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Chooklin S, Chuklin S. Hepatopulmonary syndrome: diagnosis and treatment. EMERGENCY MEDICINE 2024; 19:511-518. [DOI: 10.22141/2224-0586.19.8.2023.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Hepatopulmonary syndrome (HPS) is one of the lung diseases associated with liver cirrhosis and portal hypertension. The diagnosis is based on the triad: liver disease and portal hypertension, evidence of intrapulmonary vascular dilatation and impaired gas exchange. HPS impairs prognosis (23 % survival after 5 years) and patients’ quality of life, so early diagnosis and timely treatment are of great importance. Liver transplantation allows for regression of intrapulmonary vascular dilatation in almost 100 % of cases, normalization of gas exchange and improves a 5-year survival after transplantation from 76 to 87 %. This is the only treatment method indicated for patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60 mm Hg. However, in the face of a global shortage of transplants, it is necessary to develop medical therapies to delay or even defer liver transplantation. This goal seems possible due to the growing understanding of the HPS pathophysiology and the development of therapies targeting key mechanisms, mainly inflammatory and angiogenic. This article provides an overview of the clinical manifestations, diagnosis and treatment of HPS based on literature sources from the MEDLINE database on the PubMed platform.
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Luo BW, Du ZY. Advances in Diagnostic Imaging of Hepatopulmonary Syndrome. Front Med (Lausanne) 2022; 8:817758. [PMID: 35083259 PMCID: PMC8784805 DOI: 10.3389/fmed.2021.817758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is a serious pulmonary complication of progressive liver disease that leads to a poor clinical prognosis. Patients with HPS may develop acute respiratory failure, which requires intensive care and therapy. At present, the only effective treatment is liver transplantation; therefore, early diagnosis and timely treatment are of considerable significance. The three main features of HPS are liver disease, oxygenation disorder, and intrapulmonary vascular dilatation (IPVD). Diagnosing HPS is challenging due to the difficulty in detecting the presence or absence of IPVD. As such, imaging examination is very important for detecting IPVD. This paper reviews the imaging methods for diagnosing HPS such as ultrasound, dynamic pulmonary perfusion imaging, pulmonary angiography, and computed tomography.
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Affiliation(s)
- Bi-Wei Luo
- Department of Hepatobiliary and Pancreas Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Zhi-Yong Du
- Department of Hepatobiliary and Pancreas Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
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Soulaidopoulos S, Vlachou M, Cholongitas E, Giannakoulas G, Panagiotidis T, Drakopoulou M, Karvounis H, Goulis I. Assessment of biventricular function in patients with hepatopulmonary syndrome. Int J Cardiovasc Imaging 2021; 37:2891-2900. [PMID: 34114149 DOI: 10.1007/s10554-021-02260-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
Cardiac function impairment in the setting of hepatopulmonary syndrome (HPS) in patients with end stage liver disease remains an issue of debate. The current study evaluated possible correlations between HPS and biventricular systolic function in patients with decompensated cirrhosis. Consecutive liver transplantation candidates with stable decompensated cirrhosis were prospectively evaluated. HPS was defined as the presence of an elevated alveolar-arterial oxygen gradient and intrapulmonary vasodilatation, detected by contrast enhanced echocardiography. HPS severity was determined based on arterial blood oxygen pressure values, while shunt size was assessed with a semi-quantitative method. Demographic, clinical and laboratory parameters were also prospectively collected. In total, 130 patients (mean age 56.5, M/F: 94/36, MELD score 14.6 ± 5.6) were enrolled, of whom 45 (34.6%) fulfilled the criteria for HPS diagnosis (mild: 57.7%, moderate: 33.3%, severe 4.4% and very severe 4.4%). Significantly lower absolute left ventricular (LV) global longitudinal strain (GLS) values (- 21.6 ± 2.3 vs. - 22.6 ± 2.5%, p = 0.041) were measured in patients with HPS compared to cirrhotic patients without HPS, while there was no statistically significant difference regarding right ventricular GLS (- 22.1 ± 3.3 vs. - 23.2 ± 3.5%, p = 0.061) between the two groups. Lower LV ejection fraction values were also recorded in the HPS group (53.9 ± 3.5 vs. 56.3 ± 4.5%, p < 0.01). No other echocardiographic parameter was correlated to HPS. Intrapulmonary shunt grading was correlated to HPS classification (χ2 = 19.8, p < 0.01), with lower arterial oxygen values being recorded in higher stages of intrapulmonary shunt. In patients with cirrhosis, the presence of HPS is associated with worse LV contractile performance.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Cardiology Department, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
- Fourth Department of Internal Medicine, 'Hippokration' General Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloníki, Greece.
