH and n = 2 with exercise PH. CONCLUSION In chronic liver disease, excluding acute decompensation and other causes of PH, POPH and severe HPS are rare findings while mild to moderate HPS and mild PH or exercise PH are more frequent.
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Affiliation(s)
- Philipp Douschan
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elisabeth Tatscher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Franziska Durchschein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
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12
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Kawut SM, Krowka MJ, Forde KA, Al-Naamani N, Krok KL, Patel M, Bartoli CR, Doyle M, Moutchia J, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB. Impact of hepatopulmonary syndrome in liver transplantation candidates and the role of angiogenesis. Eur Respir J 2022; 60:2102304. [PMID: 34949701 PMCID: PMC10967655 DOI: 10.1183/13993003.02304-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome affects 10-30% of patients with cirrhosis and portal hypertension. We evaluated the serum angiogenic profile of hepatopulmonary syndrome and assessed the clinical impact of hepatopulmonary syndrome in patients evaluated for liver transplantation. METHODS The Pulmonary Vascular Complications of Liver Disease 2 study was a multicentre, prospective cohort study of adults undergoing their first liver transplantation evaluation. Hepatopulmonary syndrome was defined as an alveolar-arterial oxygen gradient ≥15 mmHg (≥20 mmHg if age >64 years), positive contrast-enhanced transthoracic echocardiography and absence of lung disease. RESULTS We included 85 patients with hepatopulmonary syndrome and 146 patients without hepatopulmonary syndrome. Patients with hepatopulmonary syndrome had more complications of portal hypertension and slightly higher Model for End-Stage Liver Disease-Na score compared to those without hepatopulmonary syndrome (median (interquartile range) 15 (12-19) versus 14 (10-17), p=0.006). Hepatopulmonary syndrome patients had significantly lower 6-min walk distance and worse functional class. Hepatopulmonary syndrome patients had higher circulating angiopoietin 2, Tie2, tenascin C, tyrosine protein kinase Kit (c-Kit), vascular cell adhesion molecule 1 and von Willebrand factor levels, and lower E-selectin levels. Patients with hepatopulmonary syndrome had an increased risk of death (hazard ratio 1.80, 95% CI 1.03-3.16, p=0.04), which persisted despite adjustment for covariates (hazard ratio 1.79, 95% CI 1.02-3.15, p=0.04). This association did not vary based on levels of oxygenation, reflecting the severity of hepatopulmonary syndrome. CONCLUSION Hepatopulmonary syndrome was associated with a profile of abnormal systemic angiogenesis, worse exercise and functional capacity, and an overall increased risk of death.
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Affiliation(s)
- Steven M Kawut
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kimberly A Forde
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen L Krok
- Dept of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Dept of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiothoracic Surgery, Dept of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Margaret Doyle
- Dept of Pathology, University of Vermont, Burlington, VT, USA
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Raevens S, Boret M, Fallon MB. Hepatopulmonary syndrome. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100527. [PMID: 36035361 PMCID: PMC9403489 DOI: 10.1016/j.jhepr.2022.100527] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of liver disease, which adversely affects prognosis. The disease is characterised by intrapulmonary vascular dilatations and shunts, resulting in impaired gas exchange. A complex interaction between the liver, the gut and the lungs, predominately impacting pulmonary endothelial cells, immune cells and respiratory epithelial cells, is responsible for the development of typical pulmonary alterations seen in HPS. Liver transplantation is the only therapeutic option and generally reverses HPS. Since the implementation of the model for end-stage liver disease (MELD) standard exception policy, outcomes in patients with HPS have been significantly better than they were in the pre-MELD era. This review summarises current knowledge and highlights what’s new regarding the diagnosis and management of HPS, and our understanding of pathogenesis based on experimental models and translational studies.
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14
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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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15
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Gandhi KD, Taweesedt PT, Sharma M, Surani S. Hepatopulmonary syndrome: An update. World J Hepatol 2021; 13:1699-1706. [PMID: 34904039 PMCID: PMC8637683 DOI: 10.4254/wjh.v13.i11.1699] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/25/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized by defects in oxygenation caused by intra-pulmonary vasodilation occurring because of chronic liver disease, portal hypertension, or congenital portosystemic shunts. Clinical implications of portal hypertension are very well-known, however, awareness of its effect on multiple organs such as the lungs are less known. The presence of HPS in chronic liver disease is associated with increased mortality. Medical therapies available for HPS have not been proven effective and definitive treatment for HPS is mainly liver transplantation (LT). LT improves mortality for patients with HPS drastically. This article provides a review on the definition, clinical presentation, diagnosis, and management of HPS.
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Affiliation(s)
- Kejal D Gandhi
- Department of Internal Medicine, Medstar Washington Hospital Center/Georgetown University, Washigton, DC 20010, United States
| | - Pahnwat Tonya Taweesedt
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Munish Sharma
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University, Bryan, TX 78413, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
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16
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Rock NM, Beghetti M, Tissot C, Willi JP, Bouhabib M, McLin VA, Maggio ABR. Reliable Detection of Intrapulmonary Shunts Using Contrast-Enhanced Echocardiography in Children With Portal Hypertension or Portosystemic Shunt. J Pediatr Gastroenterol Nutr 2021; 73:73-79. [PMID: 33605662 DOI: 10.1097/mpg.0000000000003079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of this study was to analyze if contrast-enhanced echocardiography (CEE) is as reliable as lung perfusion scintigraphy (LPS) to detect intrapulmonary shunting (IPS) in children with portal hypertension (PHTN) or congenital/surgical portosystemic shunts (PSS) and to define the number of cardiac cycles required to exclude intrapulmonary shunting. METHODS Inclusion criteria for this cross-sectional study were: (1) presence of PHTN or PSS diagnosed on abdominal ultrasound, (2) technically valid saline contrast echocardiography, (3) lung perfusion scintigraphy within 6 months of CEE. The number of cardiac cycles between right atrial opacification and the arrival of contrast in the left atrium were counted. We analyzed our CEE data at three and five cardiac cycles and compared them with LPS results. RESULTS The study population was composed of 78 children (38 girls, 49%) ages 2.1-18.8 years (mean 9.8). Sixty-nine patients had PHTN (88%), and nine had a PSS (11%). Eleven subjects (14%) presented evidence of IPS on LPS. Peripheral oxygen saturation was lower in the subjects with IPS detected on LPS (95.3 ± 1.7% vs 99.0 ± 1.4%; P < 0.01). Comparison of LPS with CEE before three and five cardiac cycles showed that CEE is highly specific (95.7%) as early as three cardiac cycles with markedly better sensitivity (72.7%) when using five cardiac cycles. Furthermore, a negative study using five cardiac cycles ruled out IPS with a 95% negative predictive value. The cardiac cycle at which the bubbles appeared in the left atrium was inversely correlated to the shunt index measured using LPS (r = -0.563; P = 0.001). CONCLUSION CEE is sufficient for the screening of IPS in children with PHTN or congenital/surgical PSS, obviating the need for LPS.
