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Remillard TC, Cronley AC, Pilch NA, Dubay DA, Willner IR, Houston BA, Jackson GR, Inampudi C, Ramu B, Kilic A, Fudim M, Wright SP, Hajj ME, Tedford RJ. Hemodynamic and Clinical Determinants of Left Atrial Enlargement in Liver Transplant Candidates. Am J Cardiol 2022; 172:121-129. [PMID: 35341576 DOI: 10.1016/j.amjcard.2022.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/03/2022] [Accepted: 02/08/2022] [Indexed: 11/26/2022]
Abstract
New-onset heart failure is a frequent complication after orthotopic liver transplantation (OLT). Left atrial enlargement (LAE) may be a sign of occult left heart disease. Our primary objective was to determine invasive hemodynamic and clinical predictors of LAE and then investigate its effect on post-transplant outcomes. Of 609 subjects who received OLT between January 1, 2010, and October 1, 2018, 145 who underwent preoperative right-sided cardiac catheterization and transthoracic echocardiography were included. Seventy-eight subjects (54%) had pretransplant LAE. Those with LAE had significantly lower systemic vascular resistance with higher cardiac and stroke volume index (61.0 vs 51.7 ml/m2; p <0.001), but there was no difference in pulmonary artery wedge pressure. There was a linear relation between left atrial volume index and stroke volume index (R2 = 0.490, p<0.001), but not pulmonary artery wedge pressure. The presence of severe LAE was associated with a reduced likelihood (hazard ratio = 0.26, p = 0.033) of reaching the composite end point of new-onset systolic heart failure, heart failure hospitalization, or heart failure death within 12 months post-transplant. There was also a significant reduction in LAE after transplantation (p = 0.013). In conclusion, LAE was common in OLT recipients and was more closely associated with stroke volume than left heart filling pressures. The presence of LAE was associated with a reduced likelihood of reaching composite outcomes and tended to regress after transplant.
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Salah HM, Pandey A, Soloveva A, Abdelmalek MF, Diehl AM, Moylan CA, Wegermann K, Rao VN, Hernandez AF, Tedford RJ, Parikh KS, Mentz RJ, McGarrah RW, Fudim M. Relationship of Nonalcoholic Fatty Liver Disease and Heart Failure With Preserved Ejection Fraction. JACC Basic Transl Sci 2021; 6:918-932. [PMID: 34869957 PMCID: PMC8617573 DOI: 10.1016/j.jacbts.2021.07.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022]
Abstract
Although there is an established bidirectional relationship between heart failure with reduced ejection fraction and liver disease, the association between heart failure with preserved ejection fraction (HFpEF) and liver diseases, such as nonalcoholic fatty liver disease (NAFLD), has not been well explored. In this paper, the authors provide an in-depth review of the relationship between HFpEF and NAFLD and propose 3 NAFLD-related HFpEF phenotypes (obstructive HFpEF, metabolic HFpEF, and advanced liver fibrosis HFpEF). The authors also discuss diagnostic challenges related to the concurrent presence of NAFLD and HFpEF and offer several treatment options for NAFLD-related HFpEF phenotypes. The authors propose that NAFLD-related HFpEF should be recognized as a distinct HFpEF phenotype.