| | - Maria Vlachou
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Evangelos Cholongitas
- First Department of Internal Medicine, 'Laiko' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George Giannakoulas
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Theofilos Panagiotidis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Maria Drakopoulou
- First Cardiology Department, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Haralambos Karvounis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, 'Hippokration' General Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloníki, Greece
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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Ning Q. Main Complications of AECHB and Severe Hepatitis B (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498917 DOI: 10.1007/978-94-024-1603-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qin Ning
- Department of Infectious Disease, Tongji Hospital, Wuhan, China
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Soulaidopoulos S, Cholongitas E, Giannakoulas G, Vlachou M, Goulis I. Review article: Update on current and emergent data on hepatopulmonary syndrome. World J Gastroenterol 2018; 24:1285-1298. [PMID: 29599604 PMCID: PMC5871824 DOI: 10.3748/wjg.v24.i12.1285] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/01/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of end-stage liver disease, characterized by impaired arterial oxygenation induced by intrapulmonary vascular dilatation. Its prevalence ranges from 4% to 47% in patients with cirrhosis due to the different diagnostic criteria applied among different studies. Nitric oxide overproduction and angiogenesis seem to be the hallmarks of a complicated pathogenetic mechanism, leading to intrapulmonary shunting and ventilation-perfusion mismatch. A classification of HPS according to the severity of hypoxemia has been suggested. Contrast-enhanced echocardiography represents the gold standard method for the detection of intrapulmonary vascular dilatations which is required, in combination with an elevated alveolar arterial gradient to set the diagnosis. The only effective treatment which can modify the syndrome’s natural history is liver transplantation. Although it is usually asymptomatic, HPS imparts a high risk of pretransplantation mortality, independently of the severity of liver disease, while there is variable data concerning survival rates after liver transplantation. The potential of myocardial involvement in the setting of HPS has also gained increasing interest in recent research. The aim of this review is to critically approach the existing literature of HPS and emphasize unclear points that remain to be unraveled by future research.
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Affiliation(s)
- Stergios Soulaidopoulos
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki 54621, Greece
| | - Maria Vlachou
- Department of Cardiology, AHEPA University Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki 54621, Greece
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Krynytska I, Marushchak M, Mikolenko A, Bob A, Smachylo I, Radetska L, Sopel O. Differential diagnosis of hepatopulmonary syndrome (HPS): Portopulmonary hypertension (PPH) and hereditary hemorrhagic telangiectasia (HHT). Bosn J Basic Med Sci 2017; 17:276-285. [PMID: 28759737 PMCID: PMC5708897 DOI: 10.17305/bjbms.2017.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is a severe complication of advanced liver disease associated with an extremely poor prognosis. HPS is diagnosed in 4-47% of patients with cirrhosis and in 15-20% of candidates for liver transplantation. In addition, severe hypoxia is associated with a high risk of complications of liver transplantation (a 30% chance during the first 90 days) and increases the gap between transplantation and improving arterial oxygenation. The pathogenesis of HPS is not fully understood, and no effective pharmacological treatment has been developed yet. Currently, the treatment of choice for HPS is orthotopic liver transplantation. Non-specific clinical criteria and the lack of standardized diagnostic criteria for determining HPS can lead to diagnostic errors. Portopulmonary hypertension and hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu syndrome, are pulmonary complications of liver disease which should be differentially diagnosed from HPS.
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Affiliation(s)
- Inna Krynytska
- Functional and Laboratory Diagnostics Department, I. Horbachevsky Ternopil State Medical University, Ternopil, Ukraine.