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Affiliation(s)
- Nathalie M Rock
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Cécile Tissot
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | | | - Maya Bouhabib
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Valérie A McLin
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Albane B R Maggio
- Pediatric Sport Medicine and Obesity Care Program, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Switzerland
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17
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Nema R, Rajanna C, Ray A, Jadon RS, Vikram NK. When sitting suffocates: a rare cause of platypnoea-orthodeoxia syndrome. Breathe (Sheff) 2021; 16:200205. [PMID: 33664834 PMCID: PMC7910018 DOI: 10.1183/20734735.0205-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Platypnoea-orthodeoxia syndrome refers to shortness of breath and oxygen desaturation in an upright position. Ventilation/perfusion mismatch is a rare cause of the same. Herein, we report a case of bilateral lower lobe tuberculosis, causing platypnoea and orthodeoxia. https://bit.ly/3jhJEQ1.
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Affiliation(s)
- Rahul Nema
- Dept of Medicine, AIIMS New Delhi, New Delhi, India
| | | | - Animesh Ray
- Dept of Medicine, AIIMS New Delhi, New Delhi, India
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18
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Dobbermann H, Marquetand C, Marquardt JU, Reil JC. Echocardiographic evidence of an intrapulmonary shunt in a patient with severe liver cirrhosis. Clin Res Cardiol 2021; 110:1128-1131. [PMID: 33620503 PMCID: PMC8238719 DOI: 10.1007/s00392-021-01817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/03/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Henrike Dobbermann
- Klinik Für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Christoph Marquetand
- Klinik Für Innere Medizin II, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
| | - Jens U Marquardt
- Klinik Für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Jan-Christian Reil
- Klinik Für Innere Medizin II, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
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19
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Kim KY, Kim TH, Lee JM, Yi NJ, Kim HY, Moon JS, Ko JS. Clinical outcomes and risk factors of hepatopulmonary syndrome in children. Sci Rep 2021; 11:4134. [PMID: 33603173 PMCID: PMC7892858 DOI: 10.1038/s41598-021-83785-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is defined as three distinct features: liver disease, hypoxemia, and intrapulmonary vasodilation. The purpose of this study was to investigate the clinical outcomes of pediatric HPS and to identify the risk factors for HPS in children with biliary atresia (BA). We performed a retrospective cohort study of all children who were diagnosed with HPS between 2000 and 2018 at Seoul National University Hospital. The clinical features and outcomes of the 10 patients diagnosed with HPS were reviewed. To clarify the risk factors of HPS in patients with BA, we reviewed 120 patients diagnosed with BA. Underlying liver disease was BA in 8 patients, portal vein agenesis in 1 patient, and portal vein thrombosis in 1 patient. A total of 7 patients underwent liver transplantation (LT). Currently, all seven patients, including 3 patients with severe HPS, survived after LT. The prevalence of HPS in children with BA was 7%. Polysplenia/interrupted inferior vena was the only risk factor for HPS in BA patients in multivariate analysis. The Pediatric End-Stage Liver Disease score was not associated with the development of HPS. Children with severe HPS undergoing LT had excellent outcomes. Screening for HPS in children with BA is required regardless of the severity of liver diseases.
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Affiliation(s)
- Kwang Yeon Kim
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, Seoul, 110-769, Korea
| | - Tae Hyeong Kim
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, Seoul, 110-769, Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, Seoul, 110-769, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, Seoul, 110-769, Korea.
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20
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A novel application of pulmonary transit time to differentiate between benign and malignant pulmonary nodules using myocardial contrast echocardiography. Int J Cardiovasc Imaging 2020; 37:1215-1223. [PMID: 33231789 DOI: 10.1007/s10554-020-02104-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/08/2020] [Indexed: 10/22/2022]
Abstract
Malignant pulmonary nodules (PNs) are often accompanied by vascular dilatation and structural abnormalities. Pulmonary transit time (PTT) measurement by contrast echocardiograghy has used to assess the cardiopulmonary function and pulmonary vascular status, such as hepatopulmonary syndrome and pulmonary arteriovenous fistula, but has not yet been attempted in the diagnosis and differential diagnosis of PNs. The aim of this work was to evaluate the feasibility and performance of myocardial contrast echocardiography (MCE) for differentiating malignant PNs from benign ones. The study population consisted of 201 participant: 66 healthy participants, 65 patients with benign PNs and 70 patients with malignant PNs. Their clinical and conventional echocardiographic characteristics were collected. MCE with measurements of PTT were performed. There was no difference in age, sex, heart rate, blood pressure, smoking rate, background lung disease, pulmonary function, ECG, myocardial enzymes, cardiac size and function among the healthy participant, patients with benign and malignant PNs (P > 0.05). PTT did not differ significantly in patients with PNs of different sizes, nor did they differ in patients with PNs of different enhancement patterns (P > 0.05). However, the PTT were far shorter (about one half) in patients with malignant PNs than in patients with benign ones (1.88 ± 0.37 vs. 3.73 ± 0.35, P < 0.001). There was no significantly different between patients with benign PNs and healthy participant (3.73 ± 0.35 vs.3.89 ± 0.36, P > 0.05). The area under the receiver operating characteristics curve (AUC) of PTT was 0.99(0.978-1.009) in discriminating between benign and malignant PNs. The optimal cutoff value was 2.78 s, with a sensitivity of 98.52%, a specificity of 97.34%, and a accuracy of 97.69%. MCE had a powerful performance in differentiating between benign and malignant PNs, and a pulmonary circulation time of < 2.78 s indicated malignant PNs.
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21
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Raghunathan V, Mohan N, Dhaliwal M, Bhangui P, Vohra V, Soin AS. Pediatric liver transplantation in severe hepatopulmonary syndrome and use of inhaled nitric oxide for post-transplant hypoxemia-a single center experience. Pediatr Transplant 2020; 24:e13792. [PMID: 32881212 DOI: 10.1111/petr.13792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
Data on pediatric patients with HPS undergoing LT are limited. Our aim was to study the spectrum and outcomes of pediatric patients with HPS undergoing LDLT. The role ofiNO for post-LDLT refractory hypoxemia was also assessed. Patients (aged < 18 years) undergoing LT were retrospectively studied. HPS was diagnosed based on European Respiratory Society Taskforce 2004 criteria. HPS was graded based on oxygenation criteria and contrast-enhanced echocardiogram. Post-operative course was studied. Refractory post-operative hypoxemia was treated with iNO by institutionally developed protocol. 23/150 pediatric patients undergoing LDLT had HPS. BA was the most common underlying cause (52.2%). By oxygenation criteria, 6 (26.1%) had VS-HPS. VS-HPS was associated with longer LOS (p = .031) and prolonged oxygen requirement (p = .001) compared with other HPS patients. 4/6 patients with VS-HPS had pO2 < 45 mm Hg. Among these, 2 developed ICH post-operatively and 1 died. 3 developed refractory post-operative hypoxemia, successfully treated with iNO. Mean duration of iNO was 26.3 days. In the group of patients with HPS, the incidence of HAT and portal vein thrombosis was 17.3% and 4.3%, respectively. One year post-LDLT survival of patients with HPS was similar to non-HPS patients (86.9% vs 94.4%; p = .88). We concluded that, pediatric patients with VS-HPS, especially those with pre-operative pO2 < 45 mm Hg, have long and difficult post-LT course. Refractory postoperative hypoxemia can be successfully overcome with strategic use of iNO. Vigilant monitoring and good intensive care support are essential.