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Key Words
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- AV, arteriovenous
- BCAA, branched-chain amino acid
- GLP, glucagon-like peptide
- HF, heart failure
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- IL, interleukin
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- NAFLD
- NAFLD, nonalcoholic fatty liver disease
- NASH, nonalcoholic steatohepatitis
- NT-proBNP, N terminal pro–B-type natriuretic peptide
- RAAS, renin-angiotensin aldosterone system
- SGLT2, sodium-glucose cotransporter 2
- SPSS, spontaneous portosystemic shunt(s)
- TNF, tumor necrosis factor
- cardiomyopathy
- heart failure
- liver
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Affiliation(s)
- Husam M. Salah
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Anzhela Soloveva
- Department of Cardiology, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Manal F. Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Anna Mae Diehl
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Cynthia A. Moylan
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Kara Wegermann
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Vishal N. Rao
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adrian F. Hernandez
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kishan S. Parikh
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert W. McGarrah
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Toshima T, Shirabe K, Yoshiya S, Muto J, Ikegami T, Yoshizumi T, Maehara Y. Outcome of hepatectomy for hepatocellular carcinoma in patients with renal dysfunction. HPB (Oxford) 2012; 14:317-24. [PMID: 22487069 PMCID: PMC3384851 DOI: 10.1111/j.1477-2574.2012.00452.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There are few reports on the efficacy of hepatectomy for hepatocellular carcinoma (HCC) in patients with renal dysfunction (RD). This study aimed to clarify the validity of hepatectomy for treating HCC in RD patients, and to compare postoperative courses in RD and non-RD patients. METHODS The clinical features of 722 HCC patients who underwent curative hepatectomy between 1986 and 2009 were retrospectively reviewed. Seventeen patients (2.4%) with preoperative serum creatinine levels of >2.0 mg/dl were defined as the RD group, and, of these, seven who did not receive preoperative haemodialysis were defined as borderline patients. Clinicopathological characteristics and postoperative outcomes were compared between the RD group (n= 17) and the non-RD group (n= 705). The postoperative courses of borderline patients were reviewed in detail. RESULTS Overall survival (P= 0.177) and disease-free survival (P= 0.942) after hepatectomy did not differ significantly between the groups. Incidences of massive ascites (35.3% vs. 14.3%; P= 0.034) and pleural effusion (52.9% vs. 17.6%; P= 0.001), defined as massive effusion (ME), were significantly higher in the RD group than in the non-RD group. Hypoalbuminaemia (≤2.8 g/dl; P= 0.031), heavy blood loss (≥1000 ml; P= 0.012) and intraoperative blood transfusion (P= 0.007) were risk factors for ME. Among the borderline patients, serum creatinine values were not increased immediately after surgery and four patients underwent haemodialysis. CONCLUSIONS Preoperative hypoalbuminaemia, heavy blood loss and blood transfusion are independent risk factors for ME in RD patients. Preoperative improvement of anaemia and reduction of blood loss by meticulous surgical techniques may prevent ME in RD patients who require hepatectomy for HCC.
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Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
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Nasr G, Hassan A, Ahmed S, Serwah A. Predictors of large volume paracantesis induced circulatory dysfunction in patients with massive hepatic ascites. J Cardiovasc Dis Res 2011; 1:136-44. [PMID: 21187868 PMCID: PMC2982202 DOI: 10.4103/0975-3583.70914] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE In patients with massive ascites, large volume paracentesis may be associated with complications as circulatory dysfunction. Selection of appropriate patients might reduce such side effects. PATIENTS AND METHODS Forty-five patients known to have liver cirrhosis and presenting with massive ascites were included. There were 27 males and 18 females, with age (mean 51.2+10.64). All patients were subjected to full history, clinical examination, complete blood picture, prothrombin time, serum albumin, total plasma protein, serum bilirubin, serum creatinine, serum electrolytes and plasma renin activity measured by radioimmunoassay. Echocardiographic evaluation for cardiac output, pulmonary artery pressure, diastolic and systolic function before and after paracentesis. Large-volume paracentesis (LVP) ranging 8-18 liters with a mean 9.9 L was performed to all patients. Paracentesis induced circulatory dysfunction (PICD) was defined as increase in plasma renin activity (PRA) of more than 50% of pretreatment value to a level greater than 7.5ng /ml/ hour on the 6th day after paracentesis. RESULTS The incidence of PICD in patients with massive hepatic ascites was 73.3% (87.5% with Dextran and 38.5% with albumin). There were no serious systemic or local side effects one week following LVP. Type of plasma expander and younger ages were the only independent predictors (odd ratio OR with 95% confidence interval CI, 3.01<21.79<157.58 and 0.80<.88<.97 respectively) Gender and other clinical and laboratory parameters had no influence. Neither electrolytes levels nor hematocrite value had an influence. Ascitic patients showed higher heart rate and cardiac output and lower arterial pressure that was accentuated after LVP (P < 0.01). Echocardiographic diastolic function, A wave velocity and deceleration time of the E wave were markedly increased in cirrhotic patients with tense ascites and the E/A ratio was markedly reduced (0.9 ± 0.3) but was not significantly affected by LVP. Ejection fraction had similar values of the normal patients with a tendency to increase after paracentesis. There were no changes in the left ventricular wall thickness. CONCLUSION LVP is a safe and effective procedure for treatment of tense/refractory ascites. PICD is a frequently occurring silent complication following LVP. Salt free human albumin should be the plasma expander of choice especially if at least 8 liters are evacuated. Left ventricular diastolic function is altered in cirrhosis with tense ascites. This may represent an early stage of hepatic cardiomyopathy but was not affected by LVP and this was not reflected on the occurrence of PICD.
