Portopulmonary hypertension and hepatopulmonary syndrome

Celiac disease associated with nodular regenerative hyperplasia, pulmonary abnormalities, and IgA anticardiolipin antibodies

The association of nodular regenerative hyperplasia with celiac disease is not as well established as it is with hepatopulmonary syndrome and portopulmonary hypertension. IgA anticardiolipin antibodies were reported recently in celiac patients with nodular regenerative hyperplasia. The subject of this study was the description of pulmonary abnormalities and IgA anticardiolipin antibodies in celiac patients with noncirrhotic portal hypertension. Five patients with portal hypertension were investigated to diagnose its etiology. Celiac disease was diagnosed by means of autoantibody reactivity and duodenal biopsies. Liver histology revealed nodular regenerative hyperplasia in four patients and suggested its presence in 1 case. Two cyanotic patients had severe hypoxemia with a confirmed diagnosis of hepatopulmonary syndrome. Another case exhibited features of hepatopulmonary syndrome with increased levels of arterial pulmonary pressure. The remaining 2 cases had slight abnormalities of arterial oxygenation. Three patients had reactivity to IgA anticardiolipin antibodies. The concomitance of celiac disease and nodular regenerative hyperplasia, two infrequent conditions, raises suspicion of there being a nonfortuitous coincidence. Pulmonary abnormalities, and especially hepatopulmonary syndrome, are described for the first time in association with celiac disease and nodular regenerative hyperplasia.

Reversion of severe hepatopulmonary syndrome in a non cirrhotic patient after corticosteroid treatment for granulomatous hepatitis: A case report and review of the literature

Hepatopulmonary syndrome (HPS) is defined as a clinical triad including liver disease, abnormal pulmonary gas exchange and evidence of intrapulmonary vascular dilatations. We report a 61-year-old male presented with fatigue, long-lasting fever, loss of weight, signs of portal hypertension, hepatosplenomegaly, cholestasis and progressive dyspnoea over the last year. Clinical, laboratory and histological findings confirmed the diagnosis of granulomatous hepatitis. HPS due to hepatic granuloma-induced portal hypertension was proved to be the cause of severe hypoxemia of the patient as confirmed by contrast-enhanced echocardiography. Reversion of HPS after corticosteroid therapy was confirmed by a new contrast-enhanced echocardiography along with the normalization of cholestatic enzymes and improvement of the patient’s conditions. This is the first case of complete reversion of HPS in a non-cirrhotic patient with hepatic granuloma, indicating that intrapulmonary shunt in liver diseases is a functional phenomenon and HPS can be developed even in miscellaneous liver involvement as in this case.

Portopulmonary hypertension in childhood presenting as sudden death

We present the case of a 9-year-old boy with portal hypertension who died suddenly and unexpectedly due to pulmonary hypertensive crisis during a routine endoscopic procedure. He had known portal hypertension with esophageal varices but had no preceding clinical symptoms suggestive of significant pulmonary hypertensive disease despite postmortem histological evidence of advanced pulmonary vascular changes. Portopulmonary hypertension is a well-described and distinct clinical syndrome that is rare in childhood and is associated with a relatively poor prognosis. Occasional patients with histologically advanced disease may remain asymptomatic but present with pulmonary hypertensive crisis. Children with portopulmonary hypertension should be considered at high risk for surgical procedures, and pulmonary hypertensive complications should be excluded as a cause of death in all children dying suddenly in the setting of portal hypertension.

An Overview of Solid Organ Transplantation

Once a medical curiosity, solid organ transplantation is now a commonplace occurrence, with more than 27,000 procedures performed in the United States in 2004 alone. This article offers an overview of the various solid organ transplant procedures to provide a context within which subsequent articles on pulmonary complications can be viewed.

Effects of Dobutamine on Right Ventricular Function and Pulmonary Circulation in Pulmonary Hypertension During Liver Transplantation

INTRODUCTION

In the setting of orthotopic liver transplantation (OLT), pulmonary hypertension (PH) affects right ventricular (RV) function. When RV failure occurs, reducing RV afterload, optimizing RV preload, and preserving coronary perfusion through maintenance of systemic blood pressure are the primary goals of intraoperative treatment.

