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Qiu Y, Hilmi I. The applications of ECMO in liver transplant recipients. Transplant Rev (Orlando) 2024; 38:100816. [PMID: 38104398 DOI: 10.1016/j.trre.2023.100816] [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: 09/21/2023] [Revised: 11/23/2023] [Accepted: 12/03/2023] [Indexed: 12/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has emerged as a vital instrument for sustaining respiratory and cardiac functions when traditional methods have failed. Its function in managing acute pulmonary and cardiac challenges during liver transplantation (LT) has expanded significantly. While ECMO was initially viewed as a rescue strategy for acute intraoperative or posttransplant complications, its application now also encompasses the pretransplant stage of LT. Our review aims to thoroughly summarize both research and specific cases where ECMO has been utilized across pre- and perioperative phases in liver transplant recipients. By assessing the published literature, we discuss specific indications, the types of ECMO employed, their outcomes, and the unique challenges of applying ECMO during LT. In particular, the pretransplant use of ECMO is increasing, and its prudent introduction prior to LT, supported by meticulous planning, has the potential to optimize patient outcomes. It is challenging to manage liver transplant patients on ECMO. More research and experience are needed to refine the techniques and improve patient outcomes. Furthermore, decision-making must be tailored to each patient's unique circumstances, and a clear, practical, and well-defined plan for subsequent steps is essential.
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Affiliation(s)
- Yue Qiu
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Department of Anesthesiology and Perioperative Medicine Education Office, Liliane S. Kaufmann Building, 3471 Fifth AVE, Suite 402, Pittsburgh, PA 15213, USA.
| | - Ibtesam Hilmi
- Anesthesiology and Perioperative Medicine, Clinical and Translational Science Institute, University of Pittsburgh, School of Medicine, Montefiore Anesthesiology Office 200 Lothrop St, Pittsburgh, PA 15213, USA.
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2
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Qiu Y, Hilmi I. The applications of ECMO in liver transplant recipients. Transplant Rev (Orlando) 2024; 38:100816. [DOI: https:/doi.org/10.1016/j.trre.2023.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
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3
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Huang Y, Zhang J, Zhao Q, Hu X, Zhao H, Wang S, Wang L, Jiang R, Wu W, Liu J, Yuan P, Gong S. Impact of reduced apolipoprotein A-I levels on pulmonary arterial hypertension. Hellenic J Cardiol 2023:S1109-9666(23)00195-1. [PMID: 37940001 DOI: 10.1016/j.hjc.2023.10.004] [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: 06/27/2023] [Revised: 08/27/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The significance of apolipoprotein A-I (ApoA-I) is the anti-inflammatory functional component of high-density lipoprotein, which needs to be further studied in relation to pulmonary arterial hypertension (PAH). This study aimed to identify the predictive value of ApoA-1 on the risk and prognosis of PAH, as well as the underlying anti-inflammatory mechanism. METHODS Proteomic analysis was conducted on lung tissue from 6 PAH patients and 4 lung donors. Prediction of risk and mortality risk factors associated with PAH in 343 patients used logistic analysis and Cox regression analysis, respectively. The protective function of ApoA-I was assessed in human pulmonary arterial endothelial cells (HPAEC), while its anti-inflammatory function was evaluated in THP-1 macrophages. RESULTS In the lung tissues of patients with PAH, 168 differentially expressed proteins were associated with lipid metabolism according to GO and KEGG enrichment analysis. A protein-protein interaction network identified ApoA-I as a key protein associated with PAH. Lower ApoA-I levels were independent risk factors for PAH and displayed a stronger predictive value for PAH mortality. Plasma interleukin 6 (IL-6) levels were positively correlated with risk stratification and was higher in PAH patients with lower ApoA-I levels. ApoA-I was downregulated in lung tissues of MCT-induced rats. ApoA-I could reduce IL-6-induced pro-proliferative and pro-migratory abilities of HPAEC and inhibit secretion of IL-6 from macrophages, which is compromised under hypoxic conditions. CONCLUSION Our study identified the significance of ApoA-I as a biomarker for predicting the survival outcome of PAH patients, which might relate to its altered anti-inflammatory properties.
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Affiliation(s)
- Yuxia Huang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Ji Zhang
- Department of Lung Transplantation, First Affiliated Hospital, School of Medical, Zhejiang University, Hangzhou 310000, China
| | - Qinhua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Xiaoyi Hu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Hui Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China; Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai 200000, China
| | - Shang Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Wenhui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China
| | - Jinming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China.
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China.
| | - Sugang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200000, China.
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4
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Panackel C, Fawaz M, Jacob M, Raja K. Pulmonary Assessment of the Liver Transplant Recipient. J Clin Exp Hepatol 2023; 13:895-911. [PMID: 37693254 PMCID: PMC10483013 DOI: 10.1016/j.jceh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.
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Affiliation(s)
| | - Mohammed Fawaz
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Jacob
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Kaiser Raja
- King's College Hospital London, Dubai Hills, Dubai, United Arab Emirates
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5
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Jose A, Kopras EJ, Shah SA, Elwing JM. Portopulmonary hypertension practice patterns after liver transplantation. Liver Transpl 2023; 29:365-376. [PMID: 36117426 PMCID: PMC9985659 DOI: 10.1002/lt.26575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022]
Abstract
Portopulmonary hypertension (POPH) is a type of pulmonary arterial hypertension occurring exclusively in those with portal hypertensive liver disease. Liver transplantation (LT) can significantly improve outcomes. Current guidelines counsel against immediate adjustments to targeted therapy after LT and suggest routine echocardiography as sufficiently informative to guide therapeutic adjustments. Current practice patterns for adjusting targeted therapy after LT in POPH, and how they compare with guidelines, are not well established. To answer this question, we performed an institutional review board-approved, cross-sectional mixed-methods survey-based study of US POPH providers. Anonymized requests to complete the survey were sent through professional networks between January 20, 2022, and April 20, 2022. Responses were compared between cardiologists and pulmonologists using Fisher's exact tests, at a significance of 0.05. A total of 85 POPH physicians were included in the final analysis (66% pulmonologists and 34% cardiologists). Following LT, the majority of respondents routinely used a combination of standard cardiopulmonary assessment modalities to guide adjustment of targeted therapy following LT. Most respondents (69%) started by adjusting parenteral prostacyclins with small titrations and frequent reassessments within 3 months of LT, but some (19.7%) adjusted targeted therapy immediately after LT. Our results showed that the majority of respondents favored serial integrated cardiopulmonary testing (including routine right heart catheterization) to guide the adjustment of targeted therapy in POPH after LT, and almost one-fifth of respondents weaned therapy immediately after LT. Our study demonstrates heterogeneity in POPH practice patterns after LT, highlights differences between current practice patterns and the most recent guidelines, emphasizes the need for additional research, and supports a team-based approach to standardize care for these high-risk patients and optimize post-LT outcomes.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH
| | - Elizabeth J. Kopras
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH
| | - Shimul A. Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Jean M. Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH
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Bhan I, Schaefer EA, Bradley WR, Rodriguez-Lopez JM, Crowley JC, Hutchison B. Case 4-2023: A 56-Year-Old Man with Abnormal Results on Liver Testing. N Engl J Med 2023; 388:544-554. [PMID: 36780679 DOI: 10.1056/nejmcpc2201249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Irun Bhan
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
| | - Esperance A Schaefer
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
| | - William R Bradley
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
| | - Josanna M Rodriguez-Lopez
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
| | - Jerome C Crowley
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
| | - Bailey Hutchison
- From the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Massachusetts General Hospital, and the Departments of Medicine (I.B., E.A.S., J.M.R.-L.), Radiology (W.R.B.), Anesthesia (J.C.C.), and Pathology (B.H.), Harvard Medical School - both in Boston
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7
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Lai YK, Kwo PY. Portopulmonary Hypertension. Clin Liver Dis 2023; 27:71-84. [PMID: 36400468 DOI: 10.1016/j.cld.2022.08.002] [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: 01/31/2023]
Abstract
PoPH is a well-recognized complication of portal hypertension with or without cirrhosis and is classified as a subset of PAH. Identification of PoPH is crucial as it has a major impact on prognosis and liver transplant candidacy. Echocardiogram is the initial screening tool of choice and the patient should proceed to RHC for confirmation. PAH-directed therapy is the treatment of choice, allowing the patient to achieve a hemodynamic threshold to undergo a liver transplant safely.
