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Kiko T, Asano R, Endo H, Nishi N, Hayashi H, Ueda J, Aoki T, Tsuji A, Ogo T. Clinical outcomes of upfront combination therapy for portopulmonary hypertension. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200294. [PMID: 38872733 PMCID: PMC11168483 DOI: 10.1016/j.ijcrp.2024.200294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
Background Limited data exists on upfront combination therapy for portopulmonary hypertension. We evaluated the clinical efficacy, long-term outcomes, and safety of upfront combination therapy in patients with portopulmonary hypertension. Methods We performed a retrospective, single-center cohort study involving a final analysis of 33 consecutive patients diagnosed with portopulmonary hypertension who were taking pulmonary arterial hypertension-specific medication. We compared hemodynamic parameters, risk profiles, composite clinical worsening events, and safety between monotherapy (n = 23) and upfront combination therapy (n = 10). Results Twenty-seven patients (82 %) were classified into the Child-Pugh A stage. The change ratios of pulmonary vascular resistance (-32 % vs. -57 %, P = 0.006) were significantly better with upfront combination therapy. Upfront combination therapy also showed significant improvement in risk profiles. Kaplan-Meier analysis showed that the composite event-free rate was significantly lower in patients who received upfront combination therapy than in those who received monotherapy (P = 0.016), although no statistical differences were observed in all-cause death. In the univariate Cox proportional hazards analysis, upfront combination therapy was a factor for decreasing composite clinical worsening outcomes (hazard ratio 0.190, 95 % confidence interval 0.042-0.854; P = 0.030). No significant hepatic impairments were observed over 2 years of follow-up in the upfront combination group. Conclusions In patients with portopulmonary hypertension, upfront combination therapy significantly improved symptoms and short-term hemodynamics, and reduced long-term clinical worsening events without serious adverse effects. This study's findings suggest that patients with portopulmonary hypertension presenting with mild hepatic impairment benefit from upfront combination therapy.
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Affiliation(s)
- Takatoyo Kiko
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Ryotaro Asano
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Japan
| | - Hiroyuki Endo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Naruhiro Nishi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroya Hayashi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Jin Ueda
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Tatsuo Aoki
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Akihiro Tsuji
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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Dondossola D, Lonati C, Pini A, Bignamini D, Zanella A, Lombardi R, Scaravilli V, La Mura V, Forzenigo L, Biondetti P, Grasselli G, Fracanzani A, Paleari C, Cespiati A, Todaro S, Cattaneo E, Di Feliciantonio M, Sigon G, Valsecchi C, Guzzardella A, Battistin M, Iuculano F. Portal hypertension-like pattern in coronavirus disease 2019 acute respiratory distress syndrome. J Crit Care 2024; 82:154759. [PMID: 38461659 DOI: 10.1016/j.jcrc.2024.154759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Although respiratory failure is the most common feature in coronavirus disease 2019 (COVID-19), abdominal organ involvement is likewise frequently observed. To investigate visceral and thoracic circulation and abdominal organ damage in COVID-19 patients. MATERIALS AND METHODS A monocentric observational study was carried on. In COVID-19 patients affected by acute respiratory distress syndrome (ARDS) (n = 31) or mild pneumonia (n = 60) thoracoabdominal circulation was evaluated using Doppler-ultrasound and computed tomography. The study also included non-COVID-19 patients affected by ARDS (n = 10) or portal hypertension (n = 10) for comparison of the main circulatory changes. RESULTS Patients affected by COVID-19 ARDS showed hyperdynamic visceral flow and increased portal velocity, hepatic artery resistance-index, and spleen diameter relative to those with mild-pneumonia (p = 0.001). Splanchnic circulatory parameters significantly correlated with the main respiratory indexes (p < 0.001) and pulmonary artery diameter (p = 0.02). The chest and abdominal vascular remodeling pattern of COVID-19 ARDS patients resembled the picture observed in the PH group, while differed from that of the non-COVID ARDS group. A more severe COVID-19 presentation was associated with worse liver dysfunction and enhanced inflammatory activation; these parameters both correlated with abdominal (p = 0.04) and chest imaging measures (p = 0.03). CONCLUSION In COVID-19 ARDS patients there are abdominal and lung vascular modifications that depict a portal hypertension-like pattern. The correlation between visceral vascular remodeling, pulmonary artery enlargement, and organ damage in these critically ill patients is consistent with a portal hyperlfow-like syndrome that could contribute to the peculiar characteristics of respiratory failure in these patients. CLINICAL RELEVANCE STATEMENT our data suggest that the severity of COVID-19 lung involvement is directly related to the development of a portal hyperflow-like syndrome. These observations should help in defining the need for a closer monitoring, but also to develop dedicated therapeutic strategies.
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Affiliation(s)
- Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy.
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Alessia Pini
- Department of Statistical Sciences, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Daniela Bignamini
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Rosa Lombardi
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Vincenzo La Mura
- Internal Medicine, Hemostasis and Thrombosis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy; Department of Biomedical Science for Health, Università degli Studi of Milan, 20019 Milan, Italy
| | - Laura Forzenigo
- Division of Radiology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Pierpaolo Biondetti
- Division of Radiology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Anna Fracanzani
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Chiara Paleari
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Annalisa Cespiati
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Serena Todaro
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Emanuele Cattaneo
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Marianna Di Feliciantonio
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Giordano Sigon
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Carlo Valsecchi
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Amedeo Guzzardella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Federica Iuculano
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
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Jose A, Rahman N, Opotowsky AR, Glorioso TJ, Waldo SW, Zeder K, Seto A, Elwing JM, McCormack FX, Maron BA. Association of Cardiopulmonary Hemodynamics and Mortality in Veterans With Liver Cirrhosis: A Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e033847. [PMID: 38567662 PMCID: PMC11262483 DOI: 10.1161/jaha.123.033847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking. METHODS AND RESULTS As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m2, the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy. CONCLUSIONS These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.
