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Gananandan K, Wiese S, Møller S, Mookerjee RP. Cardiac dysfunction in patients with cirrhosis and acute decompensation. Liver Int 2024; 44:1832-1841. [PMID: 38712826 DOI: 10.1111/liv.15896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Signe Wiese
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastroenterology Unit, Medical Division, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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2
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Ortega-Lobete O, Clemente-Sánchez A, Bañares R, Rincón D. Hepatic hemodynamic study: More than just HVPG measurement. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:199-205. [PMID: 37028758 DOI: 10.1016/j.gastrohep.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 04/09/2023]
Abstract
Evaluation and staging of liver disease is essential in the clinical decision-making process of liver tumors. The severity of portal hypertension (PH) is the main prognostic factor in advanced liver disease. Performing an accurate hepatic venous pressure gradient (HVPG) measurement is not always possible, especially when veno-venous communications are present. In those complex cases, a refinement in HVPG measurement with a thorough evaluation of each of the components of PH is mandatory. We aimed at describing how some technical modifications and complementary procedures may contribute to an accurate and complete clinical evaluation to improve therapeutic decisions.
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Affiliation(s)
- Olga Ortega-Lobete
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Clemente-Sánchez
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Rafael Bañares
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Diego Rincón
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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3
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Michele B, Leonardo DM, Roberta S, Filippo C, Mirko Z, Veronica P, Donatella I, Andrea D, David S. Hepatofugal portal flow is highly predictive of acute-on-chronic liver failure: A new hemodynamic patho-physiological hypothesis. Dig Liver Dis 2024:S1590-8658(24)00208-1. [PMID: 38281869 DOI: 10.1016/j.dld.2024.01.190] [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: 10/02/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a severe complication of advanced liver disease. A significant number of ACLF patients have not clear precipitating factors. The aim of the study was to investigate the role of alterations in porto-hepatic hemodynamics, especially non-forward portal flow (NFPF), in ACLF and liver-related mortality. METHODS 233 cirrhotic patients were included in the study with a median follow-up of 24 months. Color-Doppler ultrasound was used to assess portal vein patency, flow direction and significant porto-systemic collaterals (>8 mm). Patients with active cancer, both at baseline and during follow-up and severe non liver-related comorbidities were excluded. ACLF and liver-related mortality were recorded during follow-up. RESULTS Fifty-six patients (24%) developed ACLF; 24 (10,3%) had baseline NFPF. In survival analysis, NFPF, but not portal vein thrombosis, was independently associated with ACLF development (HR 2.85 95% C.I. [1.49-5.42], p = 0.001) and liver-related mortality (HR 2.24 95% C.I. [1.16-4.28], p = 0.015), even after adjustment for liver disease severity scores, age and etiology of liver disease. CONCLUSION NFPF is independently associated with ACLF development and liver-related mortality, regardless of etiology, severity disease scores and portal vein thrombosis. Although there is no specific measure to reverse NFPF, patients with NFPF should receive prompt intensive management and urgent prioritization for liver transplantation. CLINICAL TRIAL NUMBER 2730 CESC.
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Affiliation(s)
- Bevilacqua Michele
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - De Marco Leonardo
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Stupia Roberta
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Cattazzo Filippo
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Zoncapé Mirko
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Paon Veronica
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Ieluzzi Donatella
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Dalbeni Andrea
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Sacerdoti David
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.
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4
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Yusuff H, Chawla S, Sato R, Dugar S, Bangash MN, Antonini MV, Shelley B, Valchanov K, Roscoe A, Scott J, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Zochios V. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 2. J Cardiothorac Vasc Anesth 2023; 37:2318-2326. [PMID: 37625918 DOI: 10.1053/j.jvca.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 08/27/2023]
Abstract
The right ventricle (RV) is intricately linked in the clinical presentation of critical illness; however, the basis of this is not well-understood and has not been studied as extensively as the left ventricle. There has been an increased awareness of the need to understand how the RV is affected in different critical illness states. In addition, the increased use of point-of-care echocardiography in the critical care setting has allowed for earlier identification and monitoring of the RV in a patient who is critically ill. The first part of this review describes and characterizes the RV in different perioperative states. This second part of the review discusses and analyzes the complex pathophysiologic relationships between the RV and different critical care states. There is a lack of a universal RV injury definition because it represents a range of abnormal RV biomechanics and phenotypes. The term "RV injury" (RVI) has been used to describe a spectrum of presentations, which includes diastolic dysfunction (early injury), when the RV retains the ability to compensate, to RV failure (late or advanced injury). Understanding the mechanisms leading to functional 'uncoupling' between the RV and the pulmonary circulation may enable perioperative physicians, intensivists, and researchers to identify clinical phenotypes of RVI. This, consequently, may provide the opportunity to test RV-centric hypotheses and potentially individualize therapies.
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Affiliation(s)
- Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Centre Singapore, Singapore
| | - Jeffrey Scott
- Jackson Health System / Miami Transplant Institute, Miami, FL
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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Ripoll C, Ibáñez‐Samaniego L, Neumann B, Vaquero J, Greinert R, Bañares R, Zipprich A. Evaluation of the definition of hyperdynamic circulation in patients with cirrhosis and ascites. Hepatol Commun 2022; 6:3528-3538. [PMID: 36221228 PMCID: PMC9701480 DOI: 10.1002/hep4.2102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to evaluate potential criteria for defining hyperdynamic circulation in patients with cirrhosis according to the severity of ascites and its association with the activation of vasoactive systems and markers of systemic inflammation. Cross-sectional study of patients with cirrhosis and right heart catheter measurement from two different academic centers. We evaluated systemic vascular resistance (SVR)/cardiac output (CO) according to ascites severity. The first substudy evaluated the possible definition, the second validated the findings, and the third evaluated the possible mechanisms. Comparisons were performed by means of t test, Mann-Whitney U test, and analysis of variance. Finally, linear regression curves were adjusted to evaluate the relationship between CO and SVR according to the severity of ascites and compensated or decompensated stage of cirrhosis. The study included 721 patients (substudy 1, n = 437; substudy 2, n = 197; substudy 3, n = 87). Hyperdynamic circulation (HC), defined by absolute cutoffs, had no association with the presence or severity of ascites in the first two cohorts. No association was observed between HC with renin, aldosterone, or markers of bacterial translocation. Comparison of linear regression curves showed a shift of the CO-SVR relationship to the left in patients with refractory ascites (p < 0.001) compared to patients without ascites as well as to patients with decompensated cirrhosis (p = 0.002). Conclusion: HC according to the traditional concept of high CO and low SVR is not always present in ascites. Evaluation of the CO-SVR relationship according to the severity of ascites shows a shift to the left, suggesting that the presence of HC would be defined by this shift, independent of absolute values.
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Affiliation(s)
- Cristina Ripoll
- Department of Internal Medicine IMartin‐Luther University Halle‐WittenbergHalleGermany,Department of Internal Medicine IVJena University Hospital, Friedrich‐Schiller University JenaJenaGermany
| | | | - Beatrix Neumann
- Department of Internal Medicine IMartin‐Luther University Halle‐WittenbergHalleGermany
| | - Javier Vaquero
- Hospital General Universitario Gregorio Marañón. CiberEHDMadridSpain
| | - Robin Greinert
- Department of Internal Medicine IMartin‐Luther University Halle‐WittenbergHalleGermany
| | - Rafael Bañares
- Hospital General Universitario Gregorio Marañón. CiberEHDMadridSpain
| | - Alexander Zipprich
- Department of Internal Medicine IMartin‐Luther University Halle‐WittenbergHalleGermany,Department of Internal Medicine IVJena University Hospital, Friedrich‐Schiller University JenaJenaGermany
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6
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Prognostic implications of systolic function in patients with cirrhosis. GASTROENTEROLOGÍA Y HEPATOLOGÍA 2022; 46:446-454. [DOI: 10.1016/j.gastrohep.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022]
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7
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Nabilou P, Danielsen KV, Kimer N, Hove JD, Bendtsen F, Møller S. Blunted cardiovascular effects of beta-blockers in patients with cirrhosis: Relation to severity? PLoS One 2022; 17:e0270603. [PMID: 35763518 PMCID: PMC9239488 DOI: 10.1371/journal.pone.0270603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Aims Patients with cirrhosis and portal hypertension are at high risk of developing complications such as variceal hemorrhage, ascites, and cardiac dysfunction, the latter of which is known as cirrhotic cardiomyopathy. Since non-selective beta-blockers (NSBB) may aggravate hemodynamic complications we investigated the effect of real-time propranolol infusion on cardiac function in patients with varying degrees of cirrhosis. Methods Thirty-eight patients with Child-Pugh A (n = 17), B (n = 17) and C (n = 4) underwent liver vein catheterization and cardiac magnetic resonance imaging. We assessed the effect of real-time propranolol infusion on the hepatic venous pressure gradient, cardiac index, stroke volume, ejection fraction, heart rate, and contractility. Results Nineteen patients were classified as responders to beta-blocker therapy. In pooling Child-Pugh B and C patients, the reduction in cardiac index by beta-blockade was weaker than in Child-Pugh A patients (-8.5% vs. -20.5%, p = 0.043). The effect of NSBB on portal pressure was inversely correlated to changes in the left atrium where the left atrial volume changed by 4 mL±18 in responders compared to 15 mL±11 in non-responders (p = 0.03). Finally, the baseline ejection fraction correlated inversely with the reduction in portal pressure (r = -0.39, p = 0.02). Conclusion We found the effect of beta-blockade on cardiac index in patients with advanced cirrhosis to be less potent than in patients with early cirrhosis, indicating that underlying cirrhotic cardiomyopathy increases, and the cardiac compensatory reserve becomes more compromised, with disease progression. The differential effects of beta-blockade in the left atrium may be used to predict the effect of beta-blockers on portal pressure, but further studies are needed to investigate this possibility.