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Affiliation(s)
- G Nasr
- Department of Cardiology, Suez Canal University, Ismailia, Egypt
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Hsu CY, Huang YH, Hsia CY, Su CW, Lin HC, Loong CC, Chiou YY, Chiang JH, Lee PC, Huo TI, Lee SD. A new prognostic model for hepatocellular carcinoma based on total tumor volume: the Taipei Integrated Scoring System. J Hepatol 2010; 53:108-17. [PMID: 20451283 DOI: 10.1016/j.jhep.2010.01.038] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/15/2010] [Accepted: 01/16/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The currently used staging systems for hepatocellular carcinoma (HCC) are not satisfactory. The optimal prognostic model for HCC is still under intense debate. This study aimed to propose a new staging system for HCC based on total tumor volume (TTV) and to compare it with the currently used systems. METHODS A total of 2030 HCC patients undergoing different treatment strategies were retrospectively analyzed. TTV was defined as the sum of the volume of each tumor [(4/3)x3.14x(radius of tumor in cm)(3)]. The discriminatory ability of the TTV-based staging system and the four current systems, including the Barcelona Clinic Liver Cancer, Cancer of the Liver Italian Program (CLIP), Japan Integrated Staging system, and Tokyo system, was examined by comparing the Akaike information criterion (AIC) using the Cox proportional hazards model. RESULTS A higher TTV correlated well with the decreased survival in HCC patients (p<0.001). Among the 12 TTV-based staging systems, the TTV-Child-Turcotte-Pugh (CTP)-alpha-fetoprotein (AFP) combination provided the lowest AIC value. The TTV-CTP-AFP model consistently showed a better prognostic ability in comparison to the current four staging systems. In 936 HCC patients receiving curative treatment, the TTV-CTP-AFP model provided the second best predictive accuracy following the CLIP score. Alternatively, in 1094 patients undergoing non-curative treatment, the TTV-CTP-AFP model exhibited the smallest AIC value. CONCLUSIONS TTV may be a feasible tumoral prognostic predictor for HCC. In this single-hospital study that included patients with early to advanced cancer stages, the TTV-CTP-AFP model provides the best prognostic ability among 12 TTV-based and currently used staging systems.
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Affiliation(s)
- Chia-Yang Hsu
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Al-Hamoudi WK, Alqahtani S, Tandon P, Ma M, Lee SS. Hemodynamics in the immediate post-transplantation period in alcoholic and viral cirrhosis. World J Gastroenterol 2010; 16:608-12. [PMID: 20128030 PMCID: PMC2816274 DOI: 10.3748/wjg.v16.i5.608] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the hemodynamics in the immediate post transplant period and compare patients with alcoholic vs viral cirrhosis.
METHODS: Between 2000-2003, 38 patients were transplanted for alcoholic cirrhosis and 28 for postviral cirrhosis. Heart rate (HR), central venous pressure (CVP), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance index (SVRI), pulmonary artery pressure (PAP), and pulmonary vascular resistance index (PVRI) were measured immediately and 24 h post transplantation.
RESULTS: Hyperdynamic circulation persisted at 24 h following transplantation with an elevated CI of 5.4 ± 1.3 L/(min × m2) and 4.9 ± 1.0 L/(min × m2) in the viral and alcoholic groups, respectively, and was associated with a decreased SVRI. Within the first 24 h, there was a significant decrease in HR and increase in MAP; the extent of the change was similar in both groups. The CVP, PCWP, and SVRI increased, and CI decreased in the viral patients, but not the alcoholic patients. Alcoholics showed a lower PVRI (119 ± 52 dynes/(cm5× m2) vs 166 ± 110 dynes/(cm5× m2), P < 0.05) and PAP (20 ± 7 mmHg vs 24 ± 7 mmHg, P < 0.05) compared to the viral group at 24 h.
CONCLUSION: Hyperdynamic circulation persists in the immediate post-transplant period with a faster improvement in the viral group. Alcoholic patients have a more pronounced pulmonary vasodilatation.