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Affiliation(s)
- Arun Jose
- Veterans Affairs Cincinnati Healthcare SystemCincinnatiOH
- University of CincinnatiOH
| | - Natalia Rahman
- Rocky Mountain Regional VA Medical CenterAuroraCO
- Denver Research InstituteAuroraCO
| | - Alexander R. Opotowsky
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of CincinnatiOH
| | - Thomas J. Glorioso
- CART Program, Office of Quality and Patient Safety, Veterans Health AdministrationWashingtonDC
| | - Stephen W. Waldo
- Rocky Mountain Regional VA Medical CenterAuroraCO
- CART Program, Office of Quality and Patient Safety, Veterans Health AdministrationWashingtonDC
- University of Colorado School of MedicineAuroraCO
| | - Katarina Zeder
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMA
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMD
- The University of Maryland‐Institute for Health ComputingBethesdaMD
- Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of GrazAustria
| | - Arnold Seto
- Veteran’s Affairs Long Beach Healthcare SystemLong BeachCA
| | | | - Francis X. McCormack
- Veterans Affairs Cincinnati Healthcare SystemCincinnatiOH
- University of CincinnatiOH
| | - Bradley A. Maron
- Veterans Affairs Boston Healthcare SystemBostonMA
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMA
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMD
- The University of Maryland‐Institute for Health ComputingBethesdaMD
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Kim NH, Chin KM, McLaughlin VV, DuBrock H, Restrepo-Jaramillo R, Safdar Z, MacDonald G, Martin N, Rosenberg D, Solonets M, Channick R. Safety of Macitentan for the Treatment of Portopulmonary Hypertension: Real-World Evidence from the Combined OPUS/OrPHeUS Studies. Pulm Ther 2024; 10:85-107. [PMID: 38184507 PMCID: PMC10881949 DOI: 10.1007/s41030-023-00251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/14/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Portopulmonary hypertension (PoPH) carries a worse prognosis than other forms of pulmonary arterial hypertension (PAH). Data regarding use of PAH-specific therapies in patients with PoPH are sparse as they are usually excluded from clinical trials. This analysis describes patient characteristics, treatment patterns, outcomes, and safety profiles in patients with PoPH newly initiating macitentan in the USA using the OPUS/OrPHeUS combined dataset. METHODS OPUS was a prospective, US, multicenter, observational drug registry (April 2014-June 2020); OrPHeUS was a retrospective, US, multicenter chart review (October 2013-March 2017). Additional information regarding patients' liver disease was retrospectively collected for patients with PoPH in OPUS. RESULTS The OPUS/OrPHeUS dataset included 206 patients with PoPH (median age 58 years; 52.4% female), with baseline cirrhosis and liver test abnormalities reported in 72.8% and 31.6% of patients respectively. Macitentan was initiated as combination therapy in 74.8% of patients and median (Q1, Q3) exposure to macitentan was 11.9 (3.1, 26.0) months. One-year Kaplan-Meier estimates (95% confidence limit, CL) of patients free from all-cause hospitalization and survival were 48.6% (40.7, 56.0) and 82.2% (75.1, 87.4). Of the 96 patients with PoPH in OPUS, 29.2% were classified as in need of liver transplant due to underlying liver disease during the study; transplant waitlist registration was precluded because of PAH severity for 32.1% and 17.9% were transplanted. Hepatic adverse events (HAE) were experienced by 49.0% of patients; the most common being increased bilirubin (16.0%), ascites (7.3%), and hepatic encephalopathy (5.8%); 1.5% and 21.8% of patients discontinued macitentan as a result of HAE and non-hepatic adverse events. CONCLUSION There were no unexpected safety findings in patients with PoPH treated with macitentan. These data add to the evidence supporting the safety and tolerability of macitentan in patients with PoPH. A graphical abstract is available with this article. TRIAL REGISTRATION OPsumit® Users Registry (OPUS): NCT02126943; OPsumit® Historical Users cohort (OrPHeUS): NCT03197688; www. CLINICALTRIALS gov .
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Affiliation(s)
- Nick H Kim
- UC San Diego Health, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, 9300 Campus Point Dr, La Jolla, CA, 92037-7381, USA.
| | | | | | | | | | - Zeenat Safdar
- Houston Methodist, Weill Cornell Medical College, Houston, TX, USA
| | - Gwen MacDonald
- Global Medical Affairs, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Nicolas Martin
- Statistical Decision Science, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Daniel Rosenberg
- Global Epidemiology, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Maria Solonets
- Global Medical Safety, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Richard Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Radchenko GD, Sirenko YM. When Pulmonary Arterial Hypertension may be Associated with Portal Hypertension: A Case Report of Two Different Hepatic Disorders in One Patient with Pulmonary Hypertension. Curr Cardiol Rev 2023; 20:CCR-EPUB-135441. [PMID: 37881075 PMCID: PMC11071676 DOI: 10.2174/011573403x267162231011154808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 08/06/2023] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND pulmonary arterial hypertension (PAH) is a rare complication of hepatic diseases with portal hypertension that, however, has a significant influence on prognosis. We present a mini-review of how to diagnose and treat it based on a clinical case. CASE PRESENTATION in early childhood, a patient had portal hypertension associated with cavernous transformation of the portal vein. It was successfully treated by reno-splenic surgery. At the age of 20 years, this patient experienced increased dyspnea at minimal physical activity after the hepatic biopsy due to a hepatocellular adenoma. The examination in the specialized unit showed PAH, which was evaluated as associated with portal hypertension (PAH-PoH). The specific two-drug combination therapy was started with prominent improvement in patient's state. Successful surgical tumor treatment was provided some months later. The practical and clinical approaches to the diagnosis and treatment of PAH-PoH are discussed. It was emphasized that not all patients with portal hypertension have pulmonary hypertension, which needs to be treated. A lot of evidence gaps exist in management of these patients. CONCLUSION all patients, even with past history of portal hypertension, should be monitored closely and screened for PAH earlier, for better results of treatment.
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Affiliation(s)
- Ganna D. Radchenko
- State Institution National Scientific Center “Institute of Cardiology, Clinical and Regenerative Medicine named after acad. M.D. Strazhesko” of National Academy of Medical Science, Kyiv, Ukraine
| | - Yuriy M. Sirenko
- State Institution National Scientific Center “Institute of Cardiology, Clinical and Regenerative Medicine named after acad. M.D. Strazhesko” of National Academy of Medical Science, Kyiv, Ukraine
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Torres G, Lancaster AC, Yang J, Griffiths M, Brandal S, Damico R, Vaidya D, Simpson CE, Martin LJ, Pauciulo MW, Nichols WC, Ivy DD, Austin ED, Hassoun PM, Everett AD. Low-affinity insulin-like growth factor binding protein 7 and its association with pulmonary arterial hypertension severity and survival. Pulm Circ 2023; 13:e12284. [PMID: 37674873 PMCID: PMC10477418 DOI: 10.1002/pul2.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023] Open
Abstract
Insulin-like growth factor (IGF) binding proteins (IGFBPs) are a family of growth factor modifiers, some of which are known to be independently associated with pulmonary arterial hypertension (PAH) survival. IGF factor binding protein 7 (IGFBP7) is a unique low-affinity IGFBP that, independent of IGF, stimulates prostacyclin production. This study proposed to establish associations between IGFBP7 and PAH severity and survival, using enrollment and longitudinal samples. Serum IGFBP7 levels were significantly elevated in patients with PAH compared to controls. After adjusting for age and sex, logarithmic increases in IGFBP7 were associated with a 20 m shorter six-minute walk distance (6MWD; p < 0.001), a 2-3 mmHg higher mean right atrial pressure (p < 0.001 and 0.02), and a higher likelihood of a greater REVEAL 2.0 risk category placement (p < 0.001). Kaplan-Meier analysis demonstrated significantly decreased survival with IGFBP7 above the median and Cox multivariable analysis adjusted for age and sex, demonstrated higher serum IGFBP7 was an independent predictor of survival. Though the exact mechanism is still unknown, given IGFBP7's role as a prostacyclin stimulant, it has potential use as a therapeutic target for disease modulation.
