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Çekmen N, Uslu A. Anaesthesia management for liver transplantation: A narrative review. J Perioper Pract 2024; 34:226-240. [PMID: 37970678 DOI: 10.1177/17504589231193551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Orthotopic liver transplantation is the definitive standard treatment for end-stage liver disease. Orthotopic liver transplantation anaesthesia management is a complex procedure that requires a multidisciplinary team approach. Understanding the complex pathophysiology of end-stage liver disease and its complications in the affected systems is essential for proper anaesthesia management in orthotopic liver transplantation. Orthotopic liver transplantation is a dynamic process, and preoperative optimisation is essential in these patients. Therefore, anaesthesiologists should focus on rapidly fluctuating physiology, haemodynamics, metabolic, and coagulation status in the anaesthesia management of these patients. Perioperative care and anaesthesia for orthotopic liver transplantation can be divided into preoperative evaluation, anaesthesia induction and management, dissection, anhepatic, neo-hepatic, and postoperative care, with essential anaesthetic considerations at each point. Considering the clinical situation, haemodynamic changes, misapplications, knowledge, attitude, and multimodal and multidisciplinary approach are vital in anaesthesia and the perioperative period. In our review, in line with the literature, we aimed to present the perioperative and anaesthesia management in orthotopic liver transplantation patients.
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Affiliation(s)
- Nedim Çekmen
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Ahmed Uslu
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
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2
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Nie G, Zhang H, Xie D, Yan J, Li X. Liver cirrhosis and complications from the perspective of dysbiosis. Front Med (Lausanne) 2024; 10:1320015. [PMID: 38293307 PMCID: PMC10824916 DOI: 10.3389/fmed.2023.1320015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024] Open
Abstract
The gut-liver axis refers to the intimate relationship and rigorous interaction between the gut and the liver. The intestinal barrier's integrity is critical for maintaining liver homeostasis. The liver operates as a second firewall in this interaction, limiting the movement of potentially dangerous compounds from the gut and, as a result, contributing in barrier management. An increasing amount of evidence shows that increased intestinal permeability and subsequent bacterial translocation play a role in liver damage development. The major pathogenic causes in cirrhotic individuals include poor intestinal permeability, nutrition, and intestinal flora dysbiosis. Portal hypertension promotes intestinal permeability and bacterial translocation in advanced liver disease, increasing liver damage. Bacterial dysbiosis is closely related to the development of cirrhosis and its related complications. This article describes the potential mechanisms of dysbiosis in liver cirrhosis and related complications, such as spontaneous bacterial peritonitis, hepatorenal syndrome, portal vein thrombosis, hepatic encephalopathy, and hepatocellular carcinoma, using dysbiosis of the intestinal flora as an entry point.
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Affiliation(s)
- Guole Nie
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Honglong Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Danna Xie
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Jun Yan
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory of Biotherapy and Regenerative Medicine of Gansu Province, Lanzhou, China
- Cancer Prevention and Control Center of Lanzhou University Medical School, Lanzhou, China
- Gansu Institute of Hepatobiliary and Pancreatic Surgery, Lanzhou, China
- Gansu Clinical Medical Research Center of General Surgery, Lanzhou, China
| | - Xun Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- Key Laboratory of Biotherapy and Regenerative Medicine of Gansu Province, Lanzhou, China
- Cancer Prevention and Control Center of Lanzhou University Medical School, Lanzhou, China
- Gansu Institute of Hepatobiliary and Pancreatic Surgery, Lanzhou, China
- Gansu Clinical Medical Research Center of General Surgery, Lanzhou, China
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3
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Morais Passos R, Cardoso F, Teixeira da Silva F, Corga da Silva R, Caldeiro J. Hepatopulmonary Syndrome Diagnosis in the ICU: The Relevance of Bedside Contrast Saline Echocardiography. Cureus 2024; 16:e52658. [PMID: 38380202 PMCID: PMC10877994 DOI: 10.7759/cureus.52658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Hepatopulmonary syndrome (HPS) is an underdiagnosed complication of chronic liver disease (CLD) characterised by the presence of hypoxaemia due to intrapulmonary vascular dilatations. We present two cases of HPS diagnosed during their stay in the ICU. Both patients had a medical history of alcoholic CLD with portal hypertension (PH). The first patient was transferred to the ICU for acute hypoxic respiratory failure (AHRF) due to decompensated cirrhosis with large-volume hydrothorax and diagnosis of acute-on-chronic liver failure (ACLF) grade 2. The presence of orthodeoxia, an alveolar-arterial oxygen gradient (O2 A-a grad) of 27 mmHg and positive contrast saline echocardiography confirmed the HPS diagnosis. The second patient was transferred to our general ICU from the surgical ward where he was initially admitted with mild AHRF due to polytrauma conditioning left side rib fractures and a small contusion in the left inferior lobe. Upon ICU admission, he was diagnosed with septic shock (nosocomial pneumonia as the primary site of infection) and required invasive mechanical ventilation. During the initial period of his ICU stay, although an improvement in multiple organ dysfunction was observed, severe AHRF persisted. Moreover, O2 A-a grad of 30 mmHg and positive bedside contrast saline echocardiography confirmed the HPS diagnosis. In this study, we discuss the diagnostic approach of HPS and the increasing relevance of contrast saline echocardiography at the bedside, particularly in critically ill patients. The performance of this technique by trained intensivists at the bedside in the ICU minimises critical moments, such as the time required for intra-hospital transport of patients for complementary examinations, considering they have severe ventilatory compromise, thereby allowing HPS diagnosis with high sensitivity.
