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Zhao DT, Yan HP, Han Y, Zhang WM, Zhao Y, Liao HY. Prevalence and prognostic significance of main metabolic risk factors in primary biliary cholangitis: a retrospective cohort study of 789 patients. Front Endocrinol (Lausanne) 2023; 14:1142177. [PMID: 38027142 PMCID: PMC10663935 DOI: 10.3389/fendo.2023.1142177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Metabolic risk factors in primary biliary cholangitis (PBC) have not been well described in China. Additionally, it is unclear whether these factors have an impact on the prognosis of PBC patients. Therefore, this study aimed to investigate the prevalence of main metabolic risk factors in PBC, and to evaluate their prognostic values for liver-related outcomes. Methods A cohort of 789 PBC patients was retrospectively studied between July 2008 and September 2019 by investigating the main metabolic risk factors and analyzing liver-related outcomes. Results At presentation, 271 (34.3%) patients had concomitant hyperlipidemia, 126 (16.0%) had hypertension, 94 (11.9%) had type 2 diabetes mellitus (T2DM), and 17 (2.2%) had nonalcoholic fatty liver disease (NAFLD). Hyperlipidemia was found to be associated with the lower risk of liver-related death [P<0.0001, hazard ratio (HR): 0.397, 95% confidence interval (CI): 0.268-0.588] and adverse outcomes (P<0.0001, HR: 0.487, 95% CI:0.367-0.646), while hypertension was noted as a risk factor for liver-related death (P=0.001, HR: 1.788, 95% CI:1.268-2.521) and adverse outcomes (P=0.014, HR: 1.417, 95% CI:1.074-1.869). Moreover, age ≥ 55 years old (P=0.005) and cirrhosis (P<0.0001) had superimposition effects on hypertension as a risk factor for liver-related death, while only cirrhosis (P<0.0001) had an effect on hypertension as a risk factor for adverse outcomes. Additionally, anti-sp100 was associated with adverse outcomes (P=0.013) in PBC patients with hypertension in univariate Cox regression analysis. Conclusion Hyperlipidemia, hypertension, and T2DM were found as main metabolic risk factors in PBC in China. Hyperlipidemia indicated a benign clinical outcome of PBC, while hypertension indicated a poor outcome of PBC. Older age and cirrhosis had superimposition effects on hypertension for liver-related poor outcomes. Anti-sp100 might be associated with adverse outcomes, especially in PBC patients with hypertension.
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Affiliation(s)
- Dan-Tong Zhao
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Hui-Ping Yan
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Ying Han
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Wei-Ming Zhang
- Department of Clinical Laboratory Diagnosis, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Yan Zhao
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
- Clinical Laboratory Center, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Hui-Yu Liao
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
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2
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Arman HE, Ali SA, Zenisek J, Patidar KR, Orman E, Elsner N, Ofner S, Li X, Kubal C, Frick K. Assessment of Vascular and Valvular Calcification Improves Screening for Coronary Artery Disease Before Liver Transplantation. Am J Cardiol 2023; 191:23-31. [PMID: 36623410 DOI: 10.1016/j.amjcard.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/29/2022] [Accepted: 12/10/2022] [Indexed: 01/09/2023]
Abstract
Coronary artery disease (CAD) is common in patients with cirrhosis who underwent orthotopic liver transplantation (OLT) evaluation and stress echocardiogram (echo) has a low sensitivity in these patients. This study aimed to assess the impact of vascular and valvular calcification on the ability to identify CAD before OLT. We performed a case-control study of 88 patients with and 97 without obstructive CAD who underwent OLT evaluation. All patients had a preoperative stress echo, abdominal computed tomography, and cardiac catheterization. A series of nested logistic regression models of CAD were fit by adding independent variables of vascular (including coronary) calcification, aortic and mitral valve calcification, age, gender, and history of diabetes mellitus requiring insulin to a baseline model of abnormal stress echo. Compared with stress echo alone, identification of the presence or absence of vascular and valvular calcification on routine preoperative computed tomography and echo improved the diagnostic performance for the detection of CAD based on coronary angiogram when combined with stress echo in patients with cirrhosis who underwent OLT evaluation (area under the curve 0.58 vs 0.73, p <0.001), which is even further improved when age, gender, and history of diabetes mellitus requiring insulin are considered (area under the curve 0.58 vs 0.80, p <0.001). Achieving target heart rate (p = 0.92) or rate-pressure product >25,000 (p = 0.63) did not improve the ability of stress echo to identify CAD. In conclusion, the use of abdominal vascular, coronary artery, and valvular calcification, along with stress echo, improves the ability to identify and rule out obstructive CAD before OLT compared with stress echo alone.
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Affiliation(s)
- Huseyin E Arman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Saad A Ali
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joseph Zenisek
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Nathaniel Elsner
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Susan Ofner
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandrashekhar Kubal
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kyle Frick
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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3
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Aikins AO, Little JT, Rybalchenko N, Cunningham JT. Norepinephrine innervation of the supraoptic nucleus contributes to increased copeptin and dilutional hyponatremia in male rats. Am J Physiol Regul Integr Comp Physiol 2022; 323:R797-R809. [PMID: 36189988 PMCID: PMC9639772 DOI: 10.1152/ajpregu.00086.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 11/22/2022]
Abstract
Dilutional hyponatremia associated with liver cirrhosis is due to inappropriate release of arginine vasopressin (AVP). Elevated plasma AVP causes water retention resulting in a decrease in plasma osmolality. Cirrhosis, in this study caused by ligation of the common bile duct (BDL), leads to a decrease in central vascular blood volume and hypotension, stimuli for nonosmotic AVP release. The A1/A2 neurons stimulate the release of AVP from the supraoptic nucleus (SON) in response to nonosmotic stimuli. We hypothesize that the A1/A2 noradrenergic neurons support chronic release of AVP in cirrhosis leading to dilutional hyponatremia. Adult, male rats were anesthetized with 2-3% isoflurane (mixed with 95% O2/5% CO2) and injected in the SON with anti-dopamine β-hydroxylase (DBH) saporin (DSAP) or vehicle followed by either BDL or sham surgery. Plasma copeptin, osmolality, and hematocrit were measured. Brains were processed for ΔFosB, dopamine β-hydroxylase (DBH), and AVP immunohistochemistry. DSAP injection: 1) significantly reduced the number of DBH immunoreactive A1/A2 neurons (A1, P < 0.0001; A2, P = 0.0014), 2) significantly reduced the number of A1/A2 neurons immunoreactive to both DBH and ΔFosB positive neurons (A1, P = 0.0015; A2, P < 0.0001), 3) reduced the number of SON neurons immunoreactive to both AVP and ΔFosB (P < 0.0001), 4) prevented the increase in plasma copeptin observed in vehicle-injected BDL rats (P = 0.0011), and 5) normalized plasma osmolality and hematocrit (plasma osmolality, P = 0.0475; hematocrit, P = 0.0051) as compared with vehicle injection. Our data suggest that A1/A2 neurons contribute to increased plasma copeptin and hypoosmolality in male BDL rats.
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Affiliation(s)
- Ato O Aikins
- Department of Physiology and Anatomy, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - Joel T Little
- Department of Physiology and Anatomy, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - Nataliya Rybalchenko
- Department of Physiology and Anatomy, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - J Thomas Cunningham
- Department of Physiology and Anatomy, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
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4
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Barrere V, Sanchez M, Cambronero S, Dupré A, Rivoire M, Melodelima D. Evaluation of Ultrasonic Attenuation in Primary and Secondary Human Liver Tumors and Its Potential Effect on High-Intensity Focused Ultrasound Treatment. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1761-1774. [PMID: 33895037 DOI: 10.1016/j.ultrasmedbio.2021.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 06/12/2023]
Abstract
Primary and secondary liver tumors are completely different diseases but are usually treated similarly using high-intensity focused ultrasound (HIFU). However, the acoustic parameters of these tissues are not well documented. In this study, attenuation coefficients were evaluated in fresh primary (N = 8) and secondary (N = 13) human liver tumor samples recovered by hepatectomy. The average attenuation coefficients of the primary and secondary liver tumors were 0.10 ± 0.03 and 0.20 ± 0.04 Np/cm/MHz, respectively. The average attenuation coefficients of the liver tissue surrounding the primary and secondary tumors were 0.16 ± 0.07 and 0.07 ± 0.02 Np/cm/MHz, respectively. Numerical simulations performed using these values revealed that completely different HIFU ablation patterns were created in primary and secondary liver tumors using the same exposure parameters. The dimensions of a typical HIFU lesion were two times larger in secondary liver tumors than in primary tumors. HIFU treatment parameters should be set properly according to the acoustic properties of the diseased liver tissue.
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Affiliation(s)
- Victor Barrere
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France
| | - Marine Sanchez
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France
| | - Sophie Cambronero
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France
| | - Aurelien Dupré
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France
| | - Michel Rivoire
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France
| | - David Melodelima
- LabTAU, INSERM, Centre Léon Bérard, Université Lyon 1, Univ Lyon, Lyon, France.
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5
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Association of Preoperative Prognostic Nutritional Index and Postoperative Acute Kidney Injury in Patients Who Underwent Hepatectomy for Hepatocellular Carcinoma. J Pers Med 2021; 11:jpm11050428. [PMID: 34069960 PMCID: PMC8157861 DOI: 10.3390/jpm11050428] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/08/2021] [Accepted: 05/17/2021] [Indexed: 01/14/2023] Open
Abstract
Various biological indicators are reportedly associated with postoperative acute kidney injury (AKI) in the surgical treatment of hepatocellular carcinoma (HCC). However, only a few studies have evaluated the association between the preoperative prognostic nutritional index (PNI) and postoperative AKI. This study evaluated the association of the preoperative PNI and postoperative AKI in HCC patients. We retrospectively analyzed 817 patients who underwent open hepatectomy between December 2007 and December 2015. Multivariate regression analysis was performed to evaluate the association between the PNI and postoperative AKI. Additionally, we evaluated the association between the PNI and outcomes such as postoperative renal replacement therapy (RRT) and mortality. Cox regression analysis was performed to assess the risk factors for one-year and five-year mortality. In the multivariate analysis, high preoperative PNI was significantly associated with a lower incidence of postoperative AKI (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.85 to 0.99, p = 0.021). Additionally, diabetes mellitus and the use of synthetic colloids were significantly associated with postoperative AKI. PNI was associated with postoperative RRT (OR: 0.76, 95% CI: 0.60 to 0.98, p = 0.032) even after adjusting for other potential confounding variables. In the Cox regression analysis, high PNI was significantly associated with low one-year mortality (Hazard ratio (HR): 0.87, 95% CI: 0.81 to 0.94, p < 0.001), and five-year mortality (HR: 0.93, 95% CI: 0.90–0.97, p < 0.001). High preoperative PNI was significantly associated with a lower incidence of postoperative AKI and low mortality. These results suggest that the preoperative PNI might be a predictor of postoperative AKI and surgical prognosis in HCC patients undergoing open hepatectomy.