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Affiliation(s)
- Guillermo Torres
- Department of Pediatrics, Division of Pediatric CardiologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Jun Yang
- Department of Pediatrics, Division of Pediatric CardiologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Megan Griffiths
- Department of Pediatrics, Division of Pediatric CardiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Stephanie Brandal
- Department of Pediatrics, Division of Pediatric CardiologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Rachel Damico
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Dhananjay Vaidya
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of General Internal MedicineJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Catherine E. Simpson
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Lisa J. Martin
- Department of Pediatrics, Division of Human Genetics, Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Michael W. Pauciulo
- Department of Pediatrics, Division of Human Genetics, Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - William C. Nichols
- Department of Pediatrics, Division of Human Genetics, Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - David D. Ivy
- Department of Pediatric CardiologyChildren's Hospital ColoradoDenverColoradoUSA
| | - Eric D. Austin
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Paul M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Allen D. Everett
- Department of Pediatrics, Division of Pediatric CardiologyJohns Hopkins UniversityBaltimoreMarylandUSA
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7
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Zhao YN, Liu GH, Wang C, Zhang YX, Yang P, Yu M. Pulmonary hypertension, nephrotic syndrome, and polymyositis due to hepatitis C virus infection: A case report. World J Gastroenterol 2023; 29:3040-3047. [PMID: 37274804 PMCID: PMC10237099 DOI: 10.3748/wjg.v29.i19.3040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Hepatitis C infection not only damages the liver but also often accompanies many extrahepatic manifestations. Incidences of pulmonary hypertension (PH) caused by hepatitis C are rare, and incidences of concurrent nephrotic syndrome and polymyositis are even rarer.
CASE SUMMARY Herein we describe the case of a 57-year-old woman who was admitted to our department for intermittent chest tightness upon exertion for 5 years, aggravated with dyspnea for 10 d. After relevant examinations she was diagnosed with PH, nephrotic syndrome, and polymyositis due to chronic hepatitis C infection. A multi-disciplinary recommendation was that the patient should be treated with sildenafil and macitentan in combination and methylprednisolone. During treatment autoimmune symptoms, liver function, hepatitis C RNA levels, and cardiac parameters of right heart catheterization were monitored closely. The patient showed significant improvement in 6-min walking distance from 100 to 300 m at 3-mo follow-up and pulmonary artery pressure drops to 50 mmHg. Long-term follow-up is needed to confirm further efficacy and safety.
CONCLUSION Increasing evidence supports a relationship between hepatitis C infection and diverse extrahepatic manifestations, but it is very rare to have PH, nephrotic syndrome, and polymyositis in a single patient. We conducted a literature review on the management of several specific extrahepatic manifestations of hepatitis C.
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Affiliation(s)
- Ya-Nan Zhao
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Guo-Hui Liu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Chang Wang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Yi-Xuan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Ming Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
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Portopulmonary Hypertension: Management and Liver Transplantation Evaluation. Chest 2023:S0012-3692(23)00043-0. [PMID: 36649754 DOI: 10.1016/j.chest.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Portopulmonary hypertension (POPH) affects 5% to 6% of patients with advanced liver disease and accounts for 5% to 15% of pulmonary arterial hypertension (PAH) cases. Compared with idiopathic PAH, POPH is associated with significantly worse survival. Recent studies have improved our understanding of the role of both PAH therapy and liver transplantation (LT) in the management of POPH and their impact on overall prognosis. We performed a review of the published literature to summarize the available evidence and guidelines regarding the diagnosis and management of POPH. POPH is defined by the presence of precapillary PH in the context of portal hypertension. POPH is associated with increased perioperative risk at the time of LT, which can be stratified by mean pulmonary arterial pressure and pulmonary vascular resistance. Screening with echocardiography is recommended in all LT candidates to facilitate detection and treatment of POPH. Despite a paucity of evidence, POPH is treated similarly to idiopathic PAH with PAH therapy. These therapies are associated with improved pulmonary hemodynamics and facilitation of safe LT. LT can result in improvement or resolution of POPH in half of patients and has been associated with improved survival in highly selected patients. The prognosis in POPH is poor and is impacted by the severity of both PH and liver disease. Management with a combination of PAH therapy and LT in selected patients has been associated with improved pulmonary hemodynamics and survival.
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Cajigas HR, Burger CD, Cartin-Ceba R, DuBrock H, Swanson K, Vargas HE, Keaveny AP, Watt KD, Krowka M. Portopulmonary Hypertension in Nontransplanted Patients: Results of the Largest US Single-Institution Registry. Mayo Clin Proc 2022; 97:2236-2247. [PMID: 36336515 DOI: 10.1016/j.mayocp.2022.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore clinical characteristics, risk profiles, and outcomes of patients with portopulmonary hypertension (PoPH) who have contraindications to liver transplant (LT). METHODS From the largest US single-institution registry of patients with PoPH, we analyzed 160 patients who did not receive LT between 1988 to 2019. Pulmonary arterial hypertension (PAH)-pertinent characteristics, hemodynamic features, treatments, and risk stratification were compared at baseline, first follow-up visit, and censor/death time. RESULTS Median survival for the entire cohort was 27.5 months from the diagnosis of PoPH. Overall survival was 89%, 77%, 51%, and 38% at 6 months, 1 year, 3 years, and 5 years, respectively. Survival was significantly affected by the severity of liver disease (P<.001). Most patients received PAH-specific therapies (136 [85%]), predominantly monotherapy (123 [77%)]. With treatment, significant improvements were noted in World Health Organization functional class (P=.04), 6-minute walk distance (P<.001), right ventricular function (P<.001), pulmonary vascular resistance (P<.001), and Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL) Lite 2 score (P=.02) univariately. Per European Society of Cardiology risk stratification, no patient met full criteria for low risk at baseline or at follow-up. In a multivariate Cox risk model, 6-minute walk distance, right atrial pressure, pulmonary capillary wedge pressure, bilirubin level, and Model for End-Stage Liver Disease-sodium score of 15 or higher were associated with increased risk of death. CONCLUSION Patients with PoPH who did not undergo LT had a poor prognosis. This persisted despite use of PAH-specific therapies and significant improvements in hemodynamics, echocardiography parameters of right ventricle function, 6-minute walk distance, and World Health Organization functional class.