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Affiliation(s)
- Veena Raghunathan
- Department of Pediatric Critical Care, Medanta The Medicity, Gurgaon, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplant, Medanta The Medicity, Gurgaon, India
| | - Maninder Dhaliwal
- Department of Pediatric Critical Care, Medanta The Medicity, Gurgaon, India
| | - Prashant Bhangui
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
| | - Vijay Vohra
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
| | - Arvinder Singh Soin
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
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Pereira JLF, Galant LH, Rosa LHTD, Garcia E, BrandÃo ABDM, Marroni CA. CAPACITY OF EXERCISE AND SURVIVAL IN PATIENTS WITH CIRRHOSIS WITH AND WITHOUT HEPATOPULMONARY SYNDROME AFTER LIVER TRANSPLANTATION. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:262-266. [PMID: 32935745 DOI: 10.1590/s0004-2803.202000000-49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is a complication associated with cirrhosis that may contribute to worsening exercise capacity and reduced survival after liver transplantation (LT). OBJECTIVE To evaluate exercise capacity, complications and survival after LT in patients with cirrhosis and HPS and to compare these results with the results of patients with cirrhosis without HPS. METHODS A prospective cohort study, consisting initially of 178 patients, of whom 90 underwent LT (42 with HPS and 48 without HPS). A previous evaluation consisted of the six-minute walk test (6MWT), an exercise test and manovacuometry. Those who underwent LT were evaluated for the mechanical ventilation time (MV), noninvasive ventilation (NIV) use, and survival two years after the procedure. In the statistical analysis, we used the Kolmogorov-Smirnov test, Student's t-test, the linear association square test, and the Kaplan-Meier survival curve. The data were analyzed with the SPSS 16.00 program and considered significant at P<0.05. RESULTS The HPS group demonstrated a lower peak of oxygen consumption (VO2peak) (14.2±2.3 vs 17.6±2.6) P<0.001 and a shorter distance walked on the 6MWT (340.8±50.9 vs 416.5±91.4) P<0.001 before LT compared with the non-HPS group. The transplanted patients with HPS remained longer hours in MV (19.5±4.3 vs 12.5±3.3) P=0.02, required more NIV (12 vs 2) P=0.01, and had lower survival two years after the procedure (P=0.01) compared with the transplanted patients without HPS. CONCLUSION Patients with HPS had worse exercise capacity before LT, more complications and shorter survival after this procedure than patients without HPS.
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Affiliation(s)
- José Leonardo Faustini Pereira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Lucas Homercher Galant
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Luis Henrique Telles da Rosa
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação Ciências da Reabilitação, Porto Alegre, RS, Brasil
| | - Eduardo Garcia
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Cláudio Augusto Marroni
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
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Benz F, Mohr R, Tacke F, Roderburg C. Pulmonary Complications in Patients with Liver Cirrhosis. J Transl Int Med 2020; 8:150-158. [PMID: 33062591 PMCID: PMC7534492 DOI: 10.2478/jtim-2020-0024] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Patients with advanced chronic liver diseases, particularly with decompensated liver cirrhosis, can develop specific pulmonary complications independently of any pre-existing lung disease. Especially when dyspnea occurs in combination with liver cirrhosis, patients should be evaluated for hepato-pulmonary syndrome (HPS), porto-pulmonary hypertension (PPHT), hepatic hydrothorax and spontaneous bacterial empyema, which represent the clinically most relevant pulmonary complications of liver cirrhosis. Importantly, the pathophysiology, clinical features, diagnosis and the corresponding therapeutic options differ between these entities, highlighting the role of specific diagnostics in patients with liver cirrhosis who present with dyspnea. Liver transplantation may offer a curative therapy, including selected cases of HPS and PPHT. In this review article, we summarize the pathogenesis, clinical features, diagnostic algorithms and treatment options of the 4 specific pulmonary complications in patients with liver cirrhosis.
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Affiliation(s)
- Fabian Benz
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Raphael Mohr
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Frank Tacke
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Christoph Roderburg
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
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24
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Weinfurtner K, Forde K. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Current Status and Implications for Liver Transplantation. CURRENT HEPATOLOGY REPORTS 2020; 19:174-185. [PMID: 32905452 PMCID: PMC7473417 DOI: 10.1007/s11901-020-00532-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are both pulmonary vascular complications of advanced liver disease; however, these syndromes have distinct pathophysiology, clinical implications, and management. RECENT FINDINGS While both conditions are associated with portal hypertension, HPS results from diffuse pulmonary capillary vasodilation and PoPH results from vasoconstriction and vascular remodeling of pulmonary arteries. In HPS, no medical therapies clearly improve outcomes; however, patients have excellent post-LT outcomes with near uniform reversal of hypoxemia. In PoPH, several medical therapies used in idiopathic pulmonary hypertension have been shown improve pulmonary hemodynamics, symptoms, and potentially LT outcomes; however, further study is needed to determine best treatment regimens, long-term outcomes on medical therapy, and role of LT. SUMMARY While HPS results in severe hypoxemia that is usually reversible by LT, PoPH patients develop progressive pulmonary hypertension that may improve with medical therapy.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
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26
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Zhao H, Tsauo J, Zhang XW, Ma HY, Weng NN, Tang GS, Li X. Technetium-99m-labeled macroaggregated albumin lung perfusion scan for diagnosis of hepatopulmonary syndrome: A prospective study comparing brain uptake and whole-body uptake. World J Gastroenterol 2020; 26:1088-1097. [PMID: 32205999 PMCID: PMC7080996 DOI: 10.3748/wjg.v26.i10.1088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/06/2020] [Accepted: 01/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is an arterial oxygenation defect induced by intrapulmonary vascular dilatation (IPVD) in the setting of liver disease and/or portal hypertension. This syndrome occurs most often in cirrhotic patients (4%–32%) and has been shown to be detrimental to functional status, quality of life, and survival. The diagnosis of HPS in the setting of liver disease and/or portal hypertension requires the demonstration of IPVD (i.e., diffuse or localized abnormally dilated pulmonary capillaries and pulmonary and pleural arteriovenous communications) and arterial oxygenation defects, preferably by contrast-enhanced echocardiography and measurement of the alveolar-arterial oxygen gradient, respectively.
AIM To compare brain and whole-body uptake of technetium for diagnosing HPS.
METHODS Sixty-nine patients with chronic liver disease and/or portal hypertension were prospectively included. Brain uptake and whole-body uptake were calculated using the geometric mean of technetium counts in the brain and lungs and in the entire body and lungs, respectively.
