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Suparschi V, Le Bihan E, Toussaint A, Saptefrat D, Ben Abdallah H, Gloulou F, Aouati F, Gauss T, Paugam-Burtz C. Noninvasive assessment of Cardiac Index using impedance cardiography during liver transplantation surgery: a comparison with pulmonary artery thermodilution. Minerva Anestesiol 2018; 85:28-33. [PMID: 29745622 DOI: 10.23736/s0375-9393.18.12391-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Liver transplantation (LT) is a high-risk surgery associated with significant hemodynamic changes requiring advanced hemodynamic monitoring. Pulmonary Artery Catheter (PAC) is still considered as a gold-standard for Cardiac Index (CI) measurement during LT despite association with an increased risk of complications. Noninvasive impedance cardiography (ICG) could be an interesting alternative tool for CI monitoring. The aim of this study was to compare the precision and trending ability of ICG versus PAC methods during LT. METHODS Patients undergoing LT were prospectively included. CI was measured with PAC and ICG at 4 time points (T1: before surgical incision, T2: during anhepatic phase, T3: after portal reperfusion, T4: during wound closure). Bias and percentage error (PE) between CI measured with PAC and ICG were analyzed with the Bland-Altman method for repeated measurements. Trending ability was studied with 4-quadrant and polar plots and correlation coefficient. RESULTS We included 43 patients with 156 measures. Mean bias was -0.95 L.min-1.m-2, SD±1.07, limits of agreement -3.73 to 1.83 L.min-1.m-2 and PE 58%. There was a significant increase in bias during LT (P<0.001). Assessment of trending ability displayed a concordance rate of 72% on the 4-quadrant plot and a mean angular bias of -8.4° (SD±28°) and radial limits of agreement ±55° on the polar plot. CONCLUSIONS CI measurements using ICG exhibited a low precision and a poor trending ability when compared to thermodilution method during LT. Consequently, ICG is not an adequate hemodynamic tool to monitor CI during LT.
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Affiliation(s)
- Vlad Suparschi
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France -
| | - Eric Le Bihan
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Amélie Toussaint
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Diana Saptefrat
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Heykel Ben Abdallah
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Faouzi Gloulou
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Farida Aouati
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Tobias Gauss
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Catherine Paugam-Burtz
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France.,Denis Diderot University, PRES Sorbonne Paris Cité, Paris, France.,Inserm UMR-S1149, Center for Research on Inflammation, Paris, France
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2
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Schmid PM, Bouazzaoui A, Doser K, Schmid K, Hoffmann P, Schroeder JA, Riegger GA, Holler E, Endemann DH. Endothelial dysfunction and altered mechanical and structural properties of resistance arteries in a murine model of graft-versus-host disease. Biol Blood Marrow Transplant 2014; 20:1493-500. [PMID: 24813168 DOI: 10.1016/j.bbmt.2014.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 05/01/2014] [Indexed: 12/17/2022]
Abstract
A putative involvement of the vasculature seems to play a critical role in the pathophysiology of graft-versus-host disease (GVHD). We aimed to characterize alterations of mesenteric resistance arteries in GVHD in a fully MHC-mismatched model of BALB/c mice conditioned with total body irradiation that underwent transplantation with bone marrow cells and splenocytes from syngeneic (BALB/c) or allogeneic (C57BL/6) donors. After 4 weeks, animals were sacrificed and mesenteric resistance arteries were studied in a pressurized myograph. The expression of endothelial (eNOS) and inducible nitric oxide (NO)-synthase (iNOS) was quantified and vessel wall ultrastructure was investigated with electron microscopy. The myograph study revealed an endothelial dysfunction in allogeneic-transplant recipients, whereas endothelium-independent vasodilation was similar to syngeneic-transplant recipients or untreated controls. The expression of eNOS was decreased and iNOS increased, possibly contributing to endothelial dysfunction. Additionally, arteries of allogeneic transplant recipients exhibited a geometry-independent increase in vessels strain. For both findings, electron microscopy provided a structural correlate by showing severe damage of the whole vessel wall in allogeneic-transplant recipient animals. Our study provides further data to prove, and is the first to characterize, functional and structural vascular alterations in the early course after allogeneic transplantation directly in an ex vivo setting and, therefore, strongly supports the hypothesis of a vascular form of GVHD.
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Affiliation(s)
- Peter M Schmid
- Medical Clinic 2, Cardiology, University Hospital Regensburg, Germany.