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Affiliation(s)
- Hector R Cajigas
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Charles D Burger
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hilary DuBrock
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen Swanson
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Andrew P Keaveny
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Krowka
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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10
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Tamura Y, Tamura Y, Taniguchi Y, Tsujino I, Inami T, Matsubara H, Shigeta A, Sugiyama Y, Adachi S, Abe K, Baba Y, Hatano M, Ikeda S, Kusunose K, Sugimura K, Usui S, Takeishi Y, Dohi K, Hasegawa-Tamba S, Horimoto K, Kikuchi N, Kumamaru H, Tatsumi K. Clinical Management and Outcomes of Patients With Portopulmonary Hypertension Enrolled in the Japanese Multicenter Registry. Circ Rep 2022; 4:542-549. [PMID: 36408361 PMCID: PMC9638513 DOI: 10.1253/circrep.cr-22-0098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 02/12/2024] Open
Abstract
Background: Portopulmonary hypertension (PoPH) is one of the major underlying causes of pulmonary arterial hypertension (PAH). However, PoPH, especially treatment strategies, has been poorly studied. Therefore, this study evaluated current treatments for PoPH, their efficacy, and clinical outcomes of patients with PoPH. Methods and Results: Clinical data were collected for patients with PoPH who were enrolled in the Japan Pulmonary Hypertension Registry between 2008 and 2021. Hemodynamic changes, functional class, and clinical outcomes were compared between patients with PoPH treated with monotherapy and those treated with combination therapies. Clinical data were analyzed for 62 patients with PoPH, including 25 treatment-naïve patients, from 21 centers in Japan. In more than half the patients, PAH-specific therapy improved the New York Heart Association functional class by at least one class. The 3- and 5-year survival rates of these patients were 88.5% (95% confidence interval [CI] 76.0-94.7) and 80.2% (95% CI 64.8-89.3), respectively. Forty-one (66.1%) patients received combination therapy. Compared with patients who had received monotherapy, the mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac index were significantly improved in patients who had undergone combination therapies. Conclusions: Combination therapy was commonly used in patients with PoPH with a favorable prognosis. Combination therapies resulted in significant hemodynamic improvement without an increased risk of side effects.
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Affiliation(s)
- Yudai Tamura
- Cardiovascular Center, International University of Health and Welfare (IUHW) Mita Hospital Tokyo Japan
| | - Yuichi Tamura
- Pulmonary Hypertension Center, IUHW Mita Hospital Tokyo Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine Kobe Japan
| | - Ichizo Tsujino
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University School of Medicine Mitaka Japan
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center Okayama Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba University Chiba Japan
| | - Yoichi Sugiyama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine Kurume Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Hospital Nagoya Japan
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences Fukuoka Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo Tokyo Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital Tokushima Japan
| | | | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University Fukushima Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine Tsu Japan
| | - Saki Hasegawa-Tamba
- Department of Cardiology, Saitama Medical University International Medical Center Hidaka Japan
| | - Koshin Horimoto
- Department of Cardiology, Matsuyama Red Cross Hospital Matsuyama Japan
| | - Noriko Kikuchi
- Department of Cardiology, Tokyo Women's Medical University Tokyo Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo Tokyo Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University Chiba Japan
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11
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Atsukawa M, Takano M, Omura J. Treatment pattern and clinical outcomes in portopulmonary hypertension: A database study in Japan. JGH OPEN 2022; 6:763-773. [DOI: 10.1002/jgh3.12820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Masanori Atsukawa
- Division of Gastroenterology and Hepatology Nippon Medical School Tokyo Japan
| | - Masashi Takano
- Medical Affairs Division Janssen Pharmaceutical K.K. Tokyo Japan
| | - Junichi Omura
- Medical Affairs Division Janssen Pharmaceutical K.K. Tokyo Japan
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12
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Douschan P, Kovacs G, Sassmann T, Stadlbauer V, Avian A, Foris V, Tatscher E, Durchschein F, Rainer F, Spindelboeck W, Wagner M, Kniepeiss D, Zollner G, Bachmaier G, Fickert P, Olschewski H, Stauber RE. Pulmonary vascular disease and exercise hemodynamics in chronic liver disease. Respir Med 2022; 202:106987. [PMID: 36115317 DOI: 10.1016/j.rmed.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are severe pulmonary vascular complications of chronic liver disease and strongly associated with morbidity and mortality. The prevalence of these complications is relatively high in patients evaluated for liver transplantation, however it is virtually unknown in patients with stable chronic liver disease. METHODS We assessed the pulmonary hypertension (PH) and HPS prevalence in a prospective registry study of our liver out-patient clinic in a tertiary center. Between 2011 and 2016, consecutive patients with cirrhosis or non-cirrhotic portal hypertension were prospectively enrolled after written informed consent. We excluded patients with acute decompensation of liver disease and other causes of PH like severe chronic heart or lung diseases and chronic thromboembolic PH. HPS was diagnosed using contrast enhanced echocardiography and blood gas analysis. Patients were screened for PH using an algorithm implementing severity of dyspnea, echocardiography, cardiopulmonary exercise testing and exercise echocardiography employing a threshold of systolic pulmonary arterial pressure (SPAP) = 50 mmHg at peak exercise. If the algorithm indicated an increased PH risk, patients were invited for invasive investigations by means of right heart and hepatic vein catheter. We defined POPH as resting mPAP≥21 mmHg and PVR>3WU and PAWP<15 mmHg, mild PH as resting mPAP = 21-24 mmHg, and exercise PH as mPAP>30 mmHg and TPR >3 WU at peak exercise. RESULTS Two-hundred-five patients were enrolled (male 75%; cirrhosis 96%; median age 57 yrs). Sixty-seven patients (33%) fulfilled HPS criteria but only two (1.0%) for severe (PaO2:50-60 mmHg) or very severe HPS (PaO2<50 mmHg). In 18/77 patients (23%) undergoing exercise echocardiography, SPAP at peak exercise exceeded 50 mmHg. Finally, n = 3 (1.5%) patients were invasively diagnosed with POPH, n = 4 (2.9%) with mild PH and n = 2 with exercise PH. CONCLUSION In chronic liver disease, excluding acute decompensation and other causes of PH, POPH and severe HPS are rare findings while mild to moderate HPS and mild PH or exercise PH are more frequent.
