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Solanki R, Sreesh S, Attumalil TV, Mohapatra SD, Narayanan V, Madhu D, Chakravorty A, Pal R, Nair ANKK, Devadas K. A case-cohort study of left ventricular diastolic dysfunction in patients with cirrhosis: the liver-heart axis. Ann Gastroenterol 2023; 36:678-685. [PMID: 38023969 PMCID: PMC10662073 DOI: 10.20524/aog.2023.0837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/20/2023] [Indexed: 12/01/2023] Open
Abstract
Background Left ventricular diastolic dysfunction (LVDD) is an early manifestation of cirrhotic cardiomyopathy. Few studies have addressed its clinical significance in cirrhosis. We assessed the association of LVDD with the factors affecting cirrhosis patients' severity, complications, and survival. Methods A total of 203 cirrhosis patients were enrolled and underwent investigations, including 2-dimensional echocardiography with tissue Doppler imaging, and 139 patients with LVDD (cases) were compared with 64 patients without LVDD (controls). Logistic regression and Kaplan-Meier analysis were applied. Results Mean age was 52.76±10 years. Among LVDD patients, 56% had grade-1, and 44% had grade-2 LVDD. Cirrhosis related to NASH had a more significant association with LVDD (P<0.001) than other etiologies. LVDD was significantly associated with a greater incidence of Child-Turcotte-Pugh (CTP) class C (P<0.001), higher model for end-stage liver disease scores (P=0.001), duration of cirrhosis >2 years since diagnosis (P=0.028), ascites (P<0.001), hepatic encephalopathy (P<0.010), hepatorenal syndrome (P<0.001), and a history of obesity (P=0.004). Multivariate analysis showed that higher CTP score, ascitic fluid protein and prolonged QTc interval were independently associated with LVDD (P=0.009; P=0.018; P=0.016, respectively). Kaplan-Meier survival analysis showed significantly poorer survival status in patients with higher grades of LVDD (P<0.001). The area under the receiver operating characteristic curve (0.78) was greatest for ascitic fluid protein in predicting LVDD, with a cutoff of >1 g/dL. Conclusions Higher CTP score, prolonged QTc, higher ascitic fluid protein levels, and poor survival are significantly associated with LVDD. Ascitic fluid protein >1 g/dL could be an indicator for evaluating LVDD.
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Affiliation(s)
- Rushil Solanki
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | - Srijaya Sreesh
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | | | - Shivabrata dhal Mohapatra
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | - Vijay Narayanan
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | - Devika Madhu
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | - Avisek Chakravorty
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | - Ravindra Pal
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
| | | | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala (Rushil Solanki, Srijaya Sreesh, Shivabrata dhal Mohapatra, Vijay Narayanan, Devika Madhu, Avisek Chakravorty, Ravindra Pal, Krishnadas Devadas)
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Meucci MC, Hoogerduijn Strating MM, Butcher SC, van Rijswijk CSP, Van Hoek B, Delgado V, Bax JJ, Tushuizen ME, Marsan NA. Left atrial dysfunction is an independent predictor of mortality in patients with cirrhosis treated by transjugular intrahepatic portosystemic shunt. Hepatol Commun 2022; 6:3163-3174. [PMID: 36029167 PMCID: PMC9592786 DOI: 10.1002/hep4.2062] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/09/2022] [Accepted: 07/18/2022] [Indexed: 12/14/2022] Open
Abstract
The present study aimed to investigate (1) the association between left ventricular diastolic dysfunction (LVDD), graded according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium, and long-term survival in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) and (2) the additive prognostic value of left atrial (LA) function, as assessed by LA reservoir strain, using two-dimensional speckle-tracking echocardiography (2D-STE). A total of 129 TIPS candidates (mean ± SD, 61 ± 12 years; 61% men) underwent a comprehensive preprocedural echocardiography. LA dysfunction was defined by LA reservoir strain ≤35%, based on a previously suggested cut-off value. The outcome was all-cause mortality after TIPS. In the current cohort, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD, and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (based on LA reservoir strain ≤35%) was noted in 67 (52%) patients. After a median follow-up of 36 months (range, 12-80), 65 (50%) patients died. All-cause mortality rates increased along worse grades of LVDD (log-rank p = 0.007) and with LA dysfunction (log-rank p = 0.001). On multivariable Cox regression analysis, Model for End-Stage Liver Disease score (hazard ratio [HR],1.06; p = 0.003), hemoglobin (HR, 0.74; p = 0.022), and LA strain, expressed as a continuous variable (HR, 0.96; p = 0.005) were independently associated with all-cause mortality. Notably, the addition of LA strain to the model provided incremental prognostic value over the established prognostic variables (delta χ2 = 8.27, p = 0.004). Conclusion: LA dysfunction assessed with 2D-STE is independently associated with all-cause mortality in patients with cirrhosis treated by TIPS.