| | | | - Kristina Doser
- Medical Clinic 3, Hematology/Oncology, University Hospital Regensburg, Germany
| | - Karin Schmid
- Medical Clinic 3, Hematology/Oncology, University Hospital Regensburg, Germany
| | - Petra Hoffmann
- Medical Clinic 3, Hematology/Oncology, University Hospital Regensburg, Germany
| | | | - Guenter A Riegger
- Medical Clinic 2, Cardiology, University Hospital Regensburg, Germany
| | - Ernst Holler
- Medical Clinic 3, Hematology/Oncology, University Hospital Regensburg, Germany
| | - Dierk H Endemann
- Medical Clinic 2, Cardiology, University Hospital Regensburg, Germany
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3
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Parkash O, Iqbal R, Jafri F, Azam I, Jafri W. Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan. BMC Res Notes 2012. [PMID: 22905795 DOI: 10.1186/1556-0500.5.446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cirrhosis produces variety of symptoms which eventually lead to a negative impact on Health Related Quality of Life (HRQOL). The general aim of this study was to evaluate the magnitude of poor HRQOL and to assess factors related with HRQOL in patients with CLD in Pakistan. FINDINGS This was a cross sectional study conducted in gastroenterology outpatient clinics of Aga Khan University Hospital, Karachi on adult patients with cirrhosis. In this study chronic liver disease questionnaire (CLDQ) was used to assess HRQOL of these patients and CLDQ score was used as an outcome measure to determine factors related with HRQOL.273 participants were recruited in the study; 155 (57%) were males. Mean age of participants was 49 ± 11 years. The most common cause for cirrhosis was viral infection 247(91.5%). Mean Model for End Stage Liver Disease (MELD) score was 12.6 ± 6.8 and 2/3 of patients 209 (76.6%) had advanced cirrhosis in Child Turcot Pugh (CTP) B or C stage. Poor HRQOL was seen in 187(69%; 95% C.I.: 63%, 74%) of the participants. Mean CLDQ score was 4.36 ± 1.1. Amongst all of the domains, fatigue domain had lower CLDQ score. Hemoglobin (β = 0.09 [SE = 0.04]), Albumin (β = 0.32[SE = 0.09]), Diastolic Blood Pressure (DBP) (β = 0.01[0.005) prior history of decompensation (β = 0.98[SE = 0.39] were significant factors associated with HRQOL in patients with liver cirrhosis. CONCLUSION Frequency of poor health related quality of life determined by CLDQ score is high in patients with liver cirrhosis. Hemoglobin, serum albumen, prior history of decompensation (like encephalopathy and upper gastro intestinal bleed), are associated with health related quality of life.
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Affiliation(s)
- Om Parkash
- Department of Medicine, Aga Khan University Karachi, Karachi, Pakistan
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4
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Parkash O, Iqbal R, Jafri F, Azam I, Jafri W. Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan. BMC Res Notes 2012; 5:446. [PMID: 22905795 PMCID: PMC3542150 DOI: 10.1186/1756-0500-5-446] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 08/10/2012] [Indexed: 12/16/2022] Open
Abstract
Background Cirrhosis produces variety of symptoms which eventually lead to a negative impact on Health Related Quality of Life (HRQOL). The general aim of this study was to evaluate the magnitude of poor HRQOL and to assess factors related with HRQOL in patients with CLD in Pakistan. Findings This was a cross sectional study conducted in gastroenterology outpatient clinics of Aga Khan University Hospital, Karachi on adult patients with cirrhosis. In this study chronic liver disease questionnaire (CLDQ) was used to assess HRQOL of these patients and CLDQ score was used as an outcome measure to determine factors related with HRQOL. 273 participants were recruited in the study; 155 (57%) were males. Mean age of participants was 49 ± 11 years. The most common cause for cirrhosis was viral infection 247(91.5%). Mean Model for End Stage Liver Disease (MELD) score was 12.6 ± 6.8 and 2/3 of patients 209 (76.6%) had advanced cirrhosis in Child Turcot Pugh (CTP) B or C stage. Poor HRQOL was seen in 187(69%; 95% C.I.: 63%, 74%) of the participants. Mean CLDQ score was 4.36 ±1.1. Amongst all of the domains, fatigue domain had lower CLDQ score. Hemoglobin (β = 0.09 [SE = 0.04]), Albumin (β = 0.32[SE = 0.09]), Diastolic Blood Pressure (DBP) (β = 0.01[0.005) prior history of decompensation (β = 0.98[SE = 0.39] were significant factors associated with HRQOL in patients with liver cirrhosis. Conclusion Frequency of poor health related quality of life determined by CLDQ score is high in patients with liver cirrhosis. Hemoglobin, serum albumen, prior history of decompensation (like encephalopathy and upper gastro intestinal bleed), are associated with health related quality of life.
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Affiliation(s)
- Om Parkash
- Department of Medicine, Aga Khan University Karachi, Karachi, Pakistan
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5
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Blanco-Rivero J, Márquez-Rodas I, Sastre E, Cogolludo A, Pérez-Vizcaíno F, del Campo L, Nava MP, Balfagón G. Cirrhosis decreases vasoconstrictor response to electrical field stimulation in rat mesenteric artery: role of calcitonin gene-related peptide. Exp Physiol 2010; 96:275-86. [PMID: 21148625 DOI: 10.1113/expphysiol.2010.055822] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Our study determines alterations in the vasoconstrictor response elicited by electric field stimulation (EFS) in mesenteric arteries from cirrhotic rats treated with CCl(4), and how calcitonin gene-related peptide (CGRP) participates in this response. Vasoconstriction induced by EFS was analysed in the absence and presence of the CGRP receptor antagonist CGRP(8-37) in arterial segments from control and cirrhotic rats. The vasodilator response to exogenous CGRP was tested in both groups of rats, and the interference of the guanylate cyclase inhibitor ODQ or the K(ATP) channel blocker glibenclamide was analysed only in segments from cirrhotic rats. The vasodilator response to the K(ATP) channel opener pinacidil and to 8-bromo-cyclic GMP was tested. The K(ATP) currents were recorded using the patch-clamp technique. Expression of receptor activity-modifying protein 1 (RAMP1), calcitonin receptor-like receptor, Kir 6.1 and sulfonylurea receptor 2B (SUR2B) was also analysed. Release of CGRP and cGMP was measured. The EFS-elicited vasoconstriction was less in segments from cirrhotic rats. The presence of CGRP(8-37) increased the EFS-induced response only in segments from cirrhotic rats. The CGRP-induced vasodilatation was greater in segments from cirrhotic rats, and was inhibited by ODQ or glibenclamide. Both pinacidil and 8-bromo-cyclic GMP induced a stronger vasodilator response in segments from cirrhotic rats. Pinacidil induced greater K(ATP) currents in cirrhotic myocytes. Expression of RAMP1, calcitonin receptor-like receptor, Kir 6.1 and SUR2B was not modified by liver cirrhosis. Liver cirrhosis increased CGRP release, but did not modify cGMP formation. The decreased vasoconstrictor response to EFS in cirrhosis is mediated by increased vasodilator response to CGRP, as well as increased K(ATP) channel gating. This effect of CGRP may play a role in the splanchnic vasodilatation present in liver cirrhosis.