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Pulmonary oedema after therapeutic ascitic paracentesis: a case report and literature review of the cardiac complications of cirrhosis. Eur J Gastroenterol Hepatol 2010; 22:241-5. [PMID: 19801941 DOI: 10.1097/meg.0b013e32833110f7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
In this study, we describe the development of acute pulmonary oedema and cardiac arrest after therapeutic ascitic paracentesis, in a gentleman with decompensated liver cirrhosis. There was no previous history of cardiorespiratory symptoms or disease. Postmortem examination revealed oedematous and congested lungs with bilateral pleural effusions; in addition, the right heart was dilated and congested. Micronodular cirrhosis was present with histological features of alpha1 antitrypsin deficiency. This is the first study of acute cardiac decompensation after large volume paracentesis. Owing to the postmortem findings, underlying asymptomatic cardiorespiratory disease may have been present. Cirrhosis is associated with cardiovascular complications including cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome which may manifest or worsen under situations of haemodynamic stress. This report thus raises the question whether routine screening for cardiovascular abnormalities is warranted in patients with decompensated cirrhosis, particularly before the procedures such as paracentesis that impose significant haemodynamic strain.
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8
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Hsu CY, Huang YH, Su CW, Lin HC, Chiang JH, Lee PC, Lee FY, Huo TI, Lee SD. Renal failure in patients with hepatocellular carcinoma and ascites undergoing transarterial chemoembolization. Liver Int 2010; 30:77-84. [PMID: 19818004 DOI: 10.1111/j.1478-3231.2009.02128.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ascites is often present in patients with hepatocellular carcinoma (HCC) with cirrhosis. Advanced cirrhosis may predispose to renal dysfunction. Acute renal failure (ARF) may occur after transarterial chemoembolization (TACE) for HCC because of radiocontrast agents. This study aimed to investigate the incidence and risk factors of ARF and prognostic predictors in HCC patients with ascites undergoing TACE. METHODS A total of 591 HCC patients receiving TACE were enrolled. RESULTS In a mean follow-up duration of 19+/-17 months, 239 (40.4%) patients undergoing TACE died. Ascites, which was present in 91 (15.4%) patients at entry, independently predicted a poor prognosis in the Cox proportional hazard model [risk ratio (RR): 1.71, P=0.002]. Of these, 11 (12.6%) of 87 patients with complete follow-up developed ARF after TACE. Serum albumin level <3.3 g/dl (odds ratio: 7.3, P=0.009) was the only independent risk factor associated with ARF in the logistic regression analysis. ARF (RR: 2.17, P=0.036), alpha-fetoprotein >400 ng/ml (RR: 1.84, P=0.04), multiple tumours (RR: 2.11, P=0.013), tumour size > or = 5 cm (RR: 2.32, P=0.006) and serum sodium level <139 mmol/L (RR: 2.4, P=0.005) were independent poor prognostic predictors for HCC patients with ascites receiving TACE. CONCLUSIONS Pre-existing ascites is associated with increased mortality in HCC patients receiving TACE. In HCC patients with ascites, hypoalbuminaemia is associated with the occurrence of post-TACE ARF. Post-TACE ARF is a poor prognostic predictor in this subset of HCC patients.
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Affiliation(s)
- Chia-Yang Hsu
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Charalabopoulos K, Peschos D, Zoganas L, Bablekos G, Golias C, Charalabopoulos A, Stagikas D, Karakosta A, Papathanasopoulos A, Karachalios G, Batistatou A. Alterations in arterial blood parameters in patients with liver cirrhosis and ascites. Int J Med Sci 2007; 4:94-7. [PMID: 17396160 PMCID: PMC1838824 DOI: 10.7150/ijms.4.94] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 03/01/2007] [Indexed: 01/10/2023] Open
Abstract
In cirrhotic patients, in addition to hepatocytes and Kuppfer cells dysfunction circulatory anatomic shunt and ventilation/perfusion (V(A)/ Q) ratio abnormalities can induce decrease in partial pressure of oxygen in arterial blood (PaO(2)), in oxygen saturation of hemoglobin (SaO(2)) as well as various acid-base disturbances. We studied 49 cases of liver cirrhosis (LC) with ascites compared to 50 normal controls. Causes were: posthepatic 37 (75.51%), alcoholic 7 (14.24%), cardiac 2 (4.08%), and cryptogenic 3 (6.12%). Complications were: upper gastrointestinal bleeding 24 (48.97), hepatic encephalopathy 20 (40.81%), gastritis 28 (57.14%), hepatoma 5 (10.2%), renal hepatic syndrome 2 (4.01%), HbsAg (+) 24 (48.97%), and hepatic pleural effusions 7 (14.28%). Average PaO(2) and SaO(2) were 75.2 mmHg and 94.5 mmHg, respectively, compared to 94.2 mmHg and 97.1 mmHg of the control group, respectively (p value in both PaO(2) and SaO(2 )was p<0.01). Respiratory alkalosis, metabolic alkalosis, metabolic acidosis, respiratory acidosis and metabolic acidosis with respiratory alkalosis were acid-base disturbances observed. In conclusion, portopulmonary shunt, intrapulmonary arteriovenous shunt and V(A)/Q inequality can induce a decrease in PaO(2) and SaO(2) as well as various acid-base disturbances. As a result, pulmonary resistance is impaired and patients more likely succumb to infections and adult respiratory distress syndrome.