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Affiliation(s)
- Rita Morais Passos
- Critical Care Department, Hospital de Santa Luzia, Viana do Castelo, PRT
- Escola de Medicina, Universidade do Minho, Braga, PRT
| | - Francisca Cardoso
- Critical Care Department, Hospital de Santa Luzia, Viana do Castelo, PRT
| | | | | | - José Caldeiro
- Critical Care Department, Hospital de Santa Luzia, Viana do Castelo, PRT
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Panackel C, Fawaz M, Jacob M, Raja K. Pulmonary Assessment of the Liver Transplant Recipient. J Clin Exp Hepatol 2023; 13:895-911. [PMID: 37693254 PMCID: PMC10483013 DOI: 10.1016/j.jceh.2023.04.003] [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: 12/22/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.
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Affiliation(s)
| | - Mohammed Fawaz
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Jacob
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Kaiser Raja
- King's College Hospital London, Dubai Hills, Dubai, United Arab Emirates
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Li L, Cook C, Liu Y, Li J, Jiang J, Li S. Endothelial glycocalyx in hepatopulmonary syndrome: An indispensable player mediating vascular changes. Front Immunol 2022; 13:1039618. [PMID: 36618396 PMCID: PMC9815560 DOI: 10.3389/fimmu.2022.1039618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is a serious pulmonary vascular complication that causes respiratory insufficiency in patients with chronic liver diseases. HPS is characterized by two central pathogenic features-intrapulmonary vascular dilatation (IPVD) and angiogenesis. Endothelial glycocalyx (eGCX) is a gel-like layer covering the luminal surface of blood vessels which is involved in a variety of physiological and pathophysiological processes including controlling vascular tone and angiogenesis. In terms of lung disorders, it has been well established that eGCX contributes to dysregulated vascular contraction and impaired blood-gas barrier and fluid clearance, and thus might underlie the pathogenesis of HPS. Additionally, pharmacological interventions targeting eGCX are dramatically on the rise. In this review, we aim to elucidate the potential role of eGCX in IPVD and angiogenesis and describe the possible degradation-reconstitution equilibrium of eGCX during HPS through a highlight of recent literature. These studies strongly underscore the therapeutic rationale in targeting eGCX for the treatment of HPS.
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Affiliation(s)
- Liang Li
- Department of Thoracic Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China,*Correspondence: Liang Li, ; Shaomin Li,
| | - Christopher Cook
- Division of Immunology and Pathogenesis, Department of Molecular and Cell Biology, University of California, Berkeley, Berkeley, CA, United States
| | - Yale Liu
- Department of Dermatology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Jianzhong Li
- Department of Thoracic Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Jiantao Jiang
- Department of Thoracic Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Shaomin Li
- Department of Thoracic Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China,*Correspondence: Liang Li, ; Shaomin Li,
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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Palot Manzil FF, Haq I, Wang X. Evaluation of Hepatopulmonary Syndrome with Technetium-99m Macroaggregated Albumin Scintigraphy. J Nucl Med Technol 2022; 50:jnmt.122.264190. [PMID: 35610042 DOI: 10.2967/jnmt.122.264190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized by intrapulmonary vascular dilatation causing hypoxemia in patients with liver disease. Technetium-99m macroaggregated albumin (99mTc-MAA) scintigraphy have diagnostic value in suspected HPS by detecting clinically significant right to left shunt. In presence of cirrhosis, MAA scan with extra-pulmonary organs visualization is specific of intrapulmonary shunting. MAA scintigraphy also provides added value of quantification of the shunt.