RESULTS Thirty-two (46%) patients had IPVD as detected by contrast-enhanced echocardiography. The demographics and clinical characteristics of the patients with and without IPVD were not significantly different with the exception of the creatinine level (0.71 ± 0.18 mg/dL vs 0.83 ± 0.23 mg/dL; P = 0.041), alveolar-arterial oxygen gradient (23.2 ± 13.3 mmHg vs 16.4 ± 14.1 mmHg; P = 0.043), and arterial partial pressure of oxygen (81.0 ± 12.1 mmHg vs 90.1 ± 12.8 mmHg; P = 0.004). Whole-body uptake was significantly higher in patients with IPVD than in patients without IPVD (48.0% ± 6.1% vs 40.1% ± 8.1%; P = 0.001). The area under the curve of whole-body uptake for detecting IPVD was significantly higher than that of brain uptake (0.75 vs 0.54; P = 0.025). The optimal cut-off values of brain uptake and whole-body uptake for detecting IPVD were 5.7% and 42.5%, respectively, based on Youden’s index. The sensitivity, specificity, and accuracy of brain uptake > 5.7% and whole-body uptake > 42.5% for detecting IPVD were 23%, 89%, and 59% and 100%, 52%, and 74%, respectively.
CONCLUSION Whole-body uptake is superior to brain uptake for diagnosing HPS.
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Affiliation(s)
- He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao-Wu Zhang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Huai-Yuan Ma
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ning-Na Weng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Gong-Shun Tang
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Alipour Z, Armin A, Mohamadi S, Tabib SM, Azizmohammadi Z, Gholamrezanezhad A, Assadi M. Hepatopulmonary Syndrome with Right-to-left Shunt in Cirrhotic Patients Using Macro-Aggregated Albumin Lung Perfusion Scan: Comparison with Contrast Echocardiography and Association with Clinical Data. Mol Imaging Radionucl Ther 2020; 29:1-6. [PMID: 32079381 PMCID: PMC7057731 DOI: 10.4274/mirt.galenos.2019.30301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objectives: The diagnosis of hepatopulmonary syndrome (HPS) which is a common complication in cirrhotic patients is still subject to debate. This study investigated the association of clinical findings with HPS in cirrhotic patients using macro-aggregated albumin lung perfusion scan (99mTc-MAA lung scintigraphy). In addition, comparison between 99mTc-MAA lung scintigraphy and contrast echocardiography (CEE) in detection of HPS was also performed. Methods: In this study, 27 patients with cirrhosis underwent 99mTc-MAA lung scintigraphy and contrast echocardiography comparison CEE and the frequency of HPS was assessed in them and also was compared across the other variables. Results: The 99mTc-MAA lung scintigraphy showed HPS in 13 patients (48.1%) while CEE demonstrated HPS in 5 patients with cirrhosis (18.51%). HPS was mild in 40.74% (11/27) of the patients, and severe in only 2 patients. There was no relationship between gender, disease duration, having diagnosis of disease previously, pulmonary symptoms and Child-Pugh score variations and HPS (p>0.05). Comparison of hemodynamic indices, arterial blood gas analysis and laboratory indices between patients with and without HPS was also non-significant (p value >0.05). Among coagulation factors assessed in cirrhotic patients, we found only significant correlation between HPS and prothrombin time (p<0.05). Conclusion: HPS, particularly its mild form, is noted in a great number of patients with cirrhosis using 99mTc-MAA lung scintigraphy. Because of its technical ease, and possibility to obtain objective quantitative information, 99mTc-MAA lung scintigraphy can be complementary to other diagnostic methods in the evaluation of HPS assessment, although additional studies are needed.
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Affiliation(s)
- Zeynab Alipour
- Bushehr University of Medical Sciences, Bushehr Medical Center Hospital, Department of Internal Medicine, Division of Gastroenterology, Bushehr, Iran
| | - Abbas Armin
- Bushehr University of Medical Sciences, Bushehr Medical Center Hospital, Department of Internal Medicine, Division of Gastroenterology, Bushehr, Iran
| | - Sudabeh Mohamadi
- Bushehr University of Medical Sciences, Faculty of Medicine, Department of Community Medicine, Bushehr, Iran
| | - Seyed Masoud Tabib
- Bushehr University of Medical Sciences, Bushehr Medical Center Hospital, Department of Internal Medicine, Division of Gastroenterology, Bushehr, Iran
| | - Zahra Azizmohammadi
- Shahid Beheshti University of Medical Sciences, Imam Hossein Hospital, Department of Nuclear Medicine, Tehran, Iran
| | - Ali Gholamrezanezhad
- University of Southern California, Keck School of Medicine, Department of Diagnostic Radiology, Los Angeles, USA
| | - Majid Assadi
- Bushehr University of Medical Sciences, Bushehr Medical University Hospital, The Persian Gulf Nuclear Medicine Research Center, Department of Molecular Imaging and Radionuclide Therapy (MIRT), Bushehr, Iran
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Gouvea AD, Fischer CH, Arakaki JSO, Mancuso FJ, Brant P, Moisés VA, Campos Filho O. Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis. Arq Bras Cardiol 2019; 113:915-922. [PMID: 31596323 PMCID: PMC7020964 DOI: 10.5935/abc.20190200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 02/13/2019] [Indexed: 11/20/2022] Open
Abstract
Background Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis. Objective To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS. Methods cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student’s t-test and the chi-square test (p < 0.05). Results cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09). Conclusion In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.
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Affiliation(s)
- Aparecida de Gouvea
- Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, SP - Brazil
| | | | | | | | - Paulo Brant
- Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, SP - Brazil
| | | | - Orlando Campos Filho
- Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, SP - Brazil
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Miura S, Fukushiro M, Yamaguchi K, Endo A, Tanabe K. Hepatopulmonary syndrome presenting as unexplained dyspnea after ventricular septal defect closure. J Echocardiogr 2019; 19:56-57. [PMID: 31452074 DOI: 10.1007/s12574-019-00439-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Shigeyoshi Miura
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Michito Fukushiro
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Kazuto Yamaguchi
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Akihiro Endo
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Kazuaki Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan.
