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Bommena S, Fallon MB. Pulmonary Complications of Portal Hypertension. Clin Liver Dis 2024; 28:467-482. [PMID: 38945638 DOI: 10.1016/j.cld.2024.03.005] [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: 07/02/2024]
Abstract
Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, 475 North 5th Street, Phoenix, AZ 85004, USA.
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2
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Mauz JB, Rieland H, Berliner D, Tiede A, Stockhoff L, Hinrichs JB, Wedemeyer H, Meyer BC, Olsson KM, Maasoumy B, Tergast TL. High Prevalence and Clinical Relevance of Intrapulmonary Vascular Dilatations in Patients Undergoing TIPS Implantation. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00434-8. [PMID: 38729401 DOI: 10.1016/j.cgh.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Considerate patient selection is vital to ensure the best possible outcomes after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, data regarding the impact of intrapulmonary vascular dilatations (IPVDs) or hepatopulmonary syndrome (HPS) on the clinical course after TIPS implantation is lacking. Hence, this study aimed to investigate the relevance of IPVD and HPS in patients undergoing TIPS implantation. METHODS Contrast enhanced echocardiography and blood gas analysis were utilized to determine presence of IPVD and HPS. Multivariable competing risk analyses were performed to evaluate cardiac decompensation (CD), hepatic decompensation (HD), and liver transplant (LTx)-free survival within 1 year of follow-up. RESULTS Overall, 265 patients were included, of whom 136 had IPVD and 71 fulfilled the HPS criteria. Patients with IPVD had lower Freiburg index of post-TIPS survival (FIPS) scores, lower creatinine, and more often received TIPS because of variceal bleeding. Presence of IPVD was associated with a significantly higher incidence of CD (hazard ratio [HR], 1.756; 95% confidence interval [CI], 1.011-3.048; P = .046) and HD (HR, 1.841; 95% CI, 1.255-2.701; P = .002). However, LTx-free survival was comparable between patients with and without IPVD (HR, 1.081; 95% CI, 0.630-1.855; P = .780). Patients with HPS displayed a trend towards more CD (HR, 1.708; 95% CI, 0.935-3.122; P = .082) and HD (HR, 1.458; 95% CI, 0.934-2.275; P = .097) that failed to reach statistical significance. LTx-free survival did not differ in those with HPS compared with patients without HPS, respectively (HR, 1.052; 95% CI, 0.577-1.921; P = .870). CONCLUSION Screening for IPVD before TIPS implantation could help to further identify patients at higher risk of CD and HD.
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Affiliation(s)
- Jim B Mauz
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Hannah Rieland
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Dominik Berliner
- Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - Anja Tiede
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany
| | - Lena Stockhoff
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Jan B Hinrichs
- St Bernward Hospital, Department of Radiology, Hildesheim, Germany
| | - Heiner Wedemeyer
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany; Excellence Cluster Resist, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Hannover Medical School, Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Karen M Olsson
- Hannover Medical School, Department of Respiratory Medicine and Infectious Diseases, Hannover, Germany; German Center for Lung Research (DZL), Hannover, Germany
| | - Benjamin Maasoumy
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany.
| | - Tammo L Tergast
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany.
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Hui Y, Wang H, Guo G, Yang W, Wang X, Cui B, Fan X, Sun C. Health-related quality of life and frailty in liver cirrhosis. BMJ Support Palliat Care 2024:spcare-2024-004839. [PMID: 38471790 DOI: 10.1136/spcare-2024-004839] [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: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND OBJECTIVES There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort. METHODS This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses. RESULTS More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty. CONCLUSIONS Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Han Wang
- Tianjin Hospital, Hexi District, Tianjin, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
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Zhao X, Kotha S, Nayyar D, Ma X, Lilly L, Castel H, Gupta S. Physiologic changes in the hepatopulmonary syndrome before and after liver transplant: A longitudinal and predictor analysis. Hepatology 2024; 79:636-649. [PMID: 37732952 PMCID: PMC10871618 DOI: 10.1097/hep.0000000000000605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. APPROACH AND RESULTS This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: -3.7 (-6.4, -0.96) mm Hg/year for partial pressure of arterial oxygen (PaO 2 ); -26 (-96, 44) m/year for 6-minute walk distance, and 3.3% (-6.6, -0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO 2 decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO 2 deterioration classes-"very severe disease, slow decliners" (PaO 2 45.0 mm Hg; -1.0 mm Hg/year); and "moderate disease, steady decliners" (PaO 2 65.5 mm Hg; -2.5 mm Hg/year). PaO 2 increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO 2 was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. CONCLUSIONS We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO 2 decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, McGill University, Montreal, Canada
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Dhruv Nayyar
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xiayi Ma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hélène Castel
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
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Sayadi A, Duhaut L, Robert F, Savale L, Coilly A. [Hepatopulmonary syndrome]. Rev Med Interne 2024; 45:156-165. [PMID: 37005097 DOI: 10.1016/j.revmed.2023.03.008] [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] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
The hepatopulmonary syndrome (HPS) is one of the lung diseases associated with cirrhosis and portal hypertension. It should be discussed for any dyspnea in cirrhotic patients. HPS is a pulmonary vascular disease characterized by intrapulmonary vascular dilatations (IPVD). The pathogenesis is complex and seems to rely on communications between the portal and pulmonary circulations. The diagnosis is based on a triad of liver disease and portal hypertension, evidence of IPVDs, and impaired gas exchange (alveolar-arterial oxygen difference [A-aO2]≥15mmHg). HPS impairs prognosis (23% survival at 5years) and patients' quality of life. Liver transplantation (LT) allows regression of IPDVD in almost 100% of cases, normalization of gas exchange and improves survival with a 5-year post-LT survival between 76 and 87%. It is the only curative treatment, indicated in patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60mmHg. When LT is not indicated or feasible, long-term oxygen therapy may be proposed as a palliative treatment. A better understanding of the pathophysiological mechanisms is needed to improve the therapeutic possibilities in a near future.
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Affiliation(s)
- A Sayadi
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - L Duhaut
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - F Robert
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France
| | - L Savale
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France; Service de pneumologie, hôpital Bicêtre, université Paris-Saclay, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - A Coilly
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France.
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Chooklin S, Chuklin S. Hepatopulmonary syndrome: diagnosis and treatment. EMERGENCY MEDICINE 2024; 19:511-518. [DOI: 10.22141/2224-0586.19.8.2023.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Hepatopulmonary syndrome (HPS) is one of the lung diseases associated with liver cirrhosis and portal hypertension. The diagnosis is based on the triad: liver disease and portal hypertension, evidence of intrapulmonary vascular dilatation and impaired gas exchange. HPS impairs prognosis (23 % survival after 5 years) and patients’ quality of life, so early diagnosis and timely treatment are of great importance. Liver transplantation allows for regression of intrapulmonary vascular dilatation in almost 100 % of cases, normalization of gas exchange and improves a 5-year survival after transplantation from 76 to 87 %. This is the only treatment method indicated for patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60 mm Hg. However, in the face of a global shortage of transplants, it is necessary to develop medical therapies to delay or even defer liver transplantation. This goal seems possible due to the growing understanding of the HPS pathophysiology and the development of therapies targeting key mechanisms, mainly inflammatory and angiogenic. This article provides an overview of the clinical manifestations, diagnosis and treatment of HPS based on literature sources from the MEDLINE database on the PubMed platform.
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Han SK, Baik SK, Kim MY. [Pulmonary Complications in Patients with Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:213-223. [PMID: 37997217 DOI: 10.4166/kjg.2023.123] [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: 10/16/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023]
Abstract
Portal hypertension is a clinical syndrome defined by an increased portal venous pressure. The most frequent cause of portal hypertension is liver cirrhosis, and many of the complications of cirrhosis, such as ascites and gastroesophageal variceal bleeding, are related to portal hypertension. Portal hypertension is a pathological condition caused by the accumulation of blood flow in the portal system. This blood flow retention reduces the effective circulation volume. To compensate for these changes, neurotransmitter hormone changes and metabolic abnormalities occur, which cause complications in organs other than the liver. A hepatic hydrothorax is fluid accumulation in the pleural space resulting from increased portal pressure. Hepatopulmonary syndrome and portopulmonary hypertension are the pulmonary complications in cirrhosis by deforming the vascular structure. Symptoms, such as dyspnea and hypoxia, affect the survival and the quality of life of patients. These lung complications are usually underestimated in the management of cirrhosis. This review briefly introduces the type of lung complications of cirrhosis.
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Affiliation(s)
- Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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8
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Li YJ, Wu XF, Wang DD, Li P, Liang H, Hu XY, Gan JQ, Sun YZ, Li JH, Li J, Shu X, Song AL, Yang CY, Yang ZY, Yu WF, Yang LQ, Wang XB, Belguise K, Xia ZY, Yi B. Serum Soluble Vascular Endothelial Growth Factor Receptor 1 as a Potential Biomarker of Hepatopulmonary Syndrome. J Clin Transl Hepatol 2023; 11:1150-1160. [PMID: 37577229 PMCID: PMC10412700 DOI: 10.14218/jcth.2022.00421] [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: 08/30/2022] [Revised: 01/02/2023] [Accepted: 02/28/2023] [Indexed: 07/03/2023] Open
Abstract
Background and Aims The results of basic research implicate the vascular endothelial growth factor (VEGF) family as a potential target of hepatopulmonary syndrome (HPS). However, the negative results of anti-angiogenetic therapy in clinical studies have highlighted the need for markers for HPS. Therefore, we aimed to determine whether VEGF family members and their receptors can be potential biomarkers for HPS through clinical and experimental studies. Methods Clinically, patients with chronic liver disease from two medical centers were enrolled and examined for HPS. Patients were divided into HPS, intrapulmonary vascular dilation [positive contrast-enhanced echocardiography (CEE) and normal oxygenation] and CEE-negative groups. Baseline information and perioperative clinical data were compared between HPS and non-HPS patients. Serum levels of VEGF family members and their receptors were measured. In parallel, HPS rats were established by common bile duct ligation. Liver, lung and serum samples were collected for the evaluation of pathophysiologic changes, as well as the expression levels of the above factors. Results In HPS rats, all VEGF family members and their receptors underwent significant changes; however, only soluble VEGFR1 (sFlt-1) and the sFlt-1/ placental growth factor (PLGF) ratio were changed in almost the same manner as those in HPS patients. Furthermore, through feature selection and internal and external validation, sFlt-1 and the sFlt-1/PLGF ratio were identified as the most important variables to distinguish HPS from non-HPS patients. Conclusions Our results from animal and human studies indicate that sFlt-1 and the sFlt-1/PLGF ratio in serum are potential markers for HPS.
