Pulmonale Komplikationen der Leberzirrhose: Hepatopulmonales Syndrom, portopulmonale Hypertonie und hepatischer Hydrothorax

Model for End-Stage Liver Disease (MELD) Score Among Patients Qualified For Lung Transplantation With End-Stage Lung Diseases With Particular Consideration of Median Pulmonary Artery Pressure

BACKGROUND

Model for End-Stage Liver Disease (MELD) score is used to assess the severity of chronic liver disease. It is implemented in transplantology in the process of qualification for urgent liver transplant. The aim of our study was to assess the liver function of patients qualified for lung transplant using MELD score, taking under consideration mean pulmonary artery pressure as an important risk factor of death.

METHODS

The study group consisted of 123 patients qualified for lung transplant in Silesian Center for Heart Diseases between 2004 and 2017. Data relevant for MELD score calculations and medial pulmonary artery pressure were acquired from medical records.

RESULTS

The average MELD score among patients qualified for lung transplant was 8.24 points, and mean pulmonary pressure (mPAP) was 35.02 mm Hg. Patients with idiopathic pulmonary artery hypertension acquired the highest MELD and highest mPAP results (13.1 points and 57.7 mm Hg, respectively). Patients with idiopathic pulmonary fibrosis presented higher mean MELD-Na score among those with pulmonary arterial hypertension than those without pulmonary arterial hypertension (36.59 mm Hg; 7.74 points vs 18 mm Hg; 6.5 points). There is strong positive correlation between MELD-Na and mPAP among patients who underwent lung transplant because of idiopathic pulmonary fibrosis.

CONCLUSIONS

This is the first study in the worldwide literature assessing MELD-Na as a predictor of survival among patients qualified for lung transplant and those who already are recipients. Further studies regarding this issue are required as authors will explore this issue in the future.

Acid-base disorders in liver disease

Alongside the kidneys and lungs, the liver has been recognised as an important regulator of acid-base homeostasis. While respiratory alkalosis is the most common acid-base disorder in chronic liver disease, various complex metabolic acid-base disorders may occur with liver dysfunction. While the standard variables of acid-base equilibrium, such as pH and overall base excess, often fail to unmask the underlying cause of acid-base disorders, the physical-chemical acid-base model provides a more in-depth pathophysiological assessment for clinical judgement of acid-base disorders, in patients with liver diseases. Patients with stable chronic liver disease have several offsetting acidifying and alkalinising metabolic acid-base disorders. Hypoalbuminaemic alkalosis is counteracted by hyperchloraemic and dilutional acidosis, resulting in a normal overall base excess. When patients with liver cirrhosis become critically ill (e.g., because of sepsis or bleeding), this fragile equilibrium often tilts towards metabolic acidosis, which is attributed to lactic acidosis and acidosis due to a rise in unmeasured anions. Interestingly, even though patients with acute liver failure show significantly elevated lactate levels, often, no overt acid-base disorder can be found because of the offsetting hypoalbuminaemic alkalosis. In conclusion, patients with liver diseases may have multiple co-existing metabolic acid-base abnormalities. Thus, knowledge of the pathophysiological and diagnostic concepts of acid-base disturbances in patients with liver disease is critical for therapeutic decision making.

Peritoneal ultrafiltration for refractory fluid overload and ascites due to pulmonary arterial hypertension

Pulmonary hypertension is a common finding in patients with advanced liver disease. Similarly, among patients with advanced pulmonary arterial hypertension, right heart failure leads to congestive hepatopathy. Diuretic resistant fluid overload in both advanced pulmonary hypertension and chronic liver disease is a demanding challenge for physicians. Venous congestion and ascites-induced increased intra-abdominal pressure are essential regarding recurrent hospitalization, morbidity and mortality. Due to impaired right-ventricular function, many patients cannot tolerate extracorporeal ultrafiltration. Peritoneal dialysis, a well-established, hemodynamically tolerated treatment for outpatients may be a good alternative to control fluid status. We present a patient with pulmonary arterial hypertension and congestive hepatopathy hospitalized for over 3 months due to ascites induced refractory volume overload treated with peritoneal ultrafiltration. We report the treatment benefits on fluid balance, cardiorenal and pulmonary function, as well as its safety. In conclusion, we report a case in which peritoneal ultrafiltration was an efficient treatment option for refractory ascites in patients with congestive hepatopathy.