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6
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Kang SH, Lee M, Kim MY, Lee JH, Jun BG, Kim TS, Choi DH, Suk KT, Kim YD, Cheon GJ, Kim DJ, Baik SK. The longitudinal outcomes of applying non-selective beta-blockers in portal hypertension: real-world multicenter study. Hepatol Int 2021; 15:424-436. [PMID: 33860898 DOI: 10.1007/s12072-021-10160-3] [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: 11/15/2020] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIM We investigated the effect of non-selective β-blockers (NSBB) in real-world situations and whether low-dose NSBB is beneficial compared to maximally tolerated doses. METHODS We performed a retrospective study of 740 patients with cirrhosis requiring prophylactic treatment of esophageal varices: 473 primary prophylaxis (PP: NSBB = 349, non-NSBB = 124) and 267 secondary prophylaxis (SP: NSBB = 200, non-NSBB = 67). The NSBB group was divided into low-dose (≤ 80 mg/day) and high-dose (> 80 mg/day). RESULTS In the PP group, NSBB treatment reduced mortality and showed the most pronounced effect in patients with moderate/severe ascites (hazard ratio [HR], 0.46; p < 0.01), HVPG ≥ 16 mmHg (HR, 0.53; p = 0.04), or CTP class B/C (HR, 0.46; p < 0.01) but not in those with no/mild ascites, HVPG < 16 mmHg, or CTP class A. Low-dose NSBB group showed a significant reduction in mortality compared with non-NSBB (moderate/severe ascites: HR, 0.61; p = 0.02 and CTP class B/C: HR, 0.41; p < 0.01) and the effect size was stronger than the high-dose NSBB. NSBB was associated with a reduced risk of infection (HR, 0.36; p = 0.01). In the SP group, NSBB prolonged survival in patients with moderate/severe ascites (HR, 0.56; p = 0.02), HVPG ≥ 16 mmHg (HR, 0.42; p < 0.01), or CTP class B/C (HR, 0.52; p < 0.01). Low-dose NSBB was more beneficial with 56% risk reduction (p < 0.01) of mortality compared with 33% risk reduction in the high-dose NSBB (p = 0.05). CONCLUSION NSBB therapy was associated with longer survival in PP and SP groups who had an advanced stage of cirrhosis. Moreover, low-dose NSBB exhibited a better benefit than a standard-titrated high-dose NSBB with better tolerability.
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Affiliation(s)
- Seong Hee Kang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea.,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea.,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Minjong Lee
- School of Medicine, Ewha Womans University, Seoul, Korea.,Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Moon Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea. .,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea. .,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
| | - Jun Hyeok Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea.,Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Tae Suk Kim
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Dae Hee Choi
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Young Don Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soon Koo Baik
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea.,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea.,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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7
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Schwaiger E, Simon A, Wabel P, Schairer B, Berner C, Signorini L, Ernstbrunner M, Evstatiev R, Schwabl P, Hinterholzer G, Frommlet F, Vychytil A, Müller CJ, Hecking M. Bioimpedance spectroscopy for fluid status assessment in patients with decompensated liver cirrhosis: Implications for peritoneal dialysis. Sci Rep 2020; 10:2869. [PMID: 32071351 PMCID: PMC7028989 DOI: 10.1038/s41598-020-59817-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 01/31/2020] [Indexed: 01/08/2023] Open
Abstract
Bioimpedance spectroscopy (BIS) is routinely used in peritoneal dialysis patients and might aid fluid status assessment in patients with liver cirrhosis, but the effect of ascites volume removal on BIS-readings is unknown. Here we determined changes in BIS-derived parameters and clinical signs of fluid overload from before to after abdominal paracentesis. Per our pre-specified sample size calculation, we studied 31 cirrhotic patients, analyzing demographics, labs and clinical parameters along with BIS results. Mean volume of the abdominal paracentesis was 7.8 ± 2.6 L. From pre-to post-paracentesis, extracellular volume (ECV) decreased (20.2 ± 5.2 L to 19.0 ± 4.8 L), total body volume decreased (39.8 ± 9.8 L to 37.8 ± 8.5 L) and adipose tissue mass decreased (38.4 ± 16.0 kg to 29.9 ± 12.9 kg; all p < 0.002). Correlation of BIS-derived parameters from pre to post-paracentesis ranged from R² = 0.26 for body cell mass to R² = 0.99 for ECV. Edema did not correlate with BIS-derived fluid overload (FO ≥ 15% ECV), which occurred in 16 patients (51.6%). In conclusion, BIS-derived information on fluid status did not coincide with clinical judgement. The changes in adipose tissue mass support the BIS-model assumption that fluid in the peritoneal cavity is not detectable, suggesting that ascites (or peritoneal dialysis fluid) mass should be subtracted from adipose tissue if BIS is used in patients with a full peritoneal cavity.
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Affiliation(s)
- Elisabeth Schwaiger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Kepler University Hospital, Med Campus III, Linz, Austria
| | - Amrei Simon
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Peter Wabel
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Benjamin Schairer
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Carolin Berner
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Lorenzo Signorini
- Dipartimento di Nefrologia e Dialis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matthäus Ernstbrunner
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Rayko Evstatiev
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Georg Hinterholzer
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christian J Müller
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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8
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Mottelson MN, Lundsgaard CC, Møller S. Mechanisms in fluid retention - towards a mutual concept. Clin Physiol Funct Imaging 2019; 40:67-75. [PMID: 31823451 DOI: 10.1111/cpf.12615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/04/2019] [Indexed: 12/12/2022]
Abstract
Fluid retention is a common and challenging condition in daily clinical practice. The normal fluid homoeostasis in the human body is based on accurately counter-balanced physiological mechanisms. When compromised fluid retention occurs and is seen in pathophysiologically different conditions such as liver cirrhosis, heart and kidney failure, and in preeclampsia. These conditions may share pathophysiological mechanisms such as functional arterial underfilling, which seems to be a mutual element in cirrhosis, cardiac failure, cardiorenal and hepatorenal syndromes, and in pregnancy. However, there are also distinct differences and it is still unclear whether kidney dysfunction or arterial underfilling is the initiating factor of fluid retention or if they happen simultaneously. This review focuses on similarities and differences in water retaining conditions and points to areas where important knowledge is still needed.
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Affiliation(s)
- Mathis N Mottelson
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Internal Medicine, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Christoffer C Lundsgaard
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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9
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Wong RJ, Robinson A, Ginzberg D, Gomes C, Liu B, Bhuket T. Assessing the safety of beta-blocker therapy in cirrhosis patients with ascites: A meta-analysis. Liver Int 2019; 39:1080-1088. [PMID: 30614656 DOI: 10.1111/liv.14040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/26/2018] [Accepted: 01/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Beta-blocker therapy is effective at reducing risks of variceal bleeding. However, beta-blockers may detrimentally exacerbate the underlying haemodynamic changes in cirrhosis. A systematic review and meta-analysis was performed to evaluate impact of beta-blockers on all-cause mortality among cirrhosis patients with ascites. METHODS A literature search identified studies that evaluated beta-blocker vs no beta-blocker therapy in cirrhosis patients with ascites. The primary outcome was all-cause mortality with subcohort analysis of patients with refractory or severe ascites. Quality of observational studies was assessed with Newcastle-Ottawa Scale and overall certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Eight observational studies, representing 3627 cirrhosis patients with ascites (1630 treated with beta-blockers and 1997 not treated), were included. Pooled all-cause mortality was 38.6% in beta-blocker group vs 42.2% in no beta-blocker group (RR 0.93, 95% CI 0.77-1.13, χ2 = 54.03, I2 = 87%). Subcohort analysis of cirrhosis patients with refractory or severe ascites demonstrated 33.3% mortality in beta-blocker group vs 32.1% in no beta-blocker group (RR 0.99, 95% CI 0.70-1.40, χ2 = 32.99, and I2 = 82%). Three studies were good quality and five studies were fair quality. GRADE rating was 'very low' certainty of evidence, given concern for bias and inconsistency stemming from significant heterogeneity. CONCLUSION No significant increase in all-cause mortality was observed in cirrhosis patients with ascites treated with beta-blockers. However, given the low certainty of the evidence, high quality prospective studies are needed.
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Affiliation(s)
- Robert J Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Ann Robinson
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Dina Ginzberg
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Chantal Gomes
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
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10
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Shenoda B, Boselli J. Vascular syndromes in liver cirrhosis. Clin J Gastroenterol 2019; 12:387-397. [PMID: 30980261 DOI: 10.1007/s12328-019-00956-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 02/20/2019] [Indexed: 02/08/2023]
Abstract
Liver cirrhosis is associated with multiple vascular syndromes affecting almost all body systems. Many of these syndromes are directly related to impaired liver function and sometimes reversible after liver transplantation while others arise secondary to portal hypertension and ascites. Altered expression of angiogenic and vasoactive compounds (most importantly nitric oxide), endothelial dysfunction, dysregulated neurohormonal control, and systemic inflammatory state play differential roles in mediating homeostatic instability and abnormal vasogenic response. Important vascular features encountered in liver disease include portal hypertension, splanchnic overflow, abnormal angiogenesis and shunts, portopulmonary syndrome, hepatopulmonary syndrome, and systemic hyperdynamic circulation. Redistribution of effective circulatory volume deviating from vital organs and pooling in splanchnic circulation is also encountered in liver patients which may lead to devastating outcomes as hepatorenal syndrome. Etiologically, vascular syndromes are not isolated phenomena and vascular dysfunction in one system may lead to the development of another in a different system. This review focuses on understanding the pathophysiological factors underlying vascular syndromes related to chronic liver disease and the potential links among them. Many of these syndromes are associated with high mortality, thus it is crucial to look for early biomarkers for these syndromes and develop novel preventive and therapeutic strategies.