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Affiliation(s)
- Yu-Jie Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xian-Feng Wu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan-Dan Wang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Peng Li
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Hao Liang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiao-Yan Hu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jia-Qi Gan
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Yi-Zhu Sun
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun-Hong Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xin Shu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ai-Lin Song
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chun-Yong Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zhi-Yong Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wei-Feng Yu
- Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Li-Qun Yang
- Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Bo Wang
- LBCMCP, Centre de Biologie Intégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Karine Belguise
- LBCMCP, Centre de Biologie Intégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Zheng-Yuan Xia
- Department of Anesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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9
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Igata S, Kono Y, Van Houten T, Hang CT, Cotter BR, Strachan MG, Morikawa N, DeMaria AN. Role of Quantitation of Saline Bubble Studies in Patients with Liver Cirrhosis. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1804-1810. [PMID: 37198087 DOI: 10.1016/j.ultrasmedbio.2023.04.003] [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: 11/15/2022] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Microbubble contrast echocardiography with a late positive signal enables the detection of intrapulmonary vascular dilation, including hepatopulmonary syndrome, in patients with end-stage liver disease. We assessed the relationship between the severity of bubble study and clinical outcome. METHODS We retrospectively analyzed 163 consecutive patients with liver cirrhosis who underwent an echocardiogram with bubble study from 2018 to 2021. Patients who were diagnosed with a late positive signal were divided into three groups: grade 1 (1-9 bubbles), grade 2 (10-30 bubbles) and grade 3 (>30 bubbles). RESULTS Fifty-six percent of the patients had a late positive bubble study (grade 1: 31%, grade 2: 23%, grade 3: 46%). Patients with grade 3 had a significantly higher international normalized ratio, model for end-stage liver disease score and Child-Pugh score and a lower peripheral oxygen saturation compared with patients with a negative study. In patients undergoing liver transplant (LT), survival rates were similar among the groups (3-mo: >87%, 1-y: >87%, 2-y: >83%). However, survival rate was lower in grade 3 patients without LT (3-mo: 81%, 1-y: 64%, 2-y: 39%). CONCLUSION Patients with grade 3 had much worse mortality without LT compared with other groups. However, after LT, all grades had equal survival. Therefore, patients with grade 3 may be considered as higher priority for LT.
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Affiliation(s)
- Sachiyo Igata
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA.
| | - Yuko Kono
- Division of Hepatology, Department of Medicine, University of California, San Diego, CA, USA
| | - Thomas Van Houten
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Calvin T Hang
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Bruno R Cotter
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Monet G Strachan
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Nagisa Morikawa
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Anthony N DeMaria
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
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10
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Singh SA, Shrivastava P, Agarwal A, Nandakumar K, Nasa VK, Premkumar G, Rajakumar A, Panchwagh A, Vohra V, Ranade S, Kumar L, Saraf N, Shah V, Sudhidharan S. LTSI Consensus Guidelines: Preoperative Pulmonary Evaluation in Adult Liver Transplant Recipients. J Clin Exp Hepatol 2023; 13:523-531. [PMID: 37250889 PMCID: PMC10213854 DOI: 10.1016/j.jceh.2022.12.012] [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: 09/02/2022] [Accepted: 12/20/2022] [Indexed: 05/31/2023] Open
Abstract
The relationship between chronic liver disease and respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease (CLD) have been characterized: hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. Apart from that coexisting pulmonary disease like chronic obstructive lung disease and interstitial lung disease also complicate the outcomes after liver transplantation (LT). Assessment for evaluation of underlying pulmonary disorders is essential to improve outcomes in patients with CLD, posted for LT. This consensus guideline of the Liver Transplant Society of India (LTSI) provides a comprehensive review of pulmonary issues in CLD, related and unrelated to underlying liver disease and gives recommendations for pulmonary screening in specific clinical scenarios in adults with chronic liver disease planned for LT. This document also aims to standardize the strategies for preoperative evaluation of these pulmonary issues in this subset of patients. Proposed recommendations were based on selected single case reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Additionally, this review will highlight the lacunae in our current evaluation strategy, challenges faced, and will provide direction to potentially useful futuristic preoperative evaluation strategies.
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Affiliation(s)
- Shweta A. Singh
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Anil Agarwal
- Liver Transplant Anaesthesia, Fortis Hospital, Noida, India
| | - K. Nandakumar
- Liver Transplant Anaesthesia, Apollo Main Hospital, Greams Road, Chennai, India
| | - Vaibhav K. Nasa
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Akila Rajakumar
- Dr. Rela Institute and Medical Centre, Chromepet, Chennai, Tamil Nadu, India
| | | | - Vijay Vohra
- Medanta - The Medicity Hospital, Gurugram, India
| | - Sharmila Ranade
- Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, India
| | - Lakshmi Kumar
- Amrita Institute of Medical Sciences & Research Centre, Kochi, India
| | - Neeraj Saraf
- Medanta - The Medicity Hospital, Gurugram, India
| | - V.R. Shah
- Institute of Kidney Disease and Research Centre-ITS, Ahmedabad, Gujarat, India
| | - S. Sudhidharan
- HPB and LT Surgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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11
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Raza MH, Kwon Y, Kobierski P, Misra AC, Lim A, Goldbeck C, Etesami K, Kohli R, Emamaullee J. Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception policy and outcomes in pediatric patients with hepatopulmonary syndrome requiring liver transplantation. Liver Transpl 2023; 29:134-144. [PMID: 37160070 PMCID: PMC9868062 DOI: 10.1002/lt.26548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 01/29/2023]
Abstract
Hepatopulmonary syndrome (HPS) is associated with increased waitlist mortality in liver transplantation (LT) candidates. Children with HPS are granted Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) exception points for waitlist prioritization in the United States based on criterion developed for adults. In this study, the impact of this MELD/PELD exception policy on post-LT survival in children was examined. A retrospective cohort of patients aged younger than 18 years with a MELD/PELD exception request who underwent LT between 2007 and 2018 were identified in the Scientific Registry of Transplant Recipients. Patients were stratified by waitlist partial pressure of arterial oxygen (PaO 2 ) to assess risk factors for waitlist mortality and post-LT survival. Among 3082 pediatric LT recipients included in the study, 124 patients (4%) received MELD/PELD exception points for HPS. Patients with HPS were a median age of 9 years (interquartile range: 6, 12 years), 54.8% were girls, and 54% were White. Most patients (87.9%) were listed with laboratory MELD/PELD scores <15. Waitlist mortality for patients with HPS exception points was rare and not different from patients without HPS. When stratified by pre-LT PaO 2 , hypoxemia severity was not associated with differences in 1-, 3-, or 5-year survival rates after LT ( p = 0.13). However, patients with HPS showed a slightly lower survival rate at 5 years compared with patients without HPS (88.7% vs. 93.4%; p = 0.04). MELD/PELD exceptions for children with HPS mitigated waitlist mortality, and recipients with HPS experienced excellent 5-year survival after LT, although slightly lower than in patients without HPS. Unlike adults with HPS, the severity of pre-LT hypoxemia in children does not impact post-LT survival. These data suggest that adult criteria for granting MELD/PELD exception points may not appropriately capture HPS severity in pediatric patients. Further prospective multicenter studies to examine the risk factors predicting negative survival outcomes in children with HPS are warranted.
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Affiliation(s)
- Muhammad H Raza
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Yong Kwon
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Pierre Kobierski
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Asish C Misra
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Angelina Lim
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Cameron Goldbeck
- Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA
| | - Kambiz Etesami
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Rohit Kohli
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA.,Department of Pediatrics , University of Southern California , Los Angeles , California , USA
| | - Juliet Emamaullee
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
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12
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Chen J, Gao F, Li D, Wang J. MiR26-5p inhibits pathological pulmonary microvascular angiogenesis via down-regulating WNT5A. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2023; 26:812-819. [PMID: 37396938 PMCID: PMC10311967 DOI: 10.22038/ijbms.2023.68856.15006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/19/2023] [Indexed: 07/04/2023]
Abstract
Objectives Pathological micro angiogenesis is a key pathogenic factor in pulmonary diseases such as pulmonary hypertension and hepatopulmonary syndrome. More and more pieces of evidence show that excessive proliferation of pulmonary microvascular endothelial cells is the key event of pathological micro angiogenesis. The purpose of this research is to reveal the mechanism of miR26-5p regulating pulmonary microvascular hyperproliferation. Materials and Methods Hepatopulmonary syndrome rat model was made by common bile duct ligation. HE and IHC staining were used for analysis of the pathology of the rat. CCK8, transwell, and wound healing assay were used to assess miR26-5p or target gene WNT5A functioned toward PMVECs. microRNA specific mimics and inhibitors were used for up/down-regulated miR26-5p expression in PMVECs. Recombinant lentivirus was used for overexpression/knockdown WNT5A expression in PMVECs. And the regulation relationship of miR26-5p and WNT5A was analyzed by dual-luciferase reporter assay. Results qPCR showed that miR26-5p was significantly down-regulated in the course of HPS disease. Bioinformatics data showed that WNT5A was one of the potential key target genes of miR26-5p. Immunohistochemistry and qPCR analysis showed that WNT5A was largely expressed in pulmonary microvascular endothelial cells, in addition, this molecule was significantly up-regulated with the progression of the disease. Furthermore, dual luciferase reporter assay showed that miR26-5p could bind to WNT5A 3 'UTR region to inhibit WNT5A synthesis. Conclusion The results suggested MiR26-5p negatively regulated PMVECs proliferation and migration by WNT5A expression. Overexpression of miR26-5p may be a potentially beneficial strategy for HPS therapy.