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Affiliation(s)
- Philipp Douschan
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elisabeth Tatscher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Franziska Durchschein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
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13
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Livingstone J, Raveh Y, Souki F, Shatz V, Shah R, Ibrahim T, Shuman M, Beduschi T, Vianna R, Alvarez R, Nicolau-Raducu R. Multivisceral Transplant in a Patient With Portopulmonary Hypertension: A Case Report. Transplant Proc 2022; 54:1664-1670. [PMID: 35914967 DOI: 10.1016/j.transproceed.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022]
Abstract
Portopulmonary hypertension, a type of pulmonary arterial hypertension in the setting of cirrhotic or noncirrhotic portal hypertension, is associated with elevated morbidity and mortality during and after transplantation. Uncontrolled portopulmonary hypertension may prevent or delay listing for transplant candidates, and the prognosis without treatment and ultimately transplant is extremely poor. We present a 29-year-old White woman, who had a post-liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent a multivisceral transplant (liver, stomach, pancreaticoduodenal complex, and small and large intestine). Preoperative mean pulmonary artery pressure was <30 mm Hg with a pulmonary vascular resistance of <300 dynes.s/cm5 on oral sildenafil and intravenous epoprostenol. Intraoperatively, management required comprehensive transfusion protocols, a careful balance between correcting blood loss and preventing thrombosis. Intravenous epoprostenol, sildenafil, milrinone, and inhaled nitric oxide were used to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts. Nitric oxide and epoprostenol use unleashed antiplatelet effects on a patient already susceptible to coagulopathy. A multimodal and multidisciplinary approach continued throughout the surgery and in the postoperative period, which led to a successful outcome.
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Affiliation(s)
- J Livingstone
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Y Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - F Souki
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - V Shatz
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Shah
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Ibrahim
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - M Shuman
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Beduschi
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Alvarez
- Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
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14
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Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
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Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
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15
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DuBrock HM, Del Valle KT, Krowka MJ. Mending the Model for End-Stage Liver Disease: An in-depth review of the past, present, and future portopulmonary hypertension Model for End-Stage Liver Disease exception. Liver Transpl 2022; 28:1224-1230. [PMID: 35106916 DOI: 10.1002/lt.26422] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 02/06/2023]
Abstract
Patients with portopulmonary hypertension (POPH) have an increased cardiovascular and overall mortality risk when undergoing liver transplantation (LT). However, such risk is not captured in their Model for End-Stage Liver Disease (MELD) laboratory score. POPH MELD exception criteria were established in 2006 with the aim of prioritizing these patients for LT prior to pulmonary hypertension (PH) progression and eventual right heart failure. The original criteria emphasized a posttreatment, pre-LT mean pulmonary arterial pressure (mPAP) of <35 mm Hg and pulmonary vascular resistance (PVR) <400 dynes-s-cm-5 or <5 Wood units (WU). Since 2006, there have been important advances in the treatment of POPH with pulmonary arterial hypertension (PAH)-targeted therapies and newer evidence regarding LT outcomes and risk factors for perioperative mortality. Specifically, PVR rather than mPAP has been shown to be more strongly associated with outcomes, including mortality. In addition, among treated patients with POPH, mPAP may be persistently elevated related to an elevated cardiac output or other factors that do not necessarily reflect POPH disease severity. Thus, in February 2021, the Organ Procurement and Transplantation Network approved proposed modifications to POPH MELD exception criteria, now allowing either of the following posttreatment, pre-LT hemodynamic profiles: mPAP less than 35 mm Hg and posttreatment PVR less than 400 dynes-s-cm-5 (or less than 5 WU) or mPAP greater than or equal to 35 mm Hg and less than 45 mm Hg and posttreatment PVR less than 240 dynes-s-cm-5 (or less than 3 WU). This article reviews the history of the POPH MELD exception criteria, describes the recent modifications to the exception criteria and the evidence supporting them, and highlights unanswered questions and areas for future research.
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Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn T Del Valle
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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16
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Mazzola M, Madonna R, Badagliacca R, Caterina RD. Porto-pulmonary arterial hypertension: Translation of pathophysiological concepts to the bedside. Vascul Pharmacol 2022; 145:107022. [PMID: 35738494 DOI: 10.1016/j.vph.2022.107022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Abstract
Porto-pulmonary arterial hypertension (PoPAH) is a form of pulmonary arterial hypertension (PAH) that affects patients with cirrhosis, and - to a lesser extent - patients with non-cirrhotic liver diseases. Compared with other forms of PAH, PoPAH is more prevalent in male, in older subjects, and is characterized by lower mean pulmonary arterial pressure (mPAP) and lower pulmonary vascular resistance (PVR) with higher cardiac output. Despite more favorable hemodynamics and functional class, patients with PoPAH have a significantly worse survival than patients with other forms of PAH, likely because of liver-related events and therapeutic barriers to PAH-specific therapy. Furthermore, here cardiopulmonary and hepatic complications may affect treatment efficacy. These patients have been excluded from most randomized clinical trials testing PAH-specific treatments. To date, there is only one study investigating efficacy, safety, tolerability and pharmacokinetics of PAH-specific therapy in patients with PoPAH in a randomized placebo-controlled setting. In this trial the use of the endothelin-1 receptor antagonist macitentan showed clear hemodynamic benefit without safety concerns. However, the drug effects on functional capacity and mortality remain unclear. Here we review the current knowledge on the pathophysiology and management of PoPAH and report a case vignette of a patient with PoPAH due to hepatorenal polycystic disease.
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Affiliation(s)
- Matteo Mazzola
- Cardiovascular Division, Pisa University Hospital and University of Pisa, Pisa, Italy
| | - Rosalinda Madonna
- Cardiovascular Division, Pisa University Hospital and University of Pisa, Pisa, Italy.