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Affiliation(s)
- Puria Nabilou
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- * E-mail:
| | - Karen Vagner Danielsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jens Dahlgaard Hove
- Department of Cardiology, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Dept. Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, København, Denmark
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Téllez L, Albillos A. Non-selective beta-blockers in patients with ascites: The complex interplay among the liver, kidney and heart. Liver Int 2022; 42:749-761. [PMID: 35051310 DOI: 10.1111/liv.15166] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Non-selective beta-blockers (NSBBs) are the cornerstone of the primary and secondary prophylaxis of variceal bleeding in cirrhotic patients. They additionally prevent ascites development and death in compensated patients with clinically significant portal hypertension. After ascites onset, NSBBs remain beneficial for preventing further decompensations. However, as the cirrhosis progresses, the inflammation increases, systemic vasodilatation worsens, ascites turns refractory and cardiodynamic equilibrium becomes extremely fragile. In this scenario, NSBBs can critically impair the cardiac reserve and facilitate a haemodynamic breakdown, imperilling renal perfusion. Consequently, NSBB treatment should be carefully monitored or even avoided in such patients, and other options for portal hypertension management should be considered. In the present review, we explore the effects of NSBBs in patients with ascites and discuss the complex interplay among their hepatic, systemic and renal haemodynamic effects in this scenario.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
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9
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Liu G, Wang X, Yang T, Yan Y, Xiang T, Yang L, Luo X. High Interleukin-8 Levels Associated With Decreased Survival in Patients With Cirrhosis Following Transjugular Intrahepatic Portosystemic Shunt. Front Med (Lausanne) 2022; 9:829245. [PMID: 35295601 PMCID: PMC8918632 DOI: 10.3389/fmed.2022.829245] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background Serum cytokines—reflecting systemic inflammation has been associated with the risk of decompensation and mortality in patients with cirrhosis. However, the role of systemic inflammation in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt procedure remains unknown. Patients and Methods Patients with cirrhosis who received transjugular intrahepatic portosystemic shunt between June 2015 and September 2017 were included. Portal and hepatic venous blood samples were obtained intraoperatively; serum cytokine levels (IL-10, IL-17A, IL-1RA, IL-8, and CXCL10) were measured in 105 patients. Associations with survival and other outcomes during long-term follow-up (median: 1,564 days) were assessed using logistic regression. Results IL-17A and CXCL10 levels were higher in the portal than in the hepatic veins, whereas IL-1RA levels were higher in the hepatic than in the portal veins. However, IL-8 or IL-10 levels between hepatic and portal veins showed no differences. Multivariate analysis demonstrated that Child–Pugh scores (P = 0.017, HR: 1.484, 95% CI: 1.072–2.055) and IL-8 level in hepatic veins (P < 0.001, HR: 1.043, 95% CI: 1.019–1.068) were independent predictors for mortality during long-term follow-up, with an optimal cut-off of 5.87 pg/ml for IL-8 in hepatic veins. Patients with hepatic IL-8 levels < 5.87 pg/ml had significantly higher cumulative survival rates (98.4 vs. 72.9% at 1 year, 98.4 vs. 65.3% at 2 years, 96.7 vs. 60.3% at 3 years, 94.2 vs. 60.3% at 4 years; P < 0.0001). Conclusions IL-8 levels in hepatic veins may reflect liver cirrhosis severity. Elevated IL-8 levels suggest shorter survival in patients receiving TIPS.
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Affiliation(s)
- Guofeng Liu
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoze Wang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Tingting Yang
- Department of Andrology/Sichuan Human Sperm Bank, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuling Yan
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Tong Xiang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xuefeng Luo
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10
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Albillos A, Martin-Mateos R, Van der Merwe S, Wiest R, Jalan R, Álvarez-Mon M. Cirrhosis-associated immune dysfunction. Nat Rev Gastroenterol Hepatol 2022; 19:112-134. [PMID: 34703031 DOI: 10.1038/s41575-021-00520-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 02/08/2023]
Abstract
The term cirrhosis-associated immune dysfunction (CAID) comprises the distinctive spectrum of immune alterations associated with the course of end-stage liver disease. Systemic inflammation and immune deficiency are the key components of CAID. Their severity is highly dynamic and progressive, paralleling cirrhosis stage. CAID involves two different immune phenotypes: the low-grade systemic inflammatory phenotype and the high-grade systemic inflammatory phenotype. The low-grade systemic inflammatory phenotype can be found in patients with compensated disease or clinical decompensation with no organ failure. In this phenotype, there is an exaggerated immune activation but the effector response is not markedly compromised. The high-grade systemic inflammatory phenotype is present in patients with acute-on-chronic liver failure, a clinical situation characterized by decompensation, organ failure and high short-term mortality. Along with high-grade inflammation, this CAID phenotype includes intense immune paralysis that critically increases the risk of infections and worsens prognosis. The intensity of CAID has important consequences on cirrhosis progression and correlates with the severity of liver insufficiency, bacterial translocation and organ failure. Therapies targeting the modulation of the dysfunctional immune response are currently being evaluated in preclinical and clinical studies.
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Affiliation(s)
- Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain. .,Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain.
| | - Rosa Martin-Mateos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Schalk Van der Merwe
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Aging (CHROMETA), University of Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Melchor Álvarez-Mon
- Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain.,Department of Internal Medicine, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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11
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Guglin M, Nazif K. New onset nonischemic cardiomyopathy post liver transplantation. Heart Fail Rev 2021; 27:1829-1836. [PMID: 34799813 DOI: 10.1007/s10741-021-10196-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/25/2022]
Abstract
A new onset acute heart failure (HF) with a sudden drop in the left ventricular ejection fraction (LVEF) post orthotopic liver transplant (LT) is a rare but a potentially fatal complication. Because in most of the cases there is no evidence of coronary thrombosis, it can be classified as nonischemic cardiomyopathy. More specifically, clinical presentation of this syndrome shares many features with stress-induced or takotsubo cardiomyopathy. The known factors that predispose these patients to acute HF during or shortly after LT include cirrhotic cardiomyopathy, rapid hemodynamic changes during LT surgery, and the large concentrations of catecholamines, either administered or released endogenously during surgery. The hemodynamic changes during surgery, such as the drop in preload during the anhepatic phase (occasionally requiring massive transfusions and vasopressors) and subsequent increase in preload with acidic and hyperkalemic plasma in the reperfusion phase, lead to rapid electrolyte and hemodynamic shifts. In several cases, intraoperative onset of HF, with or without ventricular arrythmia, could be timed to the reperfusion phase (and occasionally in the anhepatic and pre-anhepatic phases). In other cases, the HF syndrome started hours to days post-surgery. Recovery of cardiac function occurred in the majority of patients during the same admission; however, these patients generally need significantly longer hospitalizations and aggressive supportive care (occasionally requiring mechanical ionotropic and ventilatory support). If recover, the patients have a similar 1-year mortality as those LT patients that did not have this complication. Because no reliable risk stratification currently exists, intraoperative transesophageal echocardiography might be the most dependable way of detecting and addressing this syndrome promptly. Given the mechanism of takotsubo cardiomyopathy, beta-blockade and a preferential use of non-catecholaminergic vasopressors may be a reasonable way to manage this syndrome.