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Affiliation(s)
- Jie Chen
- Department of Anesthesiology, People’s Hospital of Chongqing Banan District, Chongqing 401320, China
- These authors contributed equally to this work
| | - Feng Gao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing 400038, China
- These authors contributed equally to this work
| | - Dan Li
- Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Jinquan Wang
- Department of Anesthesiology, The Ninth People’s Hospital of Chongqing, Chongqing 400700, China
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13
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Prevalence and prognostic impact of hepatopulmonary syndrome in patients with unresectable hepatocellular carcinoma undergoing transarterial chemoembolization: a prospective cohort study. Chin Med J (Engl) 2022; 135:2043-2048. [PMID: 36255217 PMCID: PMC9746741 DOI: 10.1097/cm9.0000000000002034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). METHODS Fifty-four patients with unresectable HCC undergoing TACE between December 2014 and December 2015 were prospectively screened for HPS and were followed up for a maximum of 2 years or until the end of this prospective study. RESULTS Nineteen of the 54 (35.2%) patients were considered to have HPS, including one (5.3%) with severe HPS, nine (47.4%) with moderate HPS, and nine (47.4%) with mild HPS. The median overall survival (OS) was 10.1 (95% confidence interval [CI], 3.9-16.3) months for patients with HPS and 15.1 (95% CI, 7.3-22.9) months for patients without HPS, which is not a significant difference ( P = 0.100). The median progression-free survival was also not significantly different between patients with and without HPS (5.2 [95% CI, 0-12.8] vs. 8.4 [95% CI, 3.6-13.1] months; P = 0.537). In the multivariable Cox regression analyses, carbon monoxide diffusing capacity (hazard ratio [HR] = 1.033 [95% CI, 1.003-1.064]; P = 0.028) and Child-Pugh class (HR = 1.815 [95% CI, 1.011-3.260]; P = 0.046) were identified to be the independent prognostic factors of OS. CONCLUSION Mild or moderate HPS is common in patients with unresectable HCC undergoing TACE, but it does not seem to have a significant prognostic impact.
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14
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Izzy M, DuBrock HM. CAQ Corner: Cardiovascular and pulmonary evaluation of liver transplantation candidates: What you need to know for the board exam. Liver Transpl 2022; 28:1529-1538. [PMID: 35470532 DOI: 10.1002/lt.26495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Zafar M, Patel A, Ashraf M, Tibble J. Shortness of breath due to portopulmonary hypertension and hepatopulmonary syndrome: diagnostic challenges and complex management approach in frail patients. Clin Med (Lond) 2022; 22:485-489. [PMID: 38589073 PMCID: PMC9595008 DOI: 10.7861/clinmed.2022-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 60-year-old woman with a background of frailty, non-alcoholic fatty liver disease (NAFLD), cirrhosis and type 2 diabetes mellitus (T2DM), presented with worsening shortness of breath and a drop in oxygen saturation on sitting and standing up. Her chest X-ray demonstrated evidence of upper lobe venous diversion. Given the hypoxia, she had a computed tomography pulmonary angiography (CTPA) to rule out a pulmonary embolism. The only finding from the CTPA was pulmonary hypertension in the absence of any clots in the lungs. An ultrasound of the abdomen confirmed portal hypertension with splenomegaly and a cirrhotic liver, therefore, an initial diagnosis of portopulmonary hypertension and hepatopulmonary syndrome was made. The patient declined an agitated saline contrast echocardiography. Based on frailty she was not deemed to be a suitable candidate for a liver transplant and was discharged with a package of care alongside home oxygen therapy with periodic review in the gastroenterology clinic. She was assessed as stable with no new concerns while on home oxygen and diuretics. This case highlights challenges in diagnosing and managing patients with cirrhosis, portopulmonary hypertension and hepatopulmonary syndrome with a background of complex comorbidities and frailty.
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16
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Kawut SM, Krowka MJ, Forde KA, Al-Naamani N, Krok KL, Patel M, Bartoli CR, Doyle M, Moutchia J, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB. Impact of hepatopulmonary syndrome in liver transplantation candidates and the role of angiogenesis. Eur Respir J 2022; 60:2102304. [PMID: 34949701 PMCID: PMC10967655 DOI: 10.1183/13993003.02304-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome affects 10-30% of patients with cirrhosis and portal hypertension. We evaluated the serum angiogenic profile of hepatopulmonary syndrome and assessed the clinical impact of hepatopulmonary syndrome in patients evaluated for liver transplantation. METHODS The Pulmonary Vascular Complications of Liver Disease 2 study was a multicentre, prospective cohort study of adults undergoing their first liver transplantation evaluation. Hepatopulmonary syndrome was defined as an alveolar-arterial oxygen gradient ≥15 mmHg (≥20 mmHg if age >64 years), positive contrast-enhanced transthoracic echocardiography and absence of lung disease. RESULTS We included 85 patients with hepatopulmonary syndrome and 146 patients without hepatopulmonary syndrome. Patients with hepatopulmonary syndrome had more complications of portal hypertension and slightly higher Model for End-Stage Liver Disease-Na score compared to those without hepatopulmonary syndrome (median (interquartile range) 15 (12-19) versus 14 (10-17), p=0.006). Hepatopulmonary syndrome patients had significantly lower 6-min walk distance and worse functional class. Hepatopulmonary syndrome patients had higher circulating angiopoietin 2, Tie2, tenascin C, tyrosine protein kinase Kit (c-Kit), vascular cell adhesion molecule 1 and von Willebrand factor levels, and lower E-selectin levels. Patients with hepatopulmonary syndrome had an increased risk of death (hazard ratio 1.80, 95% CI 1.03-3.16, p=0.04), which persisted despite adjustment for covariates (hazard ratio 1.79, 95% CI 1.02-3.15, p=0.04). This association did not vary based on levels of oxygenation, reflecting the severity of hepatopulmonary syndrome. CONCLUSION Hepatopulmonary syndrome was associated with a profile of abnormal systemic angiogenesis, worse exercise and functional capacity, and an overall increased risk of death.
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Affiliation(s)
- Steven M Kawut
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kimberly A Forde
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen L Krok
- Dept of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Dept of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiothoracic Surgery, Dept of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Margaret Doyle
- Dept of Pathology, University of Vermont, Burlington, VT, USA
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
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17
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Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
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Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
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18
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Raevens S, Boret M, Fallon MB. Hepatopulmonary syndrome. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100527. [PMID: 36035361 PMCID: PMC9403489 DOI: 10.1016/j.jhepr.2022.100527] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of liver disease, which adversely affects prognosis. The disease is characterised by intrapulmonary vascular dilatations and shunts, resulting in impaired gas exchange. A complex interaction between the liver, the gut and the lungs, predominately impacting pulmonary endothelial cells, immune cells and respiratory epithelial cells, is responsible for the development of typical pulmonary alterations seen in HPS. Liver transplantation is the only therapeutic option and generally reverses HPS. Since the implementation of the model for end-stage liver disease (MELD) standard exception policy, outcomes in patients with HPS have been significantly better than they were in the pre-MELD era. This review summarises current knowledge and highlights what’s new regarding the diagnosis and management of HPS, and our understanding of pathogenesis based on experimental models and translational studies.
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19
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Craciun R, Mocan T, Procopet B, Nemes A, Tefas C, Sparchez M, Mocan LP, Sparchez Z. Pulmonary complications of portal hypertension: The overlooked decompensation. World J Clin Cases 2022; 10:5531-5540. [PMID: 35979136 PMCID: PMC9258359 DOI: 10.12998/wjcc.v10.i17.5531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/22/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.
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Affiliation(s)
- Rares Craciun
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Tudor Mocan
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Andrada Nemes
- Intensiv Care Unit I, Cluj County Emergency Hosptial, Cluj-Napoca 400006, Romania
| | - Cristian Tefas
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Sparchez
- 2nd Paediatric Clinic, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Please enter the state or province, Romania
| | - Lavinia-Patricia Mocan
- Department of Histology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400349, Romania
| | - Zeno Sparchez
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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20
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Iwasaki S, Ueno T, Toyama C, Deguchi K, Nomura M, Saka R, Watanabe M, Tazuke Y, Bessho K, Okuyama H. A Retransplant Case for Hepatopulmonary Syndrome Without Liver Cirrhosis or Portosystemic Shunt After Living-Donor Liver Transplantation: A Case Report. Transplant Proc 2022; 54:552-555. [PMID: 35074161 DOI: 10.1016/j.transproceed.2021.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a disease of gas exchange caused by intrapulmonary shunting secondary to liver disease-associated intrapulmonary vascular dilation. HPS is characterized by the triad of cirrhosis, chronic liver disease, or portosystemic shunting (PSS); arterial hypoxemia; and intrapulmonary arteriovenous shunting in the absence of a primary cardiopulmonary anomaly. We encountered a rare case of HPS without liver disease or PSS. The patient was an 8-year-old girl who underwent living donor liver transplantation (LDLT) shortly after developing fulminant hepatitis at 11 months of her age. Eight years after LDLT, hypoxemia and shortness of breath developed. The shunt ratio on 99mTc-macroaggregated albumin (MAA) lung perfusion scintigraphy (99mTc-MAA lung scan) was 32%. The patient had no cardiopulmonary disease, so we diagnosed her illness as HPS. We did not find cirrhosis, chronic liver disease, or PSS as a cause of HPS. We thought the graft was the cause of HPS. A second transplantation was planned. One year after the diagnosis of HPS, the shunt ratio on 99mTc-MAA lung scan worsened to 42%, digital clubbing appeared, and hypoxemia was worsening. Thus, we performed a second LDLT. After LDLT the shunt ratio on 99mTc-MAA lung scan normalized (6%) and cyanosis resolved. We determined that the graft was the cause of HPS; the typical causes of HPS were not clearly revealed in the histologic examination of the second liver explant. Acute rejection occurred twice after LDLT, so we speculated that HPS occurred because the graft became stressed over the long term.
