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Abstract
Cirrhotic cardiomyopathy (CCM) connotes systolic and/or diastolic dysfunction in patients with end-stage liver disease in the absence of prior heart disease. Its prevalence is variable across different studies but recent data suggest that CCM may affect up to one third of liver transplant candidates. The etiology of CCM is multifactorial. CCM defining features were recently revised to improve the diagnostic and prognostic yield of CCM criteria and inform candidate selection for liver transplantation. CCM appears to increase the risk for unfavorable outcomes pre- and post-transplant. Close clinical and echocardiographic follow-up of patients with CCM may mitigate adverse cardiac outcomes.
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Affiliation(s)
- MANHAL J IZZY
- Assistant Professor, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN
| | - LISA B VANWAGNER
- Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology,Department of Preventive Medicine, Division of Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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152
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DI Renzo C, Vitale A, D'Amico F, Cillo U. NAFLD: a multi-faceted morbid spectrum with uncertain diagnosis and complicated management. Where do we stand? Review of the literature. Minerva Surg 2021; 76:450-466. [PMID: 33855376 DOI: 10.23736/s2724-5691.21.08729-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
NASH can be considered the "contemporary era pandemic", because of its global widespread in parallel with obesity, diabetes and metabolic dysfunction. It is a disease that often poses many difficulties, since making a early diagnosis is often impossible since specific diagnostic tests and criteria are missing: so, it needs a high degree of suspicion. Most of the times the evolution to its more severe and terminal step, NASH cirrhosis, is unavoidable and so are the social pressure on health sistem and economic consequences it brings back. In this work we aim to review the literature about both NAFLD and NASH, thus structuring a wide, comprehensive, 360 degree work with a focus on all major aspects of NAFLD, spanning from diagnosis, physiopathology and its repercussions on liver transplantation. Moreover we also focused on patients related issues both in pre- and post-transplant management (when these patients are listed for liver transplant). NAFLD and NASH are a contemporary plague, and an exaustive knowledge of the problem throughout all its aspects is necessary in order to lower economic weight that metabolic issues bring back and to have a open view to possible solutions to all management issues that NASH patients have and that are oten prohibitive to a definitive cure (for example cardiovascular risk in patients otherwise eligible to liver transplantation). We aim to offer a complete view on the actual knowledge about NAFLD and NASH, by an extensive review of the literature.
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Affiliation(s)
- Chiara DI Renzo
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy -
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
| | - Francesco D'Amico
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
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153
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Sessa A, Allaire M, Lebray P, Medmoun M, Tiritilli A, Iaria P, Cadranel JF. From congestive hepatopathy to hepatocellular carcinoma, how can we improve patient management? JHEP Rep 2021; 3:100249. [PMID: 33665589 PMCID: PMC7902554 DOI: 10.1016/j.jhepr.2021.100249] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/09/2020] [Accepted: 12/19/2020] [Indexed: 02/06/2023] Open
Abstract
Heart failure and liver disease often coexist because of systemic disorders and diseases that affect both organs as well as complex cardio-hepatic interactions. Heart failure can cause acute or chronic liver injury due to ischaemia and passive venous congestion, respectively. Congestive hepatopathy is frequently observed in patients with congenital heart disease and after the Fontan procedure, but also in older patients with chronic heart failure. As congestive hepatopathy can evolve into cirrhosis and hepatocellular carcinoma, screening for liver injury should be performed in patients with chronic cardiac diseases and after Fontan surgery. Fibrosis starts in the centro-lobular zone and will extend progressively to the portal area. Chronic liver injury can be reversible if heart function improves. However, in the case of terminal heart failure, uncontrolled by medical resources or by assistive device support, the combination of heart and liver transplants must be discussed in patients with chronic advanced liver fibrosis. In this review of the literature, we will focus on congestive hepatopathy and its complications, such as liver fibrosis and hepatocellular carcinoma, with the aim of improving the management and surveillance of patients experiencing these complications.
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Key Words
- ACE, angiotensin-converting enzyme
- AFP, α-fetoprotein
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate amino transferase
- BNP, B-type natriuretic peptide
- Combined heart and liver transplant
- Congestive hepatopathy
- FALD, Fontan-associated liver disease
- FIB-4, Fibrosis-4 index
- Fontan-associated liver disease
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- INR, international normalised ratio
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- NFS, NAFLD fibrosis score
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Affiliation(s)
- Anna Sessa
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
- Department of Hepatology and Gastroenterology, Policlinico Federico II, Napoli, Italy
| | - Manon Allaire
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
- Inserm U1149, Centre de Recherche sur l’Inflammation, France Faculté de Médecine Xavier Bichat, Université Paris Diderot, Paris, France
| | - Pascal Lebray
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Mourad Medmoun
- Service d 'Hépato-Gastroentérologie de nutrition et d’Alcoologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Alberto Tiritilli
- Service de Cardiologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Pierre Iaria
- Service de Cardiologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Jean-François Cadranel
- Service d 'Hépato-Gastroentérologie de nutrition et d’Alcoologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
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154
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Hepatocardiac or Cardiohepatic Interaction: From Traditional Chinese Medicine to Western Medicine. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6655335. [PMID: 33777158 PMCID: PMC7981187 DOI: 10.1155/2021/6655335] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/18/2021] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
There is a close relationship between the liver and heart based on "zang-xiang theory," "five-element theory," and "five-zang/five-viscus/five-organ correlation theory" in the theoretical system of Traditional Chinese Medicine (TCM). Moreover, with the development of molecular biology, genetics, immunology, and others, the Modern Medicine indicates the existence of the essential interorgan communication between the liver and heart (the heart and liver). Anatomically and physiologically, the liver and heart are connected with each other primarily via "blood circulation." Pathologically, liver diseases can affect the heart; for example, patients with end-stage liver disease (liver failure/cirrhosis) may develop into "cirrhotic cardiomyopathy," and nonalcoholic fatty liver disease (NAFLD) may promote the development of cardiovascular diseases via multiple molecular mechanisms. In contrast, heart diseases can affect the liver, heart failure may lead to cardiogenic hypoxic hepatitis and cardiac cirrhosis, and atrial fibrillation (AF) markedly alters the hepatic gene expression profile and induces AF-related hypercoagulation. The heart can also influence liver metabolism via certain nonsecretory cardiac gene-mediated multiple signals. Moreover, organokines are essential mediators of organ crosstalk, e.g., cardiomyokines link the heart to the liver, while hepatokines link the liver to the heart. Therefore, both TCM and Western Medicine, and both the basic research studies and the clinical practices, all indicate that there exist essential "heart-liver axes" and "liver-heart axes." To investigate the organ interactions between the liver and heart (the heart and liver) will help us broaden and deepen our understanding of the pathogenesis of both liver and heart diseases, thus improving the strategies of prevention and treatment in the future.