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, University of Rome La Sapienza, Rome, Italy
| | - Raffaele De Caterina
- Cardiovascular Division, Pisa University Hospital and University of Pisa, Pisa, Italy
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17
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Certain MC, Baron A, Turpin M, Ebstein N, Boucly A, Beurnier A, Jevnikar M, Roche A, Keddache S, Bulifon S, Seferian A, Jaïs X, Montani D, Humbert M, Sitbon O, Savale L. Outcomes of cirrhotic patients with pre-capillary pulmonary hypertension and pulmonary vascular resistance between 2 and 3 Wood Units. Eur Respir J 2022; 60:13993003.00107-2022. [PMID: 35680147 DOI: 10.1183/13993003.00107-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Marie Caroline Certain
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Audrey Baron
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Matthieu Turpin
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Nathan Ebstein
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Antoine Beurnier
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne Roche
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sophia Keddache
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sophie Bulifon
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Andrei Seferian
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France .,INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Peppas S, Nagraj S, Koutsias G, Kladas M, Archontakis-Barakakis P, Schizas D, Giannakoulas G, Palaiodimos L, Kokkinidis DG. Portopulmonary Hypertension: A Review of the Current Literature. Heart Lung Circ 2022; 31:1191-1202. [PMID: 35667970 DOI: 10.1016/j.hlc.2022.04.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/05/2022] [Accepted: 04/21/2022] [Indexed: 12/20/2022]
Abstract
Portopulmonary hypertension is defined as the development of pulmonary arterial hypertension in the setting of portal hypertension with or without liver cirrhosis. Portal hypertension-associated haemodynamic changes, including hyperdynamic state, portosystemic shunts and splanchnic vasodilation, induce significant alterations in pulmonary vascular bed and play a pivotal role in the pathogenesis of the disease. If left untreated, portopulmonary hypertension results in progressive right heart failure, with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and liver transplantation candidates, right heart catheterisation remains the gold standard for the diagnosis of the disease. Severe portopulmonary hypertension exerts a prohibitive risk to liver transplantation by conferring an elevated perioperative mortality risk. It is important for haemodynamic parameters to correspond with non-severe portopulmonary hypertension before patients can proceed with the liver transplantation. Small uncontrolled studies and a recent randomised controlled trial have reported promising results with vasodilatory therapies in clinical and haemodynamic improvement of patients, allowing a proportion of patients to undergo liver transplantation. In this review, the epidemiology, pathogenesis, diagnostic approach and management of portopulmonary hypertension are discussed. We also highlight fields of ongoing investigation pertinent to risk stratification and optimal patient selection to maximise long-term benefit from currently available treatments.
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Affiliation(s)
- Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece.
| | - Sanjana Nagraj
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - George Koutsias
- Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Michail Kladas
- Internal Medicine, North Central Bronx Hospital and James J. Peters VA Medical Center, Bronx, NY, USA
| | | | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leonidas Palaiodimos
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
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19
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Abstract
IMPORTANCE Pulmonary arterial hypertension (PAH) is a subtype of pulmonary hypertension (PH), characterized by pulmonary arterial remodeling. The prevalence of PAH is approximately 10.6 cases per 1 million adults in the US. Untreated, PAH progresses to right heart failure and death. OBSERVATIONS Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 20 mm Hg and is classified into 5 clinical groups based on etiology, pathophysiology, and treatment. Pulmonary arterial hypertension is 1 of the 5 groups of PH and is hemodynamically defined by right heart catheterization demonstrating a mean pulmonary artery pressure greater than 20 mm Hg, a pulmonary artery wedge pressure of 15 mm Hg or lower, and a pulmonary vascular resistance of 3 Wood units or greater. Pulmonary arterial hypertension is further divided into subgroups based on underlying etiology, consisting of idiopathic PAH, heritable PAH, drug- and toxin-associated PAH, pulmonary veno-occlusive disease, PAH in long-term responders to calcium channel blockers, and persistent PH of the newborn, as well as PAH associated with other medical conditions including connective tissue disease, HIV, and congenital heart disease. Early presenting symptoms are nonspecific and typically consist of dyspnea on exertion and fatigue. Currently approved therapy for PAH consists of drugs that enhance the nitric oxide-cyclic guanosine monophosphate biological pathway (sildenafil, tadalafil, or riociguat), prostacyclin pathway agonists (epoprostenol or treprostinil), and endothelin pathway antagonists (bosentan and ambrisentan). With these PAH-specific therapies, 5-year survival has improved from 34% in 1991 to more than 60% in 2015. Current treatment consists of combination drug therapy that targets more than 1 biological pathway, such as the nitric oxide-cyclic guanosine monophosphate and endothelin pathways (eg, ambrisentan and tadalafil), and has shown demonstrable improvement in morbidity and mortality compared with the previous conventional single-pathway targeted monotherapy. CONCLUSIONS AND RELEVANCE Pulmonary arterial hypertension affects an estimated 10.6 per 1 million adults in the US and, without treatment, typically progresses to right heart failure and death. First-line therapy with drug combinations that target multiple biological pathways are associated with improved survival.
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Affiliation(s)
- Nicole F Ruopp
- Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Barbara A Cockrill
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Aggarwal M, Li M, Bhardwaj A, Wallace WD, Wang X, Carey WD, Dweik RA, Heresi GA, Tonelli AR. Predictors of survival in portopulmonary hypertension: a 20-year experience. Eur J Gastroenterol Hepatol 2022; 34:449-456. [PMID: 34907982 PMCID: PMC8891035 DOI: 10.1097/meg.0000000000002322] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Portopulmonary hypertension (PoPH) is a rare complication of portal hypertension associated with poor survival. Scarce data is available on predictors of survival in PoPH with conflicting results. We sought to characterize the outcomes and variables associated with survival in a large cohort of patients with PoPH in an American population of patients. STUDY DESIGN AND METHODS We identified PoPH patients from the Cleveland Clinic Pulmonary Hypertension Registry between 1998 and 2019. We collected prespecified data, particularly focusing on hepatic and cardiopulmonary assessments and tested their effect on long-term survival. RESULTS Eighty patients with PoPH with a mean ± SD age of 54 ± 10 years, (54% females) were included in the analysis. The median Model for End-Stage Liver Disease with sodium (MELD-Na) score was 13.0 (10.0-18.0) at PoPH diagnosis. World Health Association functional class III-IV was noted in 57%. Mean pulmonary arterial pressure was 47 ± 10 mmHg and pulmonary vascular resistance 6.0 ± 2.8 Woods units. A total of 63 (78.5%) patients were started on pulmonary arterial hypertension (PAH)-specific treatment during the first 6 months of diagnosis. Survival rates at 1-, 3- and 5-year were 77, 52 and 34%, respectively. Cardiopulmonary hemodynamics as well as PAH-specific treatment did not affect survival. In the multivariable model, MELD-Na, resting heart rate and the presence of hepatic encephalopathy were independent predictors of survival. CONCLUSION PoPH patients have poor 5-year survival which is strongly associated to the severity of underlying liver disease and not to the hemodynamic severity of PoPH; therefore efforts should be focused in facilitating liver transplantation for these patients.