PATIENTS AND METHODS

To verify the effect of dobutamine on RV function and RV-arterial coupling, we compared a group of 9 cirrhotic patients with mild PH treated with OLT to a group of 20 patients with normal mean pulmonary artery pressure (MPAP). All patients received dobutamine (5-10 microg/kg/min) to maintain a cardiac index (CI) >3 L/min/m(2), during the anhepatic phase. Hemodynamic profile, using a pulmonary artery catheter, was performed before and during dobutamine infusion, studying MPAP, CI, and RV end-diastolic volume index (RVEDVI). RV stroke work index (RVSWI), RV end-systolic elastance (Ees), pulmonary effective elastance (Ea), and RV-arterial coupling efficiency as the Ees/Ea ratio were also calculated.

RESULTS

RV contractility (Ees and RVSWI) and afterload (Ea) were significantly higher among the PH group. In both groups, all the studied variables improved with dobutamine: RV contractility increased, afterload decreased, and thus Ees/Ea coupling markedly increased.

CONCLUSION

Cirrhotic patients with mild PH who were undergoing OLT still have a reserve of RV contractile performance and pulmonary vasodilation.

Portopulmonary Hypertension and Liver Transplantation: Hemodynamic Consequences at Reperfusion

BACKGROUND

The absence of portopulmonary hypertension (PH) upon preoperative evaluation for liver transplantation (OLT) does not exclude the occasional occurrence of an acquired PH while awaiting a graft. We sought to estimate hemodynamic changes and right ventriculoarterial coupling during reperfusion.

METHODS

We studied 11 cirrhotic patients diagnosed with mild PH, according to the current classification: mean pulmonary artery pressure (MPAP)-25 to 34 mm Hg. These patients underwent OLT, using the piggyback technique (group PH). None of them had exhibited criteria for PH on preoperative echocardiography. This cohort was compared with 20 consecutive cirrhotic patients with normal MPAP at OLT. We performed a complete hemodynamic profile using a pulmonary artery catheter (RVEF, Baxter-Edwards, Calif, USA) before and 5 minutes after reperfusion. The variables were MPAP and right ventricular (RV) end-diastolic volume index (RVEDVI). Using standard formulas we calculated RV stroke work index (RVSWI), RV end-systolic elastance (Ees), pulmonary effective elastance (Ea), and RV-arterial coupling efficiency as the Ees/Ea ratio. Systolic ventricular function was expressed as RVSWI versus RVEDVI.

RESULTS

During the anhepatic phase, MPAP, Ees, Ea, and RVSWI were higher in the PH group; but RVEDVI was lower. After reperfusion the pressure (MPAP), contractility (RVSWI) and preload (RVEDVI) increased in both groups. However, afterload (Ea) decreased in the non-PH group; accordingly, Es/Ea increased only in these patients.

DISCUSSION

At reperfusion, the expansion in preload and cardiac output, without a similar afterload decrease, is responsible for the steady increase in pressure. Our results have shown that in the PH patient group, systolic ventricular function improves during reperfusion by a Frank-Starling mechanism; however, ventricular-arterial uncoupling is maintained (Ees/Ea < 1) because ventricular contractility is not appropriately balanced by simultaneous declines in afterload.

Diagnostic et classification des hypertensions artérielles pulmonaires

The clinical classification of types of pulmonary hypertension has made it possible to better standardize the approach to the diagnosis and treatment of patients, to perform clinical studies among homogeneous patients, and to discover common laboratory abnormalities that may serve as markers or help elucidate mechanisms of disease. Pulmonary arterial hypertension groups together different diseases that affect the small-caliber pulmonary arteries and lead to a progressive increase in pulmonary arterial resistance and right heart failure. A specific diagnosis of pulmonary arterial hypertension is generally based on a detailed and methodical clinical evaluation. Pulmonary biopsy is rarely indicated. Work-up in a center specialized in the management of this disease is frequently appropriate when the cause of the hypertension is not clear or when a specific treatment is envisaged.