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155
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Kim KS, Kwon HM, Jung KW, Sang BH, Moon YJ, Kim B, Jun IG, Song JG, Hwang GS. Markedly prolonged QTc interval in end-stage liver disease and risk of 30-day cardiovascular event after liver transplant. J Gastroenterol Hepatol 2021; 36:758-766. [PMID: 32804412 DOI: 10.1111/jgh.15179] [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: 04/16/2020] [Revised: 06/22/2020] [Accepted: 07/09/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The proportional increase of corrected QT interval (QTc) along end-stage liver disease (ESLD) severity may lead to inconsistent outcome reporting if based on conventional threshold of prolonged QTc. We investigated the comprehensive QTc distribution among ESLD patients and assessed the association between QTc > 500 ms, a criterion for diagnosing severe long-QT syndrome, and the 30-day major adverse cardiovascular event (MACE) after liver transplantation (LT) and identified the risk factors for developing QTc > 500 ms. METHODS Data were collected prospectively from the Asan LT Registry between 2011 and 2018, and outcomes were retrospectively reviewed. Multivariable analysis and propensity score-weighted adjusted odds ratios (ORs) were calculated. Thirty-day MACEs were defined as the composite of cardiovascular mortality, arrhythmias, myocardial infarction, pulmonary thromboembolism, and/or stroke. RESULTS Of 2579 patients, 194 (7.5%) had QTc > 500 ms (QTc500_Group), and 1105 (42.8%) had prolonged QTc (QTcP_Group), defined as QTc > 470 ms for women and >450 ms for men. The 30-day MACE occurred in 336 (13%) patients. QTc500_Group showed higher 30-day MACE than did those without (20.1% vs 12.5%, P = 0.003), with corresponding adjusted OR of 1.24 (95% CI: 1.06-1.46, P = 0.007). However, QTcP_Group showed comparable 30-day MACE (13.3% vs 12.8% without prolonged QTc, P = 0.764). Significant risk factors for QTc > 500 ms development were advanced liver disease, female sex, hypokalemia, hypocalcemia, high left ventricular end-diastolic volume, and tachycardia. CONCLUSION Our results revealed that, among ESLD patients, a novel threshold of QTc > 500 ms was associated with post-LT 30-day MACE but not with conventional threshold, indicating that a longer QTc threshold should be considered for this unique patient population.
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Affiliation(s)
- Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-Hyun Sang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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156
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Abstract
Cirrhotic cardiomyopathy (CCM), cardiac dysfunction in end-stage liver disease in the absence of prior heart disease, is an important clinical entity that contributes significantly to morbidity and mortality. The original definition for CCM, established in 2005 at the World Congress of Gastroenterology (WCG), was based upon known echocardiographic parameters to identify subclinical cardiac dysfunction in the absence of overt structural abnormalities. Subsequent advances in cardiovascular imaging and in particular myocardial deformation imaging have rendered the WCG criteria outdated. A number of investigations have explored other factors relevant to CCM, including serum markers, electrocardiography, and magnetic resonance imaging. CCM characteristics include a hyperdynamic circulatory state, impaired contractility, altered diastolic relaxation, and electrophysiological abnormalities, particularly QT interval prolongation. It is now known that cardiac dysfunction worsens with the progression of cirrhosis. Treatment for CCM has traditionally been limited to supportive efforts, but new pharmacological studies appear promising. Left ventricular diastolic dysfunction in CCM can be improved by targeted heart rate reduction. Ivabradine combined with carvedilol improves left ventricular diastolic dysfunction through targeted heart rate reduction, and this regimen can improve survival in patients with cirrhosis. Orthotopic liver transplantation also appears to improve CCM. Here, we canvass diagnostic challenges associated with CCM, introduce cardiac physiology principles and the application of echocardiographic techniques, and discuss the evidence behind therapeutic interventions in CCM.
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157
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von Köckritz F, Braun A, Schmuck RB, Dobrindt EM, Eurich D, Heinzel FR, Pieske B, Escher F, Zhang K. Speckle Tracking Analysis Reveals Altered Left Atrial and Ventricular Myocardial Deformation in Patients with End-Stage Liver Disease. J Clin Med 2021; 10:jcm10050897. [PMID: 33668295 PMCID: PMC7956617 DOI: 10.3390/jcm10050897] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 02/07/2023] Open
Abstract
Background: Cardiac function can be influenced by liver cirrhosis and should be thoroughly evaluated before liver transplantation. We investigated left ventricular (LV) and, for the first time, left atrial (LA) strain and strain rate in end-stage liver cirrhosis patients of different etiologies. Methods: This retrospective, cross-sectional study evaluated left heart function in 80 cirrhosis patients and 30 controls using standardized echocardiographic techniques and speckle tracking technology (STE) analysis. Serum markers of liver function were used for correlation analysis. Results: While conventional parameters demonstrated no alteration in systolic function, speckle tracking analysis showed a significant increase in LV longitudinal strain throughout all cardiac layers, with significant correlation to model of end-stage liver disease (MELD) score. LA reservoir and conduit strain as well as LA strain rate in all phases were significantly reduced in end-stage liver disease (ESLD) patients compared to control. STE for the evaluation of LA phasic function seemed to be more sensitive than volumetric methods. Kaplan-Meier curves showed a trend towards reduced post-transplant survival in patients with a reduced LA reservoir and conduit strain. Conclusion: STE analysis detected increased LV and decreased LA deformation in cirrhosis patients, thus proving to be highly sensitive to cardiac changes and useful for more precise cardiac evaluation.