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Affiliation(s)
- Maria Chiara Meucci
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands,Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCSSRomeItaly
| | - Merte M. Hoogerduijn Strating
- Department of Gastroenterology and Hepatology, Transplantation CenterLeiden University Medical CenterLeidenthe Netherlands
| | - Steele C. Butcher
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands,Department of CardiologyRoyal Perth HospitalPerthAustralia
| | | | - Bart Van Hoek
- Department of Gastroenterology and Hepatology, Transplantation CenterLeiden University Medical CenterLeidenthe Netherlands
| | - Victoria Delgado
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands,Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
| | - Jeroen J. Bax
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands,Heart CenterUniversity of Turku and Turku University HospitalTurkuFinland
| | - Maarten E. Tushuizen
- Department of Gastroenterology and Hepatology, Transplantation CenterLeiden University Medical CenterLeidenthe Netherlands
| | - Nina Ajmone Marsan
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands
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Diastolic Dysfunction Is a Predictor of Poor Survival in Patients with Decompensated Cirrhosis. Int J Hepatol 2021; 2021:5592376. [PMID: 34900353 PMCID: PMC8660240 DOI: 10.1155/2021/5592376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 11/17/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Left ventricular diastolic dysfunction (LVDD) appears to be the earliest cardiac disturbance in cirrhosis patients. There are many previous reports reporting the significance of severity of LVDD on the outcome of liver transplantation or TIPS insertion, a few Indian studies have addressed the role of LVDD on survival in decompensated cirrhosis. The objective of this study is to assess the effect of LVDD on the survival of decompensated cirrhotic patients. METHODS We prospectively evaluated 92 decompensated cirrhotic patients from April 2015 to March 2017 at IMS and SUM Hospital, Bhubaneswar, India. 2D echocardiography with tissue Doppler imaging was used to evaluate cardiac function, as per the American society of echocardiography guidelines. The primary endpoint was to evaluate the effect of LVDD on overall mortality. RESULTS Ninety-two decompensated cirrhotic patients were evaluated in this prospective cohort study. Twenty-eight out of 92 patients (30%) died due to liver-related complications after a follow-up of 24 months. The decompensated cirrhotic patients with MELD score ≥ 15 had a significantly higher E/e' ratio (11.94 ± 4.24 vs. 8.74 ± 3.32, p < 0.001) suggesting severe LV dysfunction in advanced cirrhosis. Patients with E/e' ratio > 10 had significantly higher MELD score and Child-Pugh score (19.88 ± 7.72 vs. 14.31 ± 5.83; 10.25 ± 1.74 vs. 9.02 ± 1.74, p < 0.01, respectively) as compared to theE/e' ratio < 10 group. In Cox proportional hazard multivariate analysis, E/e' ≥ 10 (HR 2.72, 95% CI 1.07-6.9, p = 0.03) and serum albumin (HR 0.32, 95% CI 0.14-0.7, p < 0.01) were found to be independent predictors of mortality in decompensated cirrhotic patients. CONCLUSION : The presence of LVDD and low serum albumin were independent predictors of mortality in decompensated cirrhotic patients. Hence, LVDD is an indicator of advanced cirrhosis and mortality.
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Trivedi PS, Jensen AM, Brown MA, Morgan RL, Lindrooth RC, Ryu RK, Ho PM, Kriss MS. High Prevalence of Transjugular Intrahepatic Portosystemic Shunt Creation Without Prior Endoscopy During Acute Variceal Bleeding Hospitalization in the United States. Hepatol Commun 2021; 5:1784-1790. [PMID: 34558832 PMCID: PMC8485889 DOI: 10.1002/hep4.1756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/07/2021] [Accepted: 05/06/2021] [Indexed: 11/06/2022] Open
Abstract
Current clinical guidelines by both American Association for the Study of Liver Disease and European Association for the Study of the Liver recommend endoscopy in all patients admitted with acute variceal bleeding within 12 hours of admission. Transjugular intrahepatic portosystemic shunt (TIPS) creation may be considered in patients at high risk if hemorrhage cannot be controlled endoscopically. We conducted a cross-sectional observational study to assess how frequently TIPS is created for acute variceal bleeding in the United States without preceding endoscopy. Adult patients undergoing TIPS creation for acute variceal bleeding in the United States (n = 6,297) were identified in the last 10 available years (2007-2016) of the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between endoscopy nonutilization and hospital characteristics, controlling for patient demographics, income level, insurance type, and disease severity. Of 6,297 discharges following TIPS creation for acute variceal bleeding in the United States, 31% (n = 1,924) did not receive first-line endoscopy during the same encounter. Rates of "no endoscopy" decreased with increasing population density of the hospital county (nonmicropolitan counties 43%, n = 114; mid-size metropolitan county 35%, n = 513; and central county with >1 million population 23%, n = 527) but not by hospital teaching status (n = 1,465, 32% teaching vs. n = 430, 26% nonteaching; P = 0.10). Higher disease mortality risk (odds ratio, 0.42; 95% confidence interval, 0.22-0.80; P = 0.02) was associated with lower odds of noncompliance. Conclusion: One third of all patients undergoing TIPS creation for acute variceal bleeding in the United States do not receive first-line endoscopy during the same encounter. Patients admitted to urban hospitals are more likely to receive guideline-concordant care.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Matthew A Brown