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Soulaidopoulos S, Goulis I, Giannakoulas G, Panagiotidis T, Doumtsis P, Karasmani A, Oikonomou T, Tzoumari T, Karvounis H, Cholongitas Ε. Hepatopulmonary syndrome is associated with the presence of hepatocellular carcinoma in patients with decompensated cirrhosis. Ann Gastroenterol 2016; 30:225-231. [PMID: 28243044 PMCID: PMC5320036 DOI: 10.20524/aog.2016.0117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/17/2016] [Indexed: 12/16/2022] Open
Abstract
Background Hepatopulmonary syndrome (HPS) is a relatively common complication in patients with decompensated cirrhosis. Our aim was to evaluate the prevalence of HPS, its clinical impact, and the possible association between HPS and characteristics of patients with decompensated cirrhosis. Methods Patients with stable decompensated cirrhosis admitted to our department and assessed for HPS were included. For each patient, several clinical, laboratory and echocardiographic parameters as well as renal function were recorded. The severity of liver disease was evaluated according to the Model for End-stage Liver Disease and Child-Pugh scores, and renal function was assessed using 51chromium complexed with ethylene diamine tetracetic acid. In addition, the short synacthen test was performed in each patient to evaluate the adrenal function. Results Sixty-three patients were enrolled, 26 (41.3%) of whom diagnosed with HPS. In multivariate analysis, the presence of hepatocellular carcinoma [odds ratio (OR) 8.1, 95% confidence interval (CI) 5.3-27.9, P=0.045] and salivary cortisol at T60 (60 min after the intravenous injection of 250 μg corticotropin) (OR 0.88, 95%CI 0.71-0.98, P=0.045) were the factors independently associated with HPS. T60 salivary cortisol had relatively good discriminative ability for the presence of HPS (area under the curve=0.73). The presence of HPS was not associated with the outcome (P=0.22). Conclusion In our cohort of patients with decompensated cirrhosis, the presence of hepatocellular carcinoma and T60 salivary cortisol were the only factors independently associated with HPS.
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Affiliation(s)
- Stergios Soulaidopoulos
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Ioannis Goulis
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - George Giannakoulas
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Theofilos Panagiotidis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Petros Doumtsis
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Areti Karasmani
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Theodora Oikonomou
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Theodora Tzoumari
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Haralampos Karvounis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Εvangelos Cholongitas
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
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Voiosu AM, Daha IC, Voiosu TA, Mateescu BR, Dan GA, Băicuş CR, Voiosu MR, Diculescu MM. Prevalence and impact on survival of hepatopulmonary syndrome and cirrhotic cardiomyopathy in a cohort of cirrhotic patients. Liver Int 2015; 35:2547-55. [PMID: 25974637 DOI: 10.1111/liv.12866] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Extrahepatic complications of cirrhosis increase the risk for decompensation of the liver disease and death. Previous studies show common pathogenetic mechanisms involved in the development of hepatopulmonary syndrome and cirrhotic cardiomyopathy. We aimed to assess the link between these entities and their effect on disease-related patient morbidity and mortality. METHODS Seventy-four consecutive cirrhotic patients without prior history of cardiovascular and pulmonary disease were included in a prospective observational study. Routine blood work, arterial blood gas analysis, pulse oximetry measurements, N-terminal pro-brain natriuretic peptide levels and contrast enhanced echocardiography examination with tissue Doppler imaging were performed in all patients. Patients were followed up for a median of 6 months and disease-related adverse events and death were the main outcomes tested. Statistical analysis was conducted according to the presence of hepatopulmonary syndrome or cirrhotic cardiomyopathy. RESULTS Hepatopulmonary syndrome was diagnosed in 17 patients (23%) and cirrhotic cardiomyopathy in 30 patients (40.5%). There was no association between the presence of cirrhotic cardiomyopathy and the existence of mild or moderate hepatopulmonary syndrome. No echocardiographic parameters were useful in predicting the presence of hepatopulmonary syndrome. N-terminal pro-brain natriuretic peptide levels and length of QT interval did not aid in diagnosis of cirrhotic cardiomyopathy. Neither entity had significant influence on disease-related outcomes in the follow-up period. CONCLUSIONS Hepatopulmonary syndrome and cirrhotic cardiomyopathy are independent complications arising in cirrhosis and have a limited influence on morbidity and mortality on a pre-liver transplantation population.