Hemodynamics and survival of patients with portopulmonary hypertension

It is not known whether patients with pulmonary arterial hypertension associated with portal hypertension (portopulmonary hypertension (PPHTN) have different disease characteristics from those of patients with other forms of pulmonary arterial hypertension. We performed a retrospective cohort study of patients with PPHTN and patients with pulmonary arterial hypertension that was idiopathic, familial, or associated with anorexigen use (IPAH) to determine whether hemodynamics or survival were different between these groups. We included consecutive patients who underwent initial pulmonary artery catheterization and vasodilator testing at our center between January 1997 and May 2001 and who were followed until January 2004. Patients with PPHTN (N = 13) had a higher cardiac index and lower pulmonary vascular resistance than patients with IPAH (N = 33) (P < or = 0.001). Right atrial pressure and pulmonary artery pressure were similar between the groups. Patients with PPHTN had a higher risk of death in multivariate analysis (hazard ratio: [HR] = 2.8, 95% CI 1.04-7.4; P = 0.04). These findings were not affected by adjustment for differences in laboratory values, hemodynamics, or therapy. In conclusion, patients with PPHTN have a higher risk of death than that of patients with IPAH, despite having a higher cardiac index and lower pulmonary vascular resistance. Future studies of the specific mechanisms of and therapy for pulmonary arterial hypertension should focus on the distinctions between the different forms of this disease.

Preoperative assessment of the patient with liver disease

Patients with liver disease are at appreciable risk when undergoing anesthesia and surgery. Attempts to quantify this risk have been thwarted by the diversity of disease states and illness severity that such patients bring to the operating theater and the myriad of procedures they may undergo. This review discusses the indications and contraindications for surgery in patients with liver disease and attempts to give specific recommendations for optimizing the clinical status of a patient with hepatic dysfunction prior to operative intervention.

Arterial hypoxemia and intrapulmonary vasodilatation in rat models of portal hypertension

BACKGROUND

Rats with chronic bile duct ligation (CBDL) and portal vein ligation (PVL) are used as models of portal hypertension. CBDL rats show hypoxemia with intrapulmonary vasodilatation (IPVD), and are recognized as a model of hepatopulmonary syndrome (HPS), while PVL rats are normoxemic. We investigated the differences in arterial oxygenation between these models, and the key factors leading to HPS.

METHODS

Forty-eight Sprague-Dawley rats were prepared as CBDL or PVL models, or as Sham rats. Arterial oxygenation, hemodynamics (reference sample method), and IPVD were simultaneously evaluated in conscious and unrestrained animals, using (141)Ce- or (113)Sn-labeled microspheres (15 microm in diameter), respectively. Endothelin-1 (ET-1) and nitrate/nitrite (end products of nitric oxide; NOx) production by the lung tissue (increment across the lungs) was also determined.

RESULTS

The extent of IPVD was similar in both models, but hypoxemia was only observed in CBDL rats. The ET-1 level and the increment in NOx were significantly increased in CBDL rats, and the increment was directly correlated with impairment of oxygenation. Blood flow through the bronchial arteries (anatomical shunting) was increased in CBDL rats, reaching more than three times the level in PVL rats or Sham rats.

CONCLUSIONS

These results support the hypothesis that NO derived from the lung tissues contributes to hypoxemia, and IPVD appears to be a prerequisite for impaired oxygenation. The considerable increase of anatomical shunting may potentially contribute to impaired oxygenation in CBDL rats.

Intensive Care Complications in Liver and Multivisceral Transplantation

The complications concerning liver and intestinal transplant surgery have relevance for the field of intensive care because they share some characteristics with those following complex long-term surgery. Thus, in this article we shall try to describe complications that are specific to liver and multivisceral transplants. A review of the existing literature on this topic reveals a large number of studies dedicated to early as well as late surgical complications, and immunosuppressive treatment, while there are far fewer contributions describing complications exclusively concerning intensive care. We shall thus attempt to focus on certain aspects where, besides the literature data, we have personal experience. In particular we want to underline the implications of failure in the functional recovery of the graft; alterations in water, electrolyte, and glycemic balance; as well as neurological, respiratory, renal, nutritional, and infective complications.

Portopulmonary hypertension in pediatric patients

OBJECTIVES

To investigate the clinical presentation, manifestations, and response to therapy of portopulmonary hypertension (PPHTN) in pediatric patients.

STUDY DESIGN

This study was a retrospective chart review describing the evaluation and course of 7 patients with PPHTN.