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Abstract
A hypothesis about the inflammatory etiopathogeny mediated by astroglia of hepatic encephalopathy is being proposed. Three evolutive phases are considered in chronic hepatic encephalopathy: an immediate or nervous phase with ischemia-reperfusion, which is associated with reperfusion injury, edema and oxidative stress; an intermediate or immune phase with microglia hyperactivity, which produces cytotoxic cytokines and chemokines and is involved in enzyme hyperproduction and phagocytosis; and a late or endocrine phase, in which neuroglial remodeling, with an alteration of angiogenesis and neurogenesis, stands out. The increasingly complex trophic meaning that the metabolic alterations have in the successive phases making up this chronic inflammation could explain the metabolic regression produced in acute and acute-on-chronic hepatic encephalopathy. In these two types of hepatic encephalopathy, characterized by edema, neuronal nutrition by diffusion would guarantee an appropriate support of substrates, in accordance with the reduced metabolic needs of the cerebral tissue.
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Affiliation(s)
- Jorge-Luis Arias
- Psychobiology Laboratory, School of Psychology, University of Oviedo, Asturias, Spain
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Hosogi H, Ikai I, Hatano E, Taura K, Fujii H, Yamamoto Y, Shimahara Y. Pancreatic arteriovenous malformation with portal hypertension. ACTA ACUST UNITED AC 2006; 13:344-6. [PMID: 16858547 DOI: 10.1007/s00534-005-1068-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 10/25/2005] [Indexed: 12/01/2022]
Abstract
A 45-year-old man with recurrent episodes of hematemesis caused by extensive varices in the esophagus and stomach was admitted. He had a history of liver cirrhosis with hepatitis C virus infection. Computed tomography revealed a conglomeration of small strong nodular stains in the pancreatic head. Angiography revealed a racemose vascular network at the same site and early appearance of the portal venous system in the arterial phase. With a diagnosis of pancreatic arteriovenous malformation with portal hypertension, he underwent pylorus-preserving pancreaticoduodenectomy, preceded, 2 days earlier, by transcatheter arterial embolization of some of the feeding arteries. The varices observed preoperatively in the esophagus and stomach disappeared, and he has been well for 6 years after the operation. We reviewed 47 cases of pancreatic arteriovenous malformation previously reported in the English-language literature, with a focus on the clinical manifestations, treatment approaches, and etiological relationship with portal hypertension and liver cirrhosis.
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Affiliation(s)
- Hisahiro Hosogi
- Department of Gastroenterological Surgery, Kyoto University Graduate School of Medicine, Shogoin, Kyoto 606-8507, Japan
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Cárdenas A, Sánchez-Fueyo A. [Circulatory dysfunction in cirrhosis. Physiopathology and clinical implications]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:447-55. [PMID: 12887860 DOI: 10.1016/s0210-5705(03)70388-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Cárdenas
- Division of Gastroenterology and Hepatology. Beth Israel Deaconess Medical Center. Harvard Medical School. Boston. MA 02215, USA.