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Affiliation(s)
- Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, OH, USA
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhishek Bhardwaj
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - William D. Carey
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R. Tonelli
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Xu H, Cheng B, Wang R, Ding M, Gao Y. Portopulmonary hypertension: Current developments and future perspectives. LIVER RESEARCH 2022. [DOI: 10.1016/j.livres.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Li Y, Qiu H, Zhao Q, He J, Jiang R, Wu W, Luo C, Li H, Wang L, Liu J, Gong S. The Different Effects of Direct Bilirubin on Portopulmonary Hypertension and Idiopathic Pulmonary Arterial Hypertension. Int J Clin Pract 2022; 2022:7021178. [PMID: 35685569 PMCID: PMC9159212 DOI: 10.1155/2022/7021178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND To observe different roles of direct bilirubin (Dbil) on portopulmonary hypertension (POPH) and idiopathic pulmonary arterial hypertension (IPAH). METHODS Thirty incident patients with POPH and 180 with IPAH (matched by the WHO functional classification in a 1 : 6 ratio) between March 2010 and December 2020 were included. The receiver operating curve and Kaplan-Meier method were applied to estimate the ability to distinguish between the two and survival, respectively. Univariate and forward multiple stepwise regression analyses were performed to access the relationship between pulmonary vascular resistance (PVR) and clinical indices. RESULTS Compared to IPAH, the POPH group had better hemodynamics including PVR (7.08 ± 3.95 vs. 14.89 ± 7.11, P < 0.001) and higher total bilirubin (Tbil) and Dbil. Tbil and Dbil had a negative correlation with PVR in the POPH group (r = -0.394, P=0.031; r = -0.364, P=0.048, respectively) but positive correlation in the IPAH group (r = 0.218, P=0.003; r = 0.178, P=0.018, respectively). Increased neutrophil counts (r = 0.394, P=0.031) and elevated NT-proBNP (r = 0.433, P < 0.001) would help predict the elevation of PVR in POPH and IPAH groups independent of Dbil, respectively. Dbil could distinguish POPH from IPAH (AUC = 0.799, P=0.009), and the ability was elevated when taking aspartate aminotransferase together (AUC = 0.835, P < 0.001). The overall survival was better in POPH than in IPAH (7 dead cases of POPH and 96 of IPAH, P=0.002). Survival was better in POPH than in IPAH in the group of Dbil ≥7 μmol/L (P=0.001) but showed no significant difference between POPH and IPAH in the group of Dbil <7 μmol/L (P=0.192). CONCLUSIONS The POPH group had a better hemodynamic profile than IPAH. Dbil was associated oppositely with the elevation of PVR in POPH and IPAH. Patients with POPH had better survival than those with IPAH in the total cohort and in the group of Dbil ≥7 μmol/L, but limited dead cases of POPH should be noted.
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Affiliation(s)
- Yuan Li
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hongling Qiu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qinhua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jing He
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wenhui Wu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cijun Luo
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Huiting Li
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jinming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Sugang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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23
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Raevens S, Fallon MB. Liver Transplantation in Portopulmonary Hypertension: Another Piece of the Puzzle? Liver Transpl 2021; 27:1709-1710. [PMID: 34392597 DOI: 10.1002/lt.26268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
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24
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Akahane T. Factors associated with portopulmonary hypertension. Hepatol Res 2021; 51:1179-1180. [PMID: 34850499 DOI: 10.1111/hepr.13721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Nara, Japan
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25
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Kawaguchi T, Honda A, Sugiyama Y, Nakano D, Tsutsumi T, Tahara N, Torimura T, Fukumoto Y. Association between the albumin-bilirubin (ALBI) score and severity of portopulmonary hypertension (PoPH): A data-mining analysis. Hepatol Res 2021; 51:1207-1218. [PMID: 34534392 DOI: 10.1111/hepr.13714] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Portopulmonary hypertension (PoPH) is a severe complication of chronic liver disease. We aimed to investigate the etiology of chronic liver disease and the factors associated with the severity of PoPH. SUBJECTS AND METHODS Echocardiography was undergone in 833 patients with chronic liver disease during 2005-2019 and 13 patients (1.6%) were diagnosed with PoPH in this observational study. At the diagnosis of PoPH, liver function was evaluated by albumin-bilirubin (ALBI) score. Severe PoPH was defined as (1) mean pulmonary arterial pressure (mPAP) ≥50 mmHg or (2) mPAP: 35-49 mmHg and pulmonary vascular resistance ≥400 dyne/s/cm5 . Factors associated with severe PoPH were evaluated by decision-tree analysis. RESULTS In patients with PoPH, the leading etiology of chronic liver disease was hepatitis C virus (HCV) (46.2% [sustained virological response (SVR): 23.1% and non-SVR: 15.4%]). Severe PoPH was observed in 53.8% of patients and the 5-year survival rate was 48.1%. There was a significant correlation of mPAP with ALBI score (r = 0.6456, p = 0.0171). In the decision-tree and random forest analyses, the most impacted classifier for severe PoPH was the ALBI score. In patients with ALBI score ≥-1.45, all patients showed severe PoPH, while the prevalence of severe PoPH was 25.0% in patients with ALBI score <-1.45. CONCLUSIONS We found that HCV including SVR was the major etiology of chronic liver disease in patients with PoPH. Moreover, we revealed that the ALBI score was the most impacted factor associated with severe PoPH. Thus, ALBI score may be useful for the estimation of pulmonary vascular resistance.