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Affiliation(s)
- Franzisca von Köckritz
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
| | - Alexander Braun
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
| | - Rosa B. Schmuck
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Eva M. Dobrindt
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Frank R. Heinzel
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
- German Heart Center Berlin, Department of Internal Medicine and Cardiology, 13353 Berlin, Germany
| | - Felicitas Escher
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Kun Zhang
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450659746
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158
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Mazumder NR, VanWagner LB. QT and outcomes in cirrhosis: A prolonged debate on causality in need of correction. Am J Transplant 2021; 21:451-452. [PMID: 32659873 PMCID: PMC7855464 DOI: 10.1111/ajt.16209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Nikhilesh R Mazumder
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lisa B VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Division of Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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159
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Koshy AN, Ko J, Farouque O, Cooray SD, Han HC, Cailes B, Gow PJ, Weinberg L, Testro A, Lim HS, Teh AW. Effect of QT interval prolongation on cardiac arrest following liver transplantation and derivation of a risk index. Am J Transplant 2021; 21:593-603. [PMID: 32530547 DOI: 10.1111/ajt.16145] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/01/2020] [Accepted: 06/06/2020] [Indexed: 01/25/2023]
Abstract
Liver transplantation (LT) has a 4-fold higher risk of periprocedural cardiac arrest and ventricular arrhythmias (CA/VAs) compared with other noncardiac surgeries. Prolongation of the corrected QT interval (QTc) is common in patients with liver cirrhosis. Whether it is associated with an increased risk of CA/VAs following LT is unclear. Rates of 30-day CA/VAs post-LT were assessed in consecutive adults undergoing LT between 2010 and 2017. Pretransplant QTc was measured by a cardiologist blinded to clinical outcomes. Among 408 patients included, CA/VAs occurred in 26 patients (6.4%). QTc was significantly longer in CA/VA patients (475 ± 34 vs 450 ± 34 ms, P < .001). Optimal QTc cut-off for prediction of CA/VAs was ≥480 ms. After adjustment, QTc ≥480 ms remained the strongest predictor for the occurrence of CA/VAs (odds ratio [OR] 5.2, 95% confidence interval [CI] 2.2-12.6). A point-based cardiac arrest risk index (CARI) was derived with the bootstrap method for yielding optimism-corrected coefficients (2 points: QTc ≥480, 1 point: Model for End-Stage Liver Disease [MELD] ≥30, 1 point: age ≥65, and 1 point: male). CARI score ≥3 demonstrated moderate discrimination (c-statistic 0.79, optimism-corrected c-statistic 0.77) with appropriate calibration. QTc ≥480 ms was associated with a 5-fold increase in the risk of CA/VAs. The CARI score may identify patients at higher risk of these events. Whether heightened perioperative cardiac surveillance, avoidance of QT prolonging medications, or beta blockers could mitigate the risk of CA/VAs in this population merits further study.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Jefferson Ko
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Shamil D Cooray
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Paul J Gow
- The University of Melbourne, Parkville, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Adam Testro
- The University of Melbourne, Parkville, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia.,Cardiology Department, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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160
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Lombardi R, Pisano G, Fargion S, Fracanzani AL. Cardiovascular involvement after liver transplantation: role of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Patients submitted to liver transplantation (LT) are exposed to high risk of cardiovascular (CV) complications which are the main determinants of both short-term and long-term morbidity and mortality in LT. Non-alcoholic fatty liver disease (NAFLD) is a very frequent condition in general population and is associated with a high risk of cardiovascular disease (CVD) which represents the first cause of death of these patients. NAFLD is predicted to become the first indication to LT and nowadays is also frequently detected in patients submitted to LT for other indications. Thus, the risk of CVD in patients submitted to LT is forecasted to increase in the next years. In this review the extent of CV involvement in patients submitted to LT and the role of NAFLD, either recurring after transplantation or as de novo presentation, in increasing CV risk is analysed. The risk of developing metabolic alterations, including diabetes, hypertension, dyslipidemia and weight gain, all manifestations of metabolic syndrome, occurring in the first months after LT, is depicted. The different presentations of cardiac involvement, represented by early atherosclerosis, coronary artery disease, heart failure and arrhythmias in patients with NAFLD submitted to LT is described. In addition, the tools to detect cardiac alterations either before or after LT is reported providing the possibility for an early diagnosis of CVD and an early therapy able to reduce morbidity and mortality for these diseases. The need for long-term concerted multidisciplinary activity with dietary counseling and exercise combined with drug treatment of all manifestations of metabolic syndrome is emphasized.
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Affiliation(s)
- Rosa Lombardi
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy 2Department of Pathophysiology and Transplantation, University of the Study of Milan, 20122 Milan, Italy
| | - Giuseppina Pisano
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Silvia Fargion
- Department of Pathophysiology and Transplantation, University of the Study of Milan, 20122 Milan, Italy
| | - Anna Ludovica Fracanzani
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy 2Department of Pathophysiology and Transplantation, University of the Study of Milan, 20122 Milan, Italy
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161
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Abstract
PURPOSE OF REVIEW As the field of transplant has advanced, cardiac events have become the leading cause of morbidity and mortality after liver and kidney transplantation ahead of graft failure and infection. This trend has been bolstered by the transplantation of older and sicker patients who have a higher burden of cardiovascular risk factors, accentuating the need to determine which patients should undergo more extensive cardiac evaluation prior to transplantation. RECENT FINDINGS Computed tomography coronary angiography with or without coronary artery calcium scoring is now preferred over stress imaging in most transplant candidates for assessment of coronary artery disease. Assessment of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended, particularly in liver transplant candidates who are at high risk of cirrhotic cardiomyopathy, for which new diagnostic criteria were recently published in 2019. SUMMARY Cardiac evaluation of liver and kidney transplant candidates requires a global assessment for both short and long-term risk for cardiac events. Imaging of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended. Risk stratification should consider both the anatomic and functional consequences of coronary artery disease in transplant candidates. VIDEO ABSTRACT http://links.lww.com/MOT/A27.