RESULTS

Causes of portal hypertension (HTN) included biliary atresia (3 cases), cavernous transformation of the portal vein (2 cases), and primary sclerosing cholangitis and cryptogenic cirrhosis (1 case each). The median interval from the diagnosis of portal HTN to PPHTN was 12.1 years. Four patients presented with a new heart murmur, 4 presented with syncope, and 3 presented with dyspnea. Although electrocardiograms (ECGs) and chest x-rays were normal in 3 and 2 patients, respectively, echocardiograms diagnosed pulmonary HTN in all 7 patients. Five patients had cardiac catheterizations; the average mean pulmonary artery pressure was 65 +/- 20 mm Hg. Response to therapy was variable, and 4 patients died. Postmortem lung tissue examination revealed plexiform lesions and pulmonary arteriopathy.

CONCLUSIONS

Because symptoms are subtle and may be overlooked, pediatric patients with portal HTN who develop a new heart murmur, dyspnea, syncope, or who are being evaluated for liver transplantation require evaluation for PPHTN. ECG and chest x-ray are insensitive screens for PPHTN. An echocardiogram and cardiology evaluation is essential for the diagnosis.

Intrapulmonary shunting and hepatopulmonary syndrome

A57-year-old woman was referred for assessment of progressive dyspnoea, decreasing exercise tolerance and worsening bluish facial discolouration. She had congenital cirrhosis complicated by portal hypertension aged 4 years, for which she underwent a portacaval shunt. She was an exsmoker of 30 years. On examination, she was centrally cyanosed and clubbed. Her jugular venous pressure was not elevated, cardiac examination was normal and there were no focal chest signs. Spider naevi were noted, but no palpable organomegaly or ascites. Her oxygen saturation, however, was 88% breathing room air, which did not alter when recumbent or supine.

A chest radiograph showed normal lung fields and vasculature, and no effusions. Renal and liver profile blood tests and international normalized ratio were normal. Arterial blood gas analysis revealed: pH 7.43 (normal 7.35–7.45), Pa∘2 7.21 kPa (normal >10.6 kPa), PaC∘2 3.96 kPa (normal 4.6–6.0 kPa) breathing room air. Her AaPa∘2 was 7.8 kPa (predicted agecorrected AaPa∘2 2.10 kPa). Pa∘2 increased to 69.8 kPa breathing 100% inspired oxygen delivered using continuous positive airway pressure. Her calculated intrapulmonary shunt fraction was 7% (normal <5%). Pulmonary function tests showed normal spirometry and preserved lung volumes, however, carbon monoxide diffusing capacity was only 38% predicted, adjusted for haemoglobin 17.8 g/dl.

Transthoracic echocardiography demonstrated normal structure and function of all cardiac chambers. Contrast echocardiography established the presence of intrapulmonary shunting (Figure 1) and confirmed the diagnosis of hepatopulmonary syndrome. She was established on long-term oxygen therapy and is currently under consideration for a liver transplant.

Preoperative optimization of patients with liver disease

PURPOSE OF REVIEW

Recent papers relevant to the preoperative evaluation and optimization of patients with severe liver disease will be discussed. The emphasis will be placed on cardiovascular, pulmonary, and renal complications. Other aspects such as preoperative management of hepatitis B and C, other infectious issues, and liver cancer will not be discussed because this rarely involves the anesthesiologist.

RECENT FINDINGS

Dobutamine stress echocardiography has been the cornerstone of cardiac evaluation of liver transplant candidates. Combining liver transplantation with cardiac procedures has been shown to be feasible. While mild hepatopulmonary syndrome is well-tolerated, severe hepatopulmonary syndrome carries a fairly high mortality rate. New treatment modalities of severe portopulmonary hypertension have been introduced, and may have advantages over epoprostenol administration. Hepatic hydrothorax requires similar therapy to ascites [repeated thoracentesis or paracentesis, and transjugular intrahepatic portosystemic shunt (TIPS)], but refractory hydrothorax may require other interventions. Hepatorenal syndrome may improve by increasing renal blood flow through the use of vasoconstrictors (vasopressin, norepinephrine) in combination with albumin administration. Interventional radiologists can now change the flow through an established TIPS. Hepatic encephalopathy may result in some irreversible changes in the brain. It remains difficult to predict whether a patient with acute fulminant failure will recover spontaneously. Support devices that include hepatocytes show early promising results. The coagulation changes in living donors are incompletely understood. Finally, autonomic neuropathy as a complication of severe liver disease results in more hemodynamic instability.