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Affiliation(s)
| | - Iqbal Haq
- University of Arkansas for Medical Sciences (UAMS), United States
| | - Xiaofei Wang
- University of Arkansas for Medical Sciences (UAMS), United States
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Okumura K, Schluger A, Dhand A, Bodin R, Nishida S. Hepatopulmonary Syndrome: Unique Radiological Association with Portal Vein Thrombosis and Porto-systemic Shunting. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
BACKGROUND Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. METHODS This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. RESULTS There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. CONCLUSION Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- AVB, acute variceal bleeding
- BMI, body mass index
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- CTP, Child Turcotte Pugh Score
- DAAs, direct-acting antiviral agents
- GGT, gamma glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HE, hepatic encephalopathy
- HR, hazard ratio
- HRQoL, health-related quality of life
- HVPG, hepatic vein pressure gradient
- MELD, Model for End Stage Liver disease
- MetS, metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NSBB, Non-selective beta blockers
- NVHCP, National Viral Hepatitis Control programme
- SAAG, Serum-ascites albumin gradient
- SBP, spontaneous bacterial peritonitis
- WHO, World Health Organization
- cirrhosis, ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
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Pellegrini JR, Munshi R, Patel P, Pelletier B, Patel P, Mustacchia P. The Impact of Hepatic Cirrhosis on Chronic Obstructive Pulmonary Disease in the United States: A Nationwide Analysis. Cureus 2021; 13:e16368. [PMID: 34408927 PMCID: PMC8361533 DOI: 10.7759/cureus.16368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Abstract
We aimed to study the impact of Hepatic Cirrhosis (HC) on chronic obstructive pulmonary disease (COPD). Our study is a retrospective cohort study using the 2016-2017 National Readmission Database (NRD). NRD is part of the Healthcare Cost and Utilization Project (HCUP), organized and supported by means of the Agency for Healthcare Research and Quality (AHRQ). Patients were included if they were 18 years or older and had a principal diagnosis of COPD based on International Classification of Diseases, Tenth Revision (ICD-10- CM) codes and had a secondary diagnosis of HC. A total of 505,004 patients were included in the study with a diagnosis of COPD, 6196 (1.23%) of whom had HC. HC was found to be more common amongst male patients between the ages of 50 and 65 years. Medicare beneficiaries with high comorbidity burden, lower socioeconomic status, and those who received treatment in a large urban teaching hospital also had higher rates of HC. Patients with HC and COPD correlated to an increase of in-hospital mortality (adjusted odds ratio (aOR: 2.21, p<0.001) and 30-day hospital readmission rate (aOR: 1.23, p<0.001) compared with patients without HC. The in-hospital mortality rate was higher during readmission compared with index admissions (5.01% versus 2.16%; p<0.001). In addition, HC was associated with higher morbidity including prolonged mechanical ventilation (aOR: 1.39, p<0.001), resource utilization with prolong length of stay (LOS) (adjusted mean difference (aMD: 0.51, p<0.001), higher total hospitalization charges (aMD: 4967, p<0.001), and costs (aMD: 1200, p<0.001). Both patient groups had similar odds of being intubated (aOR: 1.18, p-0.13), tracheostomy (aOR: 0.81, p-069) and bronchoscopy rates (aOR: 1.27, p-0.36). The most common causes of hospital readmission were found to be COPD with acute exacerbation (19.7%), sepsis, unspecified organism (6.0%, acute and chronic respiratory failure with hypoxia (4.2%), acute on chronic systolic heart failure (3.9%), and hepatic failure, unspecified coma (3.1%). Various autonomous prognosticators of readmission were sex (particularly female), alcohol dependence, LOS greater than 7 days, lower comorbidity burden, and discharge to short term hospital or against medical advice. On the other hand, males, patients without a history of alcohol dependence, greater comorbidity burden, and LOS fewer than 3 days, were less likely to be readmitted. We found that HC is related to higher in-hospital mortality, LOS, increased mechanical ventilation, resource utilization with prolonged LOS, hospital costs, odds of intubation, and tracheostomy and bronchoscopy rates. Our study aims to shed light on the impact of HC on COPD in hopes to improve future management.
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Affiliation(s)
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Pranavi Patel
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Brandon Pelletier
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Palakkumar Patel
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Paul Mustacchia
- Gastroenterology and Hepatology, Nassau University Medical Center, East Meadow, USA
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Onay ZR, Ramasli Gursoy T, Aslan AT, Sismanlar Eyuboglu T, Akkan K. Hepatopulmonary Syndrome and Multiple Arteriovenous Fistulas in a Child with Niemann-Pick Disease. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2021; 34:30-32. [PMID: 33734872 PMCID: PMC8082032 DOI: 10.1089/ped.2020.1244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/18/2020] [Indexed: 05/31/2023]
Abstract
Background: Niemann-Pick disease (NPD) is caused by abnormal storage of sphingomyelin. NPD may affect the pulmonary system and cause hypoxia. In the present case, both hepatopulmonary syndrome (HPS) and pulmonary arteriovenous fistulas (PAVFs) developed in a child with NPD and were successfully treated with repeated embolization. Case Presentation: We have reported the case of a 16-year-old-girl with NPD who suffered severe hypoxia, dyspnea, fatigue, had multiple PAVFs, and was diagnosed with type 2 HPS. To improve oxygenation, 10 PAVFs were embolized. She needed re-embolization after 9 months because of hypoxia redevelopment. Conclusions: Pulmonary involvement, HPS, and/or PAVFs could be responsible for hypoxemia in patients with NPD, who should, therefore, be investigated for HPS and PAVFs. Embolization could be beneficial. Some patients may need repeated embolization.