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Affiliation(s)
- Yu Kuang Lai
- Pulmonary, Allergy and Critical Care, Department of Medicine, Stanford University, 300 Pasteur Drive, Room H3143, Palo Alto, CA 94304, USA
| | - Paul Y Kwo
- Stanford University School of Medicine, 430 Broadway, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA.
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8
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Jose A, Jones CR, Elwing JM. Struggling Between Liver Transplantation and Portopulmonary Hypertension. Heart Fail Clin 2023; 19:55-65. [PMID: 36435573 DOI: 10.1016/j.hfc.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Portopulmonary hypertension (PoPH) is a progressive, ultimately fatal cardiopulmonary disease that occurs exclusively in patients with underlying portal hypertensive liver disease. PoPH outcomes are driven by both the severity of underlying liver disease and the degree of cardiac adaptation to elevated pulmonary pressures. The mainstay of treatment in PoPH is targeted pulmonary vascular therapy. Liver transplantation (LT) can be beneficial in some patients, but is associated with considerable risks in the PoPH population, and outcomes are variable. The optimal management strategy for PoPH, LT, or medical therapy alone, is unclear, and further research is needed to help guide clinical decision-making.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, ML 0564, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, ML 3553, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, ML 0564, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
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9
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Temporal Trends in Portopulmonary Hypertension Model for End-stage Liver Disease Exceptions and Outcomes. Transplant Direct 2022; 8:e1410. [PMID: 36398194 PMCID: PMC9666225 DOI: 10.1097/txd.0000000000001410] [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: 05/05/2022] [Revised: 09/06/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Model for end-stage liver disease (MELD) exception criteria for portopulmonary hypertension (POPH) were created to prioritize patients for liver transplant before POPH progression. Little is known about trends in POPH exception frequency, disease severity, pulmonary hypertension treatment patterns, or outcomes since the POPH MELD exception began.
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10
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Kasliwal N, Yang C, Martinez EJ, Hebeler RF, Ramamoorthy S. Combined Tricuspid Valve Repair and Orthotopic Liver Transplantation in a Patient With Severe Tricuspid Regurgitation and Pulmonary Hypertension. Cureus 2022; 14:e28146. [PMID: 36148201 PMCID: PMC9482466 DOI: 10.7759/cureus.28146] [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] [Accepted: 08/17/2022] [Indexed: 11/19/2022] Open
Abstract
Severe pulmonary hypertension and severe tricuspid regurgitation are often considered strict contraindications for orthotopic liver transplantation. A combined approach of tricuspid repair and subsequent liver transplantation could provide a novel approach for patients with severe pulmonary hypertension and tricuspid regurgitation to undergo orthotopic liver transplantation. A 62-year-old male with a history of end-stage renal disease on hemodialysis, cirrhosis, and third-degree atrioventricular heart block status post single lead pacemaker insertion presented for an orthotopic liver transplant. However, after placement of a Swan-Ganz catheter by the anesthesia team, the patient's central venous pressure was found to be high, and his mean pulmonary artery pressure was 40 mmHg. His case was canceled due to concern for poor postoperative outcomes after a subsequent transesophageal echocardiogram revealed a severely dilated right heart and 4+ tricuspid regurgitation with flow reversal into the hepatic veins. After discussion among the hospital's transplant committee, the patient was planned to have a tricuspid valve repair, liver transplant, and kidney transplant surgery several months later. The patient successfully underwent tricuspid valve repair and orthotopic liver transplant and then kidney transplant the following day.
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11
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Peppas S, Nagraj S, Koutsias G, Kladas M, Archontakis-Barakakis P, Schizas D, Giannakoulas G, Palaiodimos L, Kokkinidis DG. Portopulmonary Hypertension: A Review of the Current Literature. Heart Lung Circ 2022; 31:1191-1202. [PMID: 35667970 DOI: 10.1016/j.hlc.2022.04.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/05/2022] [Accepted: 04/21/2022] [Indexed: 12/20/2022]
Abstract
Portopulmonary hypertension is defined as the development of pulmonary arterial hypertension in the setting of portal hypertension with or without liver cirrhosis. Portal hypertension-associated haemodynamic changes, including hyperdynamic state, portosystemic shunts and splanchnic vasodilation, induce significant alterations in pulmonary vascular bed and play a pivotal role in the pathogenesis of the disease. If left untreated, portopulmonary hypertension results in progressive right heart failure, with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and liver transplantation candidates, right heart catheterisation remains the gold standard for the diagnosis of the disease. Severe portopulmonary hypertension exerts a prohibitive risk to liver transplantation by conferring an elevated perioperative mortality risk. It is important for haemodynamic parameters to correspond with non-severe portopulmonary hypertension before patients can proceed with the liver transplantation. Small uncontrolled studies and a recent randomised controlled trial have reported promising results with vasodilatory therapies in clinical and haemodynamic improvement of patients, allowing a proportion of patients to undergo liver transplantation. In this review, the epidemiology, pathogenesis, diagnostic approach and management of portopulmonary hypertension are discussed. We also highlight fields of ongoing investigation pertinent to risk stratification and optimal patient selection to maximise long-term benefit from currently available treatments.