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Møller S, Henriksen JH. Cirrhotic cardiomyopathy: a pathophysiological review of circulatory dysfunction in liver disease. Heart 2002; 87:9-15. [PMID: 11751653 PMCID: PMC1766971 DOI: 10.1136/heart.87.1.9] [Citation(s) in RCA: 232] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2001] [Indexed: 12/13/2022] Open
Abstract
The systemic circulation in patients with cirrhosis is hyperdynamic with an increased cardiac output and heart rate and a reduced systemic vascular resistance as the most pronounced alterations. The concomitant cardiac dysfunction has recently been termed "cirrhotic cardiomyopathy", which is an entity different from that seen in alcoholic heart muscle disease. Clinically, these patients present with sodium fluid retention and strain often unmasks the presence of latent heart failure. No specific treatment can yet be recommended but caution should be used with respect to procedures that may stress the heart such as shunt implantation and liver transplantation.
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Affiliation(s)
- S Møller
- Department of Clinical Physiology, 239, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark.
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14
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Krowka MJ, Wiseman GA, Burnett OL, Spivey JR, Therneau T, Porayko MK, Wiesner RH. Hepatopulmonary syndrome: a prospective study of relationships between severity of liver disease, PaO(2) response to 100% oxygen, and brain uptake after (99m)Tc MAA lung scanning. Chest 2000; 118:615-24. [PMID: 10988181 DOI: 10.1378/chest.118.3.615] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Because of the spectrum of intrapulmonary vascular dilation that characterizes hepatopulmonary syndrome (HPS), PaO(2) while breathing 100% oxygen varies. Abnormal extrapulmonary uptake of (99m)Tc macroaggregated albumin (MAA) after lung perfusion is common. GOAL To describe relationships between (1) severity of liver disease measured by the Child-Pugh (CP) classification; (2) PaO(2) while breathing room air (RA) and 100% oxygen on 100% oxygen; and (3) extrapulmonary (brain) uptake of (99m)Tc MAA after lung scanning. METHODS AND PATIENTS We prospectively measured PaO(2) on RA, PaO(2) on 100% oxygen, and brain uptake after lung perfusion of (99m)Tc MAA in 25 consecutive HPS patients. RESULTS Mean PaO(2) on RA, PaO(2) on 100% oxygen, PaCO(2) on RA, and (99m)Tc MAA brain uptake were similar when categorized by CP classification. Brain uptake was abnormal (> or = 6%) in 24 patients (96%). Brain uptake was 29 +/- 20% (mean +/- SD) and correlated inversely with PaO(2) on RA (r = -0.57; p<0.05) and PaO(2) on 100% oxygen (r = -0.41; p<0.05). Seven patients (28%) had additional nonvascular pulmonary abnormalities and lower PaO(2) on 100% oxygen (215+/-133 mm Hg vs 391+/-137 mm Hg; p<0.007). Eight patients (32%) died. Mortality in patients without coexistent pulmonary abnormalities was associated with greater brain uptake of (99m)Tc MAA (48+/-18% vs 25+/-20%; p<0.04) and lower PaO(2) on RA (40+/-7 mm Hg vs 57+/-11 mm Hg; p<0.001). CONCLUSION The degree of hypoxemia associated with HPS was not related to the CP severity of liver disease. HPS patients with additional nonvascular pulmonary abnormalities exhibited lower PaO(2) on 100% oxygen. Mortality was associated with lower PaO(2) on RA, and with greater brain uptake of (99m)Tc MAA.
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Affiliation(s)
- M J Krowka
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA.
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Wattanasirichaigoon S, Gordon FD, Resnick RH. Hyperdynamic circulation in portal hypertension: a comparative model of arterio-venous fistula. Med Hypotheses 2000; 55:77-87. [PMID: 11021333 DOI: 10.1054/mehy.1999.1034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Complications of portal hypertension remain perplexing physiologic phenomena in the understanding of shunt hemodynamics with multiple theories. Hyperdynamic circulation was also found in sepsis, chronic anemia and arterio-venous (A-V) fistula which relate to an increase in nitric oxide. We hypothesize that portosystemic collaterals may mimic an A-V fistula in which the high-pressure portal blood connects with the lower pressure systemic venous circulation. Although these collaterals decompress the portal circulation, a number of secondary hemodynamic phenomena occur which increase portal blood flow and tend to counteract the portal hypotensive effect of the portosystemic shunt. The consequent increases in cardiac output and portal blood flow perfuse the compromised liver. As portal blood flow increases, collateral flow increases and is nearly totally shunted in the systemic circulation. This shunt may eventually introduce a vicious cycle of hyperdynamic circulation into a compromised host. Ultimately, high-output cardiac failure occurs, leading to cirrhotic cardiomyopathy.