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Affiliation(s)
- Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 Senate Blvd Suite 2000, Indianapolis, IN, 46202, USA
| | - Kutaiba Nazif
- Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 Senate Blvd Suite 2000, Indianapolis, IN, 46202, USA
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12
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Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis with poor survival in the absence of liver transplantation (LT). HRS represents a state of profound circulatory and cardiac dysfunction. Whether it increases risk of perioperative major adverse cardiovascular events (MACE) following LT remains unclear. METHODS We performed a retrospective cohort study of 560 consecutive patients undergoing cardiac workup for LT of whom 319 proceeded to LT. All patients underwent standardized assessment including dobutamine stress echocardiography. HRS was defined according to International Club of Ascites criteria. RESULTS Primary outcome of 30-day MACE occurred in 74 (23.2%) patients. A significantly higher proportion of patients with HRS experienced MACE (31 [41.9%] versus 54 [22.0%]; P = 0.001). After adjusting for age, model for end-stage liver disease score, cardiovascular risk index, history of coronary artery disease, and a positive stress test, HRS remained an independent predictor for MACE (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.13-5.78). Other independent predictors included poor functional status (OR, 3.38; 95% CI, 1.41-8.13), pulmonary hypertension (OR, 3.26; 95% CI, 1.17-5.56), and beta-blocker use (OR, 2.56; 95% CI, 1.10-6.48). Occurrence of perioperative MACE was associated with a trend toward poor age-adjusted survival over 3.6-year follow-up (hazard ratio, 2.0; 95% CI, 0.98-4.10; P = 0.057). CONCLUSIONS HRS, beta-blocker use, pulmonary hypertension, and poor functional status were all associated with over a 2-fold higher risk of MACE following LT. Whether inclusion of these variables in routine preoperative assessment can facilitate cardiac risk stratification warrants further study.
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13
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Engelmann C, Clària J, Szabo G, Bosch J, Bernardi M. Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. J Hepatol 2021; 75 Suppl 1:S49-S66. [PMID: 34039492 PMCID: PMC9272511 DOI: 10.1016/j.jhep.2021.01.002] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 02/07/2023]
Abstract
Patients with acutely decompensated cirrhosis have a dismal prognosis and frequently progress to acute-on-chronic liver failure, which is characterised by hepatic and extrahepatic organ failure(s). The pathomechanisms involved in decompensation and disease progression are still not well understood, and as specific disease-modifying treatments do not exist, research to identify novel therapeutic targets is of the utmost importance. This review amalgamates the latest knowledge on disease mechanisms that lead to tissue injury and extrahepatic organ failure - such as systemic inflammation, mitochondrial dysfunction, oxidative stress and metabolic changes - and marries these with the classical paradigms of acute decompensation to form a single paradigm. With this detailed breakdown of pathomechanisms, we identify areas for future research. Novel disease-modifying strategies that break the vicious cycle are urgently required to improve patient outcomes.
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Affiliation(s)
- Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany; Institute for Liver and Digestive Health, University College London, London, United Kingdom; Section Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany; Berlin Institute of Health (BIH), Berlin, Germany.
| | - Joan Clària
- European Foundation for the Study of Chronic Liver Failure (EF-Clif) and Grifols Chair, Barcelona, Spain,Biochemistry and Molecular Genetics Service, Hospital ClínicIDIBAPS and CIBERehd, Spain,Department of Biomedical Sciences, University of Barcelona, Barcelona, Spain
| | - Gyongyi Szabo
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jaume Bosch
- IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain,Department for Biomedical Research (DBMR), Bern University, Bern, Switzerland
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences; Alma Mater Studiorum – University of Bologna; Italy
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14
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Thevenot T, Mouhat B, Cervoni JP, Chopard R. The dual role of non-selective beta-blockers in cirrhotic patients: How do we know when Dr Jekyll turns into Mr Hyde? Liver Int 2021; 41:1166-1167. [PMID: 33342043 DOI: 10.1111/liv.14770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Thierry Thevenot
- Department of Hepatology, University Hospital Besançon, Besançon, France.,EA 4266 "Pathogens and inflammation, EPILAB", Université Bourgogne - Franche Comte, UFR SMP, Besançon, France
| | - Basile Mouhat
- Department of Cardiology, University Hospital Besançon, Besançon, France
| | - Jean-Paul Cervoni
- Department of Hepatology, University Hospital Besançon, Besançon, France
| | - Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France
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15
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Systemic inflammation increases across distinct stages of advanced chronic liver disease and correlates with decompensation and mortality. J Hepatol 2021; 74:819-828. [PMID: 33075344 DOI: 10.1016/j.jhep.2020.10.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/18/2020] [Accepted: 10/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Distinct prognostic stages of advanced chronic liver disease (ACLD) are defined by severity of portal hypertension (PH) and the presence/absence of clinical complications. We characterised the degree of liver dysfunction, PH, and systemic inflammation across the distinct prognostic stages and assessed their relative impact on decompensation and mortality. METHODS A single-centre, prospective cohort of ACLD patients undergoing hepatic venous pressure gradient (HVPG) measurement between 01/2017 and 08/2019 were classified into 6 prognostic stages: mild PH (HVPG 6-9 mmHg, S0), clinically significant PH (HVPG ≥10 mmHg without varices, S1), presence of varices (S2), history of variceal bleeding (S3), first non-bleeding decompensation (S4), and further decompensation (S5). The model for end-stage liver disease (MELD), C-reactive protein (CRP), and IL-6 levels were assessed in relation to their predictive value for decompensation and death. RESULTS Among 168 ACLD patients 78 had compensated (cACLD, S0 = 13; S1 = 21; S2 = 44) and 90 had decompensated (dACLD, S3 = 10; S4 = 58; S5 = 22) disease. MELD increased across all stages (p <0.001), whereas HVPG mostly increased within cACLD substages. Significant increases in CRP and IL-6 levels were only noted across dACLD substages. IL-6 was an independent predictor of decompensation at 1-year follow-up in cACLD (hazard ratio [HR] 1.06, 95% CI 1.01-1.10; p = 0.013). In dACLD patients, IL-6 levels predicted death/transplantation after 1-year of follow-up (HR 1.02, 95% CI 1.01-1.03; p = 0.004). CONCLUSION HVPG progression occurs mostly in cACLD patients, whereas systemic inflammation, as reflected by IL-6 levels, only increases substantially across dACLD stages. IL-6 levels correlate with the risk of first decompensation in cACLD and of death/transplantation in dACLD patients. LAY SUMMARY Patients with advanced chronic liver disease (ACLD; i.e. liver cirrhosis) have a certain risk of mortality according to their stage of disease. Progression of disease is greatly influenced by increased pressure in the portal venous system (i.e. portal hypertension) and occurrence of clinical complications (i.e. decompensation). Our study demonstrates that systemic inflammation markedly increases across highest disease stages, and the inflammation biomarker IL-6 in blood may specifically indicate risk of disease progression in patients with ACLD. CLINICAL TRIALS REGISTRATION The study is registered at ClinicalTrials.gov (NCT03267615).
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16
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Wang J, Shen H, Liu J, Xiao C, Chen C, Teng H, Hu J, Yin J. School-based surveillance on visit-to-visit blood pressure variability and high blood pressure in children and adolescents. BMC Cardiovasc Disord 2021; 21:141. [PMID: 33731001 PMCID: PMC7967982 DOI: 10.1186/s12872-021-01947-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background The predictive importance of visit-to-visit blood pressure variability (VVV) for high blood pressure (HBP) in a pediatric population has been largely unsettled. We aimed to evaluate it based on Health Promotion Program for Children and Adolescents (HPPCA), a school-based surveillance conducted from 2012 to 2018 in Suzhou, China. Methods A total of 330,618 participants had BP measurement in 2018 and ≥ 3 BP records during 2012–2017, were recruited from HPPCA. Absolute BP values (in mmHg) were converted into age-, sex- and height- normalized z-scores. VVV was expressed as standard deviation (SD), coefficient of variation (CV) or average real variability (ARV) of BP z-scores during 2012–2017. Logistic regression models were used to assess the associations between VVV and HBP in 2018. Results In 2018, 42,554 (12.87%) subjects were defined as HBP. VVV, except for SBP-CV and DBP-CV, was significantly higher in the HBP group than normotensives group. After adjusting for covariates including mean BP values from 2012 to 2017, SBP-SD, SBP-ARV, DBP-SD and DBP-ARV, increased the risk of HBP by 5.70 [95% confidence interval (95% CI) 5.54–5.87], 4.10 (95% CI 4.01–4.20), 4.70 (95% CI 4.50–4.90) and 3.39 (95% CI 3.28–3.50) times, respectively. Notably, SBP-SD significantly improved risk discrimination of HBP based on other risk variables (c-statistics, net reclassification index and integrated discrimination improvement significantly increased). Conclusions Higher SD or ARV of BP, was independently related with higher probability of HBP in Chinese pediatric population. SBP-SD could be potentially helpful for detecting HBP. Future researches investigating the predictive value of VVV are warrant. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-01947-1.