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Affiliation(s)
- Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece.
| | - Sanjana Nagraj
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - George Koutsias
- Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Michail Kladas
- Internal Medicine, North Central Bronx Hospital and James J. Peters VA Medical Center, Bronx, NY, USA
| | | | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leonidas Palaiodimos
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
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12
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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13
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Treatment of Portopulmonary Hypertension (PoPH): A Review. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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14
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Jose A, Shah SA, Anwar N, Jones CR, Sherman KE, Elwing JM. Pulmonary Vascular Resistance Predicts Mortality and Graft Failure in Transplantation Patients With Portopulmonary Hypertension. Liver Transpl 2021; 27:1811-1823. [PMID: 33964116 PMCID: PMC8573056 DOI: 10.1002/lt.26091] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
Portopulmonary hypertension (POPH) is a pulmonary vascular disease associated with significant morbidity and mortality in those with liver disease, conferring a higher mortality in patients awaiting liver transplantation (LT). Although not a transplant indication, patients with POPH can experience significant clinical improvement following LT, and those maintaining a mean pulmonary artery pressure (MPAP) <35mm Hg and a pulmonary vascular resistance (PVR) <5 Woods units (WU) are granted additional listing points to expedite LT. The effect of POPH on posttransplant outcomes such as mortality and graft failure, however, is not well defined. We performed a retrospective cohort study of the US Organ Procurement and Transplantation Network database of all adult patients who underwent LT between January 1, 2006, and December 1, 2020. Using adjusted accelerated failure time models, we examined the relationship between a diagnosis of POPH and outcomes following LT and the relationship between pre-LT hemodynamics and post-LT survival (alive with a functioning graft) in patients with POPH. Compared with those undergoing transplants without exception points, patients with POPH had comparable post-LT survival rates but were significantly more likely to have graft failure. Both pre-LT MPAP and PVR predicted post-LT survival in POPH, with a pre-LT PVR of ≥1.6 WU, more than doubling the hazard for mortality (death or a nonfunctioning graft; coefficient, 2.01; standard error, 0.85; hazard ratio, 2.21; P = 0.02). POPH may confer a significantly higher risk of post-LT graft failure compared with patients with cirrhosis without POPH, and a pre-LT PVR of ≥1.6 WU may predict post-LT survival. Further investigation into the relationship between pre-LT hemodynamics, right ventricular function, and post-LT outcomes of mortality and graft failure in POPH is needed.
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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
| | - 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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15
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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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Navarro-Vergara DI, Roldan-Valadez E, Cueto-Robledo G, Jurado-Hernandez MY. Portopulmonary Hypertension: Prevalence, Clinical and Hemodynamic Features. Curr Probl Cardiol 2020; 46:100747. [PMID: 33248724 DOI: 10.1016/j.cpcardiol.2020.100747] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 02/05/2023]
Abstract
Portopulmonary hypertension (PoPH) is a vascular complication of portal hypertension. This study aims to identify the prevalence and analyzing the clinical and hemodynamic features of patients with PoPH from a cohort of pulmonary arterial hypertension (PAH) patients. A retrospective transversal descriptive and analytical study. Patients with PoPH taken from a PAH cohort. We compare with those reported in the literature. We found prevalence of 6.1% of 244 consecutive patients with PAH, 11 females and 4 males. The mean age was 62 years and the main etiology of portal hypertension was primary biliary cirrhosis. Statistical differences were found in mean pulmonary arterial pressure, pulmonary vascular resistance, right atrial pressure; we found levels lower than reported. We found significant differences in clinical and hemodynamic characteristics such as older age and hemodynamic parameters of less severity in the group of patients analyzed compared with reported data.
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Thomas C, Glinskii V, de Jesus Perez V, Sahay S. Portopulmonary Hypertension: From Bench to Bedside. Front Med (Lausanne) 2020; 7:569413. [PMID: 33224960 PMCID: PMC7670077 DOI: 10.3389/fmed.2020.569413] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
Portopulmonary hypertension (PoPH) is defined as pulmonary arterial hypertension (PAH) associated with portal hypertension and is a subset of Group 1 pulmonary hypertension (PH). PoPH is a cause of significant morbidity and mortality in patients with portal hypertension with or without liver disease. Significant strides in elucidating the pathogenesis, effective screening algorithms, accurate diagnoses, and treatment options have been made in past 20 years. Survival of PoPH has remained poor compared to IPAH and other forms of PAH. Recently, the first randomized controlled trial was done in this patient population and showed promising results with PAH specific therapy. Despite positive effects on hemodynamics and functional outcomes, it is unclear whether PAH specific therapy has a beneficial effect on long term survival or transplant outcomes. In this review, we will discuss the epidemiology, pathophysiology, clinical and hemodynamic characteristics of PoPH. Additionally, this review will highlight the lacunae in our current management strategy, challenges faced and will provide direction to potentially useful futuristic management strategies.
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Affiliation(s)
- Christopher Thomas
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Vladimir Glinskii
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Vinicio de Jesus Perez
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Sandeep Sahay
- Houston Methodist Hospital Lung Center, Houston Methodist Hospital, Houston, TX, United States
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18
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Deroo R, Trépo E, Holvoet T, De Pauw M, Geerts A, Verhelst X, Colle I, Van Vlierberghe H, Fallon MB, Raevens S. Vasomodulators and Liver Transplantation for Portopulmonary Hypertension: Evidence From a Systematic Review and Meta-Analysis. Hepatology 2020; 72:1701-1716. [PMID: 32017176 DOI: 10.1002/hep.31164] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Untreated portopulmonary hypertension (PoPH) carries a poor prognosis. Previous reports have described vasomodulator (VM) therapy and liver transplantation (LT) as treatment options. We aimed to provide summary estimates on the endpoints of pulmonary hemodynamics and survival in patients with PoPH, treated with different modalities. APPROACH AND RESULTS We performed a systematic review with meta-analysis of mainly observational and case-control studies describing no treatment, VM, LT, or VM + LT in patients with PoPH. Twenty-six studies (1,019 patients) were included. Both VM and VM + LT improve pulmonary hemodynamics. A substantial proportion of patients treated with VM become eligible for LT (44%; 95% confidence interval [CI], 31-58). Pooled estimates for 1-, and 3-year postdiagnosis survival in patients treated with VM were 86% (95% CI, 81-90) and 69% (95% CI, 50-84) versus 82% (95% CI, 52-95) and 67% (95% CI, 53-78) in patients treated with VM + LT. Of note, studies reporting on the effect of VM mainly included Child-Pugh A/B patients, whereas studies reporting on VM + LT mainly included Child-Pugh B/C. Seven studies (238 patients) included both patients who received VM only and patients who received VM + LT. Risk of death in VM-only-treated patients was significantly higher than in patients who could be transplanted as well (odds ratio, 3.5; 95% CI, 1.4-8.8); however, importantly, patients who proceeded to transplant had been selected very strictly. In 50% of patients, VM can be discontinued post-LT (95% CI, 38-62). CONCLUSIONS VM and VM + LT both improve pulmonary hemodynamics and prognosis in PoPH. In a strictly selected subpopulation of cases where LT is indicated based on severe liver disease and where LT is considered safe and feasible, treatment with VM + LT confers a better prognosis. Considering successful VM, 44% can proceed to LT, with half being able to postoperatively stop medication.