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Affiliation(s)
- Andrei M Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Ioana C Daha
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Cardiology, Colentina Clinical Hospital, Bucharest, Romania
| | - Theodor A Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Bogdan R Mateescu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Gheorghe A Dan
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Cardiology, Colentina Clinical Hospital, Bucharest, Romania
| | - Cristian R Băicuş
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
| | - Mihail R Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Mircea M Diculescu
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania
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Nasr FM, Metwaly A, khalik AA, Darwish H. Cardiac dysfunction in liver cirrhosis: A tissue Doppler imaging study from Egypt. Electron Physician 2015; 7:1135-43. [PMID: 26396725 PMCID: PMC4578531 DOI: 10.14661/2015.1135-1143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 07/27/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Patients with liver cirrhosis suffer from various cardiac abnormalities, which may influence their outcome. Tissue Doppler recording of the mitral and tricuspid annular diastolic velocities can be used to assess diastolic function accurately. There has been very little published information regarding RV diastolic function in liver cirrhosis. This study is aimed at evaluating right and left ventricular systolic and diastolic functions in post hepatitis C liver cirrhosis patients using conventional echocardiography and tissue Doppler imaging. METHODS This study was conducted on 75 adults from inpatient and outpatient services of the Theodor Bilharz Research Institute (TBRI) hospital. They were divided into two groups: Group 1 included 50 patients with post hepatitis C liver cirrhosis; and Group 2 included 25 normal adults serving as a control group. All patients and normal volunteers were subjected to clinical examination, laboratory evaluation, abdominal ultrasonography and echocardiographic studies with tissue Doppler imaging for evaluation of left and right ventricular systolic and diastolic functions. RESULTS The mitral flow showed significant increase in A wave velocity, as well as DT and IVRT with a significant decrease in E/A ratio in Group 1 compared to Group 2 (P<0.01). The tricuspid flow also showed a significant increase in A wave velocity (P<0.01) and DT (P<0.05) in addition to a significant decrease in E wave velocity and E/A ratio (P<0.01) in Group 1 as compared to Group 2. At the mitral annulus, we found a significant increase in average Aa velocity, E/Ea ratio and average systolic wave velocity S, in addition to a statistically significant decrease in the average Ea velocity and average Ea/Aa (P<0.01) in Group 1 as compared to Group 2. At the tricuspid annulus, there were significant increases in the average Aa velocity (P<0.01), S velocity (P<0.01) and E/Ea (P<0.05) together with a statistically significant decrease in the average Ea/Aa and average Ea velocity (P<0.01) in Group 1 compared to Group 2. CONCLUSION It is important to evaluate the cardiovascular function in every patient with cirrhosis, especially if the patient is a candidate for any intervention that may affect haemodynamics.
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Affiliation(s)
| | - Amna Metwaly
- Intesive Care unit, Theodor Bilharz Research Institute, Giza, Egypt
| | | | - Hesham Darwish
- Intesive Care unit, Theodor Bilharz Research Institute, Giza, Egypt
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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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12
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Raevens S, Coulon S, Van Steenkiste C, Colman R, Verhelst X, Van Vlierberghe H, Geerts A, Perkmann T, Horvatits T, Fuhrmann V, Colle I. Role of angiogenic factors/cell adhesion markers in serum of cirrhotic patients with hepatopulmonary syndrome. Liver Int 2015; 35:1499-507. [PMID: 24766195 DOI: 10.1111/liv.12579] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Hepatopulmonary syndrome is a complication of chronic liver disease resulting in increased morbidity and mortality. It is caused by intrapulmonary vascular dilations and arteriovenous connections with devastating influence on gas exchange. The pathogenesis is not completely understood but evidence mounts for angiogenesis. Aims of this study were to identify angiogenic factors in serum of patients with hepatopulmonary syndrome and to study the possibility to predict its presence by these factors. METHODS Multiplex assays were used to measure the concentration of angiogenic factors in patients with (n = 30) and without hepatopulmonary syndrome (n = 30). Diagnosis was based on the presence of gas exchange abnormality and intrapulmonary vasodilations