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Affiliation(s)
- Paul Emile Levy
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sadiya S. Khan
- Department of Medicine-Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lisa B. VanWagner
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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162
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Abstract
Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.
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163
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Sonny A. Cardiovascular adverse events after liver transplantation: a long road ahead for improvement. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 6:227-228. [PMID: 32275746 DOI: 10.1093/ehjqcco/qcaa031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02446, USA
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Koshy AN, Gow PJ, Han HC, Teh AW, Lim HS, Testro A, Jones R, Farouque O. Sudden cardiac death following liver transplantation: Incidence, trends and risk predictors. Int J Cardiol 2020; 327:171-174. [PMID: 33253736 DOI: 10.1016/j.ijcard.2020.11.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiovascular events are a leading cause of mortality following liver transplantation (LT). Although a preponderance of sudden cardiac death (SCD) in this population has been reported, there is a paucity of data evaluating the incidence, timing and predictors of SCD following LT. METHODS Using the prospectively collected Australian and New Zealand Liver Transplant Registry, a cohort study of all adult LTs from 1985 to 2017 was performed to ascertain the incidence and predictors of SCD. Recipient cause of death was adjudicated by an interdisciplinary panel. RESULTS 4265 LT patients were followed-up for 37,409 person-years. SCD was the leading mode of cardiovascular death with an incidence rate of 165 per 100,000 person-years. There was a significant increase in the hazard of SCD in the contemporary (1996-2017) vs early era (1985-1995) (hazard ratio [HR] 2.42, 95%CI 1.10-5.40; p = 0.02). On Cox regression after adjusting for significant univariate predictors including age, coronary artery disease and non-alcoholic steatohepatitis, pre-transplant diabetes was the only independent predictor of SCD (HR 2.5 95%CI 1.1-6.0). CONCLUSION SCD is the leading mode of cardiovascular cause-specific mortality following LT and diabetes was associated with a two-fold higher risk for its occurrence. Given the escalating cardiovascular risk factor profile of LT candidates, targeted therapies especially in patients with diabetes are needed to mitigate risk of post-transplant SCD.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Paul J Gow
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Adam Testro
- Department of Medicine, The University of Melbourne, Victoria, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Robert Jones
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia.
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165
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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166
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Zardi EM, Giorgi C, Dobrina A, Vecile E, Zardi DM. Analogies and differences between cirrhotic cardiomyopathy and hepatopulmonary syndrome. Med Res Rev 2020; 41:739-753. [PMID: 33174630 DOI: 10.1002/med.21755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
Cirrhotic cardiomyopathy and hepatopulmonary syndrome are two quite frequent clinical entities that may complicate the course of liver cirrhosis. The common pathophysiological origin and the same clinical presentation make them difficult to compare. Cirrhotic cardiomyopathy and hepatopulmonary syndrome may start with dyspnea and breathlessness but the former is characterized by a chronic cardiac dysfunction and the latter by a defect of oxygenation due to pulmonary shunts formation. The focus is to differentiate them as soon as possible since the treatment is different until the patient undergoes liver transplant that is the real unique cure for them.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, Campus Bio-Medico University, Rome, Italy
| | - Chiara Giorgi
- Department of Radiology, S. Maria Della Misericordia Hospital, Urbino, Italy
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Elena Vecile
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Domenico Maria Zardi
- Interventional Cardiology Department of S. Andrea Hospital, University "La Sapienza", Rome, Italy
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167
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Right ventricular dysfunction in cirrhosis: A speckle-tracking echocardiography study. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.818638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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168
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Burra P, Becchetti C, Germani G. NAFLD and liver transplantation: Disease burden, current management and future challenges. JHEP Rep 2020; 2:100192. [PMID: 33163950 PMCID: PMC7607500 DOI: 10.1016/j.jhepr.2020.100192] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.
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Key Words
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- DM, diabetes mellitus
- DPP-4, dipeptidyl peptidase-4
- ELTR, European Liver Transplant Registry
- ESLD, end-stage liver disease
- GLP1 RAs, glucagon-like peptide-1 receptor agonists
- Graft survival
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hypertension
- IRR, incidence rate ratio
- Immunosuppressant
- LT, liver transplant
- MAFLD, metabolic dysfunction-associated fatty liver disease
- Metabolic complication
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- New-onset diabetes after transplantation
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis
- OR, odds ratio
- Obesity
- Patient survival
- SGLT2, sodium-glucose co-transporter-2
- Solid organ transplantation
- UNOS, United Network for Organ Sharing
- mTORi, mammalian target of rapamycin inhibitors
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Corresponding author. Address: Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital. Tel.: +39 0498212892; fax: + 390498217848.