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Affiliation(s)
- Rebecca Deroo
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Tom Holvoet
- 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
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Isabelle Colle
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
| | - Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
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19
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Clinical Outcomes after Liver Transplantation in Patients with Portopulmonary Hypertension. Transplantation 2020; 105:2283-2290. [PMID: 33065725 DOI: 10.1097/tp.0000000000003490] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Portopulmonary hypertension (POPH) is the presence of pulmonary arterial (PA) hypertension in patients with portal hypertension and is associated with significant morbidity and mortality. In a cohort of POPH patients, we describe the clinical outcomes of POPH patients who underwent liver transplantation (LT). METHODS Retrospectively collected data from a prospectively assembled cohort of all consecutive POPH adults evaluated in three transplant centers from 1996 to 2019. RESULTS From a cohort of 228 POPH patients, 50 patients underwent LT. Significant hemodynamic improvement after PA-targeted therapy was observed, with 58% receiving only monotherapy pre-transplant. After LT, 21 (42%) patients were able to discontinue and remained off PA-targeted therapy. The 1, 3, and 5 year unadjusted survival rates after LT were 72%, 63% and 60%, respectively. An elevated pulmonary vascular resistance (PVR) before LT was associated with worse survival rate (HR 1.91, 95% CI 1.07-3.74, p=0.04). No survival difference was observed in those granted MELD exception or transplants performed before or after the year 2010. CONCLUSION Significant number of POPH patients discontinued PA-targeted therapy after LT. Higher PVR before LT was associated with worse survival, as was monotherapy use. Despite effective PA-targeted therapies, POPH survival outcomes after LT in our cohort were modest and may reflect the need for more aggressive therapy.
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20
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DuBrock HM, Krowka MJ. The Myths and Realities of Portopulmonary Hypertension. Hepatology 2020; 72:1455-1460. [PMID: 32515501 DOI: 10.1002/hep.31415] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN
| | - Michael J Krowka
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN
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21
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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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22
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Long-term Outcomes and Survival in Moderate-severe Portopulmonary Hypertension After Liver Transplant. Transplantation 2020; 105:346-353. [DOI: 10.1097/tp.0000000000003248] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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23
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Krowka MJ. Hepatopulmonary Syndrome and Portopulmonary Hypertension: The Pulmonary Vascular Enigmas of Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:S13-S24. [PMID: 32140210 PMCID: PMC7050952 DOI: 10.1002/cld.846] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael J. Krowka
- Department of Medicine, Division of Pulmonary and Critical Care, Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
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24
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Savale L, Manes A. Pulmonary arterial hypertension populations of special interest: portopulmonary hypertension and pulmonary arterial hypertension associated with congenital heart disease. Eur Heart J Suppl 2019; 21:K37-K45. [PMID: 31857799 PMCID: PMC6915053 DOI: 10.1093/eurheartj/suz221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Guidelines exist for management of pulmonary arterial hypertension (PAH), but information is limited for certain patient subgroups, including adults with portopulmonary hypertension (PoPH) or with PAH associated with congenital heart disease (PAH-CHD). This article discusses screening, clinical management, and prognosis in PoPH and PAH-CHD and, as such, considers the most recent clinical data and expert advice. A multidisciplinary consultation and follow-up by specialists are crucial for management of both PoPH and PAH-CHD, but each condition presents with unique challenges. Development of PoPH most commonly occurs among patients with liver cirrhosis. Initially, patients may be asymptomatic for PoPH and, if untreated, survival with PoPH is generally worse than with idiopathic PAH (IPAH), so early identification with screening is crucial. PoPH can be managed with PAH-specific pharmacological therapy, and resolution is possible in some patients with liver transplantation. With PAH-CHD, survival rates are typically higher than with IPAH but vary across the four subtypes: Eisenmenger syndrome, systemic-to-pulmonary shunts, small cardiac defects, and corrected defects. Screening is also crucial and, in patients who undergo correction of CHD, the presence of PAH should be assessed immediately after repair and throughout their long-term follow-up, with frequency of assessments determined by the patient’s characteristics at the time of correction. Early screening for PAH in patients with portal hypertension or CHD, and multidisciplinary management of PoPH or PAH-CHD are important for the best patient outcomes.
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Affiliation(s)
- Laurent Savale
- Faculté de Médicine, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France.,Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, DHU Thorax Innovation, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Alessandra Manes
- Cardiothoracic Department, S. Orsola University Hospital, 40138 Bologna, Italy
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25
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Portopulmonary Hypertension: A Survey of Practice Patterns and Provider Attitudes. Transplant Direct 2019; 5:e456. [PMID: 31321292 PMCID: PMC6553621 DOI: 10.1097/txd.0000000000000900] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 12/24/2022] Open
Abstract
Supplemental Digital Content is available in the text. The role of liver transplantation (LT) in the management of portopulmonary hypertension (POPH) is poorly understood. The aim of this study was to better understand provider attitudes and practice patterns regarding the management of patients with POPH and to assess the concordance between clinical practice and current guidelines.
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26
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1548] [Impact Index Per Article: 258.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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27
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Iqbal S, Smith KA, Khungar V. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Implications for Liver Transplantation. Clin Chest Med 2017; 38:785-795. [PMID: 29128026 DOI: 10.1016/j.ccm.2017.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) represent serious pulmonary complications of advanced liver diseases. Orthotopic liver transplantation (OLT) is capable of completely resolving the underlying abnormalities associated with HPS. On the other hand, post-OLT response in patients with PoPH is less predictable, although heavily influenced by pre-OLT mean pulmonary arterial pressure. It remains the case that the opportunity to reverse 2 potentially fatal organ dysfunctions in the liver and the lung make HPS and PoPH more than worthy for further clinical investigations.
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Affiliation(s)
- Shaz Iqbal
- Department of Medicine, General Internal Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 834 West Gates Building, Philadelphia, PA 19104, USA
| | - Vandana Khungar
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street 2 Dulles, Philadelphia, PA 19104, USA.