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Tsauo J, Zhao H, Zhang X, Ma H, Jiang M, Weng N, Li X. Changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome. Eur Radiol 2019; 29:3273-3280. [PMID: 30506220 DOI: 10.1007/s00330-018-5840-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/18/2018] [Accepted: 10/19/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome (BCS) patients with hepatopulmonary syndrome (HPS). METHODS From June 2014 to June 2015, all patients with BCS who underwent balloon angioplasty or transjugular intrahepatic portosystemic shunt (TIPS) creation at our institution were eligible for inclusion in this study. Arterial blood gas analysis was performed with the patient in an upright position and breathing room air at 2-3 days and 1 and 3 months after the procedure. RESULTS Eleven patients with HPS and 14 patients without HPS were included in this study. The procedure was technically successful in 24 patients. One patient with HPS had technically unsuccessful TIPS creation. Reobstruction or TIPS dysfunction was not detected in any patient within 3 months after the procedure. For patients with HPS, the alveolar-arterial oxygen gradient (A-aO2) remained comparable to baseline 2-3 days after the procedure (-3.2 ± 11.9 mmHg; p = .412), significantly improved 1 month after the procedure (-11.7 ± 6.4 mmHg; p < .001), and then returned to baseline 3 months after the procedure (-1.3 ± 12.5 mmHg; p = .757). For patients without HPS, the A-aO2 remained comparable to baseline at all three time points after the procedure (+1.4 ± 8.3 mmHg, +3.5 ± 8.1 mmHg, and +1.3 ± 8.2 mmHg; p = .543, p = .137, and p = .565). CONCLUSIONS Arterial oxygenation transiently improves after portal decompression in BCS patients with HPS. KEY POINTS • Intrapulmonary vascular dilation and hepatopulmonary syndrome are common in patients with Budd-Chiari syndrome. • Arterial oxygenation transiently improves after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Xiaowu Zhang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Huaiyuan Ma
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Mingshan Jiang
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ningna Weng
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Jin X, Sun BJ, Song JK, Roh JH, Jang JY, Kim DH, Lim YS, Song JM, Kang DH, Lee SG. Time-dependent reversal of significant intrapulmonary shunt after liver transplantation. Korean J Intern Med 2019; 34:510-518. [PMID: 29502364 PMCID: PMC6506742 DOI: 10.3904/kjim.2017.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/18/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS Although the association between intrapulmonary shunt (IPS) and liver cirrhosis is clear, data of repeated contrast echocardiography (CE) before and after liver transplantation (LT) to evaluate factors associated with IPS are limited. METHODS Hand-agitated saline was used for CE and, by assessing left-chamber opacification, IPS was classified as grade 0 to 4. Grade 3/4 constituted significant IPS and hepatopulmonary syndrome (HPS) was defined as significant IPS with the arterial partial pressure of oxygen < 70 mmHg. RESULTS Before LT, 253 patients underwent CE and the frequency of significant IPS and HPS were 44% (n = 112) and 7% (n = 17), respectively. Child-Pugh score (odds ratio [OR], 1.345; 95% confidence interval [CI], 1.090 to 1.660; p = 0.006) and arterial oxygen content (OR, 0.838; 95% CI, 0.708 to 0.991; p = 0.039) were independent determinants of significant IPS, whereas direct bilirubin (OR, 1.076; 95% CI, 1.012 to 1.144; p = 0.019) was the only variable associated with HPS. Among 153 patients who underwent successful LT, repeated CE was performed in 97 (63%), which showed significant reductions in IPS grade (from 2.6 ± 1.0 to 1.2 ± 1.3, p < 0.001) and the prevalence of significant IPS (from 56% to 20%, p = 0.038). After adjustment for pre-LT IPS grade, time from LT to repeated CE presented negative linear relationship with post-LT IPS grade (r 2 = 0.366, p < 0.001) and was the only determinant of post-LT IPS grade (OR, 1.009; 95% CI, 1.003 to 1.014; p = 0.004). CONCLUSION Repeated CE is useful to evaluate intrapulmonary vascular change before and after LT. Reversal of IPS after successful LT is time-dependent and follow-up duration should be considered for accurate assessment of IPS after LT.
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Affiliation(s)
- Xin Jin
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Joo Sun
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Kwan Song
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Jae-Kwan Song, M.D. Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2- 3010-3155 Fax: +82-2-486-5918 E-mail:
| | - Jae-Hyung Roh
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Yoon Jang
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong-Min Song
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Hyun Kang
- Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Xiang W, Wang H, Si ZZ, Chen GS, Wang GW, Li T. Type I congenital extrahepatic portosystemic shunt treated by orthotopic liver transplantation: A case report. World J Clin Cases 2019; 7:903-907. [PMID: 31024963 PMCID: PMC6473130 DOI: 10.12998/wjcc.v7.i7.903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/24/2019] [Accepted: 02/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Congenital extrahepatic portosystemic shunt, also known as Abernethy deformation, is a rare malformation caused by dysplasia in the portal vein system. There are few reports of liver transplantation as a treatment for Abernethy deformation, and our report is the first case in China. This is the second reported case with congenital extrahepatic portosystemic shunt combined with focal nodular hyperplasia and hepatopulmonary treated with liver transplantation.
CASE SUMMARY The patient was a 14-year-old girl, diagnosed preoperatively as type Ib Abernethy deformation, intrahepatic multiple space-occupying lesion, and hepatopulmonary syndrome. The patient recovered well after undergoing classic orthotopic liver transplantation. Liver function, pulmonary function, and portal vein computed tomography angiography imaging were reexamined 20 mo postoperatively, and no abnormality was observed.
CONCLUSION Liver transplantation is an effective treatment for type I Abernethy deformation combined with focal nodular hyperplasia and hepatopulmonary syndrome.
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Affiliation(s)
- Wen Xiang
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Hao Wang
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Zhong-Zhou Si
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Guang-Shun Chen
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Guan-Wu Wang
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Ting Li
- Organ Transplantation Center, The Second Xiang-Ya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Tsauo J, Zhao H, Zhang X, Ma H, Jiang M, Weng N, Li X. Effect of Transjugular Intrahepatic Portosystemic Shunt Creation on Pulmonary Gas Exchange in Patients with Hepatopulmonary Syndrome: A Prospective Study. J Vasc Interv Radiol 2019; 30:170-177. [PMID: 30717947 DOI: 10.1016/j.jvir.2018.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To evaluate effect of transjugular intrahepatic portosystemic shunt (TIPS) creation on pulmonary gas exchange in patients with hepatopulmonary syndrome (HPS). MATERIALS AND METHODS All patients with cirrhosis or Budd-Chiari syndrome undergoing elective TIPS creation at a single institution between June 2014 and June 2015 were eligible for inclusion. Twenty-three patients with HPS (age 55.0 y ± 14.4; 11 men; Model for End-Stage Liver Disease score 10.2 ± 2.7) who achieved technical success were included in the analysis. Diagnosis of HPS was established by contrast-enhanced echocardiography demonstrating intrapulmonary vascular dilatation and arterial blood gas analysis demonstrating arterial oxygenation defects. RESULTS Mean portosystemic gradient was reduced from 21.7 mm Hg ± 8.3 before TIPS creation to 10.8 mm Hg ± 5.1 after TIPS creation. Among the 5 (21.7%) patients who experienced dyspnea, 4 (80.0%) reported improvement after TIPS creation. This improvement was not maintained at 3 months after TIPS creation in 2 (50.0%) patients. Compared with before TIPS creation, mean change in alveolar-arterial oxygen gradient for patients with HPS was statistically significant at 1 month (-9.2 mm Hg ± 8.0; P < .001) after TIPS creation, but not at 2-3 days (-0.9 mm Hg ± 10.5; P = .678) or 3 months (-3.4 mm Hg ± 11.8; P = .179) after TIPS creation. CONCLUSIONS TIPS creation can transiently improve pulmonary gas exchange in patients with HPS.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaowu Zhang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huaiyuan Ma
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingshan Jiang
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ningna Weng
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Prevalence and characteristics of hepatopulmonary syndrome in children with cirrhosis in southern Brazil. Eur J Gastroenterol Hepatol 2019; 31:10-15. [PMID: 30045096 DOI: 10.1097/meg.0000000000001207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is defined as a triad characterized by arterial deoxygenation, intrapulmonary vascular dilatations (IPVDs), and liver disorder. The aims of this study were to assess the prevalence of HPS in children with cirrhosis, the clinical characteristics of patients with HPS, and the tests used for the diagnosis of IPVD. PATIENTS AND METHODS This was a prospective, cross-sectional study of 40 children with cirrhosis (median age: 44 months). Investigations of HPS included arterial blood gas analysis, contrast-enhanced transthoracic echocardiography (CE-TTE), and perfusion lung scanning using technetium-99m-labeled macroaggregated albumin (Tc-MMA). Patients' clinical characteristics (age, etiology of cirrhosis, and severity of hepatopathy) were assessed. HPS was defined as liver disease; alveolar-arterial oxygen gradient of at least 15 mmHg and/or partial pressure of arterial oxygen less than 80 mmHg; and detection of IPVD by CE-TTE or Tc-MMA scanning. Statistical significance was indicated by a P value less than 0.05. RESULTS The prevalence of HPS was 42.5% (17/40). Eight patients had moderate HPS (47%) and two patients had severe HPS (12%). In bivariate analysis, biliary atresia (P=0.033) and median age (10 months; P=0.005) were associated with HPS. In multivariate analysis, only age remained statistically significant (prevalence ratio=0.99; 95% confidence interval=0.98-0.99; P=0.010). Sixteen patients with HPS had IPVD detected by CE-TTE (94.1%) and six patients had IPVD detected by Tc-MMA scanning (35.3%), with no significant agreement between these methods (κ=-0.12; P=0.163). CONCLUSION HPS is a common complication of cirrhosis in children. A combination of clinical and imaging criteria should be used to diagnose HPS.