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Affiliation(s)
- Botros Shenoda
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, 19102, USA
| | - Joseph Boselli
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, 19102, USA. .,Drexel Internal Medicine, 205 N. Broad Street, Philadelphia, 19107, USA.
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Doytchinova AT, Feigenbaum TD, Pondicherry-Harish RC, Sepanski P, Green-Hess D, Feigenbaum H, Sawada SG. Diagnostic Performance of Dobutamine Stress Echocardiography in End-Stage Liver Disease. JACC Cardiovasc Imaging 2019; 12:2115-2122. [PMID: 30660519 DOI: 10.1016/j.jcmg.2018.10.031] [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: 03/29/2018] [Revised: 10/15/2018] [Accepted: 10/19/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study determined the test performance of dobutamine stress echocardiography (DSE) in end-stage liver disease (ESLD). BACKGROUND The reported sensitivity of DSE in ESLD has been variable. METHODS Data from 633 ESLD patients who had coronary angiography within 6 months after DSE was analyzed. RESULTS The prevalence of coronary arterial disease (CAD) (≥70% stenosis by quantitative angiography) was 12% (74 of 633 patients). DSE sensitivity was 24% (17 of 72 patients), and specificity was 90% (503 of 559 patients). The positive and negative predictive values were 23% (17 of 73 patients) and 90% (503 of 558 patients), respectively. Stratifying the cohort into low-, intermediate-, and high-risk CAD groups yielded sensitivities of 0%, 21%, and 32%, respectively. Independent predictors of an accurate ischemic DSE result included left ventricular internal dimension at end-diastole (LVIDd) >4.8 cm and assigning ischemia based on tardokinesis or lack of low-to-peak dose hyperkinesis (p < 0.05 for all). DSE sensitivity was 38% in LVIDd >4.8 cm versus 13% with LVIDd ≤4.8 cm (p = 0.013). The sensitivity was 67% when tardokinesis or lack of hyperkinesis was considered abnormal versus 15% (p < 0.001) for readings that did not consider tardokinesis or lack of hyperkinesis abnormal. There was a higher frequency of cardiac events in patients with significant CAD who had abnormal (45%) versus normal (18%) DSE (p = 0.01). CONCLUSIONS The sensitivity of DSE in ESLD was low. DSE sensitivity was higher for those with larger cavity dimension and when tardokinesis or lack of hyperkinesis was considered abnormal. An abnormal DSE in those with significant CAD was associated with worse outcome.
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Affiliation(s)
- Anisiia T Doytchinova
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana; Division of Cardiovascular Health and Disease, University of Cincinnati Medical Center, Cincinnati, Ohio.
| | - Thomas D Feigenbaum
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana
| | | | - Peter Sepanski
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana
| | - Deborah Green-Hess
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana
| | - Harvey Feigenbaum
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana
| | - Stephen G Sawada
- Krannert Institute, Indiana University School of Medicine and IU Health, Indianapolis, Indiana
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Busk TM, Bendtsen F, Poulsen JH, Clemmesen JO, Larsen FS, Goetze JP, Iversen JS, Jensen MT, Møgelvang R, Pedersen EB, Bech JN, Møller S. Transjugular intrahepatic portosystemic shunt: impact on systemic hemodynamics and renal and cardiac function in patients with cirrhosis. Am J Physiol Gastrointest Liver Physiol 2018; 314:G275-G286. [PMID: 29074483 DOI: 10.1152/ajpgi.00094.2017] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) alleviates portal hypertension and possibly increases central blood volume (CBV). Moreover, renal function often improves; however, its effects on cardiac function are unclear. The aims of our study were to examine the effects of TIPS on hemodynamics and renal and cardiac function in patients with cirrhosis. In 25 cirrhotic patients, we analyzed systemic, cardiac, and splanchnic hemodynamics by catheterization of the liver veins and right heart chambers before and 1 wk after TIPS. Additionally, we measured renal and cardiac markers and performed advanced echocardiography before, 1 wk after, and 4 mo after TIPS. CBV increased significantly after TIPS (+4.6%, P < 0.05). Cardiac output (CO) increased (+15.3%, P < 0.005) due to an increase in stroke volume (SV) (+11.1%, P < 0.005), whereas heart rate (HR) was initially unchanged. Cardiopulmonary pressures increased after TIPS, whereas copeptin, a marker of vasopressin, decreased (-18%, P < 0.005) and proatrial natriuretic peptide increased (+52%, P < 0.0005) 1 wk after TIPS and returned to baseline 4 mo after TIPS. Plasma neutrophil gelatinase-associated lipocalin, renin, aldosterone, and serum creatinine decreased after TIPS (-36%, P < 0.005; -65%, P < 0.05; -90%, P < 0.005; and -13%, P < 0.005, respectively). Echocardiography revealed subtle changes in cardiac function after TIPS, although these were within the normal range. TIPS increases CBV by increasing CO and SV, whereas HR is initially unaltered. These results indicate an inability to increase the heart rate in response to a hemodynamic challenge that only partially increases CBV after TIPS. These changes, however, are sufficient for improving renal function. NEW & NOTEWORTHY For the first time, we have combined advanced techniques to study the integrated effects of transjugular intrahepatic portosystemic shunt (TIPS) in cirrhosis. We showed that TIPS increases central blood volume (CBV) through improved cardiac inotropy. Advanced echocardiography demonstrated that myocardial function was unaffected by the dramatic increase in preload after TIPS. Finally, renal function improved due to the increase in CBV. Recognition of these physiological changes significantly contributes to our clinical understanding of TIPS.
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Affiliation(s)
- Troels M Busk
- Department of Clinical Physiology and Nuclear Medicine, Centre of Functional Imaging and Research, Copenhagen University Hospital Hvidovre , Copenhagen , Denmark.,Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre , Copenhagen , Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre , Copenhagen , Denmark
| | - Jørgen H Poulsen
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Copenhagen , Denmark
| | - Jens O Clemmesen
- Department of Hepatology, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Fin S Larsen
- Department of Hepatology, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Jens S Iversen
- Department of Nephrology, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Rasmus Møgelvang
- Department of Cardiology, Copenhagen University Rigshospitalet , Copenhagen , Denmark
| | - Erling B Pedersen
- University Clinic of Nephrology and Hypertension, Department of Medical Research and Medicine, Holstebro Hospital and Aarhus University , Aarhus , Denmark
| | - Jesper N Bech
- University Clinic of Nephrology and Hypertension, Department of Medical Research and Medicine, Holstebro Hospital and Aarhus University , Aarhus , Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Centre of Functional Imaging and Research, Copenhagen University Hospital Hvidovre , Copenhagen , Denmark
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13
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Effects of transjugular intrahepatic portosystemic shunt (TIPS) on blood volume distribution in patients with cirrhosis. Dig Liver Dis 2017; 49:1353-1359. [PMID: 28729141 DOI: 10.1016/j.dld.2017.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/10/2017] [Accepted: 06/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cirrhosis is accompanied by portal hypertension with splanchnic and systemic arterial vasodilation, and central hypovolaemia. A transjugular intrahepatic portosystemic shunt (TIPS) alleviates portal hypertension, but also causes major haemodynamic changes. AIMS To investigate effects of TIPS on regional blood volume distribution, and systemic haemodynamics. METHODS Thirteen cirrhotic patients had their regional blood volume distribution determined with gamma-camera technique before and after TIPS. Additionally, we measured systemic haemodynamics during liver vein and right heart catheterization. Central and arterial blood volume (CBV) and cardiac output (CO) were determined with indicator dilution technique. RESULTS After TIPS, the thoracic blood volume increased (+10.4% of total blood volume (TBV), p<0.01), whereas the splanchnic blood volume decreased (-11.9% of TBV, p<0.001). CO increased (+22%, p<0.0001), and systemic vascular resistance decreased (-26%, p<0.001), whereas CBV did not change. Finally, right atrial pressure and mean pulmonary artery pressure increased after TIPS (+50%, p<0.005; +40%, p<0.05, respectively). CONCLUSIONS TIPS restores central hypovolaemia by an increase in thoracic blood volume and alleviates splanchnic vascular congestion. In contrast, CBV seems unaltered. The improvement in central hypovolaemia is therefore based on an increase in thoracic blood volume that includes both the central venous and arterial blood volume. This is supported by an increase in preload, combined with a decrease in afterload.
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Fayed NA, Yassen KA, Abdulla AR. Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:1741-1750. [DOI: 10.1053/j.jvca.2017.02.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 12/16/2022]
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Loftus TJ, Jordan JR, Croft CA, Smith RS, Efron PA, Moore FA, Mohr AM, Brakenridge SC. Emergent laparotomy and temporary abdominal closure for the cirrhotic patient. J Surg Res 2016; 210:108-114. [PMID: 28457316 DOI: 10.1016/j.jss.2016.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/11/2016] [Accepted: 11/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients. METHODS We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals. RESULTS At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients. CONCLUSIONS Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Janeen R Jordan
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Chasen A Croft
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - R Stephen Smith
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Frederick A Moore
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
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Saugel B, Mair S, Meidert AS, Phillip V, Messer M, Nennstiel S, Berger H, Gaa J, Wagner JY, Schneider H, Schmid RM, Huber W. The effects of transjugular intrahepatic portosystemic stent shunt on systemic cardiocirculatory parameters. J Crit Care 2014; 29:1001-5. [DOI: 10.1016/j.jcrc.2014.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 06/17/2014] [Accepted: 06/21/2014] [Indexed: 11/29/2022]
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17
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Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2014; 60:643-53. [PMID: 24076364 DOI: 10.1016/j.jhep.2013.09.016] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 12/11/2022]
Abstract
Cirrhosis is a leading cause of death in the United States and worldwide. Beta-blockers have been established in numerous studies as part of the cornerstone of the medical management of cirrhosis, particularly in the primary and secondary prevention of variceal hemorrhage. However, new evidence has cautioned the use of beta-blockers in patients with end-stage cirrhosis and refractory ascites. In this article, we review the beneficial effects of beta-blocker therapy, the potential harms of aggressive beta-blocker therapy, and provide suggestions regarding the appropriate use of this class of medications in patients with cirrhosis.