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | - Rustain L Morgan
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Robert K Ryu
- University of Southern California Keck School of MedicineLos AngelesCAUSA
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health SystemAuroraCOUSA
| | - Michael S Kriss
- Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
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Trivedi PS, Jensen AM, Kriss MS, Brown MA, Morgan RL, Lindrooth RC, Ho PM, Ryu RK. Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States. J Vasc Interv Radiol 2021; 32:941-949.e3. [PMID: 33901695 DOI: 10.1016/j.jvir.2021.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To investigate the magnitude of racial/ethnic differences in hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding and whether hospital care processes contribute to them. METHODS Patients aged ≥18 years undergoing TIPS creation for acute variceal bleeding in the United States (n = 10,331) were identified from 10 years (2007-2016) available in the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between patient race and inpatient mortality, controlling for disease severity, treatment utilization, and hospital characteristics. RESULTS A total of 6,350 (62%) patients were White, 1,780 (17%) were Hispanic, and 482 (5%) were Black. A greater proportion of Black patients were admitted to urban teaching hospitals (Black, n = 409 (85%); Hispanic, n = 1,310 (74%); and White, n = 4,802 (76%); P < .001) and liver transplant centers (Black, n = 215 (45%); Hispanic, n = 401 (23%); and White, n = 2,267 (36%); P < .001). Being Black was strongly associated with mortality (Black, 32% vs non-Black, 15%; odds ratio, 3.0 [95% confidence interval, 1.6-5.8]; P = .001), as assessed using the risk-adjusted regression model. This racial disparity disappeared in a sensitivity analysis including only patients with a maximum Child-Pugh score of 13 (odds ratio 1.2 [95% confidence interval, 0.4-3.6]; P = .68), performed to compensate for the absence of Model for End-stage Liver Disease scores. Ethnoracial differences in access to teaching hospitals, liver transplant centers, first-line endoscopy, and transfusion did not significantly contribute (P > .05) to risk-adjusted mortality. CONCLUSIONS Black patients have a 2-fold higher inpatient mortality than non-Black patients following TIPS creation for acute variceal bleeding, possibly related to greater disease severity before the procedure.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Michael S Kriss
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew A Brown
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rustain L Morgan
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - P Michael Ho
- Division of Cardiology, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Robert K Ryu
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Radiology, University of Southern California, Los Angeles, California
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Khalid YS, Reja D, Dasu NR, Suga HP, Dasu KN, Joo LM. In-Hospital Outcomes of Patients with Acute Decompensated Heart Failure and Cirrhosis: An Analysis of the National Inpatient Sample. Cardiol Ther 2020; 9:433-445. [PMID: 32514825 PMCID: PMC7584689 DOI: 10.1007/s40119-020-00183-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Heart failure increases morbidity and mortality in patients admitted for cirrhosis. Our objective was to determine if patients with acute decompensated heart failure (ADHF) and cirrhosis would have increased mortality, hospital length of stay (LOS), and total hospital charges compared to patients with only ADHF. There is also a paucity of data regarding the influence of gender, race, ethnicity, insurance, and cirrhosis-related complications on mortality, hospital length of stay, and total hospitalization charges. In this study, we aim to identify risk factors in a national population cohort from 2016. METHODS All patients above 18 years old with cirrhosis and ADHF admitted in 2016 were identified from the Nationwide Inpatient Sample (NIS). Multivariate regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay (LOS), and total hospital charges after adjusting for the following factors: age, gender, race, Charlson and Elixhauser scores, primary insurance payer status, hospital type, hospital bed size, hospital region, and hospital teaching status. Statistical analysis was performed by using the survey procedures function in the statistical analysis system (SAS) software. Statistical significance was defined by the two-sided t-test with a p value < 0.05. RESULTS The overall sample contained 363,050 patients. A total of 355,455 patients were admitted with ADHF and 2% of these patients had concomitant cirrhosis (n = 7595) in 2016. The total mortality rate was 3.4%, hospital LOS was 6.6 days (with a median of 6.5 days), and the mean total hospital charge was $63,120.20. Patients with both ADHF and cirrhosis compared to patients without ADHF had increased mortality, hospital LOS, and cirrhosis-related complications. CONCLUSIONS As the incidence and prevalence of ADHF and cirrhosis increases worldwide, we urge the medical community to increase surveillance of patients with both diseases and perform rigorous cardiovascular risk assessments as well to improve patient outcomes.