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Forde KA, Fallon MB, Krowka MJ, Sprys M, Goldberg DS, Krok KL, Patel M, Lin G, Oh JK, Mottram CD, Scanlon PD, Kawut SM. Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation. Hepatology 2019; 69:270-281. [PMID: 30070715 PMCID: PMC6652183 DOI: 10.1002/hep.30139] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 06/05/2018] [Indexed: 01/02/2023]
Abstract
Screening for hepatopulmonary syndrome (HPS) using pulse oximetry is recommended in liver transplant (LT) candidates because mortality is increased, independently of the severity of the oxygenation defect. LT exception points may be afforded to those with HPS and severe hypoxemia. We assessed the screening characteristics of pulse oximetry for HPS. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study of adults undergoing their first LT evaluation. Patients underwent protocolized assessment of oxygen saturation by pulse oximetry (SpO2 ), arterial blood gas, spirometry, and contrast-enhanced echocardiography (CE). HPS was defined as an alveolar-arterial gradient ≥15 mm Hg (≥20 mm Hg if age >64 years), intrapulmonary vascular dilatation on CE, and absence of lung disease. The study sample included 363 patients. Of these, 75 (20.7%; 95% confidence interval [CI], 16.6%-25.2%) met the criteria for HPS. The area under the receiver operating characteristic curve (or c-statistic) for SpO2 in discriminating HPS was 0.59 (95% CI, 0.51-0.66). An SpO2 <96%, recommended by practice guidelines as a threshold to require further testing, had low sensitivity (28%; 95% CI, 18%-28%). The c-statistic of SpO2 in discriminating HPS with a partial pressure of oxygen (PaO2 ) <60 mm Hg (eligible for LT exception points) was 0.76 (95% CI, 0.46-1.00). An SpO2 cutoff of <96% had higher sensitivity for detecting HPS with PaO2 <60 mm Hg (71%; 95% CI, 38%-100%) but was still inadequate. Conclusion: Pulse oximetry is not sufficiently sensitive to screen for HPS in LT candidates. Arterial blood gas and CE are required in LT candidates for diagnosis of HPS.
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Affiliation(s)
- Kimberly A. Forde
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Michael Sprys
- Department of Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S. Goldberg
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen L. Krok
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K. Oh
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Steven M. Kawut
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lejealle C, Paradis V, Bruno O, de Raucourt E, Francoz C, Soubrane O, Lebrec D, Bedossa P, Valla D, Mal H, Vilgrain V, Durand F, Rautou PE. Evidence for an Association Between Intrahepatic Vascular Changes and the Development of Hepatopulmonary Syndrome. Chest 2019; 155:123-136. [DOI: 10.1016/j.chest.2018.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/21/2018] [Accepted: 09/05/2018] [Indexed: 02/06/2023] Open
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Riou M, Jutant EM, Mignard X, Canuet M, Humbert M, Sitbon O, Savale L, Montani D. Hépatopathies et maladies vasculaires pulmonaires. Rev Med Interne 2018; 39:925-934. [DOI: 10.1016/j.revmed.2018.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 12/26/2022]
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Zhao H, Tsauo J, Zhang X, Ma H, Weng N, Wang L, Li X. Pulmonary transit time derived from pulmonary angiography for the diagnosis of hepatopulmonary syndrome. Liver Int 2018; 38:1974-1981. [PMID: 29573542 DOI: 10.1111/liv.13741] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/12/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS Pulmonary transit time (PTT) is the transit time of blood from the right side of the heart to the left side of the heart. The aim of the present study was to evaluate the role of the PTT derived from pulmonary angiography in the diagnosis of hepatopulmonary syndrome (HPS). METHODS From December 2014 to September 2015, all patients with chronic liver disease and/or portal hypertension undergoing a venous interventional radiologic procedure at our institution were eligible for inclusion in this prospective study. Pulmonary angiography was performed in all patients, and the PTT, which was defined as the time between opacification of the pulmonary trunk and the right border of the left atrium, was determined. RESULTS A total of 53 patients were included, 20 of whom had a positive contrast-enhanced echocardiography result and an elevated alveolar-arterial oxygen gradient were considered to have HPS. PTT was significantly shorter in patients with HPS than in those without [median, 3.34 (interquartile range, 3.01-3.67) seconds vs 4.0 (interquartile range, 3.67-4.17) seconds; P < .001]. The area under the receiver operating characteristic curve of PTT for diagnosing HPS was 0.83 (95% confidence interval, 0.70-0.92). The optimal cut-off value of PTT for diagnosing HPS, based on Youden's index, was 3.55 seconds. The sensitivity, specificity and accuracy of PTT < 3.55 seconds for diagnosing HPS were 70%, 85% and 79% respectively. CONCLUSIONS Pulmonary transit time derived from pulmonary angiography is useful for diagnosing HPS, especially for patients with intracardiac shunts and inadequate echocardiographic windows.
