Respiratory muscle strength, hypoxemia and dyspnea in liver cirrhosis patients

The Relationship Between Airway Occlusion Pressure and Severity of liver Cirrhosis in Candidates for Liver Transplantation

BACKGROUND End-stage cirrhosis is an irreversible condition, and liver transplantation is the only treatment option in for the affected patients. Respiratory problems and abnormal breathing are common findings among these patients. In this study, for the first time, we examined the relationship between the severity of liver cirrhosis and respiratory drive measured by mouth occlusion pressure (P_0.1). METHODS This was a cross-sectional study conducted on 50 candidates for liver transplantation who were referred to the pulmonary clinic of Imam Khomeini Hospital for pre-operative pulmonary evaluations. Arterial blood gas analysis (ABG), pulmonary function tests, and measurement of P0.1 were performed for all patients. The severity of liver disease was assessed using the Model for End-Stage Liver Disease (MELD) score. RESULTS The median P_0.1 was 5 cm H₂ O. P_0.1 was negatively associated with PaCO₂ (r = -0.466, p = 0.001) and HCO3 - (r = -0.384, p = 0.007), and was positively correlated with forced expiratory volume at 1s (FEV1 )/ forced vital capacity (FVC) (r = 0.282, p = 0.047). There was a strong correlation between P_0.1 and MELD score (r = 0.750, p < 0.001). Backward multivariate linear regression revealed that a higher MELD score and lower PaCO₂ were associated with increased P_0.1. CONCLUSION High levels of P_0.1 and strong direct correlation between P_0.1 and MELD score observed in the present study are suggestive of the presence of abnormal increased respiratory drive in candidates for liver transplantation, which is closely related to their disease severity.

Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis

BACKGROUND:

End-stage liver disease is a common cause of morbidity and mortality worldwide, yet little is known about its symptomatology and impact on health-related quality of life.

AIM:

To describe symptom prevalence and health-related quality of life of patients with end-stage liver disease to improve care.

DESIGN:

Systematic review.

DATA SOURCES:

We searched eight electronic databases from January 1980 to June 2018 for studies investigating symptom prevalence or health-related quality of life of adult patients with end-stage liver disease. No language restrictions were applied. Meta-analyses were performed where appropriate.

RESULTS:

We included 80 studies: 35 assessing symptom prevalence, 41 assessing health-related quality of life, and 4 both. The instruments assessing symptoms varied across studies. The most frequently reported symptoms were as follows: pain (prevalence range 30%–79%), breathlessness (20%–88%), muscle cramps (56%–68%), sleep disturbance (insomnia 26%–77%, daytime sleepiness 29.5%–71%), and psychological symptoms (depression 4.5%–64%, anxiety 14%–45%). Erectile dysfunction was prevalent (53%–93%) in men. The health-related quality of life of patients with end-stage liver disease was significantly impaired when compared to healthy controls or patients with chronic liver disease. Compared with compensated cirrhosis, decompensation led to significant worsening of both components of the 36-Item Short Form Survey although to a larger degree for the Physical Component Summary score (decrease from average 6.4 (95% confidence interval: 4.0–8.8); p < 0.001) than for the Mental Component Summary score (4.5 (95% confidence interval: 2.4–6.6); p < 0.001).

CONCLUSION:

The symptom prevalence of patients with end-stage liver disease resembled that of patients with other advanced conditions. Given the diversity of symptoms and significantly impaired health-related quality of life, multidisciplinary approach and timely intervention are crucial.

Hepatopulmonary Syndrome: Oxidative Stress and Physical Exercise

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.

Association Between Dyspnea and Severity of Liver Disease in Patients in the Pre-transplantation Period-A Pilot Study

BACKGROUND

Liver transplantation is indicated at the end stage of chronic liver failure, and severity of disease will determine the precocity of this happening. At this stage, the presence of chronic dyspnea is one of several manifestations of progression of the disease, which leads the patient to inactivity. A rehabilitation program can positively influence the evolution of liver transplant recipients. The objective of this study was to establish an association between the perception of dyspnea and the severity of liver disease in patients at a single center of a Brazilian liver pre-transplantation clinic.

METHODS

Measurements were performed at a liver pre-transplantation clinic. The severity of liver disease was assessed with the use of the Model for End-Stage Liver Disease (MELD) score, and dyspnea was assessed with the use of a modified Medical Research Council scale of dyspnea (mMRC).

RESULTS

Men had a higher prevalence of viral hepatitis. Dyspnea was reported only during intense exercise. Duration of disease and MELD score showed medians of 49 months and 20, respectively.

CONCLUSIONS

We found no correlation between mMRC and the MELD score. In addition, no correlation was found between duration of disease and MELD score or mMRC.