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28
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DuBrock HM, Goldberg DS, Sussman NL, Bartolome SD, Kadry Z, Salgia RJ, Mulligan DC, Kremers WK, Kawut SM, Krowka MJ, Channick RN. Predictors of Waitlist Mortality in Portopulmonary Hypertension. Transplantation 2017; 101:1609-1615. [PMID: 28207639 DOI: 10.1097/tp.0000000000001666] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The current Organ Procurement Transplantation Network policy grants Model for End-Stage Liver Disease (MELD) exception points to patients with portopulmonary hypertension (POPH), but potentially important factors, such as severity of liver disease and pulmonary hypertension, are not included in the exception score, and may affect survival. The purpose of this study was to identify significant predictors of waitlist mortality in patients with POPH. METHODS We performed a retrospective cohort study of patients in the Organ Procurement and Transplantation Network database with hemodynamics consistent with POPH (defined as mean pulmonary arterial pressure >25 mm Hg and pulmonary vascular resistance [PVR] ≥240 dynes·s·cm) who were approved for a POPH MELD exception between 2006 and 2014. Using a Cox proportional hazards model, we identified predictors of waitlist mortality (or removal for clinical deterioration). RESULTS One hundred ninety adults were included. Age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.00-1.08; P = 0.0499), initial native MELD score (HR, 1.11; 95% CI, 1.05-1.17; P < 0.001), and initial PVR (HR, 1.12 per 100 dynes·s·cm; 95% CI, 1.02-1.23; P = 0.02) were the only significant univariate predictors of waitlist mortality and remained significant predictors in a multivariate model, which had a c-statistic of 0.71. PVR and mean pulmonary arterial pressure were not significant predictors of posttransplant mortality. CONCLUSIONS Both the severity of liver disease and POPH (as assessed by MELD and PVR, respectively) were significantly associated with waitlist, but not posttransplant, mortality in patients with approved MELD exceptions for POPH. Both factors should potentially be included in the POPH MELD exception score to more accurately reflect waitlist mortality risk.
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Affiliation(s)
- Hilary M DuBrock
- Department of Medicine, Massachusetts General Hospital Boston, MA USA
| | - David S Goldberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA USA
| | - Norman L Sussman
- Department of Surgery, Baylor College of Medicine Houston TX USA
| | - Sonja D Bartolome
- Department of Medicine, University of Texas Southwestern Medical Center Dallas, TX USA
| | - Zakiyah Kadry
- Department of Surgery, Division of Transplantation, Penn State Milton S. Hershey Medical Center Hershey, PA USA
| | - Reena J Salgia
- Department of Medicine, Henry Ford Hospital Detroit, MI USA
| | - David C Mulligan
- Department of Surgery, Transplantation and Immunology, Yale University New Haven, CT USA
| | - Walter K Kremers
- Department of Health Sciences Research, Mayo Clinic Rochester, MN USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA USA
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29
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Zardi EM, Zardi DM, Giorgi C, Chin D, Dobrina A. Portopulmonary hypertension and hepatorenal syndrome. Two faces of the same coin. Eur J Intern Med 2017; 43:22-27. [PMID: 28583409 DOI: 10.1016/j.ejim.2017.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/13/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023]
Abstract
Portopulmonary hypertension and hepatorenal syndrome are both severe local hypertensive complications of liver cirrhosis and portal hypertension. Both are characterized by vasoconstrictive manifestations regarding pulmonary and renal vascular network, respectively. This review addresses the mechanisms underlying the development of vasoconstriction that leads to local vascular hypertension in the lung and in the kidney with the result of organ dysfunction. Potential therapeutic options are available for the management of these two syndromes as a bridge for liver transplantation; clinical efficacy depends in part on the time and rapidity of intervention and in part on how serious the chain of events is that has triggered the entire vasoconstrictive process.
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Affiliation(s)
- Enrico Maria Zardi
- Internal Medicine Department of Campus Bio-Medico University, Rome, Italy.
| | - Domenico Maria Zardi
- Interventional Cardiology Department of S. Andrea Hospital, University La Sapienza of Rome, Italy
| | - Chiara Giorgi
- Radiology Department, S. Maria della Misericordia Hospital, Urbino, Italy
| | - Diana Chin
- Interventional Cardiology Department San Camillo Hospital, Rome, Italy
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
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30
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International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2017; 100:1440-52. [PMID: 27326810 DOI: 10.1097/tp.0000000000001229] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two distinct pulmonary vascular disorders, hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) may occur as a consequence of hepatic parenchymal or vascular abnormalities. HPS and POPH have major clinical implications for liver transplantation. A European Respiratory Society Task Force on Pulmonary-Hepatic Disorders convened in 2002 to standardize the diagnosis and guide management of these disorders. These International Liver Transplant Society diagnostic and management guidelines are based on that task force consensus and should continue to evolve as clinical experience dictates. Based on a review of over 1000 published HPS and POPH articles identified via a MEDLINE search (1985-2015), clinical guidelines were based on, selected single care reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Guidelines are presented in 5 parts; I. Definitions/Diagnostic criteria; II. Hepatopulmonary syndrome; III. Portopulmonary hypertension; IV. Implications for liver transplantation; and V. Suggestions for future clinical research.
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31
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Savale L, Sattler C, Coilly A, Conti F, Renard S, Francoz C, Bouvaist H, Feray C, Borentain P, Jaïs X, Montani D, Parent F, O'Connell C, Hervé P, Humbert M, Simonneau G, Samuel D, Calmus Y, Duvoux C, Durand F, Duclos-Vallée JC, Sitbon O. Long-term outcome in liver transplantation candidates with portopulmonary hypertension. Hepatology 2017; 65:1683-1692. [PMID: 27997987 DOI: 10.1002/hep.28990] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 11/06/2016] [Accepted: 11/26/2016] [Indexed: 02/04/2023]
Abstract
UNLABELLED Portopulmonary hypertension (PoPH) is diagnosed in 2-6% of liver transplantation (LT) candidates. We studied outcomes of candidates for LT suffering from PoPH. Data were collected retrospectively from a prospective registry. Pulmonary hemodynamic variables were collected at the time of PoPH diagnosis, at last evaluation before LT, and within 6 months and beyond 6 months after LT. Forty-nine patients (35 males, 48 ± 8 years) were analyzed (median Model for End-Stage Liver Disease score 20). At baseline, mean pulmonary artery pressure (mPAP) was 44 ± 10 mm Hg (range 26-73 mm Hg), cardiac index was 3.5 ± 0.9 L/min/m2 , and pulmonary vascular resistance was 5.6 ± 2.8 Wood units. Hemodynamic reassessment performed in 35 patients who were treated with pulmonary arterial hypertension-targeted therapies before LT resulted in significant decreases in both mPAP (36 ± 7 versus 47 ± 10 mm Hg, P < 0.0001) and pulmonary vascular resistance (3.0 ± 1.4 versus 6.1 ± 3.1 Wood units, P < 0.0001). Fourteen patients (29%) died without having had access to LT. Thirty-five patients underwent LT and were followed up for a median of 38 months. Eight patients (23%) died after LT including 5 due to PoPH (after 1 day to 6 months). Among survivors (n = 27), all patients treated with intravenous epoprostenol were weaned off post-LT, and endothelin receptor antagonist or phosphodiesterase type 5 inhibitors were continued in 15/27 patients (55%). At last evaluation, 20/27 patients (74%) had mPAP <35 mm Hg and 8 of them (30%) had mPAP <25 mm Hg. Overall survival estimates after LT were 80%, 77%, and 77% at 6 months, 1 year, and 3 years, respectively. CONCLUSION Stabilization or reversibility of PoPH seems to be an attainable goal using the combination of pulmonary arterial hypertension-targeted therapies and LT in patients who are transplantation candidates. (Hepatology 2017;65:1683-1692).