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Affiliation(s)
- Javier Blanco-Rivero
- Departamento de Fisiología, Facultad de Medicina, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 4, 28029 Madrid, Spain
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6
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Abstract
PURPOSE OF REVIEW Patients with cirrhosis have total extracellular fluid overload but central effective circulating hypovolaemia. The resulting neurohumoral compensatory response favours the accumulation of fluids into the peritoneal cavity (ascites) and may hinder renal perfusion (hepatorenal syndrome). Their deranged systemic haemodynamics (hyperdynamic circulatory syndrome) is characterized by elevated cardiac output with decreased systemic vascular resistance and low blood pressure. RECENT FINDINGS Molecular and biological mechanisms determining cirrhosis-induced haemodynamic alterations are progressively being elucidated. The need for a goal-directed assessment of volume resuscitation (especially with volumetric techniques) in patients with cirrhosis is becoming more and more evident. The role of fluid expansion with albumin and the use of splanchnic vasopressors in a variety of cirrhosis-related conditions has recently been investigated. SUMMARY The response to fluid loading in patients with advanced cirrhosis is abnormal, primarily resulting in expansion of their noncentral blood volume compartment. Colloid solutions, in particular albumin, are best used in these patients. Albumin may be effective in preventing the haemodynamic derangements associated with large-volume paracentesis (paracentesis-induced circulatory dysfunction), in preventing renal failure during spontaneous bacterial peritonitis and, in association with splanchnic vasopressors, in caring for patients with the hepatorenal syndrome.
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7
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Carreño FR, Ji LL, Cunningham JT. Altered central TRPV4 expression and lipid raft association related to inappropriate vasopressin secretion in cirrhotic rats. Am J Physiol Regul Integr Comp Physiol 2008; 296:R454-66. [PMID: 19091909 DOI: 10.1152/ajpregu.90460.2008] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Inappropriate vasopressin (AVP) release causes dilutional hyponatremia in many pathophysiological states such as cirrhosis. The central molecular mechanisms that mediate inappropriate AVP release are unknown. We tested the hypothesis that changes in the expression or trafficking of TRPV4 in the central nervous system may contribute to inappropriate AVP release in the bile duct ligation (BDL) model of cirrhosis in the rat. Four weeks after surgery, BDL rats demonstrated significantly increased plasma vasopressin and plasma renin activity (PRA), hypervolemia, and decreased plasma osmolality. These effects were blocked by providing BDL rats with 2% saline to drink for 15 days. TRPV4 protein expression was significantly increased in brain punches from BDL rats containing the supraoptic nucleus (SON) of the hypothalamus (100% +/- 11 to 157% +/- 4.8), and this effect was blocked in BDL rats given saline. Immunohistochemistry demonstrated a significant increase in TRPV4-positive cells and the percentage of AVP neurons that also were TRPV4-positive in the SON of BDL rats. In the hypothalamus of BDL rats, TRPV4 lipid raft association increased compared with sham (from 100% +/- 2.1 to 326.1% +/- 16). This effect was significantly attenuated in BDL rats given 2% saline to drink (174% +/- 11). In the brain stem, TRPV4 lipid raft association was reduced by BDL and inversely related to plasma AVP and PRA. We speculate that changes in TRPV4 expression and compartmentalization within lipid rafts could contribute to a feed-forward mechanism related to AVP release in cirrhosis.
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Affiliation(s)
- Flávia Regina Carreño
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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8
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Vasopressin analogues in the treatment of hepatorenal syndrome and gastrointestinal haemorrhage. Best Pract Res Clin Anaesthesiol 2008; 22:335-50. [DOI: 10.1016/j.bpa.2008.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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9
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Saner FH, Canbay A, Gerken G, Broelsch CE. Pharmacology, clinical efficacy and safety of terlipressin in esophageal varices bleeding, septic shock and hepatorenal syndrome. Expert Rev Gastroenterol Hepatol 2007; 1:207-17. [PMID: 19072411 DOI: 10.1586/17474124.1.2.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Terlipressin, a vasopressin agonist, is a commonly used drug with different indications, particularly in patients with end-stage liver disease. As a V(1) receptor agonist, it increases systemic vascular resistance, particularly in the splanchnic area, resulting in a decrease of portal pressure. Besides the approved use for variceal bleeding, terlipressin also has beneficial effects in the treatment of hepatorenal syndrome and norepinephrine-resistant septic shock. In patients with cirrhosis and variceal bleeding, the use of terlipressin reduces the portal vein pressure and decreases the pressure in esophageal varices. This can save lives when skilled endoscopists are not immediately available. Hepatorenal syndrome is associated with vasodilation in the mesenteric circulation with arterial underfilling and consecutive renal vasoconstriction. Restoration of an effective arterial blood volume can be achieved by the combination of terlipressin and volume expansion. In some cases, a success rate of up to 75% is reported. The early use of terlipressin in catecholamine-resistant shock can improve organ perfusion.
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Affiliation(s)
- Fuat H Saner
- University Essen, Department of General, Visceral and Transplant Surgery, Hufelandstr. 55, 45122 Essen, Germany.