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Affiliation(s)
- S Wattanasirichaigoon
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Vajira Hospital, Bangkok, Thailand.
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Melo J, Peters JI. Low systemic vascular resistance: differential diagnosis and outcome. Crit Care 1999; 3:71-77. [PMID: 11056727 PMCID: PMC29017 DOI: 10.1186/cc343] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/1999] [Revised: 05/10/1999] [Accepted: 05/11/1999] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE: To determine the frequency and prognosis of the various causes of low systemic vascular resistance (SVR). DESIGN: Analysis of consecutive patients over a 5-year period; retrospective review. SETTING: Medical intensive care unit of a large university hospital. PATIENTS: Fifty-five patients with unexplained hypotension and a SVR less than 800 dynes x s/cm5. BACKGROUND: There are minimal data in the medical literature determining the frequency or outcome of patients with a low SVR that is unrelated to sepsis or the sepsis syndrome. We retrospectively reviewed and analyzed all hemodynamic data in a large university hospital over a 5-year period to determine the frequency and prognosis of the various causes of low SVR. Fifty-five patients with unexplained hypotension and a SVR less than 800dynesxs/cm5were identified. MAIN RESULTS: Twenty-two patients (Groups 1 and 2) met the criteria for sepsis syndrome. The mean SVR for this group was 445 +/- 168 dynesxs/cm5 with an associated mortality of 50%. Group 3 contained 20 patients with possible sepsis. Thirteen patients (Group 4) were nonseptic. The mean SVR of this group was 435 +/- 180 dynes x s/cm5 with an associated mortality of 46%. Extremely low SVR (below 450 dynes x s/cm5) was associated with a significantly higher mortality regardless of the etiology. CONCLUSIONS: At least a quarter of patients with hypotension and a low SVR have nonseptic etiologies. The patients with nonseptic etiologies have a similar mortality to septic patients. Clinicians should be aware of the wide spectrum of conditions that induce a low SVR.
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Affiliation(s)
- Jairo Melo
- Department of Medicine, Division of Pulmonary
Diseases/Critical Care Medicine, The University of Texas Health Science Center
at San Antonio, Texas, USA
| | - Jay I Peters
- The South Texas Veterans Health Care System, Audie L.
Murphy Memorial Veterans Hospital Division, San Antonio, Texas, USA
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Fernández-Rodriguez CM, Prada IR, Prieto J, Montuenga LM, Elssasser T, Quiroga J, Moreiras M, Andrade A, Cuttitta F. Circulating adrenomedullin in cirrhosis: relationship to hyperdynamic circulation. J Hepatol 1998; 29:250-6. [PMID: 9722206 DOI: 10.1016/s0168-8278(98)80010-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Peripheral arterial vasodilation may be the key factor in the sodium and water retention of cirrhosis. The mechanism responsible for this vasodilation remains to be fully elucidated. Adrenomedullin is a novel peptide, highly expressed in cardiovascular tissues, with potent and long-lasting vasodilating activity. METHODS The possible implication of adrenomedullin in the hemodynamic changes of cirrhosis has been investigated. We measured the plasma concentration of adrenomedullin in 20 cirrhotic patients and 11 healthy subjects. In addition, systemic, portal and renal hemodynamics, hormonal factors and renal function parameters were evaluated in the same patients. RESULTS Circulating adrenomedullin was significantly higher in the group of patients with cirrhosis (72.1; 46-100 vs 21.6; 11-34 fmol/dl, respectively; p<0.02) and was directly correlated with the Pugh score (r: 0.6; p: 0.01), inversely correlated with the creatinine clearance (r: -0.6; p<0.01) and tended to inversely correlate with systemic vascular resistance index (r: -0.46; p: 0.07). There were no portal-peripheral differences in adrenomedullin levels. Transjugular intrahepatic portosystemic shunt insertion did not induce changes in the peripheral concentration of adrenomedullin, but baseline values of this hormone predicted the degree of hyperdynamic circulation after TIPS. CONCLUSIONS Circulating adrenomedullin is increased in cirrhosis. These levels increase with the severity of the disease, especially in patients with hepatorenal syndrome. This peptide may contribute to vasodilation of cirrhosis.