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Affiliation(s)
- Zeynep Reyhan Onay
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Tugba Ramasli Gursoy
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ayse Tana Aslan
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Koray Akkan
- Department of Interventional Radiology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Carrion AF, Martin P. Keeping Patients with End-Stage Liver Disease Alive While Awaiting Transplant: Management of Complications of Portal Hypertension. Clin Liver Dis 2021; 25:103-120. [PMID: 33978573 DOI: 10.1016/j.cld.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Complications of portal hypertension such as gastroesophageal variceal hemorrhage, ascites, and spontaneous bacterial peritonitis, as well as pulmonary complications, are often responsible for diminished quality of life, excess morbidity and mortality, increased health care resource use and expenditure, and dropout from the liver transplant (LT) waiting list. Therefore, the care of LT candidates on the waiting list must be centered on anticipation and prompt intervention for these complications.
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Affiliation(s)
- Andres F Carrion
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Office 1189, Miami, FL 33136, USA.
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th #1115, Miami, FL 33136, USA
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Abstract
Short telomere syndrome is a genetically inherited syndrome resulting in premature telomere shortening. This premature shortening of telomeres can result in hematologic, pulmonary, vascular, gastrointestinal, and hepatic manifestations of disease. Identifying patients with short telomere syndrome can be a clinical challenge due to the multitude of potential manifestations and lack of widely available diagnostic tests. In this review, we will highlight hepatic manifestations of short telomere syndrome with a focus on diagnosis, testing, and potential treatments.
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Affiliation(s)
- Daniel D Penrice
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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15
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Ji D, Chen G, Yang Y. Implications of BMP9/10 for patients with liver cirrhosis. EBioMedicine 2020; 57:102859. [PMID: 32629390 PMCID: PMC7334805 DOI: 10.1016/j.ebiom.2020.102859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023] Open
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16
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Shi YJ, Mckiernan P, Soltys K, Mazariegos G, Wang WL. Surgical closure of large splenorenal shunt may accelerate recovery from hepato-pulmonary syndrome in liver transplant patients. World J Emerg Med 2020; 11:60-63. [PMID: 31893005 DOI: 10.5847/wjem.j.1920-8642.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Yan-Jun Shi
- Department of Hepatobiliary & Pancreas Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China.,Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick Mckiernan
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kyle Soltys
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - George Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wei-Lin Wang
- Department of Hepatobiliary & Pancreas Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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Dimitroglou Y, Aggeli C, Alexopoulou A, Mavrogeni S, Tousoulis D. Cardiac Imaging in Liver Transplantation Candidates: Current Knowledge and Future Perspectives. J Clin Med 2019; 8:E2132. [PMID: 31817014 PMCID: PMC6947158 DOI: 10.3390/jcm8122132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular dysfunction in cirrhotic patients is a recognized clinical entity commonly referred to as cirrhotic cardiomyopathy. Systematic inflammation, autonomic dysfunction, and activation of vasodilatory factors lead to hyperdynamic circulation with high cardiac output and low peripheral vascular resistance. Counter acting mechanisms as well as direct effects on cardiac cells led to systolic or diastolic dysfunction and electromechanical abnormalities, which are usually masked at rest but exposed at stress situations. While cardiovascular complications and mortality are common in patients undergoing liver transplantation, they cannot be adequately predicted by conventional cardiac examination including transthoracic echocardiography. Newer echocardiography indices and other imaging modalities such as cardiac magnetic resonance have shown increased diagnostic accuracy with predictive implications in cardiovascular diseases. The scope of this review was to describe the role of cardiac imaging in the preoperative assessment of liver transplantation candidates with comprehensive analysis of the future perspectives anticipated by the use of newer echocardiography indices and cardiac magnetic resonance applications.