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
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169
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Sharma S, Sonny A, Dalia AA, Karamchandani K. Acute heart failure after liver transplantation: A narrative review. Clin Transplant 2020; 34:e14079. [PMID: 32941661 DOI: 10.1111/ctr.14079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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170
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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171
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Isaak A, Praktiknjo M, Jansen C, Faron A, Sprinkart AM, Pieper CC, Chang J, Fimmers R, Meyer C, Dabir D, Thomas D, Trebicka J, Attenberger U, Kuetting D, Luetkens JA. Myocardial Fibrosis and Inflammation in Liver Cirrhosis: MRI Study of the Liver-Heart Axis. Radiology 2020; 297:51-61. [PMID: 32808886 DOI: 10.1148/radiol.2020201057] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Cardiac involvement in liver cirrhosis in the absence of underlying cardiac disease is termed cirrhotic cardiomyopathy. The pathophysiology of this condition is still poorly understood. Purpose To investigate the extent of subclinical imaging changes in terms of fibrosis and inflammation and to explore the relationship between the severity of liver disease and the degree of myocardial involvement. Materials and Methods In this prospective study from November 2018 to December 2019, participants with liver cirrhosis and healthy control participants underwent hepatic and cardiac MRI. The multiparametric scan protocol assessed hepatic (T1 and T2 relaxation times, extracellular volume [ECV], and MR elastography-based liver stiffness) and cardiac (T1 and T2 relaxation times, ECV, myocardial edema, late gadolinium enhancement [LGE], and myocardial strain) parameters. Student t tests, one-way analysis of variance, Pearson correlation, and multivariable binary regression analysis were used for statistical analyses. Results A total of 42 participants with liver cirrhosis (mean age ± standard deviation, 57 years ± 11; 23 men) and 18 control participants (mean age, 54 years ± 19; 11 men) were evaluated. Compared with control participants, the participants with liver cirrhosis displayed reduced longitudinal strain and elevated markers of myocardial disease (T1 and T2 relaxation times, ECV, and qualitative and quantitative LGE). Myocardial T1 (978 msec ± 23 vs 1006 msec ± 29 vs 1044 msec ± 14; P < .001) and T2 relaxation times (56 msec ± 4 vs 59 msec ± 3 vs 62 msec ± 8; P = .04) and ECV (30% ± 5 vs 33% ± 5 vs 38% ± 7; P = .009) were higher depending on Child-Pugh class (A vs B vs C). Positive LGE lesions (three of 11 [27%] vs 10 of 19 [53%] vs nine of 11 [82%]; P = .04) were more prevalent in advanced Child-Pugh classes. MR elastography-based liver stiffness was an independent predictor for LGE (odds ratio, 1.6; 95% confidence interval: 1.2%, 2.1%; P = .004) and correlated with quantitative LGE (r = 0.67; P < .001), myocardial T1 relaxation times (r = 0.55; P < .001), and ECV (r = 0.39; P = .01). Conclusion In participants with liver cirrhosis, systolic dysfunction and elevated parameters of myocardial edema and fibrosis were observed at MRI, which were more abnormal with greater severity of liver disease. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by de Roos and Lamb in this issue.
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Affiliation(s)
- Alexander Isaak
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Michael Praktiknjo
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Christian Jansen
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Anton Faron
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Alois M Sprinkart
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Claus C Pieper
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Johannes Chang
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Rolf Fimmers
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Carsten Meyer
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Darius Dabir
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Daniel Thomas
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Jonel Trebicka
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Ulrike Attenberger
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Daniel Kuetting
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Julian A Luetkens
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
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Mechelinck M, Hartmann B, Hamada S, Becker M, Andert A, Ulmer TF, Neumann UP, Wirtz TH, Koch A, Trautwein C, Roehl AB, Rossaint R, Hein M. Global Longitudinal Strain at Rest as an Independent Predictor of Mortality in Liver Transplant Candidates: A Retrospective Clinical Study. J Clin Med 2020; 9:jcm9082616. [PMID: 32806645 PMCID: PMC7464171 DOI: 10.3390/jcm9082616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/02/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
Speckle tracking echocardiography enables the detection of subclinical left ventricular dysfunction at rest in many heart diseases and potentially in severe liver diseases. It could also possibly serve as a predictor for survival. In this study, 117 patients evaluated for liver transplantation in a single center between May 2010 and April 2016 with normal left ventricular ejection fraction were included according to clinical characteristics of their liver disease: (1) compensated (n = 29), (2) clinically significant portal hypertension (n = 49), and (3) decompensated (n = 39). Standard echocardiography and speckle tracking echocardiography were performed at rest and during dobutamine stress. Follow-up amounted to three years to evaluate survival and major cardiac events. Altogether 67% (78/117) of the patients were transplanted and 32% (31/96 patients) died during the three-year follow-up period. Global longitudinal strain (GLS) at rest was significantly increased (became more negative) with the severity of liver disease (p < 0.001), but reached comparable values in all groups during peak stress. Low (less negative) GLS values at rest (male: >−17/female: >−18%) could predict patient survival in a multivariate Cox regression analysis (p = 0.002). GLS proved valuable in identifying transplant candidates with latent systolic dysfunction.
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Affiliation(s)
- Mare Mechelinck
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (B.H.); (A.B.R.); (R.R.); (M.H.)
- Correspondence:
| | - Bianca Hartmann
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (B.H.); (A.B.R.); (R.R.); (M.H.)
| | - Sandra Hamada
- Department of Internal Medicine I, Cardiology, Angiology and Internal Intensive Care Medicine, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany;
| | - Michael Becker
- Clinic for Cardiology, Nephrology and Internal Intensive Care, Rhein-Maas Klinikum, 52146 Würselen, Germany;
| | - Anne Andert
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (A.A.); (T.F.U.); (U.P.N.)
| | - Tom Florian Ulmer
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (A.A.); (T.F.U.); (U.P.N.)
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (A.A.); (T.F.U.); (U.P.N.)
| | - Theresa Hildegard Wirtz
- Department of Internal Medicine III, Gastroenterology, Metabolic Diseases and Intensive Care, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (T.H.W.); (A.K.); (C.T.)
| | - Alexander Koch
- Department of Internal Medicine III, Gastroenterology, Metabolic Diseases and Intensive Care, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (T.H.W.); (A.K.); (C.T.)
| | - Christian Trautwein
- Department of Internal Medicine III, Gastroenterology, Metabolic Diseases and Intensive Care, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (T.H.W.); (A.K.); (C.T.)
| | - Anna Bettina Roehl
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (B.H.); (A.B.R.); (R.R.); (M.H.)
| | - Rolf Rossaint
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (B.H.); (A.B.R.); (R.R.); (M.H.)
| | - Marc Hein
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (B.H.); (A.B.R.); (R.R.); (M.H.)