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Affiliation(s)
- Jiaxiang Wang
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, 215123, Jiangsu, China
| | - Hui Shen
- Suzhou Center for Disease Prevention and Control, 72 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Jieyu Liu
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, 215123, Jiangsu, China
| | - Chengqi Xiao
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, 215123, Jiangsu, China
| | - Cailong Chen
- Children Health Management Center, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Haoyue Teng
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, 215123, Jiangsu, China
| | - Jia Hu
- Suzhou Center for Disease Prevention and Control, 72 Sanxiang Road, Suzhou, 215004, Jiangsu, China.
| | - Jieyun Yin
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, 215123, Jiangsu, China.
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17
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Garcia Garcia de Paredes A, Manicardi N, Tellez L, Ibañez L, Royo F, Bermejo J, Blanco C, Fondevila C, Fernandez Lanza V, Garcia-Bermejo L, Falcon-Perez JM, Bañares R, Gracia-Sancho J, Albillos A. Molecular Profiling of Decompensated Cirrhosis by a Novel MicroRNA Signature. Hepatol Commun 2021; 5:309-322. [PMID: 33553977 PMCID: PMC7850302 DOI: 10.1002/hep4.1642] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/27/2020] [Accepted: 10/23/2020] [Indexed: 02/04/2023] Open
Abstract
Noninvasive staging of decompensated cirrhosis is an unmet clinical need. The aims of this study were to characterize and validate a novel microRNA (miRNA) signature to stage decompensated cirrhosis and predict the portal pressure and systolic cardiac response to nonselective beta-blockers (NSBBs). Serum samples from patients with decompensated cirrhosis (n = 36) and healthy controls (n = 36) were tested for a novel signature of five miRNAs (miR-452-5p, miR-429, miR-885-5p, miR-181b-5p, and miR-122-5p) identified in the secretome of primary human hepatocytes and for three miRNAs (miR-192-5p, miR-34a-5p, and miR-29a-5p) previously discovered as biomarkers of chronic liver disease. All patients had ascites, which was refractory in 18 (50%), and were placed on NSBBs for variceal bleeding prophylaxis. In all patients, serum miRNAs, hepatic venous pressure gradient, and an echocardiogram study were performed before and 1 month after NSBBs. Patients with cirrhosis had lower serum levels of miR-429, miR-885-5p, miR-181b-5p, miR-122-5p, miR-192-5p, and miR-29a-5p (P < 0.05). Baseline serum miR-452-5p and miR-429 levels were lower in NSBB responders (P = 0.006). miR-181b-5p levels were greater in refractory ascites than in diuretic-sensitive ascites (P = 0.008) and correlated with serum creatinine. miR-452-5p and miR-885-5p were inversely correlated with baseline systemic vascular resistance (ρ = -0.46, P = 0.007; and ρ = -0.41, P = 0.01, respectively) and with diminished systolic contractility (ρ = -0.55, P = 0.02; and ρ = -0.55, P = 0.02, respectively) in patients with refractory ascites after NSBBs. Conclusion: Analysis of a miRNA signature in serum discriminates between patients with decompensated cirrhosis who show more severe systemic circulatory dysfunction and compromised systolic function after beta-blockade and those more likely to benefit from NSBBs.
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Affiliation(s)
- Ana Garcia Garcia de Paredes
- Gastroenterology and Hepatology DepartmentHospital Universitario Ramon y CajalInstituto Ramon y Cajal de Investigacion Biosanitaria (IRYCIS)Universidad de AlcalaMadridSpain
| | - Nicolo Manicardi
- Liver Vascular Biology Research GroupAugust Pi i Sunyer Biomedical Research InstituteBarcelonaSpain
| | - Luis Tellez
- Gastroenterology and Hepatology DepartmentHospital Universitario Ramon y CajalInstituto Ramon y Cajal de Investigacion Biosanitaria (IRYCIS)Universidad de AlcalaMadridSpain.,Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain
| | - Luis Ibañez
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain.,Gastroenterology and Hepatology DepartmentHospital Universitario Gregorio MarañonInstituto de Investigacion Sanitaria Gregorio Marañon (IiSGM)Universidad Complutense de MadridMadridSpain
| | - Felix Royo
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain.,Exosomes LaboratoryCenter for Cooperative Research in BioscienciesBasque Research and Technology Alliance DerioDerioSpain
| | - Javier Bermejo
- Cardiology DepartmentHospital Universitario Gregorio MarañonIiSGMUniversidad Complutense de MadridMadridSpain
| | | | - Constantino Fondevila
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain.,Liver Surgery and Transplantation UnitHospital ClinicBarcelonaSpain
| | | | | | - Juan Manuel Falcon-Perez
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain.,Exosomes LaboratoryCenter for Cooperative Research in BioscienciesBasque Research and Technology Alliance DerioDerioSpain.,IKERBASQUE-Basque Foundation for ScienceBilbaoSpain
| | - Rafael Bañares
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain.,Gastroenterology and Hepatology DepartmentHospital Universitario Gregorio MarañonInstituto de Investigacion Sanitaria Gregorio Marañon (IiSGM)Universidad Complutense de MadridMadridSpain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research GroupAugust Pi i Sunyer Biomedical Research InstituteBarcelonaSpain.,Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain
| | - Agustin Albillos
- Gastroenterology and Hepatology DepartmentHospital Universitario Ramon y CajalInstituto Ramon y Cajal de Investigacion Biosanitaria (IRYCIS)Universidad de AlcalaMadridSpain.,Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y DigestivasInstituto de Salud Carlos IIIMadridSpain
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18
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Ripoll C, Zipprich A. Open or closed window: That is the question. J Hepatol 2021; 74:485-486. [PMID: 33308874 DOI: 10.1016/j.jhep.2020.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Cristina Ripoll
- First Department for Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Alexander Zipprich
- First Department for Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
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19
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Téllez L, Bañares R, Albillos A. Reply to: "Open or closed window: That is the question". J Hepatol 2021; 74:486-487. [PMID: 33309115 DOI: 10.1016/j.jhep.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Rafael Bañares
- Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBEREHD, and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain.
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20
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Téllez L, Ibáñez-Samaniego L, Pérez Del Villar C, Yotti R, Martínez J, Carrión L, Rodríguez de Santiago E, Rivera M, González-Mansilla A, Pastor Ó, Bermejo J, Bañares R, Albillos A. Non-selective beta-blockers impair global circulatory homeostasis and renal function in cirrhotic patients with refractory ascites. J Hepatol 2020; 73:1404-1414. [PMID: 32446716 DOI: 10.1016/j.jhep.2020.05.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The safety of non-selective β-blockers (NSBBs) has been questioned in refractory ascites (RA). We studied the effects of NSBBs on cardiac systolic function, systemic hemodynamics, and renal perfusion pressure (RPP) and function in patients with diuretic-responsive ascites (DRA) and RA. METHODS We performed a prospective pre-post repeated-measures study in cirrhotic patients, 18 with DRA and 20 with RA on NSBBs for variceal bleeding prophylaxis. Systolic function (by ejection intraventricular pressure difference [EIVPD]), hepatic venous pressure gradient (HVPG), cardiopulmonary pressures, RPP, and sympathetic activation were measured at baseline and after 4 weeks of propranolol. RESULTS EIVPD was elevated at baseline (RA 4.5 [2.8-5.7] and DRA 4.2 [3.1-5.7] mmHg; normal 2.4-3.6 mmHg) and directly related to the severity of vasodilation and sympathetic activation. NSBBs led to similar reductions in heart rate and HVPG in both groups. NSBBs reduced EIPVD in RA but not in DRA (-20% vs. -2%, p <0.01). In RA, the NSBB-induced reduction in EIPVD correlated with the severity of vasodilation and with higher plasma nitric oxide, norepinephrine and IL-6 (r >0.40, all p <0.05). NSBBs reduced RPP in both groups, but impaired renal function only in patients with RA. Reduced EIPVD correlated with decreases in RPP and estimated glomerular filtration rate (r >0.40, all p <0.01). After NSBB treatment, RPP dropped below the threshold of renal flow autoregulation in 11 of the 20 (55%) patients with RA, including the 4 fulfilling the criteria for HRS-AKI. CONCLUSION Renal perfusion and function depend critically on systolic function and sympathetic hyperactivation in RA. NSBBs blunt the sympathetic overdrive, hamper cardiac output, lower RPP below the critical threshold and impair renal function. β-blockade should be used cautiously or even avoided in patients with RA. LAY SUMMARY We have identified the mechanisms by which non-selective beta-blockers could impair survival in patients with refractory ascites. We show that peripheral vasodilation and sympathetic activation lead to increased left ventricle systolic function in patients with cirrhosis and ascites, which acts as an adaptive mechanism to maintain renal perfusion. When ascites becomes refractory, this compensatory cardiac response to vasodilation is critically dependent on sympathetic hyperactivation and is hardly able to maintain renal perfusion. In this setting, β-blockade blunts the sympathetic overdrive of cardiac function, hampers cardiac output, lowers renal perfusion pressure below the critical threshold and impairs renal function.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBEREHD, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Candelas Pérez Del Villar
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBERCV, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Raquel Yotti
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBERCV, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Laura Carrión
- Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBEREHD, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Maite Rivera
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Ana González-Mansilla
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBERCV, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Óscar Pastor
- Servicio de Bioquímica Clínica, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEROBN, Universidad de Alcalá, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBERCV, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Rafael Bañares
- Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), CIBEREHD, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain.