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Affiliation(s)
- Phillip S Ge
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Bruce A Runyon
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
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Ruíz-del-Árbol L, Achécar L, Serradilla R, Rodríguez-Gandía MÁ, Rivero M, Garrido E, Natcher JJ. Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine. Hepatology 2013; 58:1732-41. [PMID: 23703953 DOI: 10.1002/hep.26509] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 04/27/2013] [Indexed: 12/13/2022]
Abstract
UNLABELLED We investigated left ventricular diastolic dysfunction (LVDD) and its relationship with circulatory function and prognosis in cirrhosis with portal hypertension and normal creatinine. Conventional and tissue Doppler (TDI) echocardiography, systemic and hepatic hemodynamics, and the activity of endogenous vasoactive systems (AEVS) were measured prospectively in 80 patients. Plasma renin activity (PRA; >4 ng/mL/hour) was used as a surrogate of effective arterial blood volume. Patients were followed up for 12 months. Thirty-seven patients had LVDD (19 with grade 1 and 18 with grade 2). Left ventricular hypertrophy, left atrial volume, AEVS, and natriuretic peptide levels were significantly greater in patients with LVDD than without LVDD. Patients with grade 2 LVDD, compared to grade 1 LVDD and without LVDD, had significantly lower mean arterial pressure and higher Model for End-Stage Liver Disease (MELD) score, E-wave transmitral/early diastolic mitral annular velocity (E/e' ratio), cardiopulmonary pressures, PRA, and natriuretic peptide levels. Systolic and cardiac chronotropic function were significantly lower in patients with grade 2 LVDD than without LVDD. LVDD was more frequent in patients with ascites and increased PRA than patients without ascites or with ascites but normal PRA. Fourteen patients with LVDD developed hepatorenal syndrome (HRS) type 1 on follow-up. Survival was different according to degree of LVDD (without LVDD: 95%; grade 1 LVDD: 79%; grade 2 LVDD: 39%; P < 0.001). Independent predictive factors of mortality were MELD score and E/e' ratio. CONCLUSION LVDD occurs simultaneously with other changes in cardiac structure and function and is associated with an impairment of effective arterial blood volume. LVDD is a sensitive marker of advanced cirrhosis, type 1 HRS development, and mortality.
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Affiliation(s)
- Luís Ruíz-del-Árbol
- Hepatic Hemodynamic Unit, Gastroenterology Department, Hospital Ramón y Cajal, University of Alcalá, Madrid, Spain
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19
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Henriksen JH, Jensen GB, Larsson HBW. A century of indicator dilution technique. Clin Physiol Funct Imaging 2013; 34:1-9. [DOI: 10.1111/cpf.12068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Jens H. Henriksen
- Department of Clinical Physiology and Nuclear Medicine 239; Center of Functional and Diagnostic Imaging and Research; Hvidovre Hospital; Faculty of Health Sciences; University of Copenhagen; Hvidovre Denmark
| | - Gorm B. Jensen
- Department of Cardiology; Hvidovre Hospital; Faculty of Health Sciences; University of Copenhagen; Hvidovre Denmark
| | - Henrik B. W. Larsson
- Functional Imaging Unit; Diagnostic Department; Glostrup Hospital; Faculty of Health Sciences; University of Copenhagen; Glostrup Denmark
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20
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Living-donor liver transplantation for moderate or severe porto-pulmonary hypertension accompanied by pulmonary arterial hypertension: a single-centre experience over 2 decades in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:638-49. [PMID: 22086457 DOI: 10.1007/s00534-011-0453-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Candidates for orthotopic liver transplantation (OLT) often have porto-pulmonary hypertension (PPHTN) with pulmonary arterial hypertension (PAH). Poor outcomes of PPHTN contraindicate OLT. There are no guidelines for living-donor liver transplantation (LDLT) in PPHTN patients. METHODS We present our experiences of LDLT in six patients with moderate or severe PPHTN, along with our institutional guidelines. Three had liver cirrhosis and three were non-cirrhotic. Catheterization studies were undertaken before, during and after LDLT, and the mean pulmonary arterial pressure (mPAP), cardiac output (CO), pulmonary vascular resistance and total peripheral resistance (TPR) were monitored. RESULTS The results showed significant differences in CO and TPR between cirrhotic and non-cirrhotic patients before, during and after LDLT. Cirrhotic patients showed systemic hyperdynamic state. Two cirrhotic patients showed poor responses to pre-transplant treatment, and continued to have increased PAH and poor clinical courses after LDLT. LDLT has an advantage of flexible timing of LT. Currently in our institution, PPHTN patients with mPAP <40 mmHg are registered for LDLT after treatment and catheterization. However, LDLT is performed when mPAP is ≤35 mmHg, leading to improved outcomes. CONCLUSION PPHTN patients with well-controlled PAH, or secondary PAH resulting from porto-systemic shunts, may be appropriate candidates for LDLT after careful considerations.
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21
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Fayed N, Refaat EK, Yassein TE, Alwaraqy M. Effect of perioperative terlipressin infusion on systemic, hepatic, and renal hemodynamics during living donor liver transplantation. J Crit Care 2013; 28:775-82. [PMID: 23618777 DOI: 10.1016/j.jcrc.2013.02.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/14/2012] [Accepted: 02/24/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND End-stage liver disease is associated with marked hemodynamic disturbances that are further aggravated during liver transplantation. Terlipressin has been shown to be effective in the management of sepsis-induced hypotension and hepatorenal syndrome and recently has been tried as infusion during liver transplantation. This study assessed the effect of intraoperative and postoperative terlipressin infusion on systemic, hepatic, and renal hemodynamics during adult living donor liver transplantation. METHODS Eighty recipients were randomly allocated into control (C group; n=40) and terlipressin (TP group; n=40), in which, terlipressin infusion was started at the beginning of surgery at a dose of 3 μg kg(-1) h(-1) to be reduced to 1.5 μg kg(-1) h(-1) after reperfusion and continued for 3 postoperative days; vasoactive agents were used as appropriate in all patients. Systemic hemodynamics, hepatic and renal arterial resistive indices (HARI, RARI), and portal venous blood flow (PBF) were compared between both groups intraoperatively and for 5 postoperative days. RESULTS With terlipressin infusion, there were significant increases in both mean arterial pressure and systemic vascular resistance (P<.001), whereas heart rate and cardiac output decreased significantly (P<.001) throughout the study period compared with the C group. Vasoconstrictor drugs required during reperfusion were significantly lower in the TP group. There was a significant decrease in HARI, RARI, and portal venous blood flow in the TP group compared with the C group throughout the study period. There was no significant difference between both groups regarding liver function tests and serum lactate, whereas renal function tests were significantly better in the TP group. CONCLUSION Terlipressin infusion significantly decreased HARI, RARI, and portal vein flow and improved low systemic vascular resistance and mean arterial pressure. It helped to reduce intraoperative vasoactive support and might improve postoperative renal function.
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Affiliation(s)
- N Fayed
- Department of Anesthesia, National Liver Institute, Menofiya University, Shebeen Alkoom, Egypt.
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Christensen TN, Mortensen C, Henriksen JH, Møller S. Different injection techniques in the assessment of central haemodynamics in patients with cirrhosis. Scandinavian Journal of Clinical and Laboratory Investigation 2012; 73:42-7. [PMID: 23098342 DOI: 10.3109/00365513.2012.734395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Patients with cirrhosis often present with an abnormal distribution of blood volume with a reduced central blood volume (CBV) and central circulation time (CCT). In this group of patients it is important to determine the central haemodynamics as accurately as possible. The purpose of the present study was to compare an alternative injection technique by injecting technetium-labelled human serum albumin ((99m)Tc-HSA) from a deposit within the catheter lumen with the conventional injection technique by injecting iodine-labelled human serum albumin ((125)I-HSA) directly from a syringe. MATERIALS AND METHODS In 192 patients with cirrhosis, CCT, CBV, and cardiac output (CO) were determined according to kinetic principles. Injection of the two radiolabelled HSA were performed simultaneously and followed by arterial blood sampling every second for the first minute. RESULTS CCT was significantly shorter, and CO and CBV were significantly lower when determined by the alternative catheter deposit injection technique compared to determination by the traditional syringe deposit injection technique. The mean difference (bias) between CCT measured with the two methods was 0.38 s with limits of agreement ranging from - 0.83 s to 1.59 s. CONCLUSION This study demonstrates that different injection techniques result in a minor but significant difference of the measured haemodynamics. When highly accurate measurements of the central haemodynamics are needed, we recommend using the alternative injection technique by injection of the indicator from a deposit within the catheter in order to reduce overestimation of CCT.