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Affiliation(s)
- Shun Iwasaki
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Chiyoshi Toyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Deguchi
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Motonari Nomura
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryuta Saka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Miho Watanabe
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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21
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Hepatopulmonary syndrome delays postoperative recovery and increases pulmonary complications after hepatectomy. Eur J Gastroenterol Hepatol 2021; 33:e449-e457. [PMID: 33852512 DOI: 10.1097/meg.0000000000002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study attempted to investigate the impact of hepatopulmonary syndrome (HPS) on postoperative outcomes in hepatitis B virus-induced hepatocellular carcinoma (HBV-HCC) patients. METHODS HBV-HCC patients undergoing primary curative hepatectomy for HCC in our hospital were diagnosed with HPS by contrast-enhanced echocardiography (CEE) and arterial blood gas analysis. Patients were divided into HPS, intrapulmonary vascular dilation (IPVD) (patients with positive CEE results and normal oxygenation) and control (patients with negative CEE results) groups. Baseline information, perioperative clinical data and postoperative pulmonary complications (PPCs) were compared among all groups. Cytokines in patient serums from each group (n = 8) were also assessed. RESULTS Eighty-seven patients undergoing hepatectomy from October 2019 to January 2020 were analyzed. The average time in the postanaesthesia care unit (112.10 ± 38.57 min) and oxygen absorption after extubation [34.0 (14.5-54.5) min] in the HPS group was longer than in IPVD [81.81 ± 26.18 min and 16.0 (12.3-24.0) min] and control [93.70 ± 34.06 min and 20.5 (13.8-37.0) min] groups. There were no significant differences in oxygen absorption time after extubation between HPS and control groups. The incidence of PPCs, especially bi-lateral pleural effusions in the HPS group (61.9%), was higher than in IPVD (12.5%) and control (30.0%) groups. Increased serum levels of the growth-regulated oncogene, monocyte chemoattractant protein, soluble CD40 ligand and interleukin 8 might be related to delayed recovery in HPS patients. CONCLUSIONS HPS patients with HBV-HCC suffer delayed postoperative recovery and are at higher risk for PPCs, especially bi-lateral pleural effusions, which might be associated with changes in certain cytokines.
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22
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Jose A, Shah SA, Anwar N, Jones CR, McCormack FX, Sherman KE, Elwing JM. Predictors of outcomes following liver transplant in hepatopulmonary syndrome: An OPTN database analysis. Respir Med 2021; 190:106683. [PMID: 34784562 DOI: 10.1016/j.rmed.2021.106683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a type of pulmonary vascular disease occurring exclusively in those with underlying liver disease, associated with significant mortality in patients awaiting liver transplantation (LT). LT is curative in HPS, and these patients are granted Model for End Stage Liver Disease (MELD) exception points to expedite LT. The purpose of this study is to use multivariable competing risk Accelerated Failure Time models and propensity matching to examine the relationship between pre-LT hypoxemia and post-LT outcomes in HPS. We performed a retrospective cohort study of UNOS/OPTN database of all adult patients undergoing LT between January 1, 2006 and January 12, 2020. Pre-LT PaO2 was significantly associated with post-LT mortality in HPS, with each 1 mmHg increase in PaO2 significantly decreasing the risk of post-LT mortality (coefficient 0.039, HR = 0.95, p = 0.001). HPS patients with a pre-LT PaO2 < 54 mmHg demonstrated increased mortality following LT as compared to matched non-HPS cirrhotic patients. We conclude that HPS patients with a PaO2, 54 mmHg are at increased risk of post-LT mortality and may identify high-risk patients who would benefit from additional resources during LT, and that the effects of HPS MELD exception points to optimize post-LT outcomes should be continuously re-evaluated.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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Chen B, Yang Y, Yang C, Duan J, Chen L, Lu K, Yi B, Chen Y, Xu D, Huang H. M2 macrophage accumulation contributes to pulmonary fibrosis, vascular dilatation, and hypoxemia in rat hepatopulmonary syndrome. J Cell Physiol 2021; 236:7682-7697. [PMID: 34041750 DOI: 10.1002/jcp.30420] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 12/11/2022]
Abstract
Hepatopulmonary syndrome (HPS) markedly increases the mortality of patients. However, its pathogenesis remains incompletely understood. Rat HPS develops in common bile duct ligation (CBDL)-induced, but not thioacetamide (TAA)-induced cirrhosis. We investigated the mechanisms of HPS by comparing these two models. Pulmonary histology, blood gas exchange, and the related signals regulating macrophage accumulation were assessed in CBDL and TAA rats. Anti-polymorphonuclear leukocyte (antiPMN) and anti-granulocyte-macrophage colony stimulating factor (antiGM-CSF) antibodies, clodronate liposomes (CL), and monocyte chemoattractant protein 1 (MCP1) inhibitor (bindarit) were administrated in CBDL rats, GM-CSF, and MCP1 were administrated in bone marrow-derived macrophages (BMDMs). Pulmonary inflammatory cell recruitment, vascular dilatation, and hypoxemia were progressively developed by 1 week after CBDL, but only occurred at 4 week after TAA. Neutrophils were the primary inflammatory cells within 3 weeks after CBDL and at 4 week after TAA. M2 macrophages were the primary inflammatory cells, meantime, pulmonary fibrosis, GM-CSFR, and CCR2 were specifically increased from 4 week after CBDL. AntiPMN antibody treatment decreased neutrophil and macrophage accumulation, CL or the combination of antiGM-CSF antibody and bindarit treatment decreased macrophage recruitment, resulting in pulmonary fibrosis, vascular dilatation, and hypoxemia in CBDL rats alleviated. The combination treatment of GM-CSF and MCP1 promoted cell migration, M2 macrophage differentiation, and transforming growth factor-β1 (TGF-β1) production in BMDMs. Conclusively, our results highlight neutrophil recruitment mediates pulmonary vascular dilatation and hypoxemia in the early stage of rat HPS. Further, M2 macrophage accumulation induced by GM-CSF/GM-CSFR and MCP1/CCR2 leads to pulmonary fibrosis and promotes vascular dilatation and hypoxemia, as a result, HPS develops.
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Affiliation(s)
- Bing Chen
- Department of Anesthesia, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Yong Yang
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Congwen Yang
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Jiaxiang Duan
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Lin Chen
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Kaizhi Lu
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Bin Yi
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Yang Chen
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Duo Xu
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - He Huang
- Department of Anesthesia, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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24
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Bommena S, Gerkin RD, Agarwal S, Raevens S, Glassberg MK, Fallon MB. Diagnosis of Hepatopulmonary Syndrome in a Large Integrated Health System. Clin Gastroenterol Hepatol 2021; 19:2370-2378. [PMID: 33007510 DOI: 10.1016/j.cgh.2020.09.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/26/2020] [Accepted: 09/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Data on the accuracy of the diagnosis of hepatopulmonary syndrome (HPS) in cirrhosis is limited. We evaluated the clinical characteristics of patients with International Classification of Diseases (ICD) codes for hepatopulmonary syndrome (HPS) in a large integrated health system. METHODS A retrospective review of encounters was performed of all patients with ICD-9-CM and/or ICD-10-CM diagnosis of cirrhosis and HPS from 2014-2019 in a multi-state health system. Demographics and cardiopulmonary testing closest to the time of HPS diagnosis were recorded. HPS was defined using standard criteria. RESULTS A total of 42,749 unique individuals with cirrhosis were identified. An ICD diagnosis of HPS was found in 194 patients (0.45%), of which 182 had clinically confirmed cirrhosis. 143 (78.5%) underwent contrast-enhanced transthoracic echocardiography, and 98 (54%) had delayed shunting. Among them, 61 patients had a documented arterial blood gas, with 53 showing abnormal oxygenation (A-a gradient of >15 mm Hg). 12 were excluded due to significant pulmonary function test abnormalities and abnormal oxygenation from other cardiopulmonary diseases. Ultimately, 41 (22.5%) fulfilled the criteria for HPS. When stratifying those with an ICD code diagnosis of HPS into HPS, no HPS and indeterminate HPS groups, based on standard diagnostic criteria for HPS, we found that the confirmed HPS patients had similar complications except for less portopulmonary hypertension, worse gas exchange, less cardiopulmonary disease and were more often diagnosed in transplant centers. CONCLUSIONS The diagnosis of HPS by ICD code is made in an extremely small subset of a sizeable cirrhotic cohort. When made, only a minority of these patients meet diagnostic criteria. Our findings highlight the need for improved education and more effective screening algorithms.