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10
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Glaser SS, Ueno Y, DeMorrow S, Chiasson VL, Katki KA, Venter J, Francis HL, Dickerson IM, DiPette DJ, Supowit SC, Alpini GD. Knockout of alpha-calcitonin gene-related peptide reduces cholangiocyte proliferation in bile duct ligated mice. J Transl Med 2007; 87:914-26. [PMID: 17618297 DOI: 10.1038/labinvest.3700602] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The role of sensory innervation in the regulation of liver physiology and the pathogenesis of cholestatic liver disease are undefined. Biliary proliferation has been shown to be coordinately controlled by parasympathetic and sympathetic innervation of the liver. The aim of our study was to address the role of the sensory neuropeptide calcitonin gene-related peptide (alpha-CGRP) in the regulation of cholangiocyte proliferation during cholestasis induced by extrahepatic bile duct obstruction (BDL). Our study utilized a knockout (KO) mouse model, which lacks the sensory neuropeptide alpha-CGRP. Wild-type (WT) and alpha-CGRP KO mice were subjected to sham surgery or BDL for 3 and 7 days. In addition, immediately after BDL, WT and KO mice were administered the CGRP receptor antagonist (CGRP(8-37)) for 3 and 7 days by osmotic minipumps. Liver sections and isolated cholangiocytes were evaluated for proliferation markers. Isolated WT BDL (3 days) cholangiocytes were stimulated with alpha- and beta-CGRP and evaluated for proliferation and cAMP-mediated signaling. Lack of alpha-CGRP inhibits cholangiocyte proliferation induced by BDL at both 3 and 7 days. BDL-induced cholangiocyte proliferation in WT mice was associated with increases of circulating alpha-CGRP levels. In vitro, alpha- and beta-CGRP stimulated proliferation in purified BDL cholangiocytes, induced elevation of cAMP levels, and stimulated the activation of cAMP-dependent protein kinase A and cAMP response element binding protein DNA binding. In conclusion, sensory innervation of the liver and biliary expression of alpha-CGRP play an important role in the regulation of cholangiocyte proliferation during cholestasis.
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Affiliation(s)
- Shannon S Glaser
- Department of Medicine, Scott & White Hospital, The Texas A&M University System Health Science Center, College of Medicine, Temple, TX 76504, USA
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11
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Milani A, Zaccaria R, Bombardieri G, Gasbarrini A, Pola P. Cirrhotic cardiomyopathy. Dig Liver Dis 2007; 39:507-15. [PMID: 17383244 DOI: 10.1016/j.dld.2006.12.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2006] [Revised: 12/04/2006] [Accepted: 12/11/2006] [Indexed: 12/11/2022]
Abstract
Decompensated liver cirrhosis is characterized by a peripheral vasodilation with a low-resistance hyperdynamic circulation. The sustained increase of cardiac work load associated with such a condition may result in an inconstant and often subclinical series of heart abnormalities, constituting a new clinical entity known as "cirrhotic cardiomyopathy". Cirrhotic cardiomyopathy is variably associated with baseline increase in cardiac output, defective myocardial contractility and lowered systo-diastolic response to inotropic and chronotropic stimuli, down-regulated beta-adrenergic function, slight histo-morphological changes, and impaired electric "recovery" ability of ventricular myocardium. Cirrhotic cardiomyopathy is usually clinically latent or mild, likely because the peripheral vasodilation significantly reduces the left ventricle after-load, thus actually "auto-treating" the patient and masking any severe manifestation of heart failure. In cirrhotic patients, the presence of cirrhotic cardiomyopathy may become unmasked and clinically evident by certain treatment interventions that increase the effective blood volume and cardiac pre-load, including surgical or transjugular intrahepatic porto-systemic shunts, peritoneo-venous shunts (LeVeen) and orthotopic liver transplantation. Under these circumstances, an often transient overt congestive heart failure may develop, with increased cardiac output as well as right atrial, pulmonary artery and capillary wedge pressures.
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Affiliation(s)
- A Milani
- Department of Internal Medicine, Catholic University of Rome, Italy.
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12
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Parrilli G, Manguso F, Orsini L, Coccoli P, Vecchione R, Terracciano L, De Luca N, Cirillo N, Abazia C, Budillon G, Marchesini G. Essential hypertension and chronic viral hepatitis. Dig Liver Dis 2007; 39:466-72. [PMID: 17369113 DOI: 10.1016/j.dld.2007.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 12/04/2006] [Accepted: 01/03/2007] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Both arterial hypertension and chronic hepatitis are common disorders. The relationship between arterial pressure and liver cirrhosis has been extensively studied, but no studies are available in chronic hepatitis (CH). Recently, a few studies have reported that treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs), commonly used in arterial hypertension, reduce hepatic fibrosis in patients with viral CH and in nonalcoholic steatohepatitis. This study was aimed at comparing the evolution of post-viral CH in patients with/without concomitant essential hypertension. METHODS Two sets of observations were carried out: (a) a cross-sectional cohort study of 95 patients with viral CH, to compare the severity of histological and biochemical data at diagnosis, in relation to pharmacologically treated essential hypertension, and (b) a retrospective study with the observation of 254 patients with CH of viral etiology, followed up from 2 to 20 years, to establish the natural history of viral CH in relation to treated essential hypertension. RESULTS In the cross-sectional analysis, patients with treated hypertension had a significantly older age at diagnosis of CH (51.4 +/- 8.4 years vs. 46.2 +/- 12.2 in normotensive; P < 0.001) and histological evidence of less severe necro-inflammatory liver damage. ALT levels were also lower (109.8 +/- 62.5 U/L vs. 166.0+/-169.5 in normotensive; P < 0.001) as were endothelin-1 levels (0.74 +/- 0.97 vs. 1.77 +/- 1.51 fmol/mL; P < 0.001). The retrospective study confirmed an older age at diagnosis in patients with treated hypertension (48.7 +/- 9.8 vs. 41.9 +/- 11.8 years; P < 0.001) and lower death rates (2.2% vs. 11%; P < 0.05). CONCLUSIONS The evolution of post-viral CH seems to be less severe in subjects with essential hypertension, possibly in relation to treatment with antihypertensive drugs.