SUMMARY

Recent advances in preoperative evaluation and optimization are presented and discussed.

Successful liver transplantation for congenital absence of the portal vein complicated by intrapulmonary shunt and brain abscess

A 27-day-old boy had convulsion associated with brain abscesses and severe hypoxemia at the age of 3 months. Congenital absence of the portal vein (CAPV) and some associated anomalies were detected by radiological examinations. Brain abscess and hypoxemia were thought to be serious complications resulting from CAPV and were successfully corrected by living donor liver transplantation at the age of 4 months. This is the first report of a successful transplantation indicated for intrapulmonary shunt and brain abscess in an infant with CAPV.

[Liver transplantation: deciding between need and donor allocation]

Liver transplantation represents an established therapeutic option for advanced liver diseases. The spectrum of indications encompasses infectious, vascular, immunological and toxic diseases leading to cirrhosis, in addition to genetic, metabolic, developmental and selected neoplastic diseases. On the one hand the timing of liver transplantation is determined by the disease specific course until decompensation and the disease manifestation involving bile ducts or hepatocytes. On the other hand it represents gene therapy of diseases affecting the liver, or entities where the genetic defect lies in the liver. In view of the shortage of donor organs and an increasing requirement for liver transplantation the challenge is to provide an effective and fair waiting list management. Reform of allocation criteria has put the focus on urgency. This in turn leads to an increase in waiting time for elective transplantations, inclusion of end stage diseases and critical patients, higher perioperative costs, problems with the matching of organs and the problem of an effective use of organ resources. Fair allocation and medical necessity therefore define the challenges surrounding the indications for liver transplantation.

Liver transplantation as ultimate tool to treat portal hypertension

Portal hypertension is a complication of liver cirrhosis that may itself cause complications such as variceal bleeding, ascites and hepatorenal syndrome. There are several options for symptomatic treatment including drug therapy, endoscopy, transjugular intrahepatic portosystemic shunt (TIPS), and various surgical procedures, notably liver transplantation, the only causal treatment. The indication for liver transplantation has to be defined carefully. Progression of the primary disease, evaluation of comorbidity and overall prognosis have to be considered. Conservative symptomatic treatment is used for bridging purposes until liver transplantation can be provided to cure portal hypertension and the underlying primary disease. Careful timing of the transplantation is necessary as well as reorganization of the waiting lists by introducing new priority systems as the Model for End-Stage Liver Disease (MELD) in order to reduce mortality. Furthermore, living donor liver transplantation and split liver transplantation are methods to enlarge the donor pool, and thus accessibility of transplantation to a greater number of patients. This review evaluates the indication of liver transplantation in the treatment of portal hypertension.

Association of Limited Scleroderma and Pulmonary Hypertension in a Patient with Primary Biliary Cirrhosis

We report a male patient with primary biliary cirrhosis (PBC) who developed limited scleroderma (l-SSc) and pulmonary hypertension (PHT). He had noticed shortness of breath seven months earlier, which slowly progressed before admission. Sclerodactyly and telagiectasia of the fingers and chest wall were found. Chest X-ray and Doppler echocardiography suggested the presence of PHT. Histologic examination of the liver (needle biopsy) revealed stage two PBC, and histologic findings of the skin (obtained from the dorsum of right finger IV) were compatible with l-SSc. Direct measurement of pulmonary arterial pressure revealed PHT with normal capillary wedge pressure during right heart catheterization. A striking increment of plasma thromboxane B(2) across the lungs was found, which suggested that thromboxane A(2) (precursor of thromboxane B(2)) contributed considerably to a rise in pulmonary vascular resistance leading to PHT.

Lungentransplantation

Lung transplantation is an option for patients with endstage pulmonary diseases without contraindications. Recent European studies showed a survival benefit for patients with cystic fibrosis, fibrosis and emphysema after lung transplantation. Early mortality has been reduced recently by surgical improvements. Life expectancy after lung transplantation has improved in recent years but is still lower than in patients with other solid organ transplantations. Quality of life is consistently improved but exercise tolerance keeps reduced in comparison to the normal population. Specific problems described in detail are frequent organ rejections and infections, airway problems and a high incidence of malignant diseases. 5-year survival after lung transplantation is in average 60%.