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21
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Téllez L, Ibáñez-Samaniego L, Bañares R, Albillos A. Reply to: "Beta-blockers in refractory ascites - is it truly the end of the road?". J Hepatol 2020; 73:1291-1292. [PMID: 32861510 DOI: 10.1016/j.jhep.2020.07.035] [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: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain; Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), Universidad Complutense de Madrid, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain; Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (iISGM), Universidad Complutense de Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain.
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22
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Chouhan MD, Taylor SA, Bainbridge A, Walker-Samuel S, Davies N, Halligan S, Lythgoe MF, Mookerjee RP. Haemodynamic changes in cirrhosis following terlipressin and induction of sepsis-a preclinical study using caval subtraction phase-contrast and cardiac MRI. Eur Radiol 2020; 31:2518-2528. [PMID: 33044649 PMCID: PMC7979649 DOI: 10.1007/s00330-020-07259-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/11/2020] [Accepted: 09/04/2020] [Indexed: 12/28/2022]
Abstract
Objectives Effects of liver disease on portal venous (PV), hepatic arterial (HA), total liver blood flow (TLBF), and cardiac function are poorly understood. Terlipressin modulates PV flow but effects on HA, TLBF, and sepsis/acute-on-chronic liver failure (ACLF)-induced haemodynamic changes are poorly characterised. In this study, we investigated the effects of terlipressin and sepsis/ACLF on hepatic haemodynamics and cardiac function in a rodent cirrhosis model using caval subtraction phase-contrast (PC) MRI and cardiac cine MRI. Methods Sprague-Dawley rats (n = 18 bile duct–ligated (BDL), n = 16 sham surgery controls) underwent caval subtraction PCMRI to estimate TLBF and HA flow and short-axis cardiac cine MRI for systolic function at baseline, following terlipressin and lipopolysaccharide (LPS) infusion, to model ACLF. Results All baseline hepatic haemodynamic/cardiac systolic function parameters (except heart rate and LV mass) were significantly different in BDL rats. Following terlipressin, baseline PV flow (sham 181.4 ± 12.1 ml/min/100 g; BDL 68.5 ± 10.1 ml/min/100 g) reduced (sham − 90.3 ± 11.1 ml/min/100 g, p < 0.0001; BDL − 31.0 ± 8.0 ml/min/100 g, p = 0.02), sham baseline HA flow (33.0 ± 11.3 ml/min/100 g) increased (+ 92.8 ± 21.3 ml/min/100 g, p = 0.0003), but BDL baseline HA flow (83.8 ml/min/100 g) decreased (− 34.4 ± 7.5 ml/min/100 g, p = 0.11). Sham baseline TLBF (214.3 ± 16.7 ml/min/100 g) was maintained (+ 2.5 ± 14.0 ml/min/100 g, p > 0.99) but BDL baseline TLBF (152.3 ± 18.7 ml/min/100 g) declined (− 65.5 ± 8.5 ml/min/100 g, p = 0.0004). Following LPS, there were significant differences between cohort and change in HA fraction (p = 0.03) and TLBF (p = 0.01) with BDL baseline HA fraction (46.2 ± 4.6%) reducing (− 20.9 ± 7.5%, p = 0.03) but sham baseline HA fraction (38.2 ± 2.0%) remaining unchanged (+ 2.9 ± 6.1%, p > 0.99). Animal cohort and change in systolic function interactions were significant only for heart rate (p = 0.01) and end-diastolic volume (p = 0.03). Conclusions Caval subtraction PCMRI and cardiac MRI in a rodent model of cirrhosis demonstrate significant baseline hepatic haemodynamic/cardiac differences, failure of the HA buffer response post-terlipressin and an altered HA fraction response in sepsis, informing potential translation to ACLF patients. Key Points Caval subtraction phase-contrast and cardiac MRI demonstrate: • Significant differences between cirrhotic/non-cirrhotic rodent hepatic blood flow and cardiac systolic function at baseline. • Failure of the hepatic arterial buffer response in cirrhotic rodents in response to terlipressin. • Reductions in hepatic arterial flow fraction in the setting of acute-on-chronic liver failure.
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Affiliation(s)
- Manil D Chouhan
- Centre for Medical Imaging, Division of Medicine, UCL, University College London (UCL), London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, Division of Medicine, UCL, University College London (UCL), London, UK
| | - Alan Bainbridge
- Department of Medical Physics, University College London Hospitals NHS Trust, London, UK
| | - Simon Walker-Samuel
- Centre for Advanced Biomedical Imaging, Division of Medicine, UCL, University College London (UCL), London, UK
| | - Nathan Davies
- Institute for Liver and Digestive Health, Division of Medicine, UCL, Royal Free Hospital, University College London (UCL), NW3 2PF, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, Division of Medicine, UCL, University College London (UCL), London, UK
| | - Mark F Lythgoe
- Centre for Advanced Biomedical Imaging, Division of Medicine, UCL, University College London (UCL), London, UK
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, Division of Medicine, UCL, Royal Free Hospital, University College London (UCL), NW3 2PF, London, UK.
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23
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Alvarado-Tapias E, Ardevol A, Garcia-Guix M, Montañés R, Pavel O, Cuyas B, Graupera I, Brujats A, Vilades D, Colomo A, Poca M, Torras X, Guarner C, Concepción M, Aracil C, Torres F, Villanueva C. Short-term hemodynamic effects of β-blockers influence survival of patients with decompensated cirrhosis. J Hepatol 2020; 73:829-841. [PMID: 32298768 DOI: 10.1016/j.jhep.2020.03.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Whether the effect of β-blockers on arterial pressure and/or cardiac function may offset the benefit of reducing portal pressure in advanced cirrhosis is controversial. Herein, we aimed to evaluate the systemic and splanchnic hemodynamic effects of β-blockers in decompensated vs. compensated cirrhosis and to investigate the influence of systemic hemodynamic changes on survival times in decompensated cirrhosis. METHODS Patients with cirrhosis and high-risk esophageal varices, without previous bleeding, were consecutively included and grouped according to the presence or absence of decompensation (ascites with or without overt encephalopathy). Systemic and hepatic hemodynamic measurements were performed before starting β-blockers and again after 1 to 3 months of treatment (short-term). RESULTS Four hundred and three patients were included (190 decompensated and 213 compensated). At baseline, decompensated patients had higher portal pressure than compensated patients and were more hyperdynamic, with higher cardiac output (CO) and lower arterial pressure. Under β-blockers, decompensated patients had lower portal pressure decrease (10 ± 18% vs. 15 ± 12%; p <0.05) and had greater reductions in heart rate (p <0.001) and CO (17 ± 15% vs. 10 ± 21%; p <0.01). Among patients with decompensated cirrhosis, those who died had a greater decrease in CO with β-blockers than survivors (21 ± 14% vs. 15 ± 16%; p <0.05) and CO under β-blockers independently predicted death by competing-risk regression analysis, with good diagnostic accuracy (C-index 0.74; 95% CI 0.66-0.83). Death risk was higher in decompensated patients with CO <5 L/min vs. CO ≥5 L/min (subdistribution hazard ratio 0.44; 95% CI 0.25-0.77; p = 0.004). CONCLUSIONS In patients with high-risk varices treated to prevent first bleeding, the systemic hemodynamic response to β-blockers is greater and the portal pressure decrease is smaller in those with decompensated cirrhosis. The short-term effect of β-blockers on CO might adversely influence survival in decompensated cirrhosis. LAY SUMMARY β-blockers are often used to reduce the risk of variceal bleeding in patients with cirrhosis. However, it is not known whether the effect of β-blockers on arterial pressure and/or cardiac function may offset the benefit of reducing portal pressure. Herein, we show that in patients with decompensated cirrhosis the potentially detrimental systemic effects of β-blockers are greater than in compensated patients, while the beneficial pressure lowering effects are reduced. The short-term effect of β-blockers on cardiac output may adversely influence survival in patients with decompensated cirrhosis.