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Affiliation(s)
- Shoma Bommena
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona.
| | - Richard D Gerkin
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Sumit Agarwal
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Sarah Raevens
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Marilyn K Glassberg
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Michael B Fallon
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
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25
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Li YJ, Zhong KH, Bai XH, Tang X, Li P, Yang ZY, Zhi HY, Li XJ, Chen Y, Deng P, Qin XL, Gu JT, Ning JL, Lu KZ, Zhang J, Xia ZY, Chen YW, Yi B. A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning. J Clin Transl Hepatol 2021; 9:682-689. [PMID: 34722183 PMCID: PMC8516848 DOI: 10.14218/jcth.2020.00184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 12/04/2022] Open
Abstract
Background and Aims Screening for hepatopulmonary syndrome in cirrhotic patients is limited due to the need to perform contrast enhanced echocardiography (CEE) and arterial blood gas (ABG) analysis. We aimed to develop a simple and quick method to screen for the presence of intrapulmonary vascular dilation (IPVD) using noninvasive and easily available variables with machine learning (ML) algorithms. Methods Cirrhotic patients were enrolled from our hospital. All eligible patients underwent CEE, ABG analysis and physical examination. We developed a two-step model based on three ML algorithms, namely, adaptive boosting (termed AdaBoost), gradient boosting decision tree (termed GBDT) and eXtreme gradient boosting (termed Xgboost). Noninvasive variables were input in the first step (the NI model), and for the second step (the NIBG model), a combination of noninvasive variables and ABG results were used. Model performance was determined by the area under the curve of receiver operating characteristics (AUCROCs), precision, recall, F1-score and accuracy. Results A total of 193 cirrhotic patients were ultimately analyzed. The AUCROCs of the NI and NIBG models were 0.850 (0.738–0.962) and 0.867 (0.760–0.973), respectively, and both had an accuracy of 87.2%. For both negative and positive cases, the recall values of the NI and NIBG models were both 0.867 (0.760–0.973) and 0.875 (0.771–0.979), respectively, and the precisions were 0.813 (0.690–0.935) and 0.913 (0.825–1.000), respectively. Conclusions We developed a two-step model based on ML using noninvasive variables and ABG results to screen for the presence of IPVD in cirrhotic patients. This model may partly solve the problem of limited access to CEE and ABG by a large numbers of cirrhotic patients.
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Affiliation(s)
- Yu-Jie Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Kun-Hua Zhong
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Xue-Hong Bai
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xi Tang
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Peng Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Zhi-Yong Yang
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Hong-Yu Zhi
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xiao-Jun Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Yang Chen
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Peng Deng
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xiao-Lin Qin
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Jian-Teng Gu
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Jiao-Lin Ning
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Kai-Zhi Lu
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Ju Zhang
- University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Zheng-Yuan Xia
- Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yu-Wen Chen
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Bin Yi
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
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26
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Del Valle K, DuBrock HM. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Pulmonary Vascular Complications of Liver Disease. Compr Physiol 2021; 11:3281-3302. [PMID: 34636408 DOI: 10.1002/cphy.c210009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary vascular disease is a frequent complication of chronic liver disease and portal hypertension, affecting up to 30% of patients. There are two distinct pulmonary vascular complications of liver disease: hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS affects 25% of patients with chronic liver disease and is characterized by intrapulmonary vasodilatation and abnormal arterial oxygenation. HPS negatively impacts quality of life and is associated with a 2-fold increased risk of death compared to controls with liver disease without HPS. Angiogenesis, endothelin-1 mediated endothelial dysfunction, monocyte influx, and alveolar type 2 cell dysfunction seem to play important roles in disease pathogenesis but there are currently no effective medical therapies. Fortunately, HPS resolves following liver transplant (LT) with improvements in hypoxemia. POPH is a subtype of pulmonary arterial hypertension (PAH) characterized by an elevated mean pulmonary arterial pressure and pulmonary vascular resistance in the setting of normal left-sided filling pressures. POPH affects 5% to 6% of patients with chronic liver disease. Although the pathogenesis has not been fully elucidated, endothelial dysfunction, inflammation, and estrogen signaling have been identified as key pathways involved in disease pathogenesis. POPH is typically treated with PAH targeted therapy and may also improve with liver transplantation in selected patients. This article highlights what is currently known regarding the diagnosis, management, pathobiology, and outcomes of HPS and POPH. Ongoing research is needed to improve understanding of the pathophysiology and outcomes of these distinct and often misunderstood pulmonary vascular complications of liver disease. © 2021 American Physiological Society. Compr Physiol 11:1-22, 2021.
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27
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Parikh H, Lui E, Faughnan ME, Al-Hesayen A, Segovia S, Gupta S. Supine vs upright exercise in patients with hepatopulmonary syndrome and orthodeoxia: study protocol for a randomized controlled crossover trial. Trials 2021; 22:683. [PMID: 34625098 PMCID: PMC8500814 DOI: 10.1186/s13063-021-05633-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The hepatopulmonary syndrome (HPS) is a pulmonary complication of liver disease found in 10 to 32% of patients with cirrhosis and is characterized by intrapulmonary vascular dilatations and abnormal oxygenation. Liver transplantation is the only effective therapy for this disease. Patients with HPS have significant exercise limitations, impacting their quality of life and associated with poor liver transplant outcomes. Many patients with HPS exhibit orthodeoxia-an improvement in oxygenation in the supine compared to the upright position. We hypothesize that exercise capacity will be superior in the supine compared to the upright position in such patients. METHODS We propose a randomized controlled crossover trial in patients with moderate HPS (PaO2 < 80 mmHg) and orthodeoxia (supine to upright PaO2 decrease > 4 mmHg) comparing the effect of supine vs upright position on exercise. Patients with pulmonary hypertension, FEV1/FVC ratio < 0.65, significant coronary artery disease, disorders preventing or contraindicating use of a cycle ergometer, and/or moderate or severe ascites will be excluded. Participants will be randomized to cycle ergometry in either the supine or upright position. After a short washout period (a minimum of 1 day to a maximum of 4 weeks), participants will crossover and perform an exercise in the alternate position. Exercise will be performed at a constant work rate of 70-85% of the predicted peak work rate until the "stopping time" is reached, defined by exhaustion, profound desaturation, or safety concerns (drop in systolic blood pressure or life-threatening arrhythmia). The primary outcome will be the difference in the stopping time between exercise positions, compared with a repeated measures analysis of variance method with a mixed effects model approach. The model will be adjusted for period effects. P < 0.05 will be considered statistically significant. DISCUSSION HPS patients have hypoxemia leading to significant exercise limitations. If our study is positive, a supine exercise regimen could become a routine prescription for patients with HPS and orthodeoxia, enabling them to exercise more effectively. Future studies could explore the corresponding effects of a supine exercise training regimen on physiologic variables such as long-term exercise capacity, quality of life, dyspnea, and liver transplantation outcomes. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration and Results System (PRS) NCT04004104 . Registered on 1 July 2019.
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Affiliation(s)
- Harsh Parikh
- Li Ka Shing Knowledge Institute, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Eric Lui
- Li Ka Shing Knowledge Institute, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Marie E Faughnan
- Li Ka Shing Knowledge Institute, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, St. Michael's Hospital, Toronto, Canada
| | - Abdul Al-Hesayen
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, St Michael's Hospital, Toronto, Canada
| | | | - Samir Gupta
- Li Ka Shing Knowledge Institute, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada. .,Division of Respirology, St. Michael's Hospital, Toronto, Canada.
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28
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Kadry Z, Schaefer E, Krok K, Faust A, Stine JG, Schreibman IR, Bezinover D, Riley TR. Excellent outcomes with liver transplantation in hepatopulmonary syndrome across pre-transplant PaO 2 spectrum. JHEP Rep 2021; 3:100351. [PMID: 34604726 PMCID: PMC8473556 DOI: 10.1016/j.jhepr.2021.100351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Significantly worse survival has been reported in patients with hepatopulmonary syndrome (HPS) and partial pressure of arterial oxygen (PaO2) <45 mmHg undergoing liver transplantation. Long-term pre- and post-transplant outcomes based on degree of hypoxaemia were re-examined. Methods A retrospective analysis of 1,152 HPS candidates listed with an approved HPS model for end-stage liver disease (MELD) exception was performed. A Fine and Gray competing risks model was utilised to evaluate pre-transplant outcomes for PaO2 thresholds of <45, 45 to <60, and ≥60 mmHg. Post-transplant survival was analysed using the Kaplan-Meier method. Results Patients with a PaO2 <45 mmHg were significantly more likely to undergo transplantation (hazard ratio [HR] 1.51; 95% CI 1.12-2.03), whereas patients with higher MELD scores had lower hazard of transplant (HR 0.80, 95% CI 0.67-0.95, p = 0.011) and higher hazard of pre-transplant death (HR 2.29, 95% CI 1.55-3.37, p <0.001). Post-transplantation, patients with a PaO2 <45 mmHg had lower survival (p = 0.04) compared with patients with a PaO2 ≥45 to <50 mmHg, with survival curves significantly different at 2.6 years (75% survival compared with 86%) and median survival of 11.5 and 14.1 years, respectively. Cardiac arrest was a more likely (p = 0.025) cause of death for these patients. Cardiac arrest incidence in patients who died with a PaO2 >50 mmHg was 6.2%. Conclusions Patients with a PaO2 <45 mmHg had a significantly higher rate of transplantation, and higher calculated MELD scores were associated with significantly higher pre-transplant mortality. Although post-transplant survival was lower in patients with a PaO2 <45 mmHg, the median survival was 11.5 years, and survival curves only became significantly different at 2.6 years. This suggests that patients with HPS do benefit from transplantation up to 2-3 years post-transplant regardless of the severity of pre-transplant hypoxaemia. Lay summary A total of 1,152 patients with hepatopulmonary syndrome listed for liver transplant were analysed. Patients with a low PaO2 <45 mmHg had a high likelihood of transplantation. If associated with advanced liver disease, the mortality risk was higher for patients with hepatopulmonary syndrome on the wait list. After liver transplantation, patients with a PaO2 <45 mmHg had a lower survival, but this only became significant after 2.6 years, and the median survival was 11.5 years. This suggests that patients with hepatopulmonary syndrome do benefit from transplantation.