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Affiliation(s)
- G Parrilli
- Department of Clinical Medicine, Naples, Italy.
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13
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Abstract
Patients with cirrhosis and portal hypertension exhibit characteristic cardiovascular and pulmonary hemodynamic changes. A vasodilatatory state and a hyperdynamic circulation affecting the cardiac and pulmonary functions dominate the circulation. The recently defined cirrhotic cardiomyopathy may affect systolic and diastolic functions, and imply electromechanical abnormalities. In addition, the baroreceptor function and regulation of the circulatory homoeostasis is impaired. Pulmonary dysfunction involves diffusing abnormalities with the development of the hepatopulmonary syndrome and portopulmonary hypertension in some patients. Recent research has focused on the assertion that the hemodynamic and neurohumoral dysregulation are of major importance for the development of the cardiovascular and pulmonary complications in cirrhosis. This aspect is important to take into account in the management of these patients.
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14
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Arnal D, Garutti I, Perez-Peña J, Olmedilla L, Tzenkov IG. Radial to femoral arterial blood pressure differences during liver transplantation. Anaesthesia 2005; 60:766-71. [PMID: 16029225 DOI: 10.1111/j.1365-2044.2005.04257.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This observational study compared femoral and radial arterial blood pressure in 72 patients undergoing liver transplant surgery. Simultaneous femoral and radial arterial blood pressures, cardiac index, core temperature and vasoconstrictor therapy were recorded at seven time points during the operation. No significant differences between radial and femoral pressures were found at the start of surgery. Femoral and radial systolic arterial blood pressures were statistically significantly different during liver reperfusion (mean (SD) arterial pressure = 92 (22) mmHg vs. 76 (22) mmHg, p < 0.01). Mean arterial blood pressures showed no statistically significant differences throughout the study. Vasoconstrictor drug administration was associated with a larger systolic pressure difference between femoral and radial arteries (28 (24) mmHg in patients being given vasoconstrictor drugs vs. 9 (19) mmHg in patients not needing vasoconstrictors during reperfusion, p < 0.001). In conclusion, differences in systolic arterial blood pressure occur between femoral and radial arterial monitoring sites during liver reperfusion, and in particular in patients being given vasoconstrictor therapy. Thus, if femoral arterial monitoring is not available, clinicians should rely on mean rather than systolic arterial pressure measurements from a radial artery catheter during liver transplantation.
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Affiliation(s)
- D Arnal
- Department of Anaesthesia and Reanimation, Hospital General Universitario, Gregorio Marañón, Madrid, Spain.
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15
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Ginès P, Terra C, Torre A, Guevara M. [Role of albumin in the treatment of hepatorenal syndrome in cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:80-4. [PMID: 15710088 DOI: 10.1157/13070706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- P Ginès
- Unidad de Hepatología, Institut de Malalties Digestives, Hospital Clínic, Barcelona, Spain.
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16
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Henriksen JH. Volume adaptation in chronic liver disease: on the static and dynamic location of water, salt, protein and red cells in cirrhosis. Scandinavian Journal of Clinical and Laboratory Investigation 2005; 64:523-33. [PMID: 15370457 DOI: 10.1080/00365510410002788] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adequate size and distribution of the circulating medium are important for cardiovascular function, tissue oxygenation and fluid homoeostasis. Patients with cirrhosis have an abnormal distribution of increased blood volume, increased total vascular compliance and increased arterial compliance. The pattern and temporal relations of plasma and blood volume expansion are important for pathophysiological, diagnostic and therapeutic purposes and depend highly on the type of load (water, saline, oncotic material, red blood cells). In some aspects patients with cirrhosis respond differently from healthy subjects. Thus the reaction during volume expansion may be somewhat blunted, and in advanced cirrhosis, the non-central parts of the circulation in particular, including the splanchnic blood volume, are expanded by a volume load. The use of vasoactive drugs has provided important information on the changes in haemodynamic and homoeostatic mechanisms in patients with cirrhosis. Infusion of oncotic material (preferably albumin) may prevent circulatory dysfunction during certain types of stress. Volume expansion in advanced cirrhosis is qualitatively and quantitively different from that of healthy subjects and those with early cirrhosis. Timely volume handling is essential, but difficult as it is a balance between hypovolaemia and excess extravascular volume loading with further circulatory dysfunction in these patients with a hyperdynamic, but hyporeactive circulation.