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Affiliation(s)
- Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Caroline Sattler
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; DHU Hepatinov, Villejuif, F-94800, France
| | - Filoména Conti
- Service de Transplantation Hépatique, APHP, Hôpital Pitié Salpêtrière, Paris, France
| | - Sébastien Renard
- Département de Cardiologie, Hôpital La Timone, Aix-Marseille Université, Marseille, France
| | - Claire Francoz
- Service de Transplantation Hépatique, APHP, Hôpital Beaujon, Paris, France
| | | | - Cyrille Feray
- Service de Transplantation Hépatique, APHP, Hôpital Henri Mondor, Paris, France
| | - Patrick Borentain
- Service d'hépatogastroenterologie, Hôpital La Timone, Aix-Marseille Université, Marseille, France
| | - Xavier Jaïs
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - David Montani
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Florence Parent
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Caroline O'Connell
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Hervé
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; DHU Hepatinov, Villejuif, F-94800, France
| | - Yvon Calmus
- Service de Transplantation Hépatique, APHP, Hôpital Pitié Salpêtrière, Paris, France
| | - Christophe Duvoux
- Service de Transplantation Hépatique, APHP, Hôpital Henri Mondor, Paris, France
| | - François Durand
- Service de Transplantation Hépatique, APHP, Hôpital Beaujon, Paris, France
| | - Jean Charles Duclos-Vallée
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; DHU Hepatinov, Villejuif, F-94800, France
| | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, and AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Frost AE. The Intersection of Pulmonary Hypertension and Solid Organ Transplantation. Methodist Debakey Cardiovasc J 2017; 12:10-13. [PMID: 28298957 DOI: 10.14797/mdcj-12-4s1-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pulmonary hypertension (PH) is a complication and marker of disease severity in many parenchymal lung diseases. It also is a frequent complication of portal hypertension and negatively impacts survival with liver transplant. Pulmonary hypertension is frequently diagnosed in patients with end-stage renal disease who are undergoing dialysis, and it has recently been demonstrated to adversely affect posttransplant outcome in this patient population even though the mechanism of PH is substantially different from that associated with liver disease. The presence of PH in patients with heart failure is frequent, and the necessity for PH therapy prior to heart transplant has evolved in the last decade. We review the frequency of and risk factors for PH in recipients of and candidates for lung, liver, heart, and renal transplants as well as the impact of this diagnosis on posttransplant outcomes.
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Affiliation(s)
- Adaani E Frost
- Houston Methodist Hospital, Houston, Texas; Weill Cornell Medical College, New York, New York
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Abstract
Portopulmonary hypertension (POPH) is a form of pulmonary arterial hypertension occurring in the setting of portal hypertension with or without hepatic cirrhosis. The presence of both portal and pulmonary vascular disease contributes to complicated hemodynamics and therapeutic challenges, though the severities do not appear to correlate directly. Diagnosis of POPH, and distinction from the commonly observed hyperdynamic state of end-stage liver disease, is typically accomplished with an initial screening transthoracic echocardiogram, followed by right heart catheterization for confirmation of hemodynamic parameters. Though few studies have directly evaluated use in POPH, pulmonary artery-directed therapy is the cornerstone of management, along with consideration of liver transplantation. Perioperative and long-term outcomes are variable, but uniformly worse in the setting of uncontrolled pulmonary pressures. Risk stratification and optimal patient selection for these interventions are areas of ongoing investigation.
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Affiliation(s)
- Christopher L Wray
- Liver Transplant Division, Liver Transplant Anesthesia Fellowship, Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA.
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35
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Sithamparanathan S, Nair A, Thirugnanasothy L, Coghlan JG, Condliffe R, Dimopoulos K, Elliot CA, Fisher AJ, Gaine S, Gibbs JSR, Gatzoulis MA, E Handler C, Howard LS, Johnson M, Kiely DG, Lordan JL, Peacock AJ, Pepke-Zaba J, Schreiber BE, Sheares KKK, Wort SJ, Corris PA. Survival in portopulmonary hypertension: Outcomes of the United Kingdom National Pulmonary Arterial Hypertension Registry. J Heart Lung Transplant 2016; 36:770-779. [PMID: 28190786 DOI: 10.1016/j.healun.2016.12.014] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Portopulmonary hypertension (PoPH) is a rare condition associated with poor survival, and the effect of modern therapies that target pulmonary arterial hypertension (PAH) on long-term outcome is unknown. This study investigated the baseline characteristics and survival in the cohort of patients diagnosed with PoPH in the United Kingdom National Pulmonary Hypertension Service. METHODS A retrospective review was conducted of all incident treatment-naïve patients with PoPH within the United Kingdom national registry diagnosed between January 2001 and December 2010. RESULTS Patients with PoPH (n = 110) had survival rates of 85%, 60%, and 35% at 1, 3, and 5 years. The prevalence of PoPH was 0.85 cases/1 million. Mean age at diagnosis was 53 ± 12 years, with a balanced distribution in gender. Alcohol (n = 57) and hepatitis C (n = 10) were the most common causes of portal hypertension. Phosphodiesterase V inhibitors were the most frequently used targeted therapy, in 63.6% (n = 70) of patients, endothelin receptor antagonists were used in 10% (n = 11) and prostacyclin analogs in 12.7% (n = 14). Univariate and multivariate analysis of baseline characteristics did not demonstrate a significant influence of severity of portal hypertension or liver cirrhosis, World Health Organization Functional Class, cardiopulmonary hemodynamics, or year of diagnosis on survival. CONCLUSIONS Survival of patients with PoPH remains poor despite targeted therapy and worse than patients with idiopathic PAH. The benefit of PAH therapies in PoPH on long-term morbidity and mortality outcomes needs further consideration and study.