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Affiliation(s)
- Yannis Dimitroglou
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
| | - Constantina Aggeli
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
| | - Alexandra Alexopoulou
- Department of Internal Medicine and Research Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece
| | - Sophie Mavrogeni
- Onassis Cardiac Center and National and Kapodistrian University of Athens, 176 74 Athens, Greece;
| | - Dimitris Tousoulis
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
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18
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Chen L, Han Y, Li Y, Chen B, Bai X, Belguise K, Wang X, Chen Y, Yi B, Lu K. Hepatocyte-derived exosomal MiR-194 activates PMVECs and promotes angiogenesis in hepatopulmonary syndrome. Cell Death Dis 2019; 10:853. [PMID: 31700002 PMCID: PMC6838168 DOI: 10.1038/s41419-019-2087-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/27/2019] [Accepted: 10/21/2019] [Indexed: 12/18/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a serious vascular complication in the setting of liver disease. Factors produced by the liver are essential to regulate pulmonary angiogenesis in the pathogenesis of HPS; however, the pathogenic mechanisms of pulmonary angiogenesis are not fully understood. We investigated the role of HPS rat serum exosomes (HEs) and sham-operated rat serum exosomes (SEs) in the regulation of angiogenesis. We found that HEs significantly enhance PMVEC proliferation, migration, and tube formation. We further identified miR-194 was the most notably increased miRNA in HEs compared to SEs. Once released, hepatocyte-derived exosomal miR-194 was internalized by PMVECs, leading to the promotion of PMVEC proliferation, migration, and tube formation through direct targeting of THBS1, STAT1, and LIF. Importantly, the pathogenic role of exosomal miR-194 in initiating angiogenesis was reversed by P53 inhibition, exosome secretion inhibition or miR-194 inhibition. Additionally, high levels of miR-194 were found in serum exosomes and were positively correlated with P(A-a)O2 in HPS patients and rats. Thus, our results highlight that the exosome/miR-194 axis plays a critical pathologic role in pulmonary angiogenesis, representing a new therapeutic target for HPS.
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Affiliation(s)
- Lin Chen
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Yi Han
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Yujie Li
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Bing Chen
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Xuehong Bai
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Karine Belguise
- LBCMCP, ×tégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Xiaobo Wang
- LBCMCP, ×tégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Yang Chen
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China.
| | - Bin Yi
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China.
| | - Kaizhi Lu
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University, Chongqing, China.
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19
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Abstract
The most common pulmonary complications of chronic liver disease are hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension. Hepatic hydrothorax is a transudative pleural effusion in a patient with cirrhosis and no evidence of underlying cardiopulmonary disease. Hepatic hydrothorax develops owing to the movement of ascitic fluid into the pleural space. Hepatopulmonary syndrome and portopulmonary hypertension are pathologically linked by the presence of portal hypertension; however, their pathophysiologic mechanisms are significantly different. Hepatopulmonary syndrome is characterized by low pulmonary vascular resistance secondary to intrapulmonary vascular dilatations and hypoxemia; portopulmonary hypertension features elevated pulmonary vascular resistance and constriction/obstruction within the pulmonary vasculature.
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Affiliation(s)
- Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
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20
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Lu C, White SJ, Ye IB, Mikhail CM, Cheung ZB, Cho SK. The Effects of Liver Disease on Surgical Outcomes Following Adult Spinal Deformity Surgery. World Neurosurg 2019; 130:e498-e504. [PMID: 31254688 DOI: 10.1016/j.wneu.2019.06.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND As the prevalence of chronic liver disease continues to rise in the United States, understanding the effects of liver dysfunction on surgical outcomes has become increasingly important. The objective of this study was to assess the effects of chronic liver disease on 30-day complications following adult spinal deformity (ASD) surgery. METHODS We performed a retrospective cohort study of 2337 patients in the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent corrective ASD surgery. Patients with liver disease were identified based on a Model for End-Stage Liver Disease-Na score ≥10. A univariate analysis was performed to compare 30-day postoperative complications between patients with and without liver disease. A multivariate regression analysis adjusting for differences in baseline patient characteristics was performed to identify complications that were associated with liver disease. RESULTS Patients with liver disease had a significantly greater incidence of postoperative pulmonary complications (6.3% vs. 2.9%; P < 0.001), blood transfusion (34.6% vs. 24.0%; P < 0.001), sepsis (2.2% vs. 0.9%; P = 0.011), prolonged hospitalization (19.0% vs. 8.0%; P < 0.001), as well as any 30-day complication (45.4% vs. 29.4%; P < 0.001). The multivariate regression analysis identified liver disease as a risk factor for prolonged hospitalization (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.64-2.84; P < 0.001), pulmonary complications (OR 1.78; 95% CI 1.16-2.74; P = 0.009), blood transfusion (OR 1.67; 95% CI 1.36-2.05; P < 0.001), and any 30-day complication (OR 1.43; 95% CI 1.15-1.77; P = 0.001). CONCLUSIONS The multisystem pathophysiology of liver dysfunction predisposes patients to postoperative complications following ASD surgery. A multidisciplinary approach in surgical planning and preoperative optimization is needed to minimize liver disease-related complications and improve patient outcomes.