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173
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Kwon HM, Hwang GS. Reply. Hepatology 2020; 72:784. [PMID: 32020634 DOI: 10.1002/hep.31162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Abstract
PURPOSE OF REVIEW Cirrhotic cardiomyopathy is a syndrome of depressed cardiac function in patients with cirrhosis. We aimed to review the historical background, pathophysiology and pathogenesis, diagnostic definitions, clinical relevance, and management of this syndrome. RECENT FINDINGS An inflammatory phenotype underlies the pathogenesis: gut bacterial translocation with endotoxemia stimulates cytokines and cardiodepressant factors, such as nitric oxide and endocannabinoids. Cardiomyocyte plasma membrane biochemical and biophysical changes also play a pathogenic role. These factors lead to impaired beta-adrenergic function. Proposed new echocardiographic criteria for the diagnosis of cirrhotic cardiomyopathy include systolic global longitudinal strain and indices of diastolic dysfunction. Cardiac dysfunction participates in the pathogenesis of hepatorenal syndrome and increased morbidity/mortality of cirrhotic patients to hemorrhage, infection, and surgery, including liver transplantation. There is no specific treatment, although β-adrenergic blockade and supportive management have been proposed, but it needs further study. Cirrhotic cardiomyopathy is a clinically relevant syndrome afflicting patients with established cirrhosis. Optimum management remains unclear, and further study is needed in this area.
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Affiliation(s)
- Ki Tae Yoon
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.,Liver Center, Department of Internal Medicine, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongnam, 50612, South Korea
| | - Hongqun Liu
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Samuel S Lee
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
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175
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Wiese S, Voiosu A, Hove JD, Danielsen KV, Voiosu T, Grønbaek H, Møller HJ, Genovese F, Reese-Petersen AL, Mookerjee RP, Clemmesen JO, Gøtze JP, Andersen O, Møller S, Bendtsen F. Fibrogenesis and inflammation contribute to the pathogenesis of cirrhotic cardiomyopathy. Aliment Pharmacol Ther 2020; 52:340-350. [PMID: 32524673 DOI: 10.1111/apt.15812] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/05/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fibrogenesis and inflammation contribute to the progression of cirrhosis. However, it is unknown if these processes also contribute to the development of cirrhotic cardiomyopathy (CCM). Novel magnetic resonance imaging with quantification of the extracellular volume (ECV) provides an estimate of the fibrotic remodelling in the liver and heart. AIM To investigate the relationship between liver and cardiac ECV in cirrhosis and their association with collagen turnover and inflammation. METHODS A prospective study of 52 patients with cirrhosis and 14 healthy controls. All patients underwent contrast-enhanced MRI with T1-mapping and quantification of myocardial and liver ECV, biochemical assessments of collagen turnover (PRO-C3, PRO-C5, PRO-C6, collagen type IV degradation fragment, collagen type V degradation fragment, LG1M) and inflammation (TNFα, IL-1β, IL-6, IL-8, IL-18, SDF1α, sCD163, sMR, soluble macrophage mannose receptor). RESULTS Myocardial and liver ECV were increased in patients compared with healthy controls (myocardial ECV 31.2 ± 5.5% vs 27.4 ± 2.9%, P = 0.037; liver ECV 44.1 ± 9.6% vs 33.7 ± 6.7%, P < 0.001). Myocardial ECV correlated strongly with liver ECV (r = 0.48, P = 0.001) and biomarkers of collagen formation and inflammation (P < 0.005). Similarly, liver ECV correlated with biomarkers of collagen formation and inflammation (P < 0.003). In a multivariate analysis, liver ECV was predicted by biomarkers of collagen formation (PRO-C3 and PRO-C6), whereas myocardial ECV was predicted by biomarkers of collagen formation (PRO-C6) and inflammation (IL-6 and sMR). CONCLUSION Structural myocardial changes seem closely related to liver fibrosis in patients with cirrhosis. The strong associations with biomarkers of collagen formation and inflammation provide new insight into the role of inflammation and fibrogenesis in the development of structural cardiac abnormalities, potentially leading to CCM.
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176
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Bonavia A, Vece G, Karamchandani K. Prerenal acute kidney injury—still a relevant term in modern clinical practice? Nephrol Dial Transplant 2020; 36:1570-1577. [DOI: 10.1093/ndt/gfaa061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/24/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
The traditional taxonomy of acute kidney injury (AKI) has remained pervasive in clinical nephrology. While the terms ‘prerenal’, ‘intrarenal’ and ‘postrenal’ highlight the diverse pathophysiology underlying AKI, they also imply discrete disease pathways and de-emphasize the nature of AKI as an evolving clinical syndrome with multiple, often simultaneous and overlapping, causes. In a similar vein, prerenal AKI comprises a diverse spectrum of kidney disorders, albeit one that is often managed by using a standardized clinical algorithm. We contend that the term ‘prerenal’ is too vague to adequately convey our current understanding of hypoperfusion-related AKI and that it should thus be avoided in the clinical setting. Practice patterns among nephrologists indicate that AKI-related terminology plays a significant role in the approaches that clinicians take to patients that have this complex disease. Thus, it appears that precise terminology does impact the treatment that patients receive. We will outline differences in the diagnosis and management of clinical conditions lying on the so-called prerenal disease spectrum to advocate caution when administering intravenous fluids to these clinically decompensated patients. An understanding of the underlying pathophysiology may, thus, avert clinical missteps such as fluid and vasopressor mismanagement in tenuous or critically ill patients.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - Gregory Vece
- The Pennsylvania State College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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177
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Response to Singh, et al. Am J Gastroenterol 2020; 115:951-952. [PMID: 32304377 DOI: 10.14309/ajg.0000000000000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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178
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Left ventricular diastolic dysfunction in liver transplantation: a stronger association with non-alcoholic steatohepatitis. Clin Exp Hepatol 2020; 6:158-162. [PMID: 32728634 PMCID: PMC7380470 DOI: 10.5114/ceh.2020.95893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/20/2020] [Indexed: 12/18/2022] Open
Abstract
Aim of the study Cardiovascular death is an important cause of mortality in end stage liver disease (ESLD) patients undergoing orthotopic liver transplant (OLT). Left ventricular diastolic dysfunction (LVDD) is often the early manifestation and only measurable manifestation of cirrhotic cardiomyopathy. Therefore, it is important to understand the risk factors for LVDD in ESLD patients undergoing OLT and its immediate impact post-operatively. Material and methods Electronic medical records (EMR) of 100 consecutive patients who underwent OLT were reviewed at the University of Tennessee/Methodist University Hospital in Memphis, Tennessee, USA. Transthoracic echocardiogram (TTE) reports were accessed to evaluate for LVDD based on the latest 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. The clinical and demographic variables were obtained and variable quality measures, incidence of cardiac arrhythmias, and 30-day all-cause mortality were compared. Results Patients with LVDD were older (62.7 ±6.3 years vs. 55.9 ±12.3 years, p = 0.017) and were more often female (57% vs. 31%, p = 0.026). In addition, patients with non-alcoholic steatohepatitis (NASH) were more likely to have LVDD (48% vs. 12%, p = 0.001). In contrast, patients with alcoholic liver disease were less likely to have LVDD (10% vs. 33%, p = 0.032). In a multivariate logistic regression analysis, NASH (OR = 4.4 [95% CI: 1.33-14.5], p = 0.015) and female gender (OR = 3.31 [95% CI: 1.09-9.99], p = 0.033) were independent predictors of LVDD. Conclusions In our cohort of patients, the presence of NASH was associated with a higher risk of LVDD. However, presence of LVDD did not influence immediate post-transplant outcome or 30-day all-cause mortality.