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Affiliation(s)
- J H Henriksen
- Department of Clinical Physiology 239, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
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Kojima H, Sakurai S, Uemura M, Satoh H, Nakashima T, Minamino N, Kangawa K, Matsuo H, Fukui H. Adrenomedullin contributes to vascular hyporeactivity in cirrhotic rats with ascites via a release of nitric oxide. Scand J Gastroenterol 2004; 39:686-93. [PMID: 15370692 DOI: 10.1080/00365520410005306] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Plasma levels of adrenomedullin, a potent vasodilator peptide, are increased in cirrhotic patients, whereas its role in vascular hyporeactivity in cirrhosis has not been clarified. METHODS Adrenomedullin expression was evaluated by radioimmunoassay and reverse-transcription polymerase chain reaction. Vascular reactivity to phenylephrine, alpha-adrenoceptor agonist, was investigated in the aortic rings from control rats and CCl-induced cirrhotic rats with ascites in the presence of the neutralizing antibody against adrenomedullin, human adrenomedullin and/or N-nitro-L-arginine methyl ester, a nitric oxide synthase inhibitor. RESULTS Plasma adrenomedullin levels were significantly higher in cirrhotic rats than in controls (16.3 +/- 2.9 versus 7.4 +/- 1.7 fmol/mL, P < 0.05) and correlated negatively with systemic arterial pressure (r = -0.62, P < 0.05). Gene expression of adrenomedullin in various organs (liver, kidney, lung) and vessels (portal vein, aorta) was enhanced in cirrhotic rats compared with controls. Neutralizing antibody against adrenomedullin ameliorated the blunted contractile response to phenylephrine in cirrhotic aorta (Rmax: 1.5 +/- 0.1 versus 1.0 +/- 0.1 g/mg tissue, P < 0.05), whereas contraction remained unchanged in control aorta (Rmax: 1.9 +/- 0.2 versus 1.9 +/- 0.2 g/mg tissue). Intravenous infusion of human adrenomedullin induced a reduction of mean arterial pressure together with an increase of serum nitrate levels, which was abolished by neutralizing antibody against adrenomedullin. Human adrenomedullin caused a blunted contractile response to phenylephrine in both control and cirrhotic aortas, which was not observed in the presence of N-nitro-L-arginine methyl ester. CONCLUSIONS These findings indicate that the overproduction of adrenomedullin may contribute to vascular hyporeactivity in cirrhosis via a release of nitric oxide.
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Affiliation(s)
- H Kojima
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
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Salerno F, Cazzaniga M, Pagnozzi G, Cirello I, Nicolini A, Meregaglia D, Burdick L. Humoral and cardiac effects of TIPS in cirrhotic patients with different "effective" blood volume. Hepatology 2003; 38:1370-7. [PMID: 14647047 DOI: 10.1016/j.hep.2003.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The aim of this study was to evaluate the cardiac effects of transjugular intrahepatic portosystemic shunts (TIPS) in cirrhotic patients with different effective blood volume. Two-dimensional echocardiography was performed before and 7 and 28 days after TIPS insertion in 7 cirrhotic patients with PRA <4 ng/mL/h (group A, normal effective blood volume) and 15 with PRA >4 ng/mL/h (group B, reduced effective blood volume). Before TIPS, most cirrhotic patients showed diastolic dysfunction as indicated by reduced early maximal ventricular filling velocity (E)/late filling velocity (A) ratio. Patients of group B differed from patients of group A because of smaller left ventricular volumes and stroke volume, indicating central underfilling. After TIPS insertion, portal decompression was associated with a significant increase of cardiac output (CO) and a decrease of peripheral resistances. The most important changes were recorded in patients of group B, who showed a significant increase of both the end-diastolic left ventricular volumes and the E/A ratio and a significant decrease of PRA. In conclusion, these results show that the hemodynamic effects of TIPS differ according to the pre-TIPS effective blood volume. Furthermore, TIPS improves the diastolic cardiac function of cirrhotic patients with effective hypovolemia. This result is likely due to a TIPS-related improvement of the fullness of central blood volume.
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Brinch K, Møller S, Bendtsen F, Becker U, Henriksen JH. Plasma volume expansion by albumin in cirrhosis. Relation to blood volume distribution, arterial compliance and severity of disease. J Hepatol 2003; 39:24-31. [PMID: 12821040 DOI: 10.1016/s0168-8278(03)00160-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS The aim of the study was to investigate the effect of a standard albumin load on blood volume distribution, arterial compliance, and the renin-angiotensin-aldosterone system in patients with different degrees of cirrhosis. METHODS 31 patients with cirrhosis (Child classes A/B/C=8/14/9) received an intravenous infusion of 40 g human serum albumin during a haemodynamic investigation. RESULTS Whereas plasma- and blood volume increased by 23 and 15%, respectively (P<0.001), a significant increase in central blood volume was found only in class A patients (+8%, P<0.05), but not in class B or class C patients (+2.7%, not significant (n.s.)). In contrast, arterial compliance only increased significantly in class C patients (+18%, P<0.05), but not in class A or class B patients (+6%, n.s.). Plasma renin activity (PRA) decreased significantly in class C patients (-31%, P<0.05). When all patients were compared, the change in arterial compliance was inversely correlated to the change in PRA (r=-0.50, P<0.01). CONCLUSIONS Although infusion of albumin does not expand the central blood volume in patients with advanced cirrhosis, the results indicate a significant improvement in the low effective arterial blood volume of such patients, which may be important in the prevention of circulatory dysfunction.