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Affiliation(s)
- Charles Lu
- The New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Samuel J White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ivan B Ye
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M Mikhail
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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21
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Warner S, McKiernan PJ, Hartley J, Ong E, van Mourik ID, Gupte G, Abdel-Hady M, Muiesan P, Perera T, Mirza D, Sharif K, Kelly DA, Beath SV. Hepatopulmonary Syndrome in Children: A 20-Year Review of Presenting Symptoms, Clinical Progression, and Transplant Outcome. Liver Transpl 2018; 24:1271-1279. [PMID: 30066494 DOI: 10.1002/lt.25296] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) in stable patients with cirrhosis can easily be overlooked. We report on the presenting symptoms, disease progression, and outcomes after liver transplantation (LT) in children with HPS. Twenty patients were diagnosed with HPS between 1996 and 2016. The etiologies were as follows: biliary atresia (n = 9); alpha-1-antitrypsin deficiency (n = 2); cryptogenic liver disease (n = 3); and others (n = 6). HPS presentations were as follows; dyspnea (n = 17) and pneumonia (n = 3). For diagnostic confirmation, the following techniques were used: technetium-99m-labeled macroaggregated albumin lung perfusion scan (n = 13) or contrast echocardiogram (n = 7). There were 16 patients listed for LT, with a median age at HPS diagnosis of 10 years and an average wait from listing to LT of 9 weeks. A marked rise in hemoglobin (Hb; median, 125-143.5 g/L) and modest decrease in oxygen saturation (SpO2 ; median 91% to 88% room air) were evident over this time. Patients' need for assisted ventilation (1 day), pediatric intensive care unit (PICU) stay (3 days), and total hospital stay (20 days) were similar to our general LT recipients-the key difference in the postoperative period was the duration of supplementary O2 requirement. Hb of ≥130 g/L on the day of LT correlated with a longer PICU stay (P value = 0.02), duration of supplementary O2 (P value = 0.005), and the need for the latter beyond 7 days after LT (P value = 0.01). Fifteen patients had resolution of their HPS after LT. The 5-, 10-, and 20-year survival rates were unchanged at 87.5%. None had a recurrence of HPS. In conclusion, HPS is a life-threatening complication of cirrhosis which usually develops insidiously. This combined with the often-stable nature of the liver disease leads to delays in diagnosis and listing for LT. Progressive polycythemia extends the need for supplementary O2 and PICU stay. We advocate screening for HPS with a combination of SpO2 and Hb monitoring to facilitate earlier recognition, timely LT, and shortened recovery periods.
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Affiliation(s)
- Suz Warner
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom.,Centre for Liver Research and National Institute for Health Research Biomedical Research Unit in Liver Disease, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Patrick J McKiernan
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Jane Hartley
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Evelyn Ong
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Indra D van Mourik
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Girish Gupte
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Mona Abdel-Hady
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Thamera Perera
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Darius Mirza
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Khalid Sharif
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Deirdre A Kelly
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Susan V Beath
- The Liver Unit, Birmingham Women's and Children's Hospitals National Health Service Foundation Trust, Birmingham, United Kingdom
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22
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Dal Bosco A, Boeira Schedler F, Raskopf Colares J, Simões Dias A, Possa Marroni N. Hepatopulmonary Syndrome: Oxidative Stress and Physical Exercise. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10314105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) may be defined by hepatic disease, gas exchange abnormalities that may lead to hypoxaemia, and the presence of pulmonary vascular dilations. The balance between the many substances involved in vasodilation and vasoconstriction is regulated by the liver; thus, liver damage may generate systemic changes throughout the body. The pulmonary tissue may be damaged by reactive oxygen species or nitric oxide. Dyspnoea is the most frequent pulmonary symptom, caused by tissue damage, and may become worse when an individual exercises. In experimental research the surgical model of bile duct ligation is the optimal model to simulate the typical lung alterations present in HPS, which results in an increase in oxidative stress in hepatic and pulmonary tissues. In liver injury, the muscular system may also be damaged, for example sarcopenia may seriously aggravate cirrhosis and is associated with cirrhotic patient mortality. Muscular changes can be explained by the actions of myostatin and insulin-like growth factor and the increase in body levels of ammonia. As a result of impaired cardiopulmonary and muscular conditions, HPS patients may exhibit a low exercise tolerance, low muscle strength, and low functionality. Liver disease can contribute to HPS oxidative stress and is one of the main factors responsible for the reduction of gas exchange. Physical exercise can be performed as a way of modifying this pathophysiological state. Studies that have investigated physical exercise as a therapy for cirrhosis suggest that this approach may be beneficial for cirrhotic patients, primarily with regard to muscular and cardiorespiratory injuries.