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Key Words
- CIF, cumulative incidence function
- ECMO, extracorporeal membrane oxygenation
- HPS, hepatopulmonary syndrome
- HR, hazard ratio
- Hepatopulmonary syndrome
- Hypoxia
- Liver transplantation
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- OPTN, Organ Procurement and Transplant Network
- POPH, portopulmonary hypertension
- PaO2, partial pressure of arterial oxygen
- STAR, Standard Transplant Analysis and Research
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Zakiyah Kadry
- Division of Transplantation, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Eric Schaefer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Karen Krok
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Alison Faust
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Jonathan Gibson Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ian Roy Schreibman
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Dmitri Bezinover
- Department of Anesthesiology, Penn State College of Medicine, Hershey, PA, USA
| | - Thomas Roberts Riley
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
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29
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Alabsawy E, Serry Y, Kotha S, Berry P, Tritto G. Hepatopulmonary syndrome as the first and only manifestation of cirrhosis in a patient with hypopituitarism. BMJ Case Rep 2021; 14:e244805. [PMID: 34544714 PMCID: PMC8454452 DOI: 10.1136/bcr-2021-244805] [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] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterised by the development of intrapulmonary arteriovenous blood shunts and vascular dilatation with consequent hypoxaemia, usually in the context of end-stage liver disease (ESLD). The estimated incidence of HPS in ESLD has been reported to be 13%-47%. Chronic liver disease has been described in patients with hypothalamic-pituitary dysfunction, mainly in the form of non-alcoholic fatty liver disease due to metabolic syndrome, with occasional progression to cirrhosis. We report a challenging case of a 27-year-old man with a background of hypopituitarism with no known liver disease who presented with progressive dyspnoea and hypoxaemia and was eventually diagnosed with severe HPS.
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Affiliation(s)
- Eman Alabsawy
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yassen Serry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giovanni Tritto
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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30
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Dahiya DS, Kichloo A, Shaka H, Singh J, Singh G, Wani F, Masudi S, Koul H, Pisipati S. Hepatopulmonary Syndrome: A Nationwide Analysis of Epidemiological Trends and Outcomes From 2012 to 2018. Gastroenterology Res 2021; 14:252-258. [PMID: 34527095 PMCID: PMC8425794 DOI: 10.14740/gr1448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022] Open
Abstract
Background This study was designed to determine the epidemiological trends and adverse outcomes of hepatopulmonary syndrome (HPS). Methods This retrospective interrupted trend study analyzed data from the Nationwide Inpatient Sample (NIS) for the years 2012, 2014, 2016 and 2018 to identify adult (≥ 18 years) hospitalizations with a diagnosis of HPS. We highlighted epidemiological trends for HPS. Inpatient mortality, mean length of stay (LOS) and mean total hospital charge (THC) were estimated using multivariate regression trend analysis. Results We observed an increase in the total number of HPS hospitalizations from 1,565 in 2012 to 2,495 in 2018, with mean age ranging from 55.8 to 58.1 years. There was a trend towards increasing hospitalizations (P-trend < 0.001) with increasing mean age (P-trend = 0.003) for HPS. Whites made up most of the study population. The inpatient mortality for HPS ranged from 12.4% to 12.6%, but there was no statistically significant trend for mortality (P-trend = 0.534) between 2012 and 2018. Additionally, there was no change in both mean LOS (P-trend = 0.545) and mean THC (P-trend = 0.534) for HPS for these years. Conclusions Hospitalizations and mean age for HPS were on the rise. Inpatient mortality ranged from 12.4% to 12.6%; however, a statistically significant trend for mortality was absent.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, 1000 Houghton Ave, Saginaw, MI 48602, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, 1000 Houghton Ave, Saginaw, MI 48602, USA.,Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1969 Ogden Ave, Chicago, IL 60612, USA
| | - Jagmeet Singh
- Department of Internal Medicine, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA 18840, USA
| | - Gurdeep Singh
- Department of Internal Medicine and Endocrinology, Lady of Lourdes Memorial Hospital, 169 Riverside Dr, Binghamton, NY 13905, USA
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, 830 Washington St, Watertown, NY 13601, USA
| | - Sundas Masudi
- Department of Internal Medicine, University of Liverpool School of Medicine, Cedar House, Ashton St, Liverpool, L693GE, UK
| | - Hazique Koul
- Department of Internal Medicine, Jaharul Islam Medical College, Bajitpur, BD 2336, Bangladesh
| | - Sailaja Pisipati
- Department of Gastroenterology and Hepatology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
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Raevens S, Boret M, De Pauw M, Fallon MB, Van Vlierberghe H. Pulmonary Abnormalities in Liver Disease: Relevance to Transplantation and Outcome. Hepatology 2021; 74:1674-1686. [PMID: 33636019 DOI: 10.1002/hep.31770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/17/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Pulmonary disease in liver cirrhosis and portal hypertension (PH) constitutes a challenging clinical scenario and may have important implications with regard to prognosis, liver transplantation (LT) candidacy, and post-LT outcome. Pre-LT evaluation should include adequate screening for pulmonary diseases that may occur concomitantly with liver disease as well as for those that may arise as a complication of end-stage liver disease and PH, given that either may jeopardize safe LT and successful outcome. It is key to discriminate those patients who would benefit from LT, especially pulmonary disorders that have been reported to resolve post-LT and are considered "pulmonary indications" for transplant, from those who are at increased mortality risk and in whom LT is contraindicated. In conclusion, in this article, we review the impact of several pulmonary disorders, including cystic fibrosis, alpha 1-antitrypsin deficiency, hereditary hemorrhagic telangiectasia, sarcoidosis, coronavirus disease 2019, asthma, chronic obstructive pulmonary disease, pulmonary nodules, interstitial lung disease, hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension, on post-LT survival, as well as the reciprocal impact of LT on the evolution of lung function.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Maxine Boret
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
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Turine Neto P, Seda Neto J, da Fonseca EA, Porta G, Pugliese R, Benavides MAR, Vincenzi R, Roda KMO, Danesi VLB, Hirschfeld APM, Feier FH, Chapchap P, Miura IK. Impact of hypoxemia on pediatric liver transplantation for hepatopulmonary syndrome. Pediatr Transplant 2021; 25:e13968. [PMID: 33590638 DOI: 10.1111/petr.13968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/20/2020] [Accepted: 12/27/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of choice for patients with cirrhosis and HPS is LT. The clinical manifestations associated with hypoxemia result in limitations and a poor health-related quality of life of affected patients. The present report aims to study the differences in outcomes between patients with PaO2 < 50 mm Hg and those with PaO2 ≥ 50 mm Hg. METHODS This was a retrospective study of 21 patients under 18 years of age conducted from 2001 to 2018; the patients were divided into 2 groups: G1-PaO2 ≥ 50 mm Hg, 11 patients, and G2-PaO2 < 50 mm Hg, 10 patients. Demographic, clinical, laboratory, and perioperative data; outcome variables; and post-transplant survival were compared between the groups. RESULTS In total, 2/11 (18.2%) patients in G1 and 8/10 (80%) patients in G2 required supplemental oxygen therapy at home (P = .005). Patients in G2 required prolonged MV (median 8.5 days in G2 vs 1 day in G1, P = .015) and prolonged ICU and hospital stays (P = .002 and P = .001, respectively). Oxygen weaning time was longer in G2 (median 127.5 days) than in G1 (median 3 days; P = .004). One (9.1%) patient in G1 and three (30%) patients in G2 died (P = .22). The survival at 90 months was 90.9% in G1 and 70% in G2 (P = .22). CONCLUSION The survival between groups was similar. Patients with very severe HPS required a longer MV time, longer ICU and hospital stays, and a longer O2 weaning time than those with mild, moderate, or severe HPS.
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Affiliation(s)
- Plínio Turine Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Eduardo Antunes da Fonseca
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Gilda Porta
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Marcel Albeiro Ruiz Benavides
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Karina Moreira Oliveira Roda
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Vera Lúcia Baggio Danesi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Adriana Porta Miche Hirschfeld
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Flavia Heinz Feier
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Paulo Chapchap
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | - Irene Kazue Miura
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.,Hepatology and Liver Transplantation A. C. Camargo Cancer Center, São Paulo, Brazil.,Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
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Aragon Pinto C, Iyer VN, Albitar HAH, Anderson A, Cajigas H, Simonetto DA, Krowka MJ, DuBrock HM, Gallo de Moraes A. Outcomes of liver transplantation in patients with hepatopulmonary syndrome in the pre and post-MELD eras: A systematic review. Respir Med Res 2021; 80:100852. [PMID: 34418867 DOI: 10.1016/j.resmer.2021.100852] [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] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The lack of large hepatopulmonary syndrome cohorts undergoing liver transplantation (LT) has resulted in limited information about post-LT outcomes and expectations. METHODS The long and short-term outcomes of LT in patients with hepatopulmonary syndrome (HPS) were evaluated before and after the implementation of Model for Endstage Liver Disease (MELD) score in 2002, granting exception points for patients with HPS. PubMed/Medline, Embase, Web of Science and Scopus databases were searched for published and unpublished studies from 01/1990 to 04/2019. Studies that included HPS patients who underwent LT and reported post-LT outcomes and HPS severity were reviewed. After reviewing the full text of 1421 articles, 30 were included in the pre-MELD era (before 2002) and 60 in the post-MELD era. RESULTS A total of 598 patients (210 children and 388 adults) with HPS who underwent LT were included in this systematic review. In children, 5-year survival probability was similar in the pre and post-MELD groups (85.7% vs. 97.4; p = 0.09). Median post-transplant PaO2 in room air was higher in the post-MELD group (71 [53-87] vs. 97 [80-108] mmHg: p = 0.008). In adults, 5-year survival probability was higher in the post-MELD era (73 vs. 87.3%; p = 0.008). Median post-transplant PaO2 in room air was higher in post-MELD group (75 [63-85] vs. 87 [75-95] mmHg; p = 0.001).. CONCLUSIONS After MELD exception implementation, survival rates and post-transplant oxygenation improved in adult patients with HPS who underwent liver transplantation, whereas only post-transplant oxygenation improved in children.
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Affiliation(s)
- Catarina Aragon Pinto
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Epidemiology and Translational Research in Intensive Care group (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Alexandra Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hector Cajigas
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Epidemiology and Translational Research in Intensive Care group (METRIC), Mayo Clinic, Rochester, MN, USA.