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Affiliation(s)
- Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Alba Ardevol
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Marta Garcia-Guix
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Rosa Montañés
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Oana Pavel
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Berta Cuyas
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Isabel Graupera
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Anna Brujats
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - David Vilades
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; Cardiac imaging unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alan Colomo
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Xavier Torras
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Mar Concepción
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carles Aracil
- Hospital Universitari Arnau de Vilanova, Lleida, Institut de Recerca Biomèdica (IRBLleida)
| | - Ferran Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona; and Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Càndid Villanueva
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain.
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24
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Vilchez-Monge AL, Garutti I, Jimeno C, Zaballos M, Jimenez C, Olmedilla L, Piñeiro P, Duque P, Salcedo M, Asencio JM, Lopez-Baena JA, Maruszewski P, Bañares R, Perez-Peña JM. Intraoperative Troponin Elevation in Liver Transplantation Is Independently Associated With Mortality: A Prospective Observational Study. Liver Transpl 2020; 26:681-692. [PMID: 31944566 DOI: 10.1002/lt.25716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/09/2020] [Indexed: 01/09/2023]
Abstract
Intraoperative factors implicated in postoperative mortality after liver transplantation (LT) are poorly understood. Because LT is a particularly demanding procedure, we hypothesized that intraoperative myocardial injury may be frequent and independently associated with early postoperative outcomes. We aimed to determine the association between intraoperative high-sensitivity troponin (hsTn) elevation during LT and 30-day postoperative mortality. A total of 203 adult patients undergoing LT were prospectively included in the cohort and followed during 1 year. Advanced hemodynamic parameters and serial high-sensitivity troponin T (hsTnT) measurements were assessed at 6 intraoperative time points. The optimal hsTnT cutoff level for intraoperative troponin elevation (ITE) was identified. Patients were classified into 2 groups according to the presence of ITE. Independent impact of ITE on survival was assessed through survival curves and multivariate Cox regression analysis. Intraoperative cardiac function was compared between groups. Troponin levels increased early during surgery in the ITE group. Troponin values at abdominal closure were associated with 30-day mortality (area under the receiver operating caracteristic curve, [AUROC], 0.73; P = 0.005). Patients with ITE showing values of hsTnT ≥61 ng/L at abdominal closure presented higher 30-day mortality (29.6% versus 3.4%; P < 0.001). ITE was independently associated with 30-day mortality (hazard ratio, 3.8; 95% confidence interval, 1.1-13.8; P = 0.04) and with worse overall intraoperative cardiac function. The hsTnT upper reference limit showed no discriminant capacity during LT. Intraoperative myocardial injury identified by hsTn elevation is frequently observed during LT, and it is associated with myocardial dysfunction and short-term mortality. Determinations of hsTn may serve as a valuable intraoperative monitoring tool during LT.
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Affiliation(s)
- Almudena L Vilchez-Monge
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Garutti
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Instituto de Investigación Sanitaria of Hospital General Universitario Gregorio Marañon (IiSGM), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Concepción Jimeno
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Matilde Zaballos
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Instituto de Investigación Sanitaria of Hospital General Universitario Gregorio Marañon (IiSGM), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Consuelo Jimenez
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Luis Olmedilla
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Patricia Piñeiro
- Postoperative Care Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Patricia Duque
- Postoperative Care Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Magdalena Salcedo
- Hepatology and Liver Transplant Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Jose M Asencio
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose A Lopez-Baena
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Przemyslaw Maruszewski
- Department of Pediatric Surgery and Organ Transplantation, Children´s Memorial Health Institute, Warsaw, Poland
| | - Rafael Bañares
- Hepatology and Liver Transplant Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria of Hospital General Universitario Gregorio Marañon (IiSGM), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Jose M Perez-Peña
- Department of Anesthesiology and Intensive Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Instituto de Investigación Sanitaria of Hospital General Universitario Gregorio Marañon (IiSGM), Madrid, Spain
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25
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Kwon HM, Moon YJ, Jung KW, Park YS, Kim KS, Jun IG, Song JG, Hwang GS. Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post-Liver Transplantation Mortality. Hepatology 2020; 71:1364-1380. [PMID: 31464025 DOI: 10.1002/hep.30913] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/22/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Enhanced sympathetic nervous activation and peripheral vasodilation in end-stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all-cause mortality after liver transplantation (LT). APPROACH AND RESULTS Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end-diastolic volume index (EDVI), and end-diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4-year follow-up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%-81%) was directly proportionate to Model for End-stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat-line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90-day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4-year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4-year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817). CONCLUSIONS LVEF ≤ 60% is strongly associated with higher post-LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.
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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
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Gol Song
- 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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26
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Impaired Cardiac Reserve on Dobutamine Stress Echocardiography Predicts the Development of Hepatorenal Syndrome. Am J Gastroenterol 2020; 115:388-397. [PMID: 31738284 DOI: 10.14309/ajg.0000000000000462] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Cardiac dysfunction has been implicated in the genesis of hepatorenal syndrome (HRS). It is unclear whether a low cardiac output (CO) or attenuated contractile response to hemodynamic stress can predict its occurrence. We studied cardiovascular hemodynamics in cirrhosis and assessed whether a diminished cardiac reserve with stress testing predicted the development of HRS on follow-up. METHODS Consecutive patients undergoing liver transplant workup with dobutamine stress echocardiography (DSE) were included. CO was measured at baseline and during low-dose dobutamine infusion at 10 μg/kg/min. HRS was diagnosed using guideline-based criteria. RESULTS A total of 560 patients underwent DSE, of whom 488 were included after preliminary assessment. There were 64 (13.1%) patients with established HRS. The HRS cohort had a higher baseline CO (8.0 ± 2 vs 6.9 ± 2 L/min; P < 0.001) and demonstrated a blunted response to low-dose dobutamine (ΔCO 29 ± 22% vs 44 ± 32%, P < 0.001) driven primarily by inotropic incompetence. Optimal cutpoint for ΔCO in patients with HRS was determined to be <25% and was used to define a low cardiac reserve. Among the 424 patients without HRS initially, 94 (22.1%) developed HRS over a mean follow-up of 1.5 years. Higher proportion with a low cardiac reserve developed HRS (52 [55.0%] vs 56 [16.9%]; hazard ratio 4.5; 95% confidence interval 3.0-6.7; P < 0.001). In a Cox multivariable model, low cardiac reserve remained the strongest predictor for the development of HRS (hazard ratio 3.9; 95% confidence interval 2.2-7.0; P < 0.001). DISCUSSION Patients with HRS demonstrated a higher resting CO and an attenuated cardiac reserve on stress testing. On longitudinal follow-up, low cardiac reserve was an independent predictor for the development of HRS. Assessment of cardiac reserve with DSE may provide a novel noninvasive risk marker for developing HRS in patients with advanced liver disease.HRS is a life-threatening complication of liver disease. We studied whether an inability to increase cardiac contraction in response to stress can assist in the prediction of HRS. We demonstrate that patients with liver disease who exhibit cardiac dysfunction during stress testing had a 4-fold increased risk of developing HRS. This may improve our ability for early diagnosis and treatment of patients at a higher risk of developing HRS.
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27
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Martin Mateos R, Albillos A. Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management. Liver Transpl 2019; 25:1700-1709. [PMID: 31408581 DOI: 10.1002/lt.25621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.
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Affiliation(s)
- Rosa Martin Mateos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
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28
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Hiramine Y, Uto H, Mawatari S, Kanmura S, Imamura Y, Hiwaki T, Saishoji A, Yada T, Inada Y, Sakamoto H, Higashi H, Kubozono O, Maenohara S, Ido A. Effect of tolvaptan on the prognosis of patients with hepatic ascites. Hepatol Res 2019; 49:765-777. [PMID: 30916842 DOI: 10.1111/hepr.13337] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 12/12/2022]
Abstract
AIM Despite accumulating evidence concerning the efficacy of tolvaptan in the treatment of body fluid retention or hyponatremia, the effect of tolvaptan on the prognosis of patients with hepatic ascites has not been fully investigated. METHODS A total of 628 patients with hepatic ascites who were treated with diuretics (furosemide, spironolactone, or tolvaptan) between 2007 and 2017 were enrolled and divided into two groups: those who received tolvaptan (original tolvaptan group, n = 278) and those who did not (original control group, n = 350). The cumulative survival rates between the groups were compared and the factors associated with survival in patients with hepatic ascites were identified using a Cox regression analysis. In addition, propensity score matching was applied in patients who started conventional diuretics for new-onset hepatic ascites after September 2013 (pre-matching tolvaptan group, n = 177; pre-matching control group, n = 63), and the cumulative survival rates were compared between the post-matching tolvaptan and control groups. RESULTS The survival rate was significantly higher in the tolvaptan group than the control group (P = 0.005), and tolvaptan therapy was identified as an independent factor associated with survival (hazard ratio 0.721 for death relative to control, P < 0.001). The propensity score-matched comparison also showed a significantly higher survival rate in the tolvaptan group (n = 51) than in the control group (n = 51) (P = 0.009). CONCLUSIONS This study suggests that tolvaptan might improve the prognosis of patients with hepatic ascites.