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Affiliation(s)
- Tine N Christensen
- Centre of Functional Imaging and Research, Department of Clinical Physiology, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagoastric varices. Transplantation 2012; 94:192-6. [PMID: 22728290 DOI: 10.1097/tp.0b013e31825475c2] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hemodynamic monitoring using transesophageal echocardiography (TEE) in patients with signs of portal hypertension undergoing orthotopic liver transplantation (OLT) carries potential risk of esophageal and gastric variceal hemorrhage. The aim of our retrospective analysis was to evaluate the safety of intraoperative TEE monitoring during OLT in patients with esophagogastric varices. METHODS A retrospective analysis of 396 liver transplant recipients was performed at the Medical University of Vienna monitored by TEE during OLT between 2003 and 2010. RESULTS Varices were documented by esophagogastroduodenoscopy in 287 (72.5%) of 396 analyzed patients: 130 (32.8%) varices grade I (<5 mm under insufflation) and 157 (39.6%) varices grade II (>5 mm under insufflation). Red spot signs were identified in 40 patients (10.1%). Most varices (82.2%) were documented in the esophagus, 4.2% in the stomach, and 13.6% in both (esophagus and stomach). Only one major bleeding occurred, and it was only in a case of one patient with an esophageal varix, which was treated with a balloon tamponade during OLT. Although patients with varices demonstrated a significantly longer prothrombin time and lower platelet count, there was no significant difference in the requirement for blood products among patients with and without varices. CONCLUSIONS TEE is a relatively safe method for monitoring cardiac performance with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices undergoing OLT.
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Singh S, Nasa V, Tandon M. Perioperative monitoring in liver transplant patients. J Clin Exp Hepatol 2012; 2:271-8. [PMID: 25755443 PMCID: PMC3940305 DOI: 10.1016/j.jceh.2012.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/26/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplant (LT) is a major surgical undertaking involving major fluid shifts, hemodynamic instability and metabolic derangements in a patient with preexisting liver failure and multisystemic derangements. Monitoring and organ support initiated in the preoperative phase is continued intraoperatively and into the postoperative phase to ensure an optimal outcome. As cardiovascular events are the leading cause of non-graft related death among LT recipients, major emphasis is placed on cardiovascular monitoring. The other essential monitoring are the continuous assessment of coagulapathy, extent of metabolic derangements, dyselectrolytemis and intracranial pressure monitoring in patients with fulminant hepatic failure. The type and extent of monitoring differs with need according to preexisting child status of the patient and the extent of systemic derangements. It also varies among transplant centers and is mainly determined by individual or institutional practices.
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Key Words
- ACT, activated clotting time
- ALF
- ALF, acute liver failure
- APTT, activated partial thromboplastin time
- ARDS, acute respiratory distress syndrome
- CCO, continuous CO
- CCTs, conventional coagulation tests
- CI, cardiac index
- CL, clot lysis
- CO, cardiac output
- CR, clot rate
- CVP, central venous pressure
- ESLD, end stage liver disease
- EVLWI, extra vascular lung water index
- ICG, indocyanine green
- ICH, intracranial hypertension
- ICP, intracranial pressure
- LT, liver transplant
- MA, maximum amplitude
- ONSD, optic nerve sheath diameter
- PAC, pulmonary artery catheter
- PAOP, pulmonary arterial occlusion pressure
- PF, platelet function
- PI, pulsatility index
- PT, prothrombin time
- ROTEM, rotation thrombelastometry
- RVEDV, right ventricular end-diastolic volume
- SV, stroke volume
- SVR, systemic vascular resistance
- TCD, transcranial Doppler
- TDCO, thermodilution principle
- TEE, transesophageal echocardiography
- TEG, thrombelastography
- cirrhosis
- coagulopathy
- intracranial pressure monitoring
- liver transplant
- mPAP, mean pulmonary artery pressure
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Affiliation(s)
- Shweta Singh
- Address for correspondence: Shweta Singh, Associate Professor, Dept. of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.
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Fagundes C, Ginès P. Hepatorenal syndrome: a severe, but treatable, cause of kidney failure in cirrhosis. Am J Kidney Dis 2012; 59:874-85. [PMID: 22480795 DOI: 10.1053/j.ajkd.2011.12.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/07/2011] [Indexed: 02/08/2023]
Abstract
Hepatorenal syndrome (HRS) is a unique type of kidney failure that occurs in advanced cirrhosis. It is characterized by functional impairment of the kidneys due to vasoconstriction of the renal arteries in the setting of preserved tubular function and absence of significant histologic abnormalities. Renal vasoconstriction in HRS is due to severe vasodilation of the splanchnic arteries associated with portal hypertension, leading to a decrease in effective arterial blood volume and arterial pressure. HRS commonly develops after a trigger, usually a bacterial infection, that disrupts the arterial circulation, but it also may occur spontaneously. There are 2 forms of HRS: type 1 is characterized by an acute progressive decrease in kidney function and very short survival without treatment, whereas type 2 features stable less severe kidney failure and longer survival compared with type 1. A liver transplant is the preferred treatment for HRS. Pharmacologic treatment with vasoconstrictors to reverse splanchnic vasodilation, together with albumin, is effective in 40%-50% of patients with type 1 HRS and improves survival. The drug of choice is the vasopressin analogue terlipressin. Renal replacement therapy should not be used as first-line therapy.
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Affiliation(s)
- Cláudia Fagundes
- Liver Unit, Hospital Clínic and University of Barcelona School of Medicine, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBERHED), Insituto Reina Sofia de Investigación Nefrológica (IRSIN), Barcelona, Catalunya, Spain
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Saugel B, Phillip V, Gaa J, Berger H, Lersch C, Schultheiss C, Thies P, Schneider H, Höllthaler J, Herrmann A, Schmid RM, Huber W. Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients--a prospective study. Radiology 2011; 262:343-52. [PMID: 22025732 DOI: 10.1148/radiol.11110043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To investigate immediate and short-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on cardiocirculatory, hepatic, and renal function and characterize predictors for TIPS outcome in terms of organ function after TIPS. MATERIALS AND METHODS This prospective study was approved by the ethics committee at a university hospital and was conducted in a medical intensive care unit. Informed consent was obtained. Twenty patients with indication for TIPS were enrolled. Monitoring of hemodynamic and hepatic function (transpulmonary thermodilution, indocyanine green plasma disappearance rate [ICG-PDR]) was performed. Biochemical markers of organ function were obtained. Statistical analysis (Wilcoxon test, Spearman correlation, multivariate linear regression analysis, receiver operating characteristic [ROC] analysis) was performed. RESULTS After TIPS, central venous pressure (median, 11 vs 15 cm H(2)O; P < .001), cardiac index (3.4 vs 3.8 L/min/m(2); P = .001), and global end-diastolic volume index (GEDVI) (726 vs 775 mL/m(2); P = .003) increased significantly. Portosystemic pressure gradient (28 vs 11 cm H(2)O; P < .001) and systemic vascular resistance index (1610 vs 1384 dyn · sec · cm(-5) · m(2); P = .015) decreased significantly. Creatinine (1.1 vs 1.1 mg/dL; P = .008) and blood urea nitrogen (BUN) (27 vs 21 mg/dL; P = .006) decreased significantly. Bilirubin (1.8 vs 2.2 mg/dL; P = .032) and international normalized ratio (1.4 vs 1.5; P = .022) increased significantly. ICG-PDR significantly deteriorated after TIPS (P = .006). Higher baseline creatinine was independently associated with a decrease in creatinine after TIPS (R = 0.816, P < .001). ROC analysis identified baseline BUN (P = .026, area under ROC curve [AUC] = 0.818), cystatin C (P = .033, AUC = 0.805), and creatinine (P = .052, AUC = 0.779) as predictors of a decrease in creatinine of 0.5 mg/dL or greater and/or 25% or greater. An increase in bilirubin of 1 mg/dL or greater 1 week after TIPS was significantly associated with high baseline BUN (P = .007, AUC = 0.893) and high central venous pressure (P = .040, AUC = 0.800). Lower baseline alanine aminotransferase (P = .002, AUC = 1.000) and cardiac power index · GEDVI (P = .005, AUC = 0.960) predicted favorable TIPS outcome (creatinine decrease of ≥ 0.2 mg/dL without model for end-stage liver disease score increase of more than one point). CONCLUSION Patients with renal insufficiency, compensated hepatocellular function, decreased cardiac preload, and decreased cardiac performance benefit most from TIPS.
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Affiliation(s)
- Bernd Saugel
- 2nd Medical Department, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, D-81675 Munich, Germany.
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Kalambokis G, Tsiouris S, Tsianos EV, Baltayiannis G, Pakou B, Fotopoulos A. Effects of terlipressin and somatostatin on liver and thorax blood volumes in patients with cirrhosis. Liver Int 2010; 30:1371-8. [PMID: 20738780 DOI: 10.1111/j.1478-3231.2010.02322.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Variceal bleeding in cirrhosis can cause liver ischaemia and deteriorate the hyperdynamic state; thus, the effects of vasoconstrictor therapy on liver blood volume (LBV) and thorax blood volume (ThBV) are important. AIM To evaluate and compare the effects of terlipressin and somatostatin on LBV and ThBV in stable patients with cirrhosis and portal hypertension. METHODS Twenty patients were studied (Child-Pugh class A/B/C: 5/8/7). The radioactivities in the liver region (LRR) and the thorax region (ThRR) by single-head gamma camera technique, as indicators of LBV and ThBV, respectively, and systemic haemodynamics were measured at baseline and after intravenous infusion of 2 mg of terlipressin (n=10) or somatostatin 250 mg/h after an initial bolus of 250 mg (n=10). RESULTS LRR and ThRR decreased significantly with increasing severity of cirrhosis. Thirty minutes after terlipressin infusion, LRR and ThRR increased by 7.8 ± 4.4% (NS) and 14 ± 5.3% (P=0.01) compared with baseline values; the increase in ThRR was significantly related to the increase in LRR (r=0.682, P=0.03). In contrast, somatostatin reduced LRR and ThRR by 13.3 ± 6.5% (P=0.07) and 1 ± 4% (NS) respectively. LRR and ThRR increased significantly in the terlipressin group compared with the somatostatin group (P=0.01 and P=0.02 respectively). Terlipressin reduced cardiac output and heart rate (both P=0.01) and increased the mean arterial pressure (MAP) and systemic vascular resistance (P=0.009 and P=0.002 respectively); MAP decreased after somatostatin infusion (P=0.03). CONCLUSIONS Terlipressin, but not somatostatin, maintains LBV, increases ThBV and improves the hyperdynamic state in cirrhosis. These effects can be beneficial in variceal bleeding, particularly in patients with advanced liver disease.