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Rock NM, Beghetti M, Tissot C, Willi JP, Bouhabib M, McLin VA, Maggio ABR. Reliable Detection of Intrapulmonary Shunts Using Contrast-Enhanced Echocardiography in Children With Portal Hypertension or Portosystemic Shunt. J Pediatr Gastroenterol Nutr 2021; 73:73-79. [PMID: 33605662 DOI: 10.1097/mpg.0000000000003079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of this study was to analyze if contrast-enhanced echocardiography (CEE) is as reliable as lung perfusion scintigraphy (LPS) to detect intrapulmonary shunting (IPS) in children with portal hypertension (PHTN) or congenital/surgical portosystemic shunts (PSS) and to define the number of cardiac cycles required to exclude intrapulmonary shunting. METHODS Inclusion criteria for this cross-sectional study were: (1) presence of PHTN or PSS diagnosed on abdominal ultrasound, (2) technically valid saline contrast echocardiography, (3) lung perfusion scintigraphy within 6 months of CEE. The number of cardiac cycles between right atrial opacification and the arrival of contrast in the left atrium were counted. We analyzed our CEE data at three and five cardiac cycles and compared them with LPS results. RESULTS The study population was composed of 78 children (38 girls, 49%) ages 2.1-18.8 years (mean 9.8). Sixty-nine patients had PHTN (88%), and nine had a PSS (11%). Eleven subjects (14%) presented evidence of IPS on LPS. Peripheral oxygen saturation was lower in the subjects with IPS detected on LPS (95.3 ± 1.7% vs 99.0 ± 1.4%; P < 0.01). Comparison of LPS with CEE before three and five cardiac cycles showed that CEE is highly specific (95.7%) as early as three cardiac cycles with markedly better sensitivity (72.7%) when using five cardiac cycles. Furthermore, a negative study using five cardiac cycles ruled out IPS with a 95% negative predictive value. The cardiac cycle at which the bubbles appeared in the left atrium was inversely correlated to the shunt index measured using LPS (r = -0.563; P = 0.001). CONCLUSION CEE is sufficient for the screening of IPS in children with PHTN or congenital/surgical PSS, obviating the need for LPS.
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Affiliation(s)
- Nathalie M Rock
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Cécile Tissot
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | | | - Maya Bouhabib
- Pediatric Cardiology Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Valérie A McLin
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics
| | - Albane B R Maggio
- Pediatric Sport Medicine and Obesity Care Program, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Switzerland
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Jalan R, D'Amico G, Trebicka J, Moreau R, Angeli P, Arroyo V. New clinical and pathophysiological perspectives defining the trajectory of cirrhosis. J Hepatol 2021; 75 Suppl 1:S14-S26. [PMID: 34039485 DOI: 10.1016/j.jhep.2021.01.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
Traditionally, the complications of cirrhosis, namely variceal bleeding, ascites and hepatic encephalopathy, were thought to result predominantly from circulatory dysfunction and altered organ perfusion arising as a result of portal hypertension. Over the past 20 years, large, international prospective studies have indicated the importance of systemic inflammation and organ immunopathology as additional determinants of organ dysfunction in cirrhosis, which not only manifests in the liver, brain, circulation and the kidneys, but also the immune system, gut, muscles, adrenal glands, reproductive organs, heart and lungs. This review provides an overview of the traditional and emerging concepts around the initiation and maintenance of organ dysfunction in cirrhosis and proposes a new paradigm based upon a better understanding of acute decompensation of cirrhosis. The interaction between the traditional concepts and the emerging perspectives remains a matter of great interest and the basis for future research.
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Affiliation(s)
- Rajiv Jalan
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom.
| | - Gennaro D'Amico
- Gastroenterology Unit, Ospedale Cervello and University of Palermo, Italy
| | - Jonel Trebicka
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; JW Goethe University Hospital, Frankfurt, Germany
| | - Richard Moreau
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; APHP, Hôpital Beaujon, Service d'Hépatologie, Clichy, France; Inserm, Université de Paris, Centre de Recherche sur L'Inflammation, Paris, France
| | - Paolo Angeli
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; University of Padova, Padova, Italy
| | - Vicente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
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Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
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Gupta S, Tang R, Al-Hesayen A. Inhaled nitric oxide improves the hepatopulmonary syndrome: a physiologic analysis. Thorax 2021; 76:1142-1145. [PMID: 33859047 DOI: 10.1136/thoraxjnl-2020-216128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/10/2020] [Accepted: 03/05/2021] [Indexed: 01/30/2023]
Abstract
The hepatopulmonary syndrome (HPS) is defined by liver dysfunction, intrapulmonary vasodilatation and abnormal oxygenation. Hypoxaemia is progressive and liver transplant is the only effective treatment. Severe hypoxaemia is a life-threatening HPS complication, particularly after transplant. We evaluated gas-exchange and haemodynamic effects of invasive therapies in a consecutive sample of 26 pre-transplant patients. Inhaled nitric oxide significantly improved partial pressure of oxygen (12.4 mm Hg; p=0.001) without deleterious effects on cardiac output. Trendelenburg positioning resulted in a small improvement, and methylene blue did not, though individual responses were variable. Future studies should prospectively evaluate these strategies in severe post-transplant hypoxaemia.
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Affiliation(s)
- Samir Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Rosalind Tang
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada.,Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Abdul Al-Hesayen
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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Recent advances in the approach to hepatopulmonary syndrome and portopulmonary hypertension. Acta Gastroenterol Belg 2021; 84:95-99. [PMID: 33639700 DOI: 10.51821/84.1.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver disease, cirrhosis and portal hypertension can be complicated by pulmonary vascular disease, which may affect prognosis and influence liver transplantation (LT) candidacy. Pulmonary vascular complications comprise hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). Although these two conditions develop on a same background and share a common trigger, pulmonary responses are distinct and occur at different anatomical sites of the pulmonary circulation. HPS affects 10-30% of patients referred for LT, and is characterized by gas exchange abnormalities due to pulmonary vasodilation and right-to-left shunting. POPH occurs in 5%, and is defined by pulmonary arterial hypertension due to increased pulmonary vascular resistance, which leads to hemodynamic failure. Even though HPS and POPH may have a substantial negative impact on survival, both entities are clinically underrecognized and frequently misdiagnosed. Without intervention, the 5-year survival rate is 23% in HPS and 14% in POPH. Their presence should be actively sought by organized screening in patients presenting with dyspnea and in all patients on the waitlist for LT, also because clinical symptoms are commonly non-specific or even absent. LT may lead to resolution, however, advanced stages of either HPS or POPH may jeopardize safe and successful LT. This implicates the need of proper identification of HPS and POPH cases, as well as the need to be able to successfully 'bridge' patients to LT by medical intervention. A review article on this topic has been published in this journal in 2007 (1). This updated review focuses on recent advances in the diagnosis and management of these 2 liver-induced pulmonary vascular disorders and incorporates results from our recent work.
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Abstract
Patients with advanced chronic liver diseases, particularly with decompensated liver cirrhosis, can develop specific pulmonary complications independently of any pre-existing lung disease. Especially when dyspnea occurs in combination with liver cirrhosis, patients should be evaluated for hepato-pulmonary syndrome (HPS), porto-pulmonary hypertension (PPHT), hepatic hydrothorax and spontaneous bacterial empyema, which represent the clinically most relevant pulmonary complications of liver cirrhosis. Importantly, the pathophysiology, clinical features, diagnosis and the corresponding therapeutic options differ between these entities, highlighting the role of specific diagnostics in patients with liver cirrhosis who present with dyspnea. Liver transplantation may offer a curative therapy, including selected cases of HPS and PPHT. In this review article, we summarize the pathogenesis, clinical features, diagnostic algorithms and treatment options of the 4 specific pulmonary complications in patients with liver cirrhosis.
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40
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Pereira JLF, Galant LH, Rosa LHTD, Garcia E, BrandÃo ABDM, Marroni CA. CAPACITY OF EXERCISE AND SURVIVAL IN PATIENTS WITH CIRRHOSIS WITH AND WITHOUT HEPATOPULMONARY SYNDROME AFTER LIVER TRANSPLANTATION. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:262-266. [PMID: 32935745 DOI: 10.1590/s0004-2803.202000000-49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is a complication associated with cirrhosis that may contribute to worsening exercise capacity and reduced survival after liver transplantation (LT). OBJECTIVE To evaluate exercise capacity, complications and survival after LT in patients with cirrhosis and HPS and to compare these results with the results of patients with cirrhosis without HPS. METHODS A prospective cohort study, consisting initially of 178 patients, of whom 90 underwent LT (42 with HPS and 48 without HPS). A previous evaluation consisted of the six-minute walk test (6MWT), an exercise test and manovacuometry. Those who underwent LT were evaluated for the mechanical ventilation time (MV), noninvasive ventilation (NIV) use, and survival two years after the procedure. In the statistical analysis, we used the Kolmogorov-Smirnov test, Student's t-test, the linear association square test, and the Kaplan-Meier survival curve. The data were analyzed with the SPSS 16.00 program and considered significant at P<0.05. RESULTS The HPS group demonstrated a lower peak of oxygen consumption (VO2peak) (14.2±2.3 vs 17.6±2.6) P<0.001 and a shorter distance walked on the 6MWT (340.8±50.9 vs 416.5±91.4) P<0.001 before LT compared with the non-HPS group. The transplanted patients with HPS remained longer hours in MV (19.5±4.3 vs 12.5±3.3) P=0.02, required more NIV (12 vs 2) P=0.01, and had lower survival two years after the procedure (P=0.01) compared with the transplanted patients without HPS. CONCLUSION Patients with HPS had worse exercise capacity before LT, more complications and shorter survival after this procedure than patients without HPS.