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Affiliation(s)
- Sasiharan Sithamparanathan
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Arun Nair
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Logan Thirugnanasothy
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - J Gerry Coghlan
- Pulmonary Hypertension Unit, Royal Free Hospital, London, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Konstantinos Dimopoulos
- Royal Brompton Pulmonary Hypertension and Adult Congenital Heart Centre, Imperial College, London, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew J Fisher
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sean Gaine
- Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - J Simon R Gibbs
- National Heart and Lung Institute, Imperial College, London and Hammersmith Hospital, London, United Kingdom
| | - Michael A Gatzoulis
- Royal Brompton Pulmonary Hypertension and Adult Congenital Heart Centre, Imperial College, London, United Kingdom
| | - Clive E Handler
- Pulmonary Hypertension Unit, Royal Free Hospital, London, United Kingdom
| | - Luke S Howard
- National Heart and Lung Institute, Imperial College, London and Hammersmith Hospital, London, United Kingdom
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, Scotland
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - James L Lordan
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, Scotland
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom
| | | | - Karen K K Sheares
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom
| | - Stephen J Wort
- Royal Brompton Pulmonary Hypertension and Adult Congenital Heart Centre, Imperial College, London, United Kingdom
| | - Paul A Corris
- National Pulmonary Hypertension Service (Newcastle), The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Rodríguez-Almendros N, Toapanta-Yanchapaxi LN, Aguirre Valadez J, Espinola Zavaleta N, Muñoz-Martínez SG, García-Juárez I. [Portopulmonary hypertension: Updated review]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 88:25-38. [PMID: 27986561 DOI: 10.1016/j.acmx.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022] Open
Abstract
Portopulmonary hypertension (PPH) is a rare condition worldwide, although epidemiological data are unknown in Mexico. However, chronic liver diseases are very prevalent in Mexico. PPH is the 4th subtype in frequency in the group of pulmonary arterial hypertension. Its diagnosis is made within 2 scenarios: patients with suspected pulmonary hypertension and candidates for orthotopic liver transplantation (OLT). Both echocardiogram and a right cardiac catheterisation are crucial for diagnosis in both cases. PPH is a challenge for OLT, since it can significantly increase perioperative mortality. The use of specific therapy is the cornerstone of this disease, as a measure to improve the outcome of those who become candidates for OLT with moderate to severe PPH. It is important to recognise that PPH can be a contraindication to OLT. The role of lung-liver transplantation or heart-lung-liver transplantation as a measure to heal pulmonary vascular disease in patients with PPH is still uncertain.
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Affiliation(s)
- Nielzer Rodríguez-Almendros
- Departamento de Hipertensión Pulmonar y Función Ventricular Derecha, UMAE Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, D.F., México
| | - Liz N Toapanta-Yanchapaxi
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Jonathan Aguirre Valadez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Nilda Espinola Zavaleta
- Departamento de Ecocardiografia, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Sergio G Muñoz-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Ignacio García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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37
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Krowka MJ, Heimbach JK. Portopulmonary hypertension and liver transplantation: A duo in question. Liver Transpl 2016; 22:1633-1634. [PMID: 27779823 DOI: 10.1002/lt.24664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 02/07/2023]
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38
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Verma S, Hand F, Armstrong MJ, de Vos M, Thorburn D, Pan T, Klinck J, Westbrook RH, Auzinger G, Bathgate A, Masson S, Holt A, Houlihan DD, Ferguson JW. Portopulmonary hypertension: Still an appropriate consideration for liver transplantation? Liver Transpl 2016; 22:1637-1642. [PMID: 27593213 DOI: 10.1002/lt.24625] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/09/2016] [Indexed: 12/13/2022]
Abstract
Liver transplantation (LT) in patients with portopulmonary hypertension (PoPH) has historically resulted in unpredictable and often poor outcomes. The United Kingdom experience for the period 1992-2012 is reported in this article. A retrospective analysis of patients, preoperatively fulfilling the PoPH European Respiratory Society Task Force on Pulmonary-Hepatic Vascular Disorders diagnostic criteria was conducted across all UK LT centers. Data collection included comorbidities, use of preoperative and postoperative pharmacotherapy, patient survival, and cause of death. To enable survival stratification, PoPH was classified as mild, moderate, or severe based on mean pulmonary pressure of <35 mm Hg, 35-49 mm Hg, and ≥50 mm Hg, respectively. Of 127 patients reported to have PoPH, just 28 fulfilled the diagnostic criteria (14 mild, 9 moderate, 5 severe). Twenty (71.4%) patients were male with median age and Model for End-Stage Liver Disease of 50 years (range, 23-62 years) and 18 (range, 6-43), respectively. Twelve (42.9%) patients died within 5 years of LT. The majority of deaths (10 of 12; 83%) occurred within the first 6 months after LT, aetiologies of which included right heart failure (n = 3), progressive PoPH (n = 2), and sepsis (n = 2). Of those receiving preoperative pharmacotherapy (n = 8), 5 are currently alive and were classified as mild to moderate PoPH. Both severe PoPH patients optimized preoperatively with pharmacotherapy died within a year of LT. Development of effective vasodilatory therapies in the setting of pulmonary arterial hypertension has led to a dramatic improvement in patient survival. The available data indicate that in this era of pharmacotherapy, PoPH in isolation no longer represents a valid consideration to transplant. Liver Transplantation 22 1637-1642 2016 AASLD.
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Affiliation(s)
- Suman Verma
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Fiona Hand
- National Liver Unit, St. Vincent's University Hospital, Dublin, Ireland
| | | | | | | | - Terry Pan
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - John Klinck
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Rachel H Westbrook
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Georg Auzinger
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | | | - Andrew Holt
- University Birmingham Hospital Trust, Birmingham, United Kingdom
| | | | - James W Ferguson
- University Birmingham Hospital Trust, Birmingham, United Kingdom
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Abstract
Portopulmonary hypertension (PoPH) refers to the condition that pulmonary arterial hypertension (PAH) occur in the stetting of portal hypertension. The development of PoPH is thought to be independent of the severity of portal hypertension or the etiology or severity of liver disease. PoPH results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. Untreated PoPH is associated with a poor prognosis. As PoPH is frequently asymptomatic or symptoms are generally non-specific, patients should be actively screened for the presence of PoPH. Two-dimensional transthoracic echocardiography is a useful non-invasive screening tool, but a definitive diagnosis requires invasive hemodynamic confirmation by right heart catheterization. Despite a dearth of randomized, prospective data, an ever-expanding clinical experience shows that patients with PoPH benefit from therapy with PAH-specific medications including with endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and/or prostanoids. Due to high perioperative mortality, transplantation should be avoided in those patients who have severe PoPH that is refractory to medical therapy.