according to published guidelines. RESULTS Patients with and without hepatopulmonary syndrome had similar MELD scores (median: 11.2 vs. 11.6; P = 0.7), Child-Pugh score (P = 0.7) and PaCO2 values (median: 35 vs. 37; P = 0.06). PaO2 and P(A-a) O2 gradient were significantly different (respectively median of 80 vs. 86, P = 0.02; and 24 vs. 16, P = 0.004). Based on area under the curve (AUC) data and P-values, the best predictors were vascular cell adhesion molecule 1 (VCAM1) (AUC = 0.932; P < 0.001) and intercellular adhesion molecule 3 (ICAM3) (AUC = 0.741; P = 0.003). Combining these factors results in an AUC of 0.99 (after cross-validation still 0.99). CONCLUSIONS VCAM1 and ICAM3 might be promising biomarkers for predicting hepatopulmonary syndrome. Combining these factors results in an AUC of 0.99 and a negative predictive value of 100%. Determining the concentration of these biomarkers might be a screening method to detect hepatopulmonary syndrome. The use of these biomarkers should be validated in larger groups of patients.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
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Tumgor G. Cirrhosis and hepatopulmonary syndrome. World J Gastroenterol 2014; 20:2586-2594. [PMID: 24627594 PMCID: PMC3949267 DOI: 10.3748/wjg.v20.i10.2586] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatation and arterial hypoxemia. HPS is reported to be present in 4% to 32% of adult patients with end-stage liver disease and in 9%-20% of children. The pathogenesis of HPS has not been clearly identified. Portal hypertension causes impairment in the perfusion of the bowel and increases the enteral translocation of Gram (-) bacteria and endotoxins. This stimulates the release of vasoactive mediators, such as tumor necrosis factor-alpha, heme oxygenase-derived carbon monoxide and nitric oxide. Genetic alterations have not been associated with this syndrome yet; however, cytokines and chemokines have been suggested to play a role. Recently, it was reported that cumulated monocytes lead to the activation of vascular endothelial growth factor-dependent signaling pathways and pulmonary angiogenesis, which plays an important role in HPS pathogenesis. At present, the most effective and only radical treatment is a liver transplant (LT). Cirrhotic patients who are on the waiting list for an LT have a shorter survival period if they develop HPS. Therefore, it is suggested that all cirrhotic cases should be followed closely for HPS and they should have priority in the waiting list.
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Hoerning A, Raub S, Neudorf U, Müntjes C, Kathemann S, Lainka E, Stehling F, Hoyer PF, Gerner P. Pulse oximetry is insufficient for timely diagnosis of hepatopulmonary syndrome in children with liver cirrhosis. J Pediatr 2014; 164:546-52.e1-2. [PMID: 24321540 DOI: 10.1016/j.jpeds.2013.10.070] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 09/17/2013] [Accepted: 10/24/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To prospectively investigate the prevalence of hepatopulmonary syndrome (HPS), the importance of pulse oximetry in diagnosing HPS, and the longitudinal course after liver transplantation in children with cirrhosis referred for liver transplantation. STUDY DESIGN Fifty-six patients aged 1-17 years (mean age, 4.6 ± 5.0 years) with liver cirrhosis were screened for HPS by hyperemic capillary blood gas (CBG) analysis and contrast-enhanced transthoracic echocardiography. Eleven patients were excluded owing to conditions that can produce cardiopulmonary dysfunction, including 5 with cystic fibrosis, 1 with pulmonary arterial hypertension, and 5 with an intracardial shunt. HPS was classified in accordance with the European Respiratory Society Task Force criteria on pulmonary-hepatic disorders. Patient groups were compared for biochemical and clinical characteristics. RESULTS Eighteen children (40%) with cirrhosis were intrapulmonary vasodilatation (IPVD)-positive and had a pulse oximetry oxygen saturation level >98%. Two of these patients (11%) exhibited moderate HPS with an elevated alveolar arterial oxygen gradient >15 mm Hg and PaO2 <70 mm Hg; they died before undergoing liver transplantation. The sensitivity and specificity of CBG analysis for detecting elevated alveolar arterial oxygen gradient in children with IPVD was 94% and 53%, respectively. HPS was associated with late hepatoportoenterostomy (P < .04). Liver transplantation led to resolution of HPS in all patients. CONCLUSION IPVD is frequent in children with liver cirrhosis (40%). Pulse oximetry is insufficient for timely HPS diagnosis. Pathological CBG analysis data indicate IPVD in the majority of cases, but are imprecise in children aged <2 years. Contrast-enhanced transthoracic echocardiography and CBG analysis are recommended for evaluation of HPS in children with cirrhosis, regardless of liver synthesis capacity and clinical chemistry data.