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Affiliation(s)
- He Zhao
- Department of Interventional Therapy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaowu Zhang
- Department of Interventional Therapy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huaiyuan Ma
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ningna Weng
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Screening for Hepatopulmonary Syndrome in Cirrhotic Patients Using Technetium 99m-macroaggregated Albumin Perfusion Lung Scan (Tc-MAA): Diagnostic Approach and Clinical Correlations. J Clin Gastroenterol 2018; 52:828-834. [PMID: 28961571 DOI: 10.1097/mcg.0000000000000926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The aims of this study were to prospectively screen cirrhotic patients with arterial blood gas test and albumin perfusion scan, identify those fulfilling the classic hepatopulmonary syndrome (HPS) criteria, correlate with clinical parameters, and evaluate the survival of patients with HPS compared with those without HPS in a genetically homogenous Cretan cirrhotic population. MATERIALS AND METHODS Data on consecutive 102 patients within 1 year were collected and analyzed. All patients underwent a technetium 99m-macroaggregated albumin perfusion lung scan (Tc-MAA). Diagnosis of HPS was based on the presence of the quantitative index Tc-MAA≥6% and a [P(A-a)O2]≥15 mm Hg (≥20 mm Hg for patients over >64 y). RESULTS In 94/102 patients, complete scintigraphic data were available. In total, 24 (26%) patients fulfilled the diagnostic criteria of HPS; 95.8% of them had mild-to-moderate HPS. In 8 patients the Tc-MAA scintigraphy could not be interpreted. There was no difference in HPS between decompensated (24.6%) and compensated cirrhosis (27.3%). In the multivariate analysis only the quantitative index was significant for the diagnosis of HPS (P=0.001, odds ratio; 95% confidence interval, 7.05; 2.27-21.87). Kaplan- Meier survival curves indicated a similar overall prognosis for patients diagnosed with HPS (P=0.105). CONCLUSIONS HPS is a frequent complication of cirrhosis. Mild-to-moderate HPS has no significant effect on survival of cirrhotic patients. The quantitative Tc-MAA test is a reliable tool for diagnosis.
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Nuzzo A, Dautry R, Francoz C, Logeart D, Mégarbane B. Hepatopulmonary syndrome-attributed extreme hypoxemia and polycythemia revealing liver cirrhosis. Am J Emerg Med 2018; 37:175.e1-175.e2. [PMID: 30269997 DOI: 10.1016/j.ajem.2018.09.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
We report an unusual case of severe hepatopulmonary syndrome with previously unrecognized cirrhosis, presenting with acute on chronic dyspnoea, extreme hypoxemia, secondary polycythemia as well as direct identification of arteriovenous communications on computed tomography angiography. Hepatopulmonary syndrome, defined as the combination of hepatopathy, arterial deoxygenation and pulmonary vascular dilatation, is increasingly recognized as a life-threatening complication in advanced liver disease and transplant candidacy. It is usually diagnosed in chronic liver disease patients following pre-transplant evaluation or mild dyspnea investigation. Diagnosis relies on the indirect evidence of pulmonary arteriovenous communications suggested by echocardiography with a bubble study. Clinicians need to be aware of this rare but potential acute presentation at the emergency room.
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Affiliation(s)
- Alexandre Nuzzo
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, APHP, France; Paris-Diderot University, France.
| | - Raphael Dautry
- Paris-Diderot University, France; Department of Radiology, Lariboisière Hospital, APHP, France
| | - Claire Francoz
- Department of Hepatology, Beaujon Hospital, APHP, France
| | - Damien Logeart
- Paris-Diderot University, France; Department of Cardiology, Lariboisière Hospital, APHP, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, APHP, France; Paris-Diderot University, France; INSERM UMRS-1144, Paris, France
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1571] [Impact Index Per Article: 261.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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An Unusual Case of Refractory Hypoxia on the ICU. Case Rep Crit Care 2018; 2018:3417259. [PMID: 29850271 PMCID: PMC5932523 DOI: 10.1155/2018/3417259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/08/2018] [Indexed: 11/23/2022] Open
Abstract
We present the case of a 68-year-old gentleman who presented with breathlessness and was found to have NSTEMI, pulmonary oedema, and hypoxia. He remained hypoxic despite appropriate treatment and was found to have preserved LV function and raised cardiac output. CT pulmonary angiogram was negative but a cirrhotic liver was incidentally noted and later confirmed via ultrasound. Bedside examination was positive for orthodeoxia, suggesting a diagnosis of hepatopulmonary syndrome (HPS). The finding of significant intrapulmonary shunting on “bubble” echocardiography confirmed the diagnosis. This patient did not have previously diagnosed liver disease and had largely normal LFTs when the diagnosis was first suspected. We discuss HPS in the context of ICU and suggest how it may be screened for using simple tests. There is no correlation between the presence of HPS and severity of liver disease, yet we believe this is the first reported adult case of HPS on the ICU without previously diagnosed cirrhosis.
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The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
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Impact of Bacterial Translocation on Hepatopulmonary Syndrome: A Prospective Observational Study. Dig Dis Sci 2018; 63:248-256. [PMID: 29192374 DOI: 10.1007/s10620-017-4868-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Hepatopulmonary syndrome (HPS) is characterized by a defect in oxygenation induced by pulmonary vascular dilatation in cirrhosis. While severe HPS is responsible for a high rate of mortality, the prevalence and pathophysiology of HPS are not fully elucidated. We evaluated the prevalence and pathophysiology of HPS in patients with cirrhosis. METHODS A total of 142 patients with cirrhosis who underwent saline-agitated contrast echocardiography were enrolled in this prospective observational study. HPS was defined by positive findings on contrast echocardiography, cirrhosis, and the presence of an oxygenation defect (alveolar-arterial oxygen gradient > 15 mmHg). HPS grades from 0 to 3 were assigned based on the density and spatial distribution of microbubbles in the left ventricle. The primary endpoint was the prevalence of HPS. The secondary endpoints included clinical characteristics and levels of lipopolysaccharide (LPS), LPS-binding protein (LBP), nitric oxide, and endothelin-1 in HPS. RESULTS Fifty-nine patients (41.5%) were diagnosed with HPS (grade 1: 24, grade 2: 23, and grade 3: 12 patients). The mean levels of LPS (0.36 ± 0.02, 1.02 ± 0.18, 2.86 ± 0.77, and 6.56 ± 1.46 EU/mL, p < 0.001) and LBP (7026 ± 3336, 11,445 ± 1247, 11,947 ± 1164, and 13,791 ± 2032 ng/mL, p = 0.045) were found to be increased according to HPS grade (negative, grade 1-3). Endothelin-1 levels were significantly elevated according to HPS grade (1.83 ± 0.17, 2.62 ± 0.22, 3.69 ± 0.28, and 4.29 ± 0.34 pg/mL, p < 0.001), demonstrating a significant difference between each grade (p < 0.05). CONCLUSIONS HPS is a common complication with a prevalence of 41.5% in patients with cirrhosis. Bacterial translocation and portal pulmonary vascular dilatation are key mechanism involved in the progression of HPS.