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179
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Izzy M, VanWagner LB, Lin G, Altieri M, Findlay JY, Oh JK, Watt K, Lee SS. Reply. Hepatology 2020; 71:1884-1885. [PMID: 31709572 DOI: 10.1002/hep.31035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/22/2019] [Indexed: 12/07/2022]
Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition Transplant Hepatology, Vanderbilt University, Nashville, TN
| | - Lisa B VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Grace Lin
- Department of Cardiovascular Medicine, The Mayo Clinic, Rochester, MN
| | - Mario Altieri
- Division of Hepatology, Caen University, Caen, France
| | - James Y Findlay
- Department of Anesthesiology, The Mayo Clinic, Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Medicine, The Mayo Clinic, Rochester, MN
| | - Kymberly Watt
- Division of Gastroenterology & Hepatology, The Mayo Clinic, Rochester, MN
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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180
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Koshy AN, Farouque O, Calafiore P, Gow PJ. Letter to the Editor: Diagnosis of Cirrhotic Cardiomyopathy: The Role of an Impaired Cardiac Reserve. Hepatology 2020; 71:1883. [PMID: 31709570 DOI: 10.1002/hep.31034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia.,The University of Melbourne, Parkville, Vic, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia.,The University of Melbourne, Parkville, Vic, Australia
| | - Paul Calafiore
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Paul J Gow
- The University of Melbourne, Parkville, Vic, Australia.,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Vic, Australia
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181
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Matyas C, Erdelyi K, Trojnar E, Zhao S, Varga ZV, Paloczi J, Mukhopadhyay P, Nemeth BT, Haskó G, Cinar R, Rodrigues RM, Ahmed YA, Gao B, Pacher P. Interplay of Liver-Heart Inflammatory Axis and Cannabinoid 2 Receptor Signaling in an Experimental Model of Hepatic Cardiomyopathy. Hepatology 2020; 71:1391-1407. [PMID: 31469200 PMCID: PMC7048661 DOI: 10.1002/hep.30916] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Hepatic cardiomyopathy, a special type of heart failure, develops in up to 50% of patients with cirrhosis and is a major determinant of survival. However, there is no reliable model of hepatic cardiomyopathy in mice. We aimed to characterize the detailed hemodynamics of mice with bile duct ligation (BDL)-induced liver fibrosis, by monitoring echocardiography and intracardiac pressure-volume relationships and myocardial structural alterations. Treatment of mice with a selective cannabinoid-2 receptor (CB2 -R) agonist, known to attenuate inflammation and fibrosis, was used to explore the impact of liver inflammation and fibrosis on cardiac function. APPROACH AND RESULTS BDL induced massive inflammation (increased leukocyte infiltration, inflammatory cytokines, and chemokines), oxidative stress, microvascular dysfunction, and fibrosis in the liver. These pathological changes were accompanied by impaired diastolic, systolic, and macrovascular functions; cardiac inflammation (increased macrophage inflammatory protein 1, interleukin-1, P-selectin, cluster of differentiation 45-positive cells); and oxidative stress (increased malondialdehyde, 3-nitrotyrosine, and nicotinamide adenine dinucleotide phosphate oxidases). CB2 -R up-regulation was observed in both livers and hearts of mice exposed to BDL. CB2 -R activation markedly improved hepatic inflammation, impaired microcirculation, and fibrosis. CB2 -R activation also decreased serum tumor necrosis factor-alpha levels and improved cardiac dysfunction, myocardial inflammation, and oxidative stress, underlining the importance of inflammatory mediators in the pathology of hepatic cardiomyopathy. CONCLUSIONS We propose BDL-induced cardiomyopathy in mice as a model for hepatic/cirrhotic cardiomyopathy. This cardiomyopathy, similar to cirrhotic cardiomyopathy in humans, is characterized by systemic hypotension and impaired macrovascular and microvascular function accompanied by both systolic and diastolic dysfunction. Our results indicate that the liver-heart inflammatory axis has a pivotal pathophysiological role in the development of hepatic cardiomyopathy. Thus, controlling liver and/or myocardial inflammation (e.g., with selective CB2 -R agonists) may delay or prevent the development of cardiomyopathy in severe liver disease.