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Affiliation(s)
- Adriane Dal Bosco
- Methodist University Center, Porto Alegre, Brazil; Laboratory of Experimental Hepatology and Gastroenterology, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil
| | - Filipe Boeira Schedler
- Laboratory of Experimental Hepatology and Gastroenterology, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil
| | - Josieli Raskopf Colares
- Postgraduate program in medical sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil; Laboratory of Experimental Hepatology and Gastroenterology, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil
| | - Alexandre Simões Dias
- Laboratory of Experimental Hepatology and Gastroenterology, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil; Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Norma Possa Marroni
- Postgraduate program in medical sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil; Postgraduate program in cellular and molecular biology applied to health, Lutheran University of Brazil, Canoas, Brazil; Laboratory of Experimental Hepatology and Gastroenterology, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil; Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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23
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Persistent Unexplained Dyspnea: A Case of Hepatopulmonary Syndrome. Case Rep Cardiol 2017; 2017:1469893. [PMID: 28948051 PMCID: PMC5602492 DOI: 10.1155/2017/1469893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/01/2017] [Indexed: 11/24/2022] Open
Abstract
Regarding a patient with dyspnea, the history and physical examination often lead to the correct diagnosis. In some circumstances, when more than one underlying disease is present, the diagnostic process can be more challenging. We describe an unusual case of dyspnea and persistent hypoxemia related to a hepatopulmonary syndrome in a 53-year-old patient with known heart failure and chronic liver disease. Initially managed with intravenous diuretic therapy, due to signs of lung and peripheral congestion, our patient did not improve as expected; therefore we performed more advanced studies with a chest-abdomen CT scan and a right heart catheterization. They showed, respectively, no signs of parenchymal and vasculature lung disease, a cirrhotic liver disease, splenomegaly, signs of portal hypertension, and high cardiac output with normal pulmonary vascular resistance. These results, along with the association of hypoxemia and chronic liver disease, suggested a hepatopulmonary syndrome. The diagnosis was confirmed by the demonstration of an intrapulmonary vascular dilatation with right to left shunt during a microbubble transthoracic echocardiography and a lung perfusion scan. Liver transplantation is the only successful treatment for this syndrome; however, the patient became soon unsuitable for this strategy, due to a rapid clinical deterioration.
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24
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Iqbal S, Smith KA, Khungar V. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Implications for Liver Transplantation. Clin Chest Med 2017; 38:785-795. [PMID: 29128026 DOI: 10.1016/j.ccm.2017.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) represent serious pulmonary complications of advanced liver diseases. Orthotopic liver transplantation (OLT) is capable of completely resolving the underlying abnormalities associated with HPS. On the other hand, post-OLT response in patients with PoPH is less predictable, although heavily influenced by pre-OLT mean pulmonary arterial pressure. It remains the case that the opportunity to reverse 2 potentially fatal organ dysfunctions in the liver and the lung make HPS and PoPH more than worthy for further clinical investigations.
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Affiliation(s)
- Shaz Iqbal
- Department of Medicine, General Internal Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 834 West Gates Building, Philadelphia, PA 19104, USA
| | - Vandana Khungar
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street 2 Dulles, Philadelphia, PA 19104, USA.
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Abstract
With the evolution of surgical and anesthetic techniques, liver transplantation has become "routine," allowing for modifications of practice to decrease perioperative complications and costs. There is debate over the necessity for intensive care unit admission for patients with satisfactory preoperative status and a smooth intraoperative course. Postoperative care is made easier when the liver graft performs optimally. Assessment of graft function, vigilance for complications after the major surgical insult, and optimization of multiple systems affected by liver disease are essential aspects of postoperative care. The intensivist plays a vital role in an integrated multidisciplinary transplant team.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Charlton 1145, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - David J Kramer
- Aurora Critical Care Service, 2901 W Kinnickinnic River Parkway, Milwaukee, WI 53215, USA; University of Wisconsin, School of Medicine and Public Health, 750, Highland Avenue, Madison, WI 53705, USA
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26
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Puttappa A, Sheshadri K, Fabre A, Imberger G, Boylan J, Ryan S, Iqbal M, Conlon N. Prolonged Unexplained Hypoxemia as Initial Presentation of Cirrhosis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1-6. [PMID: 28042141 PMCID: PMC5221740 DOI: 10.12659/ajcr.900530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patient: Male, 43 Final Diagnosis: Hepatopulmonary syndrome Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Anand Puttappa
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Kumaraswamy Sheshadri
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Aurelie Fabre
- Department of Histopathology, St Vincent's University Hospital, Dublin, Ireland
| | - Georgina Imberger
- Department of Anaesthesia and Pain Medicine, Western Health, Melbourne, Australia
| | - John Boylan