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Davies T, Wythe S, O'Beirne J, Martin D, Gilbert-Kawai E. Review article: the role of the microcirculation in liver cirrhosis. Aliment Pharmacol Ther 2017; 46:825-835. [PMID: 29023881 DOI: 10.1111/apt.14279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 04/11/2017] [Accepted: 08/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis of multiple organ failure in end stage liver cirrhosis. AIM To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation. METHODS A Medline literature search was conducted using the following search terms: 'cirrhosis', 'microcirculation', 'circulation', 'systemic', 'inflammation', 'peripheral', 'hepatorenal' and 'hepatopulmonary'. RESULTS Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood. CONCLUSIONS Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy.
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Affiliation(s)
- T Davies
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - S Wythe
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - J O'Beirne
- Department of Hepatology, Nambour General Hospital, Sunshine Coast Hospital and Health Service, Nambour, Qld, Australia
| | - D Martin
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - E Gilbert-Kawai
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
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Thick section reformatted computed tomography images are useful for the diagnosis of hepatopulmonary syndrome: A case report. MARMARA MEDICAL JOURNAL 2017. [DOI: 10.5472/marumj.370862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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DuBrock HM, Krowka MJ, Forde KA, Krok K, Patel M, Sharkoski T, Sprys M, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB, Kawut SM. Clinical Impact of Intrapulmonary Vascular Dilatation in Candidates for Liver Transplant. Chest 2017; 153:414-426. [PMID: 28987478 DOI: 10.1016/j.chest.2017.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/17/2017] [Accepted: 09/06/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intrapulmonary vascular dilatations (IPVD) frequently are detected in patients with liver disease by the delayed appearance of microbubbles at contrast-enhanced echocardiography. IPVD with an elevated alveolar-arterial (A-a) gradient define hepatopulmonary syndrome (HPS); however, the importance of IPVD in the absence of abnormal gas exchange is unknown. We aimed to determine the clinical impact of IPVD in patients with liver disease. METHODS We performed a cross-sectional study within the Pulmonary Vascular Complications of Liver Disease 2 Study, a multicenter, prospective cohort study of patients being evaluated for liver transplant. We excluded patients with obstructive or restrictive lung disease, HPS, or intracardiac shunting. We compared patients with and those without IPVD. RESULTS Forty-six patients with IPVD and 81 patients without IPVD were included. Patients with IPVD were more likely to have autoimmune hepatitis and less likely to have cryptogenic cirrhosis and hepatocellular carcinoma. Patients with IPVD had higher Child-Pugh scores (6 [interquartile range (IQR), 5-7] vs 5 [IQR, 4-7]; P = .04), possibly higher Model for End-Stage Liver Disease scores (14.5 [IQR, 11.6-15.8] vs 12.2 [IQR, 9.4-15.5]; P = .06), higher PaO2 levels (97.9 [IQR, 92.0-103.0] vs 89.0 [IQR, 82.0-96.9] mm Hg; P < .001), and lower A-a gradients (9.9 [IQR, 6.2-13.5] vs 14.9 [IQR, 9.0-21.8] mm Hg; P < .001). Symptoms and quality of life were similar between the groups. CONCLUSIONS Autoimmune hepatitis and increased liver disease severity were associated with the presence of IPVD, which was characterized by higher PaO2 levels. Future studies to better characterize IPVD pathogenesis and the relationship of IPVD to HPS are warranted.
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Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kimberly A Forde
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karen Krok
- Division of Gastroenterology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Mamta Patel
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tiffany Sharkoski
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Sprys
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Carl D Mottram
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul D Scanlon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Steven M Kawut
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tonelli AR, Naal T, Dakkak W, Park MM, Dweik RA, Stoller JK. Assessing the kinetics of microbubble appearance in cirrhotic patients using transthoracic saline contrast-enhanced echocardiography. Echocardiography 2017; 34:1439-1446. [PMID: 28840954 DOI: 10.1111/echo.13662] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The number of cardiac cycles that need to be reviewed by echocardiography before a significant intrapulmonary shunt can be excluded remains unclear. METHODS We retrospectively identified patients with cirrhosis who underwent technetium-99 m-labeled macroaggregated albumin scanning. The kinetics of bubble appearance after the injection of agitated saline during transthoracic echocardiograms were assessed in these patients. RESULTS For the 64 eligible patients, the mean ± SD age was 56 ± 9 years. The median (IQR) shunt fraction by radionuclide scanning was 7.7% (2.8%-19.9%). Microbubbles were seen in the left atrium (LA) and left ventricle (LV) at a median (IQR) of 4 (2-5) and 4 (2-5) beats, respectively. The number of heart cycles before microbubbles appeared in the LA or LV was inversely associated with the nuclear scanning shunt fraction (R = -0.42, P = .001, R = -0.46, P < .001, respectively). If no microbubbles were detected by heart cycle 7, the shunt fraction was uniformly less than 3%. Patients with arterial oxygen <60 mm Hg, compared to ≥60 mm Hg, had earlier appearance of microbubbles in the left heart chambers (2.6 ± 1.9 vs 4.0 ± 2.3 beats, P = .046). CONCLUSIONS In patients with advanced cirrhosis suspected of having hepatopulmonary syndrome, a greater shunt fraction during nuclear scanning was associated with more pronounced hypoxemia and a prompt and more intense appearance of microbubbles in the left-sided heart chambers. Patients with a shunt fraction above 3% have microbubbles in the LA or LV at some point during the first seven heart cycles.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tawfeq Naal
- Pathobiology Department, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Margaret M Park
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James K Stoller
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Education Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Cirrhosis, the twelfth leading cause of death, accounts for 1.1% of all deaths in the United States. Although there are multiple pulmonary complications associated with liver disease, the most important complications that cause significant morbidity and mortality are hepatopulmonary syndrome, hepatic hydrothorax, and portopulmonary hypertension. Patients with cirrhosis who complain of dyspnea should be evaluated for these complications. This article reviews these complications.
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Affiliation(s)
- Vijaya S Ramalingam
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
| | - Sikandar Ansari
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Micah Fisher
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Emory Clinic 'A', 1365 Clifton Road, Northeast 4th Floor, Atlanta, GA 30322, USA
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50
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International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2017; 100:1440-52. [PMID: 27326810 DOI: 10.1097/tp.0000000000001229] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two distinct pulmonary vascular disorders, hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) may occur as a consequence of hepatic parenchymal or vascular abnormalities. HPS and POPH have major clinical implications for liver transplantation. A European Respiratory Society Task Force on Pulmonary-Hepatic Disorders convened in 2002 to standardize the diagnosis and guide management of these disorders. These International Liver Transplant Society diagnostic and management guidelines are based on that task force consensus and should continue to evolve as clinical experience dictates. Based on a review of over 1000 published HPS and POPH articles identified via a MEDLINE search (1985-2015), clinical guidelines were based on, selected single care reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Guidelines are presented in 5 parts; I. Definitions/Diagnostic criteria; II. Hepatopulmonary syndrome; III. Portopulmonary hypertension; IV. Implications for liver transplantation; and V. Suggestions for future clinical research.
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