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Affiliation(s)
- Kim Brinch
- Department of Clinical Physiology, 239, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark
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Møller S, Henriksen JH, Bendtsen F. Central and noncentral blood volumes in cirrhosis: relationship to anthropometrics and gender. Am J Physiol Gastrointest Liver Physiol 2003; 284:G970-9. [PMID: 12606306 DOI: 10.1152/ajpgi.00521.2002] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The size of the central and arterial blood volume (CBV) is essential in the understanding of fluid retention in cirrhosis. Previously, it has been reported decreased, normal, or increased, but no reports have analyzed CBV with respect to gender and lean body mass. The aim of the present study was by means of an optimized technique to reassess it in a large group of patients with cirrhosis compared with healthy controls and matched controls in relationship to their body dimensions and gender. Eighty-three patients with cirrhosis (male/female, 60:23), 67 patients without liver disease (male/female, 22:45), and 14 young healthy controls (male/female, 6:8) underwent a hemodynamic investigation with determination of cardiac output, central circulation time, and CBV determined according to kinetic principles. Related to gender, CBV was lower in male cirrhotics (1.48 +/- 0.30 liter) than in matched and young controls (1.68 +/- 0.33 and 1.72 +/- 0.33 liter, respectively; P < 0.05-0.01). No significant differences in CBV were seen between female cirrhotics and controls. Absolute and adjusted CBVs were lower in the females than in men with cirrhosis (P < 0.001), and men with cirrhosis had lower absolute and body weight-adjusted CBVs than matched controls (P < 0.01). Normalized values of CBV (%total blood volume) were significantly lower in patients with cirrhosis (25 +/- 4%) than in matched controls (31 +/- 7%) and young controls (28 +/- 4%; P < 0.02). CBV correlated significantly with anthropometrics, including lean body mass (r = 0.68-0.82; P < 0.0001). In conclusion, the CBV of patients with cirrhosis was lower than that of controls when adjusted for body dimensions and gender. There are significant gender differences, and signs of underfilling are more pronounced in male than in female patients. The results emphasize the importance of adjustments of blood volumes for anthropometrics and gender.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology, Hvidovre Hospital, University of Copenhagen, DK-2650 Copenhagen, Denmark.
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Henriksen JH, Gülberg V, Gerbes AL, Bendtsen F, Møller S. Increased arterial compliance in cirrhosis is related to decreased arterial C-type natriuretic peptide, but not to atrial natriuretic peptide. Scand J Gastroenterol 2003; 38:559-64. [PMID: 12795471 DOI: 10.1080/00365520310000393] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Increased arterial compliance (COMPart) has recently been described in patients with cirrhosis, particularly in advanced disease. The aim of the present study was to relate COMPart with arterial levels of the circulating natriuretic peptides: atrial natriuretic peptide (ANP) and C-type natriuretic peptide (CNP), both of which are vasodilators. METHODS Thirty-one patients with cirrhosis, 14 non-cirrhotic patients with circulatory disturbances of the ischaemic and hypertensive type, and 10 healthy controls were investigated during a haemodynamic examination. RESULTS The patients with cirrhosis showed the well-known hyperdynamic circulation with elevated cardiac output, low arterial blood pressure, and reduced systemic vascular resistance. COMPart in the patients with cirrhosis (1.30 mL/mmHg) was significantly (P < 0.01) increased compared to that of non-cirrhotic patients (0.99 mL/mmHg) and controls (1.01 mL/mmHg). In the patients with cirrhosis, a significant inverse correlation was found between CNP and COMPart (r = -0.42, P < 0.01), but not between CNP and systemic vascular resistance (r = 0.31, P = 0.08). In the non-cirrhotic patients, CNP had a significant inverse correlation to COMPart (r = -0.68, P < 0.01) and a direct correlation to systemic vascular resistance (r = 0.62, P < 0.02). ANP was not significantly related to COMPart nor to systemic vascular resistance in any of the groups. CONCLUSION The finding of an inverse relation between CNP and COMPart may suggest that a compensatory down-regulation of CNP occurs in patients with cirrhosis and other types of circulatory disorders when vasodilation persists. Regulation of large and small arteries by CNP may be different in cirrhosis. Arterial ANP is not related to properties of the large or small arteries.
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Affiliation(s)
- J H Henriksen
- Dept. of Clinical Physiology, Hvidovre Hospital, University of Copenhagen, Denmark.
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Henriksen JH, Kiszka-Kanowitz M, Bendtsen F. Review article: volume expansion in patients with cirrhosis. Aliment Pharmacol Ther 2002; 16 Suppl 5:12-23. [PMID: 12423449 DOI: 10.1046/j.1365-2036.16.s5.3.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Adequate size and distribution of the circulating medium are important for cardiovascular function, tissue oxygenation, and fluid homoeostasis. Patients with cirrhosis have cardiovascular dysfunction with a hyperkinetic systemic circulation, abnormal distribution of the blood volume, vasodilation with low systemic vascular resistance, increased whole-body vascular compliance, and increased arterial compliance. The effectiveness and temporal relations of plasma/blood volume expansion depend highly on the type of load (water, saline, oncotic material, red blood cells). Patients with cirrhosis respond in some aspects differently from healthy subjects, owing to their disturbed circulatory function and neurohormonal activation. Thus the increase in cardiac output and suppression of the renin-angiotensin-aldosterone system and sympathetic nervous system during volume expansion may be somewhat blunted, and in advanced cirrhosis, especially the non-central parts of the circulation, including the splanchnic blood volume, are expanded by a volume load. Infusion of oncotic material (preferably albumin) is important in the prevention of post-paracentesis circulatory dysfunction. In conclusion, volume expansion in advanced cirrhosis is qualitatively and quantitatively different from that of healthy subjects, and in those with early cirrhosis. Timely handling is essential, but difficult as it is a balance between the risks of excess extravascular volume loading and further circulatory dysfunction in these patients with a hyperdynamic, but hyporeactive, circulation.
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Affiliation(s)
- J H Henriksen
- Department of linical Physiology 239, Hvidovre Hospital, University of Copenhagen, Denmark.