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Affiliation(s)
- Yong Lv
- a Department of Liver Diseases and Digestive Interventional Radiology , Xijing Hospital of Digestive Diseases, Fourth Military Medical University , Xi'an , China
| | - Guohong Han
- a Department of Liver Diseases and Digestive Interventional Radiology , Xijing Hospital of Digestive Diseases, Fourth Military Medical University , Xi'an , China
| | - Daiming Fan
- b State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Xi'an , China
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40
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Goldberg DS, Fallon MB. The Art and Science of Diagnosing and Treating Lung and Heart Disease Secondary to Liver Disease. Clin Gastroenterol Hepatol 2015; 13:2118-27. [PMID: 25934564 PMCID: PMC4618073 DOI: 10.1016/j.cgh.2015.04.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/13/2015] [Accepted: 04/14/2015] [Indexed: 02/07/2023]
Abstract
Patients with chronic liver disease are at risk of extrahepatic complications related to cirrhosis and portal hypertension, as well as organ-specific complications of certain liver diseases. These complications can compromise quality of life, while also increasing morbidity and mortality before and after liver transplantation. Patients with chronic liver disease are at risk for pulmonary complications of hepatopulmonary syndrome and portopulmonary syndrome; the cardiac complication fall under the general concept of cirrhotic cardiomyopathy, which can affect systolic and diastolic function, as well as cardiac conduction. In addition, patients with certain diseases are at risk of lung and/or cardiac complications that are specific to the primary disease (ie, emphysema in α-1-antitrypsin deficiency) or occur with increased incidence in certain conditions (ie, ischemic heart disease associated with nonalcoholic steatohepatitis). This article focuses on the epidemiology, clinical presentation, pathogenesis, treatment options, and role of transplantation for lung and heart diseases secondary to liver disease, while also highlighting select liver diseases that directly affect the lungs and heart.
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Affiliation(s)
- David S Goldberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michael B Fallon
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
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41
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Asrani SK, Kamath PS. Model for end-stage liver disease score and MELD exceptions: 15 years later. Hepatol Int 2015; 9:346-54. [PMID: 26016462 DOI: 10.1007/s12072-015-9631-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/06/2015] [Indexed: 02/06/2023]
Abstract
The model for end-stage liver disease (MELD) score has been used as an objective scale of disease severity for management of patients with end-stage liver disease; it currently serves as the basis of an urgency-based organ-allocation policy in several countries. Implementation of the MELD score led to a reduction in waiting-list registration and waiting-list mortality and an increase in the number of deceased-donor transplants without adversely affecting long-term outcomes after liver transplantation (LT). The MELD score has been used for management of non-transplant patients with chronic liver disease. MELD exceptions serve as a mechanism to advance the needs of subsets of patients with liver disease not adequately addressed by MELD-based organ allocation. Several models have been proposed to refine and improve the MELD score as the environment within which it operates continues to evolve toward transplantation for sicker patients. The MELD score continues to serve and be used as a template to improve upon as an objective gauge of disease severity and as a metric enabling optimization of allocation of scarce donor organs for LT.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, 3410 Worth Street Suite 860, Dallas, TX, 75246, USA,
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42
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DuBrock HM, Channick RN, Krowka MJ. What's new in the treatment of portopulmonary hypertension? Expert Rev Gastroenterol Hepatol 2015; 9:983-92. [PMID: 25882070 DOI: 10.1586/17474124.2015.1035647] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Portopulmonary hypertension (POPH) is a complication of portal hypertension characterized by pulmonary vasoconstriction and vascular remodeling that can lead to right heart failure and death. Differentiation of POPH from other causes of pulmonary hypertension, such as volume overload or a hyperdynamic high flow state, is critical because a diagnosis of POPH has significant implications for liver transplant risk stratification, Model for End Stage Liver Disease exception points, and the use of pulmonary arterial hypertension-(PAH) specific therapy. Currently, there are 12 approved medications for the treatment of PAH in the US, and three of these were approved in 2013. This review will discuss the diagnosis, evaluation and management of POPH and the role of recently approved PAH therapies in the treatment of POPH.
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Affiliation(s)
- Hilary M DuBrock
- Massachusetts General Hospital, 55 Fruit St Boston MA 02114, USA
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43
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[Hepatocardiac disorders : Interactions between two organ systems]. Med Klin Intensivmed Notfmed 2015; 111:447-52. [PMID: 26070920 DOI: 10.1007/s00063-015-0043-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/16/2015] [Accepted: 04/03/2015] [Indexed: 12/30/2022]
Abstract
Interactions between the hepatic portal and cardiovascular systems are frequently found in patients with liver disease. Cirrhotic cardiomyopathy (CCMP) is defined as reduced cardiac function in patients with liver cirrhosis in the absence of other known causes of cardiac disease. The typical hyperdynamic circulatory state by means of increased cardiac output and reduced systemic vascular resistance may mask left ventricular failure. Portopulmonary hypertension (POPH) is defined as increased pulmonary arterial pressure and the presence of portal hypertension, and is associated with increased mortality. Targeted medical therapies include vasodilators such as prostanoids, endothelin receptor antagonists and phosphodiesterase-5 inhibitors. Hypoxic or ischaemic hepatitis (HH) is defined by a sharp increase of serum aminotransferase levels due to liver cell necrosis as result of cardiac, circulatory or respiratory failure. An overview of these diseases is provided in this article.
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44
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Raevens S, Geerts A, Van Steenkiste C, Verhelst X, Van Vlierberghe H, Colle I. Hepatopulmonary syndrome and portopulmonary hypertension: recent knowledge in pathogenesis and overview of clinical assessment. Liver Int 2015; 35:1646-60. [PMID: 25627425 DOI: 10.1111/liv.12791] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/17/2015] [Indexed: 12/14/2022]
Abstract
Hepatopulmonary syndrome and portopulmonary hypertension are cardiopulmonary complications, which are not infrequently seen in patients with liver disease and/or portal hypertension. These entities are both clinically and pathophysiologically different: the hepatopulmonary syndrome is characterized by abnormal pulmonary vasodilation and right-to-left shunting resulting in gas exchange abnormalities, whereas portopulmonary hypertension is caused by pulmonary artery vasoconstriction leading to hemodynamic failure. As both hepatopulmonary syndrome and portopulmonary hypertension are associated with significantly increased morbidity and mortality, and as these patients are commonly asymptomatic, all liver transplantation candidates should be actively screened for the presence of these two complications. The aim of is this review is to provide an overview on the hepatopulmonary syndrome and portopulmonary hypertension with primary focus on diagnosis and recent knowledge regarding pathogenesis and therapeutic targets.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Christophe Van Steenkiste
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium.,Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Colle
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium.,Department of Gastroenterology and Hepatology, Algemeen Stedelijk Ziekenhuis ASZ, Aalst, Belgium
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45
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Eyraud D. Clinics and Research in Hepatology and Gastroenterology. Editorial. Clin Res Hepatol Gastroenterol 2015; 39:151-2. [PMID: 25656981 DOI: 10.1016/j.clinre.2014.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 12/28/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Daniel Eyraud
- Department of hepatic surgery and liver transplantation, Department of anesthesiology and intensive care, GH Pitié Salpétrière, 43-87, boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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