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Affiliation(s)
- Yaser S Khalid
- Division of Internal Medicine, Rowan University School of Medicine at Jefferson Health System, Stratford, NJ, USA.
| | - Debashis Reja
- Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Neethi R Dasu
- Division of Internal Medicine, Rowan University School of Medicine at Jefferson Health System, Stratford, NJ, USA
| | - Herman P Suga
- Division of Internal Medicine, Rowan University School of Medicine at Jefferson Health System, Stratford, NJ, USA
| | - Kirti N Dasu
- Division of Biology, Syracuse University, Syracuse, NY, USA
| | - Lucy M Joo
- Division of Gastroenterology, Jefferson Health New Jersey, New Jersey, USA
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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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Satti R, Abid NUH, Bottaro M, De Rui M, Garrido M, Raoufy MR, Montagnese S, Mani AR. The Application of the Extended Poincaré Plot in the Analysis of Physiological Variabilities. Front Physiol 2019; 10:116. [PMID: 30837892 PMCID: PMC6390508 DOI: 10.3389/fphys.2019.00116] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/30/2019] [Indexed: 01/12/2023] Open
Abstract
The Poincaré plot is a geometrical technique used to visualize and quantify the correlation between two consecutive data points in a time-series. Since the dynamics of fluctuations in physiological rhythms exhibit long-term correlation and memory, this study aimed to extend the Poincaré plot by calculating the correlation between sequential data points in a time-series, rather than between two consecutive points. By incorporating this so-called lag, we hope to integrate a temporal aspect into quantifying the correlation, to depict whether a physiological system holds prolonged association between events separated by time. In doing so, it attempts to instantaneously characterize the intrinsic behavior of a complex system. We tested this hypothesis on three different physiological time-series: heart rate variability in patients with liver cirrhosis, respiratory rhythm in asthma and body temperature fluctuation in patients with cirrhosis, to evaluate the potential application of the extended Poincaré method in clinical practice. When studying the cardiac inter-beat intervals, the extended Poincaré plot revealed a stronger autocorrelation for patients with decompensated liver cirrhosis compared to less severe cases using Pearson's correlation coefficient. In addition, long-term variability (known as SD2 in the extended Poincaré plot) appeared as an independent prognostic variable. This holds significance by acting as a non-invasive tool to evaluate patients with chronic liver disease and potentially facilitate transplant selection as an adjuvant to traditional criteria. For asthmatics, employing the extended Poincaré plot allowed for a non-invasive tool to differentially diagnose various classifications of respiratory disease. In the respiratory inter-breath interval analysis, the receiver operating characteristic (ROC) curve provided evidence that the extension of the Poincaré plot holds a greater advantage in the classification of asthmatic patients, over the traditional Poincaré plot. Lastly, the analysis of body temperature from patients using the extended Poincaré plot helped identify inpatients from outpatients with cirrhosis. Through these analyses, the extended Poincaré plot provided unique and additional information which could potentially make a difference in clinical practice. Conclusively, the potential use of our work lies in its possible application of predicting mortality for the organ allocation procedure in patients with cirrhosis and non-invasively distinguish between atopic and non-atopic asthma.
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Affiliation(s)
- Reem Satti
- UCL Division of Medicine, University College London, London, United Kingdom
| | - Noor-Ul-Hoda Abid
- UCL Division of Medicine, University College London, London, United Kingdom
| | - Matteo Bottaro
- Department of Medicine, University of Padova, Padova, Italy
| | - Michele De Rui
- Department of Medicine, University of Padova, Padova, Italy
| | - Maria Garrido
- Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Ali R. Mani
- UCL Division of Medicine, University College London, London, United Kingdom
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Izrailtyan I, Qiu J, Overdyk FJ, Erslon M, Gan TJ. Risk factors for cardiopulmonary and respiratory arrest in medical and surgical hospital patients on opioid analgesics and sedatives. PLoS One 2018; 13:e0194553. [PMID: 29566020 PMCID: PMC5864099 DOI: 10.1371/journal.pone.0194553] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/06/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Opioid induced respiratory depression is a known cause of preventable death in hospitals. Medications with sedative properties additionally potentiate opioid-induced respiratory and sedative effects, thereby elevating the risk for adverse events. The goal of this study was to determine what specific factors increase the risk of in-hospital cardiopulmonary and respiratory arrest (CPRA) in medical and surgical patients on opioid and sedative therapy. METHODS The present study analyzed 14,504,809 medical inpatient and 6,771,882 surgical inpatient discharges reported into the Premier database from 2008 to 2012. Patients were divided in four categories: on opioids; on sedatives; on both opioids and sedatives; and on neither opioids nor sedatives. RESULTS During hospital admission, 57% of all medical patients and 90% of all surgical patients were prescribed opioids, sedatives, or both. Surgical patients had a higher incidence of CPRA than medical patients (6.17 vs. 3.77 events per 1000 admissions; Relative Risk: 1.64 [95%CI: 1.62-1.66; p<0.0001). Opioids and sedatives were found to be independent predictors of CPRA (adjusted OR of 2.24 [95%CI: 2.18-2.29] for opioids and adjusted OR 1.80 [95%CI: 1.75-1.85] for sedatives in medical patients, and adjusted OR of 1.12 [95%CI: 1.07-1.16] for opioids and adjusted OR of 1.58 [95%CI: 1.51-1.66] for sedatives in surgical patients), with the highest risk in groups who received both types of medications (adjusted OR of 3.83 [95% CI: 3.74-3.92] in medical patients, and adjusted OR of 2.34 [95% CI: 2.25-2.42] in surgical patients) compared with groups that received neither type of medication. The common risk factors of CPRA in medical and surgical patients receiving both opioids and sedatives were Hispanic origin, mild liver disease, obesity, and COPD. Additionally, medical and surgical groups had their own unique risk factors for CPRA when placed on opioid and sedative therapy. CONCLUSIONS Opioids and sedatives are independent and additive predictors of CPRA in both medical and surgical patients. Receiving both classes of medications further exacerbates the risk of CPRA for these patients. By identifying groups at risk among medical and surgical in-hospital patients, this study provides a step towards improving our understanding of how to use opioid and sedative medications safely, which may influence our treatment strategies and outcomes. More precise monitoring of selected high-risk patients may help prevent catastrophic cardiorespiratory complications from these medications. As a retrospective administrative database analysis, this study does not establish the causality or the temporality of the events but rather draws statistically significant associations between the clinical factors and outcomes.