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Affiliation(s)
- Yasunari Hiramine
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Hirofumi Uto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Seiichi Mawatari
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shuji Kanmura
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yasushi Imamura
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Takuya Hiwaki
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akiko Saishoji
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takazumi Yada
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Yukiko Inada
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Hidemori Sakamoto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Hirofumi Higashi
- Department of Hygiene and Public Health, National Institute of Fitness and Sports in Kanoya, Kagoshima, Japan
| | - Osamu Kubozono
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Shigeho Maenohara
- Department of Surgery, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Endocannabinoid System in Hepatic Glucose Metabolism, Fatty Liver Disease, and Cirrhosis. Int J Mol Sci 2019; 20:ijms20102516. [PMID: 31121839 PMCID: PMC6566399 DOI: 10.3390/ijms20102516] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/18/2019] [Accepted: 05/19/2019] [Indexed: 12/18/2022] Open
Abstract
There is growing evidence that glucose metabolism in the liver is in part under the control of the endocannabinoid system (ECS) which is also supported by its presence in this organ. The ECS consists of its cannabinoid receptors (CBRs) and enzymes that are responsible for endocannabinoid production and metabolism. ECS is known to be differentially influenced by the hepatic glucose metabolism and insulin resistance, e.g., cannabinoid receptor type 1(CB1) antagonist can improve the glucose tolerance and insulin resistance. Interestingly, our own study shows that expression patterns of CBRs are influenced by the light/dark cycle, which is of significant physiological and clinical interest. The ECS system is highly upregulated during chronic liver disease and a growing number of studies suggest a mechanistic and therapeutic impact of ECS on the development of liver fibrosis, especially putting its receptors into focus. An opposing effect of the CBRs was exerted via the CB1 or CB2 receptor stimulation. An activation of CB1 promoted fibrogenesis, while CB2 activation improved antifibrogenic responses. However, underlying mechanisms are not yet clear. In the context of liver diseases, the ECS is considered as a possible mediator, which seems to be involved in the synthesis of fibrotic tissue, increase of intrahepatic vascular resistance and subsequently development of portal hypertension. Portal hypertension is the main event that leads to complications of the disease. The main complication is the development of variceal bleeding and ascites, which have prognostic relevance for the patients. The present review summarizes the current understanding and impact of the ECS on glucose metabolism in the liver, in association with the development of liver cirrhosis and hemodynamics in cirrhosis and its complication, to give perspectives for development of new therapeutic strategies.
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30
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Martin-Mateos R, Alvarez-Mon M, Albillos A. Dysfunctional Immune Response in Acute-on-Chronic Liver Failure: It Takes Two to Tango. Front Immunol 2019; 10:973. [PMID: 31118937 PMCID: PMC6504833 DOI: 10.3389/fimmu.2019.00973] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/16/2019] [Indexed: 12/17/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by the acute decompensation of cirrhosis associated with organ failure and high short-term mortality. The key event in the pathogenesis is a dysfunctional immune response arising from exacerbation of the two main immunological alterations already present in cirrhosis: systemic inflammation and immune cell paralysis. High-grade systemic inflammation due to predominant activation and dysregulation of the innate immune response leads to the massive release of cytokines. Recognition of acutely increased pathogen and damage-associated molecular patterns by specific receptors underlies its pathogenesis and contributes to tissue damage and organ failure. In addition, an inappropriate compensatory anti-inflammatory response over the course of ACLF, along with the exhaustion and dysfunction of both the innate and adaptive immune systems, leads to functional immune cell paralysis. This entails a high risk of infection and contributes to a poor prognosis. Therapeutic approaches seeking to counteract the immune alterations present in ACLF are currently under investigation.
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Affiliation(s)
- Rosa Martin-Mateos
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Instituto de Salud Carlos III, Universidad de Alcalá, Madrid, Spain
| | - Melchor Alvarez-Mon
- Department of Immune System Diseases and Oncology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Hospital Universitario Príncipe de Asturias, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Instituto de Salud Carlos III, Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Instituto de Salud Carlos III, Universidad de Alcalá, Madrid, Spain
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31
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Turco L, Garcia-Tsao G, Rossi R, Villa E, Schepis F. Reply to: "It takes two "eyes" to see in depth". J Hepatol 2019; 70:791-793. [PMID: 30591265 DOI: 10.1016/j.jhep.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Laura Turco
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Guadalupe Garcia-Tsao
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy; Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA; Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Rosario Rossi
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.
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33
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Novo G, Macaione F, Giannitrapani L, Minissale MG, Bonomo V, Indovina F, Petta S, Soresi M, Montalto G, Novo S, Craxi A, Licata A. Subclinical cardiovascular damage in patients with HCV cirrhosis before and after treatment with direct antiviral agents: a prospective study. Aliment Pharmacol Ther 2018; 48:740-749. [PMID: 30095177 DOI: 10.1111/apt.14934] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/19/2018] [Accepted: 07/15/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cirrhosis is associated with morpho-functional cardiovascular alterations. AIMS To detect early features of cardiovascular damage in HCV-compensated cirrhotic patients using myocardial deformation indices and carotid arterial stiffness, and, further, to evaluate their short-term behaviour after HCV eradication with direct antiviral agents (DAAs). METHODS Thirty-nine consecutive patients with HCV cirrhosis, without previous cardiovascular events, were studied and matched for age, gender and cardiovascular risk factors to 39 controls without liver or cardiovascular disease. Patients and controls underwent a baseline echocardiographic evaluation including global longitudinal strain and ultrasound scan of carotid arteries. HCV-cirrhotics were reassessed by echocardiography and carotid ultrasound after obtaining sustained virological response (SVR) on DAAs. RESULTS HCV-cirrhotics showed at baseline a significantly reduced global longitudinal strain compared to controls -18.1 (16.3-20.5) vs -21.2 (20.4-22.3), P < 0.001. They also had a significantly higher pulse wave velocity 8.6 (7.7-9.1) m/s vs 6.6 (6.0-7.1) m/s, P = 0.0001, and β-stiffness index 12.4 (11.1-13.5) vs 8.6 (8.0-9.2) P = 0.0001. At multiple regression analysis, diabetes and HCV cirrhosis were independent predictors of global longitudinal strain. All HCV-cirrhotic patients had SVR on DAAs. Follow-up available in 32 of 39 (82%) at 9 (8-10) months showed a significant improvement of tricuspid annular plane systolic excursion (P = 0.01) and lateral E' velocity compared to baseline (P = 0.001). CONCLUSIONS HCV-cirrhotics show a significant rate of subclinical cardiac and vascular abnormalities. At a time when their survival is less linked to progression of liver disease, due to viral eradication on DAAs, cardiovascular morbidity and mortality may take a significant role.