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Silke Ryan
- Department of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Masood Iqbal
- Department of Hepatology, St Vincent's University Hospital, Dublin, Ireland
| | - Niamh Conlon
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
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27
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Orozco-Delgado M, López-Cantero M, Zampella V, Vicente R, Galán J. Predictors of mortality and early detection strategies for hepatopulmonary syndrome in liver transplant patients. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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28
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Factores predictores de mortalidad y estrategias de detección precoz de síndrome hepatopulmonar en pacientes trasplantados hepáticos. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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29
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Lei JH, Tian Y, Luo HY, Chen Z, Peng F. Guillain-Barré syndrome following acute co-super-infection of hepatitis E virus and cytomegalovirus in a chronic hepatitis B virus carrier. J Med Virol 2016; 89:368-372. [PMID: 27358107 DOI: 10.1002/jmv.24620] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/18/2022]
Abstract
Guillain-Barré syndrome (GBS) is a rare neurological complication of hepatitis B. GBS presence in acute hepatitis E virus (HEV) and cytomegalovirus (CMV) infection is also sporadically reported. Here, a rare case of GBS in a chronic Hepatitis B virus carrier co-infected with HEV and CMV was reported. Based on the analysis on the progress of the manifestations and virus serological detection results, it could be concluded that GBS might mostly likely result from super-infection of HEV and CMV. This case report is clinically important in that it provides a good example of differential diagnosis and appropriate treatment on such a rare but life-threatening case. J. Med. Virol. 89:368-372, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jian-Hua Lei
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Yi Tian
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Hong-Yu Luo
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Zi Chen
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Feng Peng
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
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30
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Predictors of mortality and early detection strategies for hepatopulmonary syndrome in liver transplant patients☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644040-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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31
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Abstract
Objective: To investigate bilirubin-induced lung alveolar epithelial cell injury together with the protection afforded by dexmedetomidine. Design: Prospective, randomized, controlled study. Setting: Research laboratory. Subjects: Sprague Dawley rats. Interventions: Alveolar epithelial A549 cell lines were cultured and received bilirubin (from 0 to 160 μM) to explore the protective pathway of dexmedetomidine on bilirubin-induced alveolar epithelial cell injury assessed by immunochemistry and flow cytometry. Sprague-Dawley rats were subjected to common bile duct ligation surgery to explore the protective effect of dexmedetomidine on hyperbilirubinemia-induced alveolar epithelial cell injury and respiratory failure in comparison with the Sham (subjected to the surgery procedure but without bile duct ligation) or dexmedetomidine control (only received intraperitoneal injection of dexmedetomidine). Measurements and Main Results: In vitro, dexmedetomidine reversed the collapse of mitochondrial membrane potential (Δψm), upregulation of cytochrome C, B cell leukemia 2 associated X protein, and cleaved-caspase 3 and 9 in A549 epithelial cells with bilirubin challenge. Furthermore, dexmedetomidine reversed the arrest of cell cycle and the downregulation of the transforming growth factorβ, phosphorylated mammalian target of rapamycin, and p42/44 mitogen-activated protein kinase induced by bilirubin. In vivo, pulmonary edema and inflammation were found after common bile duct ligation. Bilirubin and Paco2 were significantly increased, and oxygen (Pao2) was significantly decreased in the blood of common bile duct ligation rats from the postsurgery day 7 to day 21 when compared with those in the sham controls, respectively (p < 0.01). Daily intraperitoneal injection of dexmedetomidine significantly alleviated the lung edema and injury and prevented respiratory failure. Conclusion: Our data both in vitro and in vivo demonstrated that dexmedetomidine protected alveolar epithelial cell from bilirubin-induced injury. Dexmedetomidine may be a good choice of anesthetic/sedative for patients with chronic liver disease during the perioperative period.
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32
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Abstract
Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. Apart from the liver, this may involve the heart, lungs, kidneys, the immune system, the adrenal glands, and other organ systems. As the disease progresses, the circulation becomes hyperdynamic, and signs of cardiac, pulmonary, and renal dysfunction are observed, in addition to reduced survival. Infections and an altered cardiac function known as cirrhotic cardiomyopathy may be precipitators for the development of other complications such as hepatorenal syndrome. In patients with chronic organ dysfunction, various precipitating events may induce an acute-on-chronic renal failure and acute-on-chronic liver failure that negatively affect the prognosis. Future research on the pathophysiologic mechanisms of the complications and the precipitating factors is essential to understand the basics of the treatment of these challenging conditions. The aim of the present review is to focus on the development and precipitating factors of various organ failures in patients with decompensated cirrhosis.
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