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Affiliation(s)
- Igor Izrailtyan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, United States of America
| | - Jiejing Qiu
- Health Economics and Outcomes Research, Medtronic, Mansfield, MA, United States of America
| | - Frank J. Overdyk
- Department of Anesthesiology, Roper St Francis Health System, Charleston, SC, United States of America
| | - Mary Erslon
- Respiratory, Gastrointestinal & Informatics, Medtronic, Boulder, CO, United States of America
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, United States of America
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Kazankov K, Munk K, Øvrehus KA, Jensen JM, Siggaard CB, Grønbaek H, Nørgaard BL, Vilstrup H. High burden of coronary atherosclerosis in patients with cirrhosis. Eur J Clin Invest 2017; 47:565-573. [PMID: 28657113 DOI: 10.1111/eci.12777] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/23/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Population studies report increased cardiovascular mortality in patients with cirrhosis. Coronary artery disease may be a trait of end-stage liver disease, but whether it is frequent or extensive in cirrhosis in general is unknown. Thus, we aimed to assess the prevalence and extent of coronary artery disease in unselected cirrhosis patients. MATERIALS AND METHODS Using coronary computed tomography angiography, we investigated 52 patients from all Child-Pugh classes and aetiologies of cirrhosis without known cardiac disease for presence and severity of coronary artery disease in a cross-sectional design. Persons referred with new-onset chest pain served as controls. RESULTS The prevalence of coronary artery disease was not significantly different between cirrhosis patients and controls (77% vs. 65%, P=0·19). However, cirrhosis patients had a markedly higher coronary artery calcification (Agatston) score than controls (120 [interquartile range, 0-345] vs. 5 [interquartile range, 0-86] HU, P=0·001). Likewise, patients with cirrhosis had a higher prevalence of extensive (≥5 coronary segments involved; 45% vs. 18%, P=0·01) and multivessel coronary disease (≥2 vessels involved; 75% vs. 53%, P=0·02). Furthermore, the total plaque volume whether noncalcified or calcified was higher in cirrhosis (117 [interquartile range, 0-310] vs. 36 [interquartile range, 0-148] mm3 , P=0·02). CONCLUSION Coronary artery disease is equally prevalent in patients with cirrhosis and subjects with new-onset chest pain, but cirrhosis patients have more extensive and severe disease including several coronary high-risk features associated with myocardial ischaemia and a poor clinical outcome. The potential of preventive measures for coronary artery disease in cirrhosis needs attention.
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Affiliation(s)
- Konstantin Kazankov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Kim Munk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Henning Grønbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Walayat S, Martin D, Patel J, Ahmed U, N Asghar M, Pai AU, Dhillon S. Role of albumin in cirrhosis: from a hospitalist's perspective. J Community Hosp Intern Med Perspect 2017. [PMID: 28634518 PMCID: PMC5463675 DOI: 10.1080/20009666.2017.1302704] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Albumin, a negatively charged globular protein encoded on chromosome 4, is one of the most abundant proteins in the plasma and accounts for approximately 75% of plasma oncotic pressure. The role of albumin in the management of various disease states has shown to be beneficial historically. Low serum albumin is a predictor of mortality and poor outcomes. In cirrhotics undergoing paracentesis, albumin infusion prevents rapid re-accumulation of ascitic fluid while simultaneously decreasing the risk of post-paracentesis related circulatory dysfunction. Additionally, albumin is utilized in patients with hepatorenal syndrome (HRS) and spontaneous bacterial peritonitis (SBP). Overall, albumin appears to be an effective pharmacological agent in the management of cirrhosis and its complications.