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Affiliation(s)
- José Leonardo Faustini Pereira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Lucas Homercher Galant
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Luis Henrique Telles da Rosa
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação Ciências da Reabilitação, Porto Alegre, RS, Brasil
| | - Eduardo Garcia
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Cláudio Augusto Marroni
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
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Nacif LS, Torres EKD, Alvarez PSE, Pereira JM, Pinheiro RS, Rocha-Santos V, Martino RB, Waisberg DR, Macedo RA, Ducatti L, Rocha Filho JA, Galvão FH, Andraus W, Carneiro D´Albuquerque L. Hepatopulmonary syndrome in waiting list and liver transplant. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Weinfurtner K, Forde K. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Current Status and Implications for Liver Transplantation. CURRENT HEPATOLOGY REPORTS 2020; 19:174-185. [PMID: 32905452 PMCID: PMC7473417 DOI: 10.1007/s11901-020-00532-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are both pulmonary vascular complications of advanced liver disease; however, these syndromes have distinct pathophysiology, clinical implications, and management. RECENT FINDINGS While both conditions are associated with portal hypertension, HPS results from diffuse pulmonary capillary vasodilation and PoPH results from vasoconstriction and vascular remodeling of pulmonary arteries. In HPS, no medical therapies clearly improve outcomes; however, patients have excellent post-LT outcomes with near uniform reversal of hypoxemia. In PoPH, several medical therapies used in idiopathic pulmonary hypertension have been shown improve pulmonary hemodynamics, symptoms, and potentially LT outcomes; however, further study is needed to determine best treatment regimens, long-term outcomes on medical therapy, and role of LT. SUMMARY While HPS results in severe hypoxemia that is usually reversible by LT, PoPH patients develop progressive pulmonary hypertension that may improve with medical therapy.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Rochon ER, Krowka MJ, Bartolome S, Heresi GA, Bull T, Roberts K, Hemnes A, Forde KA, Krok KL, Patel M, Lin G, McNeil M, Al-Naamani N, Roman BL, Yu PB, Fallon MB, Gladwin MT, Kawut SM. BMP9/10 in Pulmonary Vascular Complications of Liver Disease. Am J Respir Crit Care Med 2020; 201:1575-1578. [PMID: 32083953 DOI: 10.1164/rccm.201912-2514le] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | | | | | - Todd Bull
- University of ColoradoDenver, Colorado
| | | | | | - Kimberly A Forde
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Karen L Krok
- Penn State College of MedicineHershey, Pennsylvania
| | - Mamta Patel
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Megan McNeil
- Penn State College of MedicineHershey, Pennsylvania.,Brigham and Women's HospitalBoston, Massachusetts
| | - Nadine Al-Naamani
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Beth L Roman
- University of Pittsburgh Graduate School of Public HealthPittsburgh, Pennsylvania
| | - Paul B Yu
- Penn State College of MedicineHershey, Pennsylvania.,Harvard Medical SchoolBoston, Massachusettsand
| | | | | | - Steven M Kawut
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
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Abstract
Purpose of Review Liver transplantation is an important therapeutic option for patients with life-limiting liver disease, which may present in the form of acute liver failure, end-stage chronic liver disease, primary hepatic cancers, or inborn metabolic disorders. While significant strides have been made with respect to liver transplantation outcomes, the practice is constrained by an organ supply/demand mismatch. The purpose of this review, therefore, is to review the general indications and contraindication to liver transplantation, and to provide an overview of the transplant evaluation process. These considerations ultimately shape the specific criteria for patient selection, which will continue to evolve as means are developed to expand the donor pool, improve surgical techniques, broaden indications for safe transplant, and extend the lifetime of a graft. Recent Findings Selected patients with unresectable hilar cholangiocarcinoma may be candidates for liver transplantation. Patients over 65 years may be transplant candidates if they possess a favorable comorbidity profile. Patients at body mass index extremes (≥ 40 or < 18.5) have increased post-transplant mortality and require nutritional evaluation. Summary Liver transplantation may be life saving for patients with acute liver failure or end-stage liver disease. It is therefore critical for healthcare providers caring for patients with liver disease to be familiar with the general indications for transplantation and to know when it is appropriate or inappropriate to refer for transplant evaluation.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA USA
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Sekioka A, Nii M, Fukumoto K, Miyake H, Urushihara N. Hepatopulmonary syndrome revealed via echocardiography in the upright position. Pediatr Int 2020; 62:646-647. [PMID: 32463571 DOI: 10.1111/ped.14145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/14/2019] [Accepted: 01/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Akinori Sekioka
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
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Sendra C, Carballo-Rubio V, Sousa JM. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Management in Liver Transplantation in the Horizon 2020. Transplant Proc 2020; 52:1503-1506. [PMID: 32278579 DOI: 10.1016/j.transproceed.2020.02.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/05/2020] [Indexed: 12/13/2022]
Abstract
Hepatopulmonary syndrome (HPS) is characterized by intrapulmonary microvasculature dilatation that causes intrapulmonary shunting and leads to a gas exchange abnormality in the presence of liver diseases, which is the most common cause of respiratory insufficiency in these patients. HPS doubles the risk of death, and liver transplantation (LT) is the only curative therapeutic option so it should be considered in patients with severe HPS, with excellent survival rates post-LT. However, pretransplant Pao2 <45 mm Hg has been associated with an increase in post-transplant morbidity and mortality, but it does not imply a contraindication for LT. The resolution of HPS usually occurs within 6 months post-LT, but it can take 1 year. Portopulmonary hypertension (PoPH) is defined as pulmonary arterial hypertension (PAH) that develops in the setting of portal hypertension with or without liver disease in the absence of other causes of PAH. The prevalence of PoPH is 5% to 10% among liver transplant (LT) candidates. The impact of LT on PoPH is unpredictable. Therefore, despite conferring a high morbidity and mortality, PoPH itself is not an indication for liver transplantation. It may be considered a contraindication for LT in severe cases.
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Affiliation(s)
- Carmen Sendra
- Unit of Digestive Diseases, Virgen del Rocío University Hospital, Sevilla, 41013, Spain
| | | | - Jose Manuel Sousa
- Unit of Digestive Diseases, Virgen del Rocío University Hospital, Sevilla, 41013, Spain.
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Resources Utilization After Liver Transplantation in Patients With and Without Hepatopulmonary Syndrome: Cleveland Clinic Experience. Transplant Direct 2020; 6:e545. [PMID: 32309631 PMCID: PMC7145001 DOI: 10.1097/txd.0000000000000990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/30/2020] [Accepted: 02/21/2020] [Indexed: 11/25/2022] Open
Abstract
Patients with hepatopulmonary syndrome (HPS) reportedly experience posttransplant morbidity and require more resources to care during perioperative period. The exact incremental increase of resources utilization compared with non-HPS population remains unknown.
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Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
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A Role for Alveolar Exhaled Nitric Oxide Measurement in the Diagnosis of Hepatopulmonary Syndrome. J Clin Gastroenterol 2020; 54:278-283. [PMID: 31306341 DOI: 10.1097/mcg.0000000000001246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GOALS The authors sought to characterize predominantly alveolar exhaled nitric oxide (eNO) in hepatopulmonary syndrome (HPS) compared with non-HPS, changes after liver transplantation, and diagnostic properties. BACKGROUND HPS is defined by liver disease, intrapulmonary vascular dilatations (IPVDs), and hypoxemia. Rat models and small human studies suggest that NO overproduction may cause IPVDs. STUDY A retrospective review of the Canadian HPS Database (2007 to 2017) and prospective eNO measurement (main outcome) in healthy controls (measurement expiratory flow, 200 mL/s). HPS was defined as: (1) liver disease; (2) contrast echocardiography consistent with IPVDs; and (3) partial pressure of arterial oxygen <70 mm Hg with alveolar-arterial gradient >20 mm Hg; subclinical HPS as criteria (1) and (2) only; and no HPS as criterion (1) only. Current smokers and subjects with asthma or pulmonary hypertension were excluded. A linear mixed effects model was used to compare eNO between groups and before and after transplantation. RESULTS eNO was 10.4±0.7 ppb in HPS (n=26); 8.3±0.6 ppb in subclinical HPS (n=38); 7.1±1.0 ppb in no HPS (n=15); and 5.6±0.7 ppb in controls (n=30) (P<0.001). eNO decreased from 10.9±0.8 ppb preliver to 6.3±0.8 ppb postliver transplant (n=6 HPS, 6 subclinical HPS) (P<0.001). eNO <6 ppb was 84.4% (73.1% to 92.2%) sensitive and ≥12 ppb was 78.1% (69.4% to 85.3%) specific for HPS (vs. subclinical HPS). CONCLUSIONS HPS subjects have higher alveolar eNO than non-HPS subjects, levels normalize with liver transplantation. Applying eNO cutoff values may aid in HPS diagnosis.
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Chronic active Epstein-Barr virus infection with intrapulmonary shunting: A case report. J Infect Chemother 2020; 26:502-505. [PMID: 31983614 DOI: 10.1016/j.jiac.2019.12.012] [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: 10/08/2019] [Revised: 11/27/2019] [Accepted: 12/14/2019] [Indexed: 10/25/2022]
Abstract
Chronic active Epstein-Barr virus (EBV) infection (CAEBV) is a high-mortality form of EBV infection. However, chronic hypoxemia is rare in these patients. We herein reported a case of severe hypoxemia due to intrapulmonary shunting in CAEBV. A 17-year-old girl presented with fever, dyspnea, cyanosis, and hepatosplenomegaly. Laboratory tests showed mild liver dysfunction and high copy numbers of EBV-DNA in the peripheral blood. A left supratrochlear lymph node biopsy showed infiltration of highly proliferative T lymphocytes with positive EBV encoded small RNA by in situ hybridization. Technetium-99m-labeled macroaggregated albumin and contrast-enhanced echocardiography confirmed the existence of intrapulmonary shunting, which was probably related to hepatopulmonary syndrome. The final diagnosis was CAEBV with intrapulmonary shunting. The patient was treated with cyclosporine A, etoposide, and dexamethasone. Finally, the patient died of respiratory failure. Intrapulmonary shunting is a rare complication of CAEBV. Early recognition and exploring the cause of hypoxemia should be highlighted in patients with CAEBV.
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