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Affiliation(s)
- George Kalambokis
- 1st Division of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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Sainz-Barriga M, Reyntjens K, Costa MG, Scudeller L, Rogiers X, Wouters P, de Hemptinne B, Troisi RI. Prospective evaluation of intraoperative hemodynamics in liver transplantation with whole, partial and DCD grafts. Am J Transplant 2010; 10:1850-60. [PMID: 20659091 DOI: 10.1111/j.1600-6143.2010.03207.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.
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Affiliation(s)
- M Sainz-Barriga
- Department of General & Hepatobiliary Surgery, Ghent University Hospital and Medical School, Belgium
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Abstract
PURPOSE OF REVIEW This review aims to identify specific criteria for cirrhotic cardiomyopathy, examine the correlation with perioperative adverse outcomes and explore options for hemodynamic monitoring. RECENT FINDINGS Cirrhotic cardiomyopathy is characterized by an increase in cardiac output, blunted systolic contractile response to stress, diastolic dysfunction and electrophysiological abnormalities. Adverse events due to cirrhotic cardiomyopathy are not as well characterized, but evidence suggests that some cardiovascular complications during surgery and in the postoperative period are caused by an impaired response to physiological stress. New developments in hemodynamic monitoring using not only thermodilution technology provide more reliable information about cardiac performance than pressure-derived measures. Transesophogeal echocardiography also offers the physician new information including the ability to visualize heart structures, shape, and function. SUMMARY To detect cirrhotic cardiomyopathy, physicians must conduct a systematic examination of the patient. Overt manifestations of cirrhotic cardiomyopathy often only become evident after a patient is exposed to physiological or drug-induced stress. Appropriate hemodynamic monitoring is a cornerstone in the perioperative management of cirrhotic patients.
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Abstract
PURPOSE OF REVIEW Patients with cirrhosis have total extracellular fluid overload but central effective circulating hypovolaemia. The resulting neurohumoral compensatory response favours the accumulation of fluids into the peritoneal cavity (ascites) and may hinder renal perfusion (hepatorenal syndrome). Their deranged systemic haemodynamics (hyperdynamic circulatory syndrome) is characterized by elevated cardiac output with decreased systemic vascular resistance and low blood pressure. RECENT FINDINGS Molecular and biological mechanisms determining cirrhosis-induced haemodynamic alterations are progressively being elucidated. The need for a goal-directed assessment of volume resuscitation (especially with volumetric techniques) in patients with cirrhosis is becoming more and more evident. The role of fluid expansion with albumin and the use of splanchnic vasopressors in a variety of cirrhosis-related conditions has recently been investigated. SUMMARY The response to fluid loading in patients with advanced cirrhosis is abnormal, primarily resulting in expansion of their noncentral blood volume compartment. Colloid solutions, in particular albumin, are best used in these patients. Albumin may be effective in preventing the haemodynamic derangements associated with large-volume paracentesis (paracentesis-induced circulatory dysfunction), in preventing renal failure during spontaneous bacterial peritonitis and, in association with splanchnic vasopressors, in caring for patients with the hepatorenal syndrome.
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Genovesi S, Prata Pizzala DM, Pozzi M, Ratti L, Milanese M, Vincenti A, Stella A, Mancia G. Baroreceptor sensitivity and baroreceptor effectiveness index in cirrhosis: the relevance of hepatic venous pressure gradient. Liver Int 2010; 30:232-9. [PMID: 19793198 DOI: 10.1111/j.1478-3231.2009.02125.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Autonomic dysfunction has been reported as one of the complications of cirrhosis. AIMS The aim of this study was to test autonomic dysfunction in cirrhotic patients by analysing the baroreflex sensitivity and the baroreceptor effectiveness index (BEI), in order to determine its correlation with the severity and the aetiology of liver disease. Moreover, we explored the relationship between baroreceptor function and mortality in our cohort of patients. METHODS Clinical and laboratory evaluation, hepatic venous pressure gradient (HVPG) and haemodynamic setting and baroreceptor function were assessed in 45 cirrhotic patients (median age 55, range 38-72 years) divided in groups according to the severity of their disease (26 patients Child A, 13 patients Child B and six patients Child C). RESULTS Baroreceptor sensitivity and BEI were impaired in more advanced cirrhotic patients compared with subjects with milder disease (P<0.001). HVPG was significantly, independently and inversely correlated with baroreceptor sensitivity (P=0.003). More severe impairment of baroreceptor function was associated with a higher mortality (P=0.04) and subjects with alcohol-related cirrhosis presented worse baroreceptor function (P=0.032) and poorer survival (P=0.003) compared with subjects with post-viral liver disease. CONCLUSIONS These data support the hypothesis that liver disease severity and particularly portal hypertension have an important role in the derangement of baroreceptor function. The aetiology of cirrhosis seems to be related to baroreceptor impairment as well. Mortality rate is higher in subjects with a more damaged autonomic system, strengthening the idea of a worse prognosis in cirrhotic patients with autonomic neuropathy.
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Affiliation(s)
- Simonetta Genovesi
- Department of Clinical Medicine and Prevention, University of Milano-Bicocca, Monza, Italy.
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Narahara Y, Kanazawa H, Taki Y, Kimura Y, Atsukawa M, Katakura T, Kidokoro H, Harimoto H, Fukuda T, Matsushita Y, Nakatsuka K, Sakamoto C. Effects of terlipressin on systemic, hepatic and renal hemodynamics in patients with cirrhosis. J Gastroenterol Hepatol 2009; 24:1791-7. [PMID: 19686420 DOI: 10.1111/j.1440-1746.2009.05873.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Terlipressin has been shown to be effective in the management of hepatorenal syndrome. However, how terlipressin exerts its effect on the renal artery is unknown. The aim of the present study was to assess the effects of terlipressin on systemic, hepatic and renal hemodynamics in cirrhosis. METHODS Twenty-eight patients with cirrhosis and portal hypertension were studied. Systemic and hepatic hemodynamics, hepatic and renal arterial resistive indices and neurohumoral factors were measured prior to and 30 min after intravenous administration of 1 mg terlipressin (n = 19) or placebo (n = 9). RESULTS After terlipressin, there were significant increases in both mean arterial pressure (P < 0.001) and systemic vascular resistance (P < 0.001), whereas heart rate (P < 0.001) and cardiac output (P < 0.001) decreased significantly. There was a significant decrease in the hepatic venous pressure gradient (P < 0.001). Portal venous blood flow also decreased significantly (P < 0.001). The mean hepatic arterial velocity increased significantly (P < 0.001). Although there was a significant decrease in the hepatic arterial resistive index (0.72 +/- 0.08 to 0.69 +/- 0.08, P < 0.001) and renal arterial resistive index (0.74 +/- 0.07 to 0.68 +/- 0.07, P < 0.001), portal vascular resistance was unchanged (P = 0.231). Plasma renin activity decreased significantly (P < 0.005), and there was a significant correlation between this decline and the decrease in renal arterial resistive index (r = 0.764, P < 0.005). The effects of terlipressin on systemic, hepatic and renal hemodynamics were observed similarly in patients with and without ascites. Placebo caused no significant effects. CONCLUSION Terlipressin decreases hepatic and renal arterial resistance in patients with cirrhosis.
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Affiliation(s)
- Yoshiyuki Narahara
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School, Tokyo, Japan.
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Garcovich M, Zocco MA, Gasbarrini A. Clinical use of albumin in hepatology. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:268-77. [PMID: 20011638 PMCID: PMC2782804 DOI: 10.2450/2008.0080-08] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Matteo Garcovich
- Dipertimento di Medicina Interna, Ospedale Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Maria Assunta Zocco
- Dipertimento di Medicina Interna, Ospedale Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Dipertimento di Medicina Interna, Ospedale Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
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Intraoperative hemodynamic monitoring during organ transplantation: what is new? Curr Opin Organ Transplant 2009; 14:291-6. [PMID: 19448537 DOI: 10.1097/mot.0b013e32832d927d] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To highlight the recent developments in hemodynamic monitoring during liver and lung transplantation. RECENT FINDINGS Even though a consensus on intraoperative hemodynamic monitoring is still lacking, the most frequently monitoring tool used is the pulmonary artery catheter (PAC). The filling pressures are widely accepted as not being able to accurately define cardiac preload. On the contrary, the use of transesophageal echocardiography (TEE), although it is operator dependent and requires a prolonged training, is increasing during the intraoperative period to directly evaluate the cardiovascular function. New frontiers have been opened by the transpulmonary thermodilution: intrathoracic blood volume has been shown to have a better correlation with preload than the filling pressures. The advanced modified PAC permits evaluation of the right heart function and preload. Recently, right ventricular end diastolic volume has been shown to correlate better with preload than the filling pressures and also the left ventricular end diastolic area. SUMMARY The PAC still represents the most used intraoperative hemodynamic monitoring technique. TEE is increasing in popularity. Recent studies demonstrate that volumetric monitoring conducted with transpulmonary thermodilution and advanced volumetric PAC give good definition of preload and should be implemented in clinical practice.