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Affiliation(s)
- Giuseppina Novo
- Cardiology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Francesca Macaione
- Cardiology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Lydia Giannitrapani
- Internal Medicine, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maria Giovanna Minissale
- Internal Medicine, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Vito Bonomo
- Cardiology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Francesco Indovina
- Cardiology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Salvatore Petta
- Gastroenterology & Hepatology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maurizio Soresi
- Internal Medicine, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Giuseppe Montalto
- Internal Medicine, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Salvatore Novo
- Cardiology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Antonio Craxi
- Gastroenterology & Hepatology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Anna Licata
- Internal Medicine, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
- Gastroenterology & Hepatology, Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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34
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Alvarado E, Garcia-Guix M, Mirabet S, Villanueva C. The relationship of hyperdynamic circulation and cardiodynamic states in cirrhosis. J Hepatol 2018; 69:746-747. [PMID: 29784565 DOI: 10.1016/j.jhep.2018.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Edilmar Alvarado
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Garcia-Guix
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sonia Mirabet
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Càndid Villanueva
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
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35
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Cardiopulmonary hemodynamics and C-reactive protein as prognostic indicators in compensated and decompensated cirrhosis. J Hepatol 2018; 68:949-958. [PMID: 29331339 DOI: 10.1016/j.jhep.2017.12.027] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/25/2017] [Accepted: 12/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The main stages of cirrhosis (compensated and decompensated) have been sub-staged based on clinical, endoscopic, and portal pressure (determined by the hepatic venous pressure gradient [HVPG]) features. Vasodilation leading to a hyperdynamic circulatory state is central in the development of a late decompensated stage, with inflammation currently considered a key driver. We aimed to assess hepatic/systemic hemodynamics and inflammation (by C-reactive protein [CRP]) among the different sub-stages of cirrhosis and to investigate their interrelationship and prognostic relevance. METHODS A single center, prospective cohort of patients with cirrhosis undergoing per protocol hepatic and right-heart catheterization and CRP measurement, were classified into recently defined prognostic stages (PS) of compensated (PS1: HVPG ≥6 mmHg but <10 mmHg; PS2: HVPG ≥10 mmHg without gastroesophageal varices; PS3: patients with gastroesophageal varices) and decompensated (PS4: diuretic-responsive ascites; PS5: refractory ascites) disease. Cardiodynamic states based on cardiac index (L/min/m2) were created: relatively hypodynamic (<3.2), normodynamic (3.2-4.2) and hyperdynamic (>4.2). RESULTS Of 238 patients, 151 were compensated (PS1 = 25; PS2 = 36; PS3 = 90) and 87 were decompensated (PS4 = 48; PS5 = 39). Mean arterial pressure decreased progressively from PS1 to PS5, cardiac index increased progressively from PS1-to-PS4 but decreased in PS5. HVPG, model for end-stage liver disease (MELD), and CRP increased progressively from PS1-to-PS5. Among compensated patients, age, HVPG, relatively hypodynamic/hyperdynamic state and CRP were predictive of decompensation. Among patients with ascites, MELD, relatively hypodynamic/hyperdynamic state, post-capillary pulmonary hypertension, and CRP were independent predictors of death/liver transplant. CONCLUSIONS Our study demonstrates that, in addition to known parameters, cardiopulmonary hemodynamics and CRP are predictive of relevant outcomes, both in patients with compensated and decompensated cirrhosis. LAY SUMMARY There are two main stages in cirrhosis, compensated and decompensated, each with a main relevant outcome. In compensated cirrhosis the main relevant outcome is the development of ascites, while in decompensated cirrhosis it is death. Major roles of cardiac dysfunction and systemic inflammation have been hypothesized in the evolution of the disease in decompensated patients. In this study, we have shown that these factors were also involved in the progression from compensated to decompensated stage.
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36
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Kwon HM, Hwang GS. Cardiovascular dysfunction and liver transplantation. Korean J Anesthesiol 2018; 71:85-91. [PMID: 29619780 PMCID: PMC5903113 DOI: 10.4097/kjae.2018.71.2.85] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/22/2017] [Accepted: 10/12/2017] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular complications have emerged as the leading cause of death after liver transplantation, particularly among those with advanced liver cirrhosis. Therefore, a thorough and accurate cardiovascular evaluation with clear comprehension of cirrhotic cardiomyopathy is recommended for optimal anesthetic management. However, cirrhotic patients manifest cardiac dysfunction concomitant with pronounced systemic hemodynamic changes, characterized by hyperdynamic circulation such as increased cardiac output, high heart rate, and decreased systemic vascular resistance. These unique features mask significant manifestations of cardiac dysfunction at rest, which makes it difficult to accurately evaluate cardiovascular status. In this review, we have summarized the current knowledge of heart and liver interactions, focusing on the usefulness and limitations of cardiac evaluation tools for identifying high-risk patients.
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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, 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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37
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Møller S, Bendtsen F. The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis. Liver Int 2018; 38:570-580. [PMID: 28921803 DOI: 10.1111/liv.13589] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/11/2017] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis and portal hypertension often develop complications from a variety of organ systems leading to a multiple organ failure. The combination of liver failure and portal hypertension results in a hyperdynamic circulatory state partly owing to simultaneous splanchnic and peripheral arterial vasodilatation. Increases in circulatory vasodilators are believed to be due to portosystemic shunting and bacterial translocation leading to redistribution of the blood volume with central hypovolemia. Portal hypertension per se and increased splanchnic blood flow are mainly responsible for the development and perpetuation of the hyperdynamic circulation and the associated changes in cardiovascular function with development of cirrhotic cardiomyopathy, autonomic dysfunction and renal dysfunction as part of a cardiorenal syndrome. Several of the cardiovascular changes are reversible after liver transplantation and point to the pathophysiological significance of portal hypertension. In this paper, we aimed to review current knowledge on the pathophysiology of arterial vasodilatation and the hyperdynamic circulation in cirrhosis.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Faculty of Health Sciences, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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38
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Yotti R, Ripoll C, Bermejo J, Bañares R. Cardiac function, A key component in evaluation for liver transplant. Liver Transpl 2018; 24:7-8. [PMID: 29193630 DOI: 10.1002/lt.24987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Raquel Yotti
- Departments of Cardiology and Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) and
| | - Cristina Ripoll
- Digestive Diseases and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Hospital General Universitario Gregorio Marañón Instituto de Investigación Sanitaria Gregorio Marañón Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Bermejo
- Departments of Cardiology and Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) and
| | - Rafael Bañares
- Digestive Diseases and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Hospital General Universitario Gregorio Marañón Instituto de Investigación Sanitaria Gregorio Marañón Facultad de Medicina, Universidad Complutense, Madrid, Spain
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39
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Jansen C, Cox A, Schueler R, Schneider M, Lehmann J, Praktiknjo M, Pohlmann A, Chang J, Manekeller S, Nickenig G, Berlakovich G, Strassburg CP, Hammerstingl C, Staufer K, Trebicka J. Increased myocardial contractility identifies patients with decompensated cirrhosis requiring liver transplantation. Liver Transpl 2018; 24:15-25. [PMID: 28834154 DOI: 10.1002/lt.24846] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/04/2017] [Accepted: 08/03/2017] [Indexed: 01/13/2023]
Abstract
Late allocation of organs for transplant impairs post-liver transplantation (LT) survival. Cardiac dysfunction, especially diastolic and autonomic dysfunction, is frequent and plays an important role in the prognosis of patients with cirrhosis. However, the role of myocardial contractility is unexplored, and its prognostic value is controversially discussed. This study analyses the role of myocardial contractility assessed by speckle tracking echocardiography in LT allocation. In total, 168 patients with cirrhosis (training cohort, 111; validation cohort [VC], 57) awaiting LT in 2 centers were included in this retrospective study. Also, 51 patients from the training and all patients from the VC were transplanted, 36 patients of the training and 38 of the VC were alive at the end of follow-up, and 21 nontransplanted patients died. Contractility of the left ventricle (LV) increased with severity of the Child-Pugh score. Interestingly, higher LV contractility in the training cohort patients, especially in those with Child-Pugh C, was an independent predictor of reduced transplant-free survival. In male patients, the effects on survival of increased left and right ventricular myocardial contractility were more pronounced. Notably, competing risk analysis demonstrated that increased contractility is associated with earlier LT, which could be confirmed in the VC. Importantly, LV myocardial contractility had no impact on survival of patients not receiving LT or on post-LT survival. In conclusion, this study demonstrates for the first time that increased myocardial contractility in decompensated patients identifies patients who require LT earlier, but without increased post-LT mortality. Liver Transplantation 24 15-25 2018 AASLD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Gabriela Berlakovich
- Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Katharina Staufer
- Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jonel Trebicka
- Departments of Internal Medicine I.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,European Foundation for Study of Chronic Liver Failure, Barcelona, Spain.,Institute of Bioengineering Catalunya, Barcelona, Spain
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40
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Shin WJ, Hwang GS. Reply to: "Pressure volume curves in cirrhosis: More than meets the eye". J Hepatol 2017; 67:657-658. [PMID: 28499556 DOI: 10.1016/j.jhep.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/01/2017] [Indexed: 12/04/2022]
Affiliation(s)
- Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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41
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Ripoll C, Yotti R, Bañares R, Bermejo J. Pressure volume curves in cirrhosis: More than meets the eye. J Hepatol 2017; 67:656-657. [PMID: 28495426 DOI: 10.1016/j.jhep.2017.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/16/2017] [Indexed: 12/04/2022]
Affiliation(s)
- Cristina Ripoll
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Raquel Yotti
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Rafael Bañares
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain.
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42
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Møller S, Hove JD. Assessment of systolic function in the evaluation of patients with cirrhosis. Hepatology 2017; 65:1799-1802. [PMID: 28317147 DOI: 10.1002/hep.29163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/15/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Søren Møller
- Centre of Functional Imaging and Research Department of Clinical Physiology and Nuclear Medicine 239 Hvidovre Hospital Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Hove
- Department of Cardiology Hvidovre Hospital Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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