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Affiliation(s)
- Saqib Walayat
- Department of Internal Medicine, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Daniel Martin
- Department of Gastroenterology and Hepatology, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Jaymon Patel
- Department of Internal Medicine, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Umair Ahmed
- Department of Internal Medicine, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Muhammad N Asghar
- Department of Internal Medicine, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA.,Department of Medicine, CMH Lahore Medical College, Lahore, Pakistan
| | - Aparna U Pai
- Department of Internal Medicine, Palos Community Hospital, Palos Heights, IL, USA
| | - Sonu Dhillon
- Department of Gastroenterology and Hepatology, University of Illinois Peoria Campus, OSF Saint Francis Medical Center, Peoria, IL, USA
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12
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Ascha M, Abuqayyas S, Hanouneh I, Alkukhun L, Sands M, Dweik RA, Tonelli AR. Predictors of mortality after transjugular portosystemic shunt. World J Hepatol 2016; 8:520-529. [PMID: 27099653 PMCID: PMC4832094 DOI: 10.4254/wjh.v8.i11.520] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/21/2016] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt (TIPS) can provide prognostic information that will enhance risk stratification of patients.
METHODS: We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution. We recorded information regarding patient demographics, underlying liver disease, indication for TIPS, baseline laboratory values, hemodynamic determinations at the time of TIPS, and echocardiographic measurements both before and after TIPS. We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations. We also calculated Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) class. The following pre- and post-TIPS echocardiographic determinations were recorded: Left ventricular ejection fraction, right ventricular (RV) systolic pressure, subjective RV dilation, and subjective RV function. We recorded the following hemodynamic measurements: Right atrial (RA) pressure before and after TIPS, inferior vena cava pressure before and after TIPS, free hepatic vein pressure, portal vein pressure before and after TIPS, and hepatic venous pressure gradient (HVPG).
RESULTS: We reviewed 418 patients with portal hypertension undergoing TIPS. RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmHg (P < 0.001), HVPG decreased by 6.8 ± 3.5 mmHg (P < 0.001). In multivariate linear regression analysis, a higher MELD score, lower platelet count, splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure (R = 0.55). Three variables predicted 3-mo mortality after TIPS in a multivariate analysis: Age, MELD score, and CTP grade C. Change in the RA pressure after TIPS predicted long-term mortality (per 1 mmHg change, HR = 1.03, 95%CI: 1.01-1.06, P < 0.012).
CONCLUSION: RA pressure increased immediately after TIPS particularly in patients with worse liver function, portal hypertension, emergent TIPS placement and history of splenectomy. The increase in RA pressure after TIPS was associated with increased mortality. Age, splenectomy, MELD score and CTP grade were independent predictors of long-term mortality after TIPS.
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13
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Abstract
Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.
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14
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Licata A, Corrao S, Petta S, Genco C, Cardillo M, Calvaruso V, Cabibbo G, Massenti F, Cammà C, Licata G, Craxì A. NT pro BNP plasma level and atrial volume are linked to the severity of liver cirrhosis. PLoS One 2013; 8:e68364. [PMID: 23940514 PMCID: PMC3734231 DOI: 10.1371/journal.pone.0068364] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023] Open
Abstract
Background and Aims Plasma levels of NT-pro-BNP, a natriuretic peptide precursor, are raised in the presence of fluid retention of cardiac origin and can be used as markers of cardiac dysfunction. Recent studies showed high levels of NT pro BNP in patients with cirrhosis. We assessed NT pro-BNP and other parameters of cardiac dysfunction in patients with cirrhosis, with or without ascites, in order to determine whether the behaviour of NT pro BNP is linked to the stage of liver disease or to secondary cardiac dysfunction. Methods Fifty eight consecutive hospitalized patients mostly with viral or NAFLD-related cirrhosis were studied. All underwent abdominal ultrasound and upper GI endoscopy. Cardiac morpho-functional changes were evaluated by echocardiography and NT-pro-BNP plasma levels determined upon admission. Twenty-eight hypertensive patients, without evidence of liver disease served as controls. Results Fifty eight cirrhotic patients (72% men) with a median age of 62 years (11% with mild arterial hypertension and 31% with type 2 diabetes) had a normal renal function (mean creatinine 0.9 mg/dl, range 0.7–1.06). As compared to controls, cirrhotic patients had higher NT pro-BNP plasma levels (365.2±365.2 vs 70.8±70.6 pg/ml; p<0.001). Left atrial volume (LAV) (61.8±26.3 vs 43.5±14.1 ml; p = 0.001), and left ventricular ejection fraction (62.7±6.9 vs. 65.5±4%,; p = 0.05) were also altered in cirrhotic patients that in controls. Patients with F2-F3 oesophageal varices as compared to F0/F1, showed higher e' velocity (0.91±0.23 vs 0.66±0.19 m/s, p<0.001), and accordingly a higher E/A ratio (1.21±0.46 vs 0.89±0.33 m/s., p = 0.006). Conclusion NT-pro-BNP plasma levels are increased proportionally to the stage of chronic liver disease. Advanced cirrhosis and high NT-pro-BNP levels are significantly associated to increased LAV and to signs of cardiac diastolic dysfunction. NT pro-BNP levels could hence be an useful prognostic indicators of early decompensation of cirrhosis.