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Affiliation(s)
- Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Akihiro Honda
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoichi Sugiyama
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Dan Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tsubasa Tsutsumi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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26
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Boucly A, Weatherald J, Savale L, de Groote P, Cottin V, Prévot G, Chaouat A, Picard F, Horeau-Langlard D, Bourdin A, Jutant EM, Beurnier A, Jevnikar M, Jaïs X, Simonneau G, Montani D, Sitbon O, Humbert M. External validation of a refined 4-strata risk assessment score from the French pulmonary hypertension Registry. Eur Respir J 2021; 59:13993003.02419-2021. [PMID: 34737227 PMCID: PMC9245192 DOI: 10.1183/13993003.02419-2021] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/28/2021] [Indexed: 11/05/2022]
Abstract
Introduction Contemporary risk assessment tools categorise patients with pulmonary arterial hypertension (PAH) as low, intermediate or high risk. A minority of patients achieve low risk status with most remaining intermediate risk. Our aim was to validate a four-stratum risk assessment approach categorising patients as low, intermediate-low, intermediate-high or high risk, as proposed by the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) investigators. Methods We evaluated incident patients from the French PAH Registry and applied a four-stratum risk method at baseline and at first reassessment. We applied refined cut-points for three variables: World Health Organization functional class, 6-min walk distance and N-terminal pro-brain natriuretic peptide. We used Kaplan–Meier survival analyses and Cox proportional hazards regression to assess survival according to three-stratum and four-stratum risk approaches. Results At baseline (n=2879), the four-stratum approach identified four distinct risk groups and performed slightly better than a three-stratum method for predicting mortality. Four-stratum model discrimination was significantly higher than the three-stratum method when applied during follow-up and refined risk categories among subgroups with idiopathic PAH, connective tissue disease-associated PAH, congenital heart disease and portopulmonary hypertension. Using the four-stratum approach, 53% of patients changed risk category from baseline compared to 39% of patients when applying the three-stratum approach. Those who achieved or maintained a low risk status had the best survival, whereas there were more nuanced differences in survival for patients who were intermediate-low and intermediate-high risk. Conclusions The four-stratum risk assessment method refined risk prediction, especially within the intermediate risk category of patients, performed better at predicting survival and was more sensitive to change than the three-stratum approach. A four-stratum risk assessment method with low, intermediate-low, intermediate-high and high risk categories was better at discriminating survival in pulmonary arterial hypertension than a three-stratum method with low, intermediate and high risk groupshttps://bit.ly/3mA6kj7
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.,Both authors contributed equally
| | - Laurent Savale
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Pascal de Groote
- Université de Lille, Service de cardiologie, CHU Lille, Institut Pasteur de Lille, Inserm U1167, Lille, France
| | - Vincent Cottin
- Université Lyon 1, INRAE, UMR754, IVPC, National Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Lyon, France
| | - Grégoire Prévot
- CHU de Toulouse, Hôpital Larrey, Service de pneumologie, Toulouse, France
| | - Ari Chaouat
- Département de Pneumologie, Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, CHRU de Nancy, Vandoeuvre-lès-Nancy, France
| | - François Picard
- Université Bordeaux, Hôpital Cardiologique du Haut-Lévêque, Heart Failure Unit and Pulmonary Hypertension Expert Centre, Bordeaux, France
| | | | - Arnaud Bourdin
- Department of Respiratory Diseases, Université Montpellier, CHU Montpellier, Montpellier, France
| | - Etienne-Marie Jutant
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Service de pneumologie, CHU Poitiers, Poitiers, France
| | - Antoine Beurnier
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Mitja Jevnikar
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Xavier Jaïs
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Gérald Simonneau
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
| | - Marc Humbert
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France .,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
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27
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Del Valle K, DuBrock HM. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Pulmonary Vascular Complications of Liver Disease. Compr Physiol 2021; 11:3281-3302. [PMID: 34636408 DOI: 10.1002/cphy.c210009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary vascular disease is a frequent complication of chronic liver disease and portal hypertension, affecting up to 30% of patients. There are two distinct pulmonary vascular complications of liver disease: hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS affects 25% of patients with chronic liver disease and is characterized by intrapulmonary vasodilatation and abnormal arterial oxygenation. HPS negatively impacts quality of life and is associated with a 2-fold increased risk of death compared to controls with liver disease without HPS. Angiogenesis, endothelin-1 mediated endothelial dysfunction, monocyte influx, and alveolar type 2 cell dysfunction seem to play important roles in disease pathogenesis but there are currently no effective medical therapies. Fortunately, HPS resolves following liver transplant (LT) with improvements in hypoxemia. POPH is a subtype of pulmonary arterial hypertension (PAH) characterized by an elevated mean pulmonary arterial pressure and pulmonary vascular resistance in the setting of normal left-sided filling pressures. POPH affects 5% to 6% of patients with chronic liver disease. Although the pathogenesis has not been fully elucidated, endothelial dysfunction, inflammation, and estrogen signaling have been identified as key pathways involved in disease pathogenesis. POPH is typically treated with PAH targeted therapy and may also improve with liver transplantation in selected patients. This article highlights what is currently known regarding the diagnosis, management, pathobiology, and outcomes of HPS and POPH. Ongoing research is needed to improve understanding of the pathophysiology and outcomes of these distinct and often misunderstood pulmonary vascular complications of liver disease. © 2021 American Physiological Society. Compr Physiol 11:1-22, 2021.
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Fernandes CJ, Calderaro D, Assad APL, Salibe-Filho W, Kato-Morinaga LT, Hoette S, Piloto B, Castro MA, Lisboa RP, da Silva TAF, Martins MDA, Alves-Jr JL, Jardim C, Terra-Filho M, de Souza R. Update on the Treatment of Pulmonary Arterial Hypertension. Arq Bras Cardiol 2021; 117:750-764. [PMID: 34709302 PMCID: PMC8528352 DOI: 10.36660/abc.20200702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/13/2020] [Accepted: 11/04/2020] [Indexed: 11/28/2022] Open
Abstract
In the last decades, important advances have been made in the treatment of pulmonary arterial hypertension (PAH), a severe, progressive, incurable, and potentially fatal disease. For an adequate therapy, correct hemodynamic diagnosis and etiology classification are fundamental. Many etiologies - rheumatic disease, portal hypertension, congenital heart diseases, schistosomiasis - require specific measures, in addition to drug therapy for PAH. The specific therapy for PAH is based on medications that act on three pathophysiological pathways - prostacyclin, endothelin, and nitric oxide pathways. These drugs have multiple presentations (oral, intravenous, subcutaneous, and inhaled) and have changed the history of PAH. This review presents an overview of drug therapy strategies and different forms and peculiarities of PAH.
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Affiliation(s)
- Caio J. Fernandes
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Instituto do CâncerFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Câncer da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Daniela Calderaro
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Medicina Interdisciplinar - Divisão de Cardiologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Ana Paula Luppino Assad
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilDisciplina de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - William Salibe-Filho
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luciana Tamie Kato-Morinaga
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Susana Hoette
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Bruna Piloto
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Marcela Araújo Castro
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Roberta Pontes Lisboa
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Taysa Antonia Felix da Silva
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Murillo de Araújo Martins
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Jose L. Alves-Jr
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Instituto do CâncerFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Câncer da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Carlos Jardim
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Mario Terra-Filho
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Rogerio de Souza
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
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Management of severe idiopathic pulmonary hypertension in a patient with acute liver failure treated with liver transplantation. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Causes and Circumstances of Death in Portopulmonary Hypertension. Transplant Direct 2021; 7:e710. [PMID: 34124346 PMCID: PMC8191691 DOI: 10.1097/txd.0000000000001162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/25/2022] Open
Abstract
The causes and circumstances surrounding death are poorly studied in patients with portopulmonary hypertension (PoPH). We sought to determine the specific reasons for dying and characteristics surrounding this process in patients with PoPH.
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Lazaro Salvador M, Quezada Loaiza CA, Rodríguez Padial L, Barberá JA, López-Meseguer M, López-Reyes R, Sala-Llinas E, Alcolea S, Blanco I, Escribano-Subías P. Portopulmonary hypertension: prognosis