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Affiliation(s)
- Csaba Matyas
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Katalin Erdelyi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Eszter Trojnar
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Suxian Zhao
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Zoltan V. Varga
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA,ZVV’s present affiliation: HCEMM-SU Cardiometabolic Immunology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Janos Paloczi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Partha Mukhopadhyay
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Balazs T. Nemeth
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - György Haskó
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | - Resat Cinar
- Laboratory of Physiologic Studies, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Robim M. Rodrigues
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Yeni Ait Ahmed
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Bin Gao
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
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182
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Toma L, Stanciu AM, Zgura A, Bacalbasa N, Diaconu C, Iliescu L. Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy. ACTA ACUST UNITED AC 2020; 56:medicina56020068. [PMID: 32050594 PMCID: PMC7073951 DOI: 10.3390/medicina56020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.
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Affiliation(s)
- Letitia Toma
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Adriana Mercan Stanciu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
| | - Anca Zgura
- Chemotherapy Department, OncoFort Hospital, 022328 Bucharest, Romania;
| | - Nicolae Bacalbasa
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Camelia Diaconu
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 022328 Bucharest, Romania;
| | - Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Correspondence: ; Tel.: +407-22-235-695
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183
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Li M, Guo Z, Zhang D, Xu X, Romeiro FG, Mancuso A, Zhang J, Feng R, Zhou X, Hong C, Qi X. Correlation of Serum Cardiac Markers with Acute Decompensating Events in Liver Cirrhosis. Gastroenterol Res Pract 2020; 2020:4019289. [PMID: 33029132 PMCID: PMC7532360 DOI: 10.1155/2020/4019289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/01/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023] Open
Abstract
METHODS Cirrhotic patients who were consecutively hospitalized between January 2016 and March 2019 were screened. Serum cardiac biomarkers at admission, including N-Terminal pro-B-type natriuretic peptide (NT-pro BNP), high-sensitivity cardiac troponin T (hs-cTnT), creatine kinase (CK), creatine kinase MB (CK-MB), and lactate dehydrogenase (LDH), were collected. Acute decompensating events at admission, primarily including ascites, acute gastrointestinal hemorrhage, and acute-on-chronic liver failure (ACLF), were recorded. RESULTS The NT-pro BNP level was significantly higher in cirrhotic patients with acute decompensating events than in those without any decompensating events (median: 140.75 pg/mL versus 41.86 pg/mL, P < 0.001). The NT-pro BNP level significantly correlated with ascites, acute gastrointestinal hemorrhage, and ACLF. The hs-cTnT level was significantly higher in cirrhotic patients with acute decompensating events than in those without decompensating events (median: 0.008 ng/mL versus 0.006 ng/mL, P = 0.007). The hs-cTnT level significantly correlated with acute gastrointestinal hemorrhage, but not ascites or ACLF. LDH (185.0 U/L versus 173.5 U/L, P = 0.281), CK (71 U/L versus 84 U/L, P = 0.157), and CK-MB (29.5 U/L versus 33.0 U/L, P = 0.604) levels were not significantly different between cirrhotic patients with and without acute decompensating events. CONCLUSION The elevated NT-pro BNP level seems to be closely related to the development of acute decompensating events in liver cirrhosis.
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Affiliation(s)
- Miaomiao Li
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 2Department of Clinical Laboratory, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zeqi Guo
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Dan Zhang
- 3Department of General Surgery, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 4Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang, China
| | | | - Andrea Mancuso
- 6Department of Internal Medicine, ARNAS Civico, Palermo, Italy
| | - Jingqiao Zhang
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 4Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang, China
| | - Ruirui Feng
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xinmiao Zhou
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Cen Hong
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xingshun Qi
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
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Wyawahare M, Singh A, Sarin K, Rajendiran S, Subrahmanyam D, Satheesh S. Association of N- terminal pro brain natriuretic peptide with echocardiographic measures of diastolic dysfunction in cirrhosis. Adv Biomed Res 2020; 9:55. [PMID: 33457338 PMCID: PMC7792875 DOI: 10.4103/abr.abr_250_19] [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: 12/05/2019] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Liver cirrhosis is associated with cardiac dysfunction in 40%–60% of the patients. Serum NT-ProBNP is a potential additional marker of cirrhotic cardiomyopathy. Materials and Methods: It was a cross-sectional analytical study done in a tertiary care center in South India on 100 patients of cirrhosis of liver. Diastolic function was assessed from mitral inflow parameters as well as tissue Doppler imaging of the left ventricle in 95 patients. Serum NT-ProBNP levels was measured once at the time of inclusion into the study. Cirrhotic cardiomyopathy was diagnosed in those with abnormal echocardiographic parameters and its association with NT-Pro BNP levels was analyzed. Data were analyzed using SPSS version 22. Results: Diastolic dysfunction was found in 40 (42.1%) participants. Twenty-two (23.2%) had Grade I, 16 (16.8%) had Grade II, and 2 (2.1%) had Grade III diastolic dysfunction. The mean NT-Pro-BNP was elevated (107.38 [±66.76] ng/ml) in patients with diastolic dysfunction. NT-ProBNP was higher in Child–Pugh B and C disease when compared to milder disease. NT-ProBNP was not a good screening tool for cardiomyopathy in cirrhotic patients. Area under the curve was 0.517 with 95% confidence interval and the P = 0.77. However, positive correlation was present between the NT-ProBNP value and two echocardiographic parameters of diastolic dysfunction (E/A, E/E'). Conclusion: Increased serum NT-ProBNP levels in cirrhosis of liver have a positive correlation with echocardiographic measures of diastolic dysfunction of the heart but it is not a good tool for screening for cirrhotic cardiomyopathy.
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185
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Baiges A, Garcia-Pagán JC. Predicting Heart Failure After TIPS: Still More Questions Than Answers. Hepatology 2019; 70:1889-1891. [PMID: 31520412 DOI: 10.1002/hep.30948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/09/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Anna Baiges
- Barcelona Hepatic Hemodynamics Laboratory, Liver Unit, Hospital Clinic, Barcelona, Spain
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