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Ginès P, Guevara M, De Las Heras D, Arroyo V. Review article: albumin for circulatory support in patients with cirrhosis. Aliment Pharmacol Ther 2002; 16 Suppl 5:24-31. [PMID: 12423450 DOI: 10.1046/j.1365-2036.16.s5.4.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Renal function abnormalities and ascites in cirrhosis are the final consequence of a circulatory dysfunction characterized by marked splanchnic arterial vasodilation. This causes a reduction in effective arterial blood volume and the homoeostatic activation of vasoconstrictor and sodium-retaining systems. Albumin is very effective in preventing renal failure associated with large-volume paracentesis and spontaneous bacterial peritonitis, conditions that are known to cause an impairment of circulatory function in patients with cirrhosis and ascites. Moreover, albumin administration improves survival in patients with spontaneous bacterial peritonitis. In patients with hepatorenal syndrome the administration of vasoconstrictor drugs in combination with albumin improves circulatory and renal function markedly and survival slightly. By contrast, the administration of albumin without vasoconstrictors has marginal or no effects on renal function in this setting.
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Affiliation(s)
- P Ginès
- Liver Unit, Institut de Malalties Digestives, Hospital Clínic, Barcelona, Spain.
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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: 10.5] [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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Kiszka-Kanowitz M, Henriksen JH, Møller S, Bendtsen F. Blood volume distribution in patients with cirrhosis: aspects of the dual-head gamma-camera technique. J Hepatol 2001; 35:605-12. [PMID: 11690706 DOI: 10.1016/s0168-8278(01)00175-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Patients with cirrhosis have increased total blood volume (TBV). The size of the "effective" blood volume has been closely investigated, whereas the distribution of the blood volume outside the thorax has not been examined. The aim was to estimate the blood volume distribution in patients with cirrhosis and portal hypertension, using a dual-head gamma-camera technique (DHGCT) and to validate this technique. METHODS Twenty-three patients with cirrhosis, 11 non-cirrhotic control patients, and six healthy controls had their blood volume distribution determined by the DHGCT. RESULTS The close relation between the estimated blood volume in the thorax region and the central and arterial blood volume, obtained by the dynamic indicator dilution technique (r=0.87, P<0.001), indicates validity of the DHGCT. Whole-body scintigraphy showed altered blood volume distribution in the cirrhotic patients with increased splanchnic blood volume (SpBV: 25.0 vs. 18.2% of TBV in controls, P<0.001), and all but one patient with hepatic venous pressure gradient above 12 mmHg had SpBV above 20% of TBV, but the blood volumes in the liver region were similar. CONCLUSIONS DHGCT is a valid method of estimating the blood volume distribution. Patients with cirrhosis and portal hypertension have grossly increased blood pooling in the splanchnic region, indicating splanchnic congestion.
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Affiliation(s)
- M Kiszka-Kanowitz
- Department of Gastroenterology, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark
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Henriksen JH, Fuglsang S, Bendtsen F, Christensen E, Møller S. Arterial compliance in patients with cirrhosis: stroke volume-pulse pressure ratio as simplified index. Am J Physiol Gastrointest Liver Physiol 2001; 280:G584-94. [PMID: 11254484 DOI: 10.1152/ajpgi.2001.280.4.g584] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Arterial function may be altered in patients with cirrhosis. We determined compliance of the arterial tree (C(1)) in relation to systemic and splanchnic hemodynamic derangement and clinical variables. C(1) and the stroke volume-pulse pressure index (SV/PP) were significantly higher (+62% and +40%, respectively; P < 0.001) in cirrhotic patients (n = 49) than in control subjects (n = 19), and a close correlation between C(1) and SV/PP was found in both cirrhotic patients (r = 0.86, P < 0.001) and control subjects (r = 0.96, P < 0.001). Univariate analysis showed significant relations between C(1) and SV/PP on one side and age, sex, body weight, portal pressure, systemic hemodynamics, biochemical variables, and severity of disease on the other. In the multiple-regression analysis, sex, age, mean arterial blood pressure, systemic vascular resistance, and biochemical variables were significant independent predictors of SV/PP (P < 0.005-0.00001). In conclusion, arterial compliance is elevated in cirrhosis. A simplified SV/PP index seems to reflect abnormalities in the arterial compliance of these patients.
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Affiliation(s)
- J H Henriksen
- Department of Clinical Physiology, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark.
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Abstract
The hyperdynamic circulation begins in the portal venous bed as a consequence of portal hypertension due to the increased resistance to flow from altered hepatic vascular morphology of chronic liver disease. Dilatation of the portal vein is associated with increased blood flow, as well as the opening up or formation of veno-venous shunts and splenomegaly. At the same time, portal hypertension leads to subclinical sodium retention resulting in expansion of all body fluid compartments, including the systemic and central blood volumes. This blood volume expansion is associated with vasorelaxation, as manifested by suppression of the renin--angiotensin--aldosterone system, initially only when the patient is in the supine position. Acute volume depletion in such patients results in normalisation of the hyperdynamic circulation, whilst acute volume expansion results in exaggerated natriuresis. As liver disease progresses and liver function deteriorates, the systemic hyperdynamic circulation becomes more manifest with activation of the renin--angiotensin--aldosterone system. The presence of vasodilatation in the presence of highly elevated levels of circulating vasoconstrictors may be explained by vascular hyporesponsiveness due to increased levels of vasodilators such as nitric oxide, as well as the development of an autonomic neuropathy. However, vasodilatation is not generalised, but confined to certain vascular beds, such as the splanchnic and pulmonary beds. Even here, the status may change with the natural history of the disease, since even portal blood flow may decrease and become reversed with advanced disease. The failure of these changes to reverse following liver transplantation may be due to remodelling and angiogenesis.
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Affiliation(s)
- L Blendis
- Institute of Gastroenterology, Sourasky Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
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