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Affiliation(s)
- André Hoerning
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Simon Raub
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Neudorf
- Clinic for Pediatrics III, Department of Pediatric Cardiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Carsten Müntjes
- Clinic for Pediatrics III, Department of Pediatric Cardiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Simone Kathemann
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Clinic for Pediatrics III, Department of Pediatric Pulmonology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Peter F Hoyer
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Patrick Gerner
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Wiese S, Hove JD, Bendtsen F, Møller S. Cirrhotic cardiomyopathy: pathogenesis and clinical relevance. Nat Rev Gastroenterol Hepatol 2014; 11:177-86. [PMID: 24217347 DOI: 10.1038/nrgastro.2013.210] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cirrhosis is known to cause alterations in the systemic haemodynamic system. Cirrhotic cardiomyopathy designates a cardiac dysfunction that includes impaired cardiac contractility with systolic and diastolic dysfunction, as well as electromechanical abnormalities in the absence of other known causes of cardiac disease. This condition is primarily revealed by inducing physical or pharmacological stress, but echocardiography is excellent at revealing diastolic dysfunction and might also be used to detect systolic dysfunction at rest. Furthermore, measurement of circulating levels of cardiac biomarkers could improve the diagnostic assessm+ent. Cirrhotic cardiomyopathy contributes to various complications in cirrhosis, especially as an important factor in the development of hepatic nephropathy. Additionally, cirrhotic cardiomyopathy seems to be associated with the development of heart failure in relation to invasive procedures such as shunt insertion and liver transplantation. Current pharmacological treatment is nonspecific and directed towards left ventricular failure, and liver transplantation is currently the only proven treatment with specific effect on cirrhotic cardiomyopathy.
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Affiliation(s)
- Signe Wiese
- Centre for Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Jens D Hove
- Department of Cardiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastroenterology Unit, Medical Division, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Søren Møller
- Centre for Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
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Darstein F, König C, Hoppe-Lotichius M, Grimm D, Knapstein J, Mittler J, Zimmermann A, Otto G, Lang H, Galle PR, Zimmermann T. Preoperative left ventricular hypertrophy is associated with reduced patient survival after liver transplantation. Clin Transplant 2013; 28:236-42. [PMID: 24372847 DOI: 10.1111/ctr.12304] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 12/13/2022]
Abstract
UNLABELLED Left ventricular hypertrophy (LVH) has been described in the context of cirrhotic cardiomyopathy. The influence of LVH on survival of liver transplant (LT) recipients has not been clarified. Therefore, we evaluated the effect of LVH on survival in LT recipients. In total, data from 352 LT patients were analyzed. LVH was diagnosed by echocardiographic measurement of left ventricular wall thickness before LT. Patients were followed up for a mean of 4.2 yr. LVH was diagnosed in 135 (38.4%) patients. Patients with LVH had significantly more frequently male gender (p = 0.046), diastolic dysfunction (p < 0.001), and hepatocellular carcinoma (HCC; p = 0.004). Furthermore, LVH patients were older (p < 0.001) and had a higher body mass index (BMI; p = 0.001). There was no difference in frequency of arterial hypertension, pre-transplant diabetes mellitus, or etiology of liver cirrhosis. Patients without LVH had a better survival (log rank: p = 0.05) compared with LVH patients. In a multivariate Cox regression LVH (p = 0.031), end-stage renal disease (ESRD; p = 0.003) and lack of arterial hypertension (p = 0.004) but not MELD score (p = 0.885) were associated with poorer survival. CONCLUSION LVH is frequently diagnosed in patients on the waiting list and influences survival after LT.
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Affiliation(s)
- F Darstein
- I. Medizinische Klinik der Universitätsmedizin Mainz, Mainz, Germany
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New insights into cirrhotic cardiomyopathy. Int J Cardiol 2013; 167:1101-8. [DOI: 10.1016/j.ijcard.2012.09.089] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 07/02/2012] [Accepted: 09/15/2012] [Indexed: 02/06/2023]
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