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Umgelter A, Wagner K, Reindl W, Nurtsch N, Huber W, Schmid RM. Haemodynamic effects of plasma-expansion with hyperoncotic albumin in cirrhotic patients with renal failure: a prospective interventional study. BMC Gastroenterol 2008; 8:39. [PMID: 18752670 PMCID: PMC2556671 DOI: 10.1186/1471-230x-8-39] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 08/27/2008] [Indexed: 12/14/2022] Open
Abstract
Background Patients with advanced cirrhosis of the liver typically display circulatory disturbance. Haemodynamic management may be critical for avoiding and treating functional renal failure in such patients. This study investigated the effects of plasma expansion with hyperoncotic albumin solution and the role of static haemodynamic parameters in predicting volume responsiveness in patients with advanced cirrhosis. Methods Patients with advanced cirrhosis (Child B and C) of the liver receiving albumin substitution because of renal compromise were studied using trans-pulmonary thermodilution. Paired measurements before and after two infusions of 200 ml of 20% albumin per patient were recorded and standard haemodynamic parameters such as central venous pressure (CVP), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), cardiac index (CI) and derived variables were assessed, including global end-diastolic blood volume index (GEDVI), a parameter that reflects central blood volume Results 100 measurements in 50 patients (33 m/17 w; age 56 years (± 8); Child-Pugh-score 12 (± 2), serum creatinine 256 μmol (± 150) were analyzed. Baseline values suggested decreased central blood volumes GEDVI = 675 ml/m2 (± 138) despite CVP within the normal range (11 mmHg (± 5). After infusion, GEDVI, CI and CVP increased (682 ml/m2 (± 128) vs. 744 ml/m2 (± 171), p < 0.001; 4.3 L/min/m2 (± 1.1) vs. 4.7 L/min/m2 (± 1.1), p < 0.001; 12 mmHg (± 6) vs. 14 mmHg (± 6), p < 0.001 respectively) and systemic vascular resistance decreased (1760 dyn s/cm5/m2 (± 1144) vs. 1490 dyn s/cm5/m2 (± 837); p < 0.001). Changes in GEDVI, but not CVP, correlated with changes in CI (r2 = 0.51; p < 0.001). To assess the value of static haemodynamic parameters at baseline in predicting an increase in CI of 10%, receiver-operating-characteristic curves were constructed. The areas under the curve were 0.766 (p < 0.001) for SVRI, 0.723 (p < 0.001) for CI, 0.652 (p = 0.010) for CVP and 0.616 (p = 0.050) for GEDVI. Conclusion In a substantial proportion of patients with advanced cirrhosis, plasma expansion results in an increase in central blood volume. GEDVI but not CVP behaves as an indicator of cardiac preload, whereas high baseline SVRI is predictive of fluid responsiveness.
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Affiliation(s)
- Andreas Umgelter
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, D-81675 München, Germany.
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Vasopressin analogues in the treatment of hepatorenal syndrome and gastrointestinal haemorrhage. Best Pract Res Clin Anaesthesiol 2008; 22:335-50. [DOI: 10.1016/j.bpa.2008.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Della Rocca G, Costa MG, Chiarandini P, Bertossi G, Lugano M, Pompei L, Coccia C, Sainz-Barriga M, Pietropaoli P. Arterial pulse cardiac output agreement with thermodilution in patients in hyperdynamic conditions. J Cardiothorac Vasc Anesth 2008; 22:681-7. [PMID: 18922423 DOI: 10.1053/j.jvca.2008.02.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare continuous cardiac output (CCO) obtained using the arterial pulse wave (APCO) measurement with a simultaneous measurement of the intermittent cardiac output (ICO) and CCO obtained with a pulmonary artery catheter (PAC) in liver transplant patients. DESIGN A prospective, single-center evaluation. SETTING A university hospital intensive care unit. PATIENTS Eighteen patients after liver transplantation. INTERVENTIONS Pulmonary artery catheters were placed in all patients, and ICO and CCO were determined using thermodilution. APCO measurements were made with the Vigileo System (Edwards Lifesciences, Irvine, CA). MEASUREMENTS AND MAIN RESULTS The authors obtained 126 data pairs of ICO and APCO and 864 pairs of CCO and APCO. ICO data were collected after intensive care unit admission and every 8 hours until the 48th postoperative hour. CCO and APCO data were collected every hour from admission until the 48th postoperative hour. Bias and precision were 0.95 +/- 1.41 L/min for ICO versus APCO and 1.29 +/- 1.28 L/min for CCO and APCO. Bias and precision for cardiac output (CO) data pairs less than 8 L/min were 0.32 +/- 1.14 L/min between ICO and APCO and 0.71 +/- 0.98 L/min between CCO and APCO. For CO data pairs higher than 8 L/min, bias and precision were 1.79 +/- 1.54 L/min between ICO and APCO and 2.25 +/- 1.14 L/min between CCO and APCO. CONCLUSIONS APCO enables the assessment of CO with clinically acceptable bias and precision. At higher CO levels, APCO underestimates PAC measurements and it is not as reliable as thermodilution in hyperdynamic liver transplant patients.
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Affiliation(s)
- Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University of Udine, Udine, Italy
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ICU Management of the Liver Transplant Patient. Intensive Care Med 2008. [DOI: 10.1007/978-0-387-77383-4_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Saner FH, Canbay A, Gerken G, Broelsch CE. Pharmacology, clinical efficacy and safety of terlipressin in esophageal varices bleeding, septic shock and hepatorenal syndrome. Expert Rev Gastroenterol Hepatol 2007; 1:207-17. [PMID: 19072411 DOI: 10.1586/17474124.1.2.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Terlipressin, a vasopressin agonist, is a commonly used drug with different indications, particularly in patients with end-stage liver disease. As a V(1) receptor agonist, it increases systemic vascular resistance, particularly in the splanchnic area, resulting in a decrease of portal pressure. Besides the approved use for variceal bleeding, terlipressin also has beneficial effects in the treatment of hepatorenal syndrome and norepinephrine-resistant septic shock. In patients with cirrhosis and variceal bleeding, the use of terlipressin reduces the portal vein pressure and decreases the pressure in esophageal varices. This can save lives when skilled endoscopists are not immediately available. Hepatorenal syndrome is associated with vasodilation in the mesenteric circulation with arterial underfilling and consecutive renal vasoconstriction. Restoration of an effective arterial blood volume can be achieved by the combination of terlipressin and volume expansion. In some cases, a success rate of up to 75% is reported. The early use of terlipressin in catecholamine-resistant shock can improve organ perfusion.
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Affiliation(s)
- Fuat H Saner
- University Essen, Department of General, Visceral and Transplant Surgery, Hufelandstr. 55, 45122 Essen, Germany.
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Donati G, Piscaglia F, Colì L, Silvagni E, Righini R, Donati G, Pini P, Stefoni S, Bolondi L. Acute systemic, splanchnic and renal haemodynamic changes induced by molecular adsorbent recirculating system (MARS) treatment in patients with end-stage cirrhosis. Aliment Pharmacol Ther 2007; 26:717-26. [PMID: 17697205 DOI: 10.1111/j.1365-2036.2007.03420.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM To evaluate the acute effect of treatment with the molecular adsorbent recirculating system (MARS) on splanchnic, renal and systemic haemodynamics in patients with end-stage cirrhosis. METHODS Twelve patients with end-stage cirrhosis, undergoing MARS treatment, were enrolled. The following haemodynamic parameters were measured by means of Doppler ultrasonography and thoracic electrical bioimpedance, before and after each session: portal velocity, renal and splenic resistance indices, cardiac output, cardiac stroke volume, heart rate, mean arterial pressure, systemic vascular resistance. RESULTS Median portal velocity increased significantly after treatment (23.7 vs. 20.3 cm/s, P < 0.05) while renal resistance index (0.72 vs. 0.75, P < 0.05) and splenic resistance index (0.60 vs. 0.65, P < 0.05) decreased significantly. Mean arterial pressure (83 vs. 81 mmHg, P < 0.05) and vascular resistance (899 vs. 749 dyne. s/cm5, P < 0.05) increased significantly, while cardiac output and stroke volume showed no significant changes. CONCLUSIONS Data emerging from this investigation suggest that MARS treatment improves significantly various haemodynamic alterations in cirrhotic patients in the short term. The observed decrease in renal vascular resistance and improvement in splenic resistance index, a parameter related to portal resistance, which leads us to hypothesize that these haemodynamic effects are probably mediated by clearance of vasoactive substances during MARS treatment.
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Affiliation(s)
- G Donati
- Division of Internal Medicine, Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy
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Abstract
Assessing the optimal volemia in the perioperative course of liver transplantation is a challenge for the anesthesiologist. Traditional estimates of intravascular volume status, such as pulmonary artery occlusion pressure (PAOP), have been widely shown to poorly correlate with changes in cardiac output among critically ill patients. Hence, there has been recent interest in alternative, catheter-related, bedside device volume estimates using thermodilution. Continuous end diastolic volume (CEDVI) showed better correlations with cardiac performance than cardiac filling pressures in studies performed in critically ill patients. When compared with conventional pressure-derived data, preload monitoring estimated as intrathoracic blood volume index (ITBVI) with the PiCCO system based on an integrated transpulmonary thermodilution technique better reflected left ventricular filling both in critically ill patients and those who underwent liver transplantation. Moreover, in liver transplantation, the use of transoesophageal echocardiography (TEE) has been increasing for it provides rapid visualization of the dimension and function of heart chambers as well as the left ventricular end diastolic area index (EDAI) that seem to correlate with graded acute hypovolemia, although its validity as on preload index is still under discussion.
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Affiliation(s)
- M G Costa
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliera Universitaria, University of Udine, Udine, Italy.
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Møller S, Krag A, Henriksen JH, Bendtsen F. Pathophysiological aspects of pulmonary complications of cirrhosis. Scand J Gastroenterol 2007; 42:419-27. [PMID: 17454850 DOI: 10.1080/00365520601151695] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Søren Møller
- Department of Clinical Physiology 239, Hvidovre Hospital, DK-2650 Hvidovre, Denmark.