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Affiliation(s)
- Anna Licata
- Sezione di Gastroenterologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DI.BI.M.I.S, University of Palermo, Palermo, Italy.
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15
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Alexopoulou A, Papatheodoridis G, Pouriki S, Chrysohoou C, Raftopoulos L, Stefanadis C, Pectasides D. Diastolic myocardial dysfunction does not affect survival in patients with cirrhosis. Transpl Int 2012; 25:1174-81. [PMID: 22909305 DOI: 10.1111/j.1432-2277.2012.01547.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Left ventricular diastolic dysfunction (DDF) has been considered as a component of cirrhotic cardiomyopathy. The clinical significance of DDF in cirrhotics has not been clarified. We prospectively evaluated the echocardiographic-Doppler, tissue-Doppler (TDI) findings of left ventricular function and survival in cirrhotics with or without DDF. Seventy-six cirrhotics without endogenous heart disease were included. DDF was diagnosed by mitral inflow Doppler parameters and diastolic myocardial velocities. Assessments of demographics, liver dysfunction, laboratory, echocardiographic systolic/diastolic indices, TDI of mitral annular motion and M-mode echocardiography were recorded. Patients were followed-up for a median of 25 months (15-40). DDF was diagnosed in 51 (67%) patients. Patients with compared with those without DDF had significantly older age and higher pulse rate as well as more frequently severe ascites, greater aortic root diameter and interventricular septal thickness. There was no difference in systolic myocardial function between two groups. Patients with DDF had a trend for worse survival (long rank, P = 0.094). A multivariate analysis showed that age, MELD and sodium but no DDF were predictive of death. DDF is prevalent in advanced cirrhosis and is associated with severe ascites. Systolic myocardial function and mortality do not seem to be strongly affected by the presence of DDF.
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Affiliation(s)
- Alexandra Alexopoulou
- 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece.
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16
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Pimenta J, Paulo C, Gomes A, Silva S, Rocha-Gonçalves F, Bettencourt P. B-type natriuretic peptide is related to cardiac function and prognosis in hospitalized patients with decompensated cirrhosis. Liver Int 2010; 30:1059-66. [PMID: 20492497 DOI: 10.1111/j.1478-3231.2010.02266.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) concentrations are high in cirrhosis, possibly related to volume status and cirrhotic cardiomyopathy. The prognostic significance of BNP in cirrhosis is unknown. AIMS We aimed to evaluate (i) the influence of haemodynamic parameters and volaemia, assessed by impedance cardiography (ICG), in BNP levels, (ii) the performance of BNP as a prognostic marker, in a cohort of cirrhotic patients. METHODS Patients consecutively hospitalized with decompensated cirrhosis during 1 year were evaluated. At admission, ICG and BNP measurements were performed in 83 patients (median age 56 years; median Child-Pugh score=10). The 70 patients discharged were followed for the occurrence of death within 6 months. RESULTS Median BNP levels were 130.3 (65.2-363.3) pg/ml. Independent BNP predictors in multivariate linear regression analysis were cardiac output, age and haemoglobin (R(2)=36.7%). The 24 patients with cardiac systolic dysfunction, defined by low cardiac output, had higher BNP concentrations than the other patients (230.8 vs 98.5 pg/ml, P=0.003). BNP levels above median were associated with an increased occurrence of death within 6 months of discharge (log rank P=0.023). Cardiac output and BNP were predictors of survival in univariate Cox regression analysis. Only BNP remained independently related to the outcome in multivariate analysis [hazard ratio=2.86 (1.11-7.38), P=0.03]. CONCLUSIONS BNP levels in cirrhosis reflect cardiac systolic function and non-cardiac variables that should be considered in their interpretation. BNP is an independent predictor of medium-term survival in advanced cirrhosis, suggesting its utility in risk stratification of decompensated cirrhotic patients.
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Affiliation(s)
- Joana Pimenta
- Department of Internal Medicine, Hospital S. João, Porto, Portugal.
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17
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Fukazawa K, Gologorsky E, Manmohansingh V, Nishida S, Vigoda MM, Pretto EA. Is the immediate reversal of diastolic dysfunction of cirrhotic cardiomyopathy after liver transplantation a sign of the metabolic etiology? Liver Transpl 2009; 15:1417-9. [PMID: 19877209 DOI: 10.1002/lt.21861] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cirrhotic cardiomyopathy currently is believed to be a multifactorial entity. This communication describes a case of immediate intraoperative recovery of diastolic function following liver transplantation. This suggests that an underlying metabolic inhibition of myocardial metabolism is an important factor in the development of cardiomyopathy in end-stage liver disease. Liver Transpl 15:1417-1419, 2009. (c) 2009 AASLD.