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Abstract
Hepatorenal syndrome may occur in any form of severe liver disease. It appears less common in children than adults, but still carries a poor prognosis. There are several factors involved in its aetiology, including a decreased renal perfusion pressure, activation of the renal sympathetic nervous system and increased synthesis of several vasoactive mediators, which may modulate glomerular filtration by acting as both renal vasoconstrictors and dynamic regulators of the glomerular capillary ultrafiltration coefficient, through their action on mesangial cells. This review will discuss the pathophysiology of the hepatorenal syndrome and some of the principles of management of patients with renal failure and severe liver disease. The role of renal support and liver transplantation will also be covered.
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Affiliation(s)
- G Van Roey
- Department of Medicine, Royal Free Hospital School of Medicine, London, UK
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Fernández-Rodriguez CM, Prieto J, Quiroga J, Zozoya JM, Andrade A, Núñez M, Sangro B, Penas J. Plasma levels of substance P in liver cirrhosis: relationship to the activation of vasopressor systems and urinary sodium excretion. Hepatology 1995; 21:35-40. [PMID: 7528711 DOI: 10.1002/hep.1840210108] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The mediators of the hyperdynamic circulation of liver cirrhosis are not well characterized. Substance P is a potent vasodilatory peptide produced by the enteric nervous system and partly cleared by the liver. In this work we have investigated the plasma levels of substance P and their relationship to the hemodynamic, neurohormonal, and renal function changes occurring in patients with cirrhosis. Seven healthy subjects (control group), 7 cirrhotic patients without ascites (group I), and 24 cirrhotic patients with ascites (group II) were studied. Cardiac output (CO), femoral blood flow (FBF), blood volume (BV), femoral arteriovenous difference of oxygen content (Ca-v O2), plasma renin activity (PRA), plasma aldosterone concentration (PAC), and plasma norepinephrine (NE) were determined. Five patients underwent trans-jugular intrahepatic porto-systemic stent shunt (TIPSS) because of refractory ascites. Immunoreactive substance P (irSP) was measured by radioimmunoassay after plasma extraction. irSP was higher in ascitic patients than in healthy controls (P < .01) and directly correlated with PRA, PAC, plasma NE, and Pugh's score and was inversely correlated with urinary sodium excretion, glomerular filtration rate, and Ca-v O2. No differences were observed between portal and peripheral vein irSP concentration. TIPSS placement induced a decrease in portal pressure and an increase in CO but circulating irSP remained unchanged. Our data show that circulating irSP is increased in decompensated cirrhotic patients and may be involved in the pathogenesis of the hemodynamic changes of cirrhosis. Alleviation of portal hypertension did not result in decreased plasma levels of this vasodilatory substance.
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Fernández-Rodriguez C, Prieto J, Quiroga J, Zozaya JM, Andrade A, Rodriguez-Martinez D. Atrial natriuretic factor in cirrhosis: relationship to renal function and hemodynamic changes. J Hepatol 1994; 21:211-6. [PMID: 7989711 DOI: 10.1016/s0168-8278(05)80397-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Plasma atrial natriuretic factor concentrations and different hemodynamic parameters, including the evaluation of femoral arteriovenous shunting by measuring the arteriovenous difference of oxygen content (Ca-vO2), were determined in eight healthy subjects and 24 patients with cirrhosis without renal failure (group I: seven patients without ascites, group II: nine patients with ascites and UNaV > 10 mEq/24 h and group III: eight patients with ascites and UNaV < or = 10 mEq/24 h). Atrial natriuretic factor was 34 +/- 4.7 pg/ml in the control group and 44.28 +/- 5.4, 67.89 +/- 8.8 and 84 +/- 10.8 pg/ml in groups I, II and III respectively (p < 0.001. group III vs. I and control and II vs. control). Atrial natriuretic factor directly correlated with cardiac index (p < 0.01), blood volume (p: 0.01), femoral blood flow (p < 0.01) and inversely with systemic and femoral vascular resistances (p < 0.02), Ca-vO2 (p < 0.01), serum albumin (r: -0.61; p < 0.01) and prothrombin index (r: -0.63; p < 0.02). These results indicate that plasma atrial natriuretic factor is increased in patients with cirrhosis, especially in those with advanced disease and marked renal sodium retention. This suggests that in cirrhosis, arteriolar vasodilation and peripheral arteriovenous shunting influence renal function while inducing a state of overflow at the central venous compartment leading to increased atrial natriuretic factor secretion. Increased production of this vasodilatory hormone may thus contribute to the hyperkinetic circulation of cirrhosis.
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