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Sharma P, Kumar A, Mehta V, Sharma BC, Sarin SK. Systemic and pulmonary hemodynamics in patients with non-cirrhotic portal fibrosis (NCPF) is similar to compensated cirrhosis. Hepatol Int 2007; 1:275-80. [PMID: 19669349 PMCID: PMC2720720 DOI: 10.1007/s12072-007-5006-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Non-cirrhotic portal fibrosis (NCPF) is an important cause of portal hypertension (PHT) and variceal bleeding, especially in the developing countries. While the hepatic parenchyma and liver functions are normal, the patho-anatomic defect in these patients is pre- and peri-sinusoidal in nature. AIM To study the systemic and pulmonary hemodynamic alterations in patients with NCPF and compare them with compensated cirrhotic patients. PATIENTS AND METHODS Patients with NCPF (n = 20, mean age 29.3 +/- 9.8 year) and matched Child's A cirrhotic patients (n = 17, age 34.1 +/- 9.8 year) who had bled in the past, underwent hemodynamic measurements using a balloon tipped catheter. RESULTS In NCPF patients, the hepatic venous pressure gradient (HVPG) was significantly lower than in the cirrhotic patients (4.9 +/- 1.5 mmHg vs. 15.7 +/- 4.5 mmHg; P < 0.01). NCPF patients had hyperdynamic circulation and peripheral vasodilatation comparable to cirrhotic patients; cardiac output (8.0 +/- 1.2 l/min vs. 8.4 +/- 1.9 l/min; P = 0.4), cardiac index (5.4 +/- 0.8 l/min/m(2) vs. 5.5 +/- 1.9 l/min/m(2); P = 0.86), mean arterial pressure (88.2 +/- 14.1 mmHg vs. 89.9 +/- 17.3 mmHg; P = 0.73), systemic vascular resistance (852.8 +/- 204.3 dynes . s/cm(5) vs. 854.1 +/- 189.9 dynes . s/cm(5); P = 0.98) and pulmonary vascular resistance (41.6 +/- 18.1 dynes . s/cm(5) vs. 41.3 +/- 17.9 dynes . s/cm(5); P = 0.95) were comparable in the two groups. CONCLUSIONS NCPF associated portal hypertension leads to a hyperdynamic state with high cardiac index and low systemic and pulmonary vascular resistance comparable to compensated cirrhosis. These novel observations suggest a primary role of portal hypertension in the development of hyperdynamic state.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Ashish Kumar
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Vimal Mehta
- Department of Cardiology, G. B. Pant Hospital, New Delhi, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Shiv Kumar Sarin
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
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44
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Andreu V, Garcia-Pagan JC, Lionetti R, Piera C, Abraldes JG, Bosch J. Effects of propranolol on venous compliance in conscious rats with pre-hepatic portal hypertension. J Hepatol 2006; 44:1040-5. [PMID: 16581151 DOI: 10.1016/j.jhep.2005.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Revised: 10/03/2005] [Accepted: 10/24/2005] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIMS The venous system is the primary capacitance region in the body. However, the influence of active changes in the venous system on the hemodynamic alterations of portal hypertension is poorly understood. To investigate venous compliance (VC) in conscious partial portal vein ligated rats (PPVL) and the effect of propranolol on VC. METHODS Venous compliance was derived from the relationship between changes in mean circulatory filling pressure (MCFP) and changes in blood volume (BV). Measurements were performed before and after i.v. propranolol (7.5 mg/Kg) or placebo in rats with portal hypertension due to PPVL and sham operated controls. RESULTS PPVL rats had an increased VC when compared to Sham (4.9+/-1.4 vs. 3.7+/-0.9 ml kg-1 mm Hg-1; P<0.02). VC did not change after placebo but was significantly reduced by Propranolol in PPVL (-32.9+/-15.7%; P<0,007). Propranolol did not modify venous compliance in sham operated rats (+10.9+/-13.4%; P=ns). CONCLUSIONS Venous compliance is increased in portal hypertensive rats, suggesting that the venous system contributes to the profound circulatory changes encountered in portal hypertension. The increased venous compliance is markedly attenuated by propranolol, suggesting that this abnormality is related to increased adrenergic activity.
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Affiliation(s)
- Victoria Andreu
- Hepatic Hemodynamic Lab., Liver Unit, Institut Clínic de Malalties Digestives i Metabolisme, Hospital Clínic de Barcelona, Institut de Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Møller S, Bendtsen F, Henriksen JH. Determinants of the renin-angiotensin-aldosterone system in cirrhosis with special emphasis on the central blood volume. Scand J Gastroenterol 2006; 41:451-8. [PMID: 16635914 DOI: 10.1080/00365520500292962] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Several studies have shown activation of the renin-angiotensin-aldosterone system (RAAS) in cirrhosis. Although the activated RAAS may have several determinants, the system is often considered a surrogate marker of effective hypovolaemia. In this study we investigated the activity of the RAAS and its potential determinants with special focus on the central and arterial blood volume (CBV). MATERIAL AND METHODS Eighty-nine patients (Child class A/B/C: 19/41/29) and 32 controls were included in the study. All were given a haemodynamic examination with measurement of determinants of the RAAS, including the CBV. Circulating plasma renin concentrations were measured using an immunoradiometric assay. RESULTS Arterial renin concentrations were significantly higher in the patients than in the controls (p < 0.003). Plasma renin correlated significantly with several indicators of liver dysfunction and splanchnic and systemic haemodynamics (r = - 0.56-0.55), but only weakly with CBV (r = - 0.25, p < 0.02). In a multivariate regression analysis, plasma renin was determined by serum sodium, alkaline phosphatases and systolic blood pressure (p < 0.04 to p < 0.001). CONCLUSIONS CBV correlates weakly with circulating renin, and activation of the RAAS can therefore only partly be considered as an indicator of central hypovolaemia. Mechanisms other than central hypovolaemia relating to the liver disease and portal hypertension contribute significantly to the RAAS activation.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology, University of Copenhagen, Denmark.
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46
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Abstract
Characteristic findings in patients with cirrhosis are vasodilatation with low overall systemic vascular resistance, high arterial compliance, increased cardiac output, secondary activation of counter-regulatory systems (renin-angiotensin-aldosterone system, sympathetic nervous system, release of vasopressin), and resistance to vasopressors. The vasodilatory state is mediated through adrenomedullin, calcitonin gene-related peptide, nitric oxide, and other vasodilators, and is most pronounced in the splanchnic area. This constitutes an effective (although relative) counterbalance to increased arterial blood pressure. This review considers the alterations in systemic hemodynamics in patients with cirrhosis in relation to essential hypertension and arterial hypertension of the renal origin. Subjects with arterial hypertension (essential, secondary) may become normotensive during the development of cirrhosis, and arterial hypertension is rarely manifested in patients with cirrhosis, even in cases with renovascular disease and high circulating renin activity. There is much dispute as to the understanding of homoeostatic regulation in cirrhotic patients with manifest arterial hypertension. This most likely includes the combination of vasodilatation and vasoconstriction in parallel.
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Affiliation(s)
- Jens H Henriksen
- Department of Clinical Physiology, 239 Hvidovre University Hospital, DK-2650 Hvidovre, Denmark.
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Abstract
Patients with cirrhosis and portal hypertension exhibit characteristic cardiovascular and pulmonary hemodynamic changes. A vasodilatatory state and a hyperdynamic circulation affecting the cardiac and pulmonary functions dominate the circulation. The recently defined cirrhotic cardiomyopathy may affect systolic and diastolic functions, and imply electromechanical abnormalities. In addition, the baroreceptor function and regulation of the circulatory homoeostasis is impaired. Pulmonary dysfunction involves diffusing abnormalities with the development of the hepatopulmonary syndrome and portopulmonary hypertension in some patients. Recent research has focused on the assertion that the hemodynamic and neurohumoral dysregulation are of major importance for the development of the cardiovascular and pulmonary complications in cirrhosis. This aspect is important to take into account in the management of these patients.
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Rosner MH, Gupta R, Ellison D, Okusa MD. Management of cirrhotic ascites: physiological basis of diuretic action. Eur J Intern Med 2006; 17:8-19. [PMID: 16378879 DOI: 10.1016/j.ejim.2005.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Revised: 07/24/2005] [Accepted: 08/25/2005] [Indexed: 11/16/2022]
Abstract
Ascites is a significant complication of cirrhosis that occurs in approximately 50% of patients. The mortality rate is high in patients with cirrhosis and ascites. Conventional interventions rest with dietary sodium restriction, diuretic use, large-volume paracentesis, peritoneovenous shunts and transjugular intrahepatic portosystemic shunts. The mainstay of therapy, however, is the judicious use of diuretics. This article reviews the physiological basis of diuretic use in patients with cirrhosis and ascites, as well as recent concepts on the pathogenesis of ascites formation. Through a better understanding of the pathophysiology of ascites formation and the mechanism of action of diuretics, improved extracellular fluid balance can be achieved in these patients.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, Box 133 Health Science Center, Charlottesville, VA 22908-0001, USA.
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Bartoli E. Pathophysiology of Na and water retention in liver cirrhosis and its correction with vasoconstrictors and aquaretics. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.16.1.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ytting H, Henriksen JH, Fuglsang S, Bendtsen F, Møller S. Prolonged Q-T(c) interval in mild portal hypertensive cirrhosis. J Hepatol 2005; 43:637-44. [PMID: 16083986 DOI: 10.1016/j.jhep.2005.04.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Revised: 04/12/2005] [Accepted: 04/16/2005] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIMS The Q-T(c) interval is prolonged in a substantial fraction of patients with cirrhosis, thus indicating delayed repolarisation. However, no information is available in mild portal hypertensive patients. We therefore determined the Q-T(c) interval in cirrhotic patients with hepatic venous pressure gradient (HVPG) < 12 mmHg. METHODS Forty-four patients with cirrhosis and HVPG < 12 mmHg underwent a haemodynamic study. They were compared with 36 cirrhotic patients with clinically significant portal hypertension (HVPG> or = 12 mmHg) and controls without liver disease. RESULTS The fraction with prolonged Q-T(c) interval (> 0.440 s(1/2)) was similar in the two cirrhotic groups (49 vs 50%, ns) and significantly above that of the controls (5%, P < 0.005). Q-T(c) was normal in patients with normal HVPG. Likewise, mean Q-T(c) was 0.449 and 0.447 s(1/2) in the two cirrhotic groups (ns), values which are significantly above that of the controls (0.410 s(1/2), P < 0.01). In the mild portal hypertensive group, the Q-T(c) interval was inversely related to indicators of liver function, such as indocyanine green clearance (r = -0.34, P < 0.02). CONCLUSIONS Delayed repolarisation of the myocardium already occurs in a substantial fraction of patients with cirrhosis with only a mild increase in portal pressure. The prolonged Q-T(c) interval may be related to liver dysfunction and to the presence of portal hypertension.
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Affiliation(s)
- Henriette Ytting
- Department of Clinical Physiology and Nuclear Medicine 239, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark
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