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Affiliation(s)
- Kyota Fukazawa
- Division of Solid Organ Transplant, Department of Anesthesiology, Preoperative, and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
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18
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Martín-Llahí M, Pépin MN, Guevara M, Díaz F, Torre A, Monescillo A, Soriano G, Terra C, Fábrega E, Arroyo V, Rodés J, Ginès P. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology 2008; 134:1352-9. [PMID: 18471512 DOI: 10.1053/j.gastro.2008.02.024] [Citation(s) in RCA: 376] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 01/24/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Hepatorenal syndrome is common in patients with advanced cirrhosis and constitutes a major problem in liver transplantation. There is no effective medical treatment for hepatorenal syndrome. METHODS Forty-six patients with cirrhosis and hepatorenal syndrome, hospitalized in a tertiary care center, were randomly assigned to receive either terlipressin (1-2 mg/4 hour, intravenously), a vasopressin analogue, and albumin (1 g/kg followed by 20-40 g/day) (n = 23) or albumin alone (n = 23) for a maximum of 15 days. Primary outcomes were improvement of renal function and survival at 3 months. RESULTS Improvement of renal function occurred in 10 patients (43.5%) treated with terlipressin and albumin compared with 2 patients (8.7%) treated with albumin alone (P = .017). Independent predictive factors of improvement of renal function were baseline urine volume, serum creatinine and leukocyte count, and treatment with terlipressin and albumin. Survival at 3 months was not significantly different between the 2 groups (terlipressin and albumin: 27% vs albumin 19%, P = .7). Independent predictive factors of 3-month survival were baseline model for end-stage liver disease score and improvement of renal function. Cardiovascular complications occurred in 4 patients treated with albumin alone and in 10 patients treated with terlipressin and albumin, yet permanent terlipressin withdrawal was required in only 3 cases. CONCLUSIONS As compared with albumin, treatment with terlipressin and albumin is effective in improving renal function in patients with cirrhosis and hepatorenal syndrome. Further studies with large sample sizes should be performed to test whether the improvement of renal function translates into a survival benefit.
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Affiliation(s)
- Marta Martín-Llahí
- Liver Unit, Hospital Clínic, University of Barcelona School of Medicine, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Centro de Investigacíon Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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Fava M, Meneses L, Loyola S, Castro P, Barahona F. TIPSS procedure in the treatment of a single patient after recent heart transplantation because of refractory ascites due to cardiac cirrhosis. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S188-91. [PMID: 18071789 DOI: 10.1007/s00270-007-9251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 10/30/2007] [Accepted: 11/15/2007] [Indexed: 11/26/2022]
Abstract
We present the case of a female patient with arrhythmogenic dysplasia of the right ventricle who evolved to refractory heart failure, ascites, and peripheral edema. As a result, heart transplantation was performed. Subsequently, refractory ascites impaired the patient's respiratory function, resulting in prolonged mechanical ventilation. She was successfully treated with transjugular intrahepatic portosystemic shunt (TIPSS) placement, which allowed satisfactory weaning of ventilatory support.
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Affiliation(s)
- Mario Fava
- Radiology Department, Hospital Clínico Universidad Católica de Chile, Marcoleta 367, Santiago, Chile
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20
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Abstract
Cirrhotic cardiomyopathy is the term used to describe a constellation of features indicative of abnormal heart structure and function in patients with cirrhosis. These include systolic and diastolic dysfunction, electrophysiological changes, and macroscopic and microscopic structural changes. The prevalence of cirrhotic cardiomyopathy remains unknown at present, mostly because the disease is generally latent and shows itself when the patient is subjected to stress such as exercise, drugs, hemorrhage and surgery. The main clinical features of cirrhotic cardiomyopathy include baseline increased cardiac output, attenuated systolic contraction or diastolic relaxation in response to physiologic, pharmacologic and surgical stress, and electrical conductance abnormalities (prolonged QT interval). In the majority of cases, diastolic dysfunction precedes systolic dysfunction, which tends to manifest only under conditions of stress. Generally, cirrhotic cardiomyopathy with overt severe heart failure is rare. Major stresses on the cardiovascular system such as liver transplantation, infections and insertion of transjugular intrahepatic portosystemic stent-shunts (TIPS) can unmask the presence of cirrhotic cardiomyopathy and thereby convert latent to overt heart failure. Cirrhotic cardiomyopathy may also contribute to the pathogenesis of hepatorenal syndrome. Pathogenic mechanisms of cirrhotic cardiomyopathy are multiple and include abnormal membrane biophysical characteristics, impaired β-adrenergic receptor signal transduction and increased activity of negative-inotropic pathways mediated by cGMP. Diagnosis and differential diagnosis require a careful assessment of patient history probing for excessive alcohol, physical examination for signs of hypertension such as retinal vascular changes, and appropriate diagnostic tests such as exercise stress electrocardiography, nuclear heart scans and coronary angiography. Current management recommendations include empirical, nonspecific and mainly supportive measures. The exact prognosis remains unclear. The extent of cirrhotic cardiomyopathy generally correlates to the degree of liver insufficiency. Reversibility is possible (either pharmacological or after liver transplantation), but further studies are needed.
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Affiliation(s)
- Soon Koo Baik
- Dept of Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | | | - Samuel S Lee
- Liver Unit, University of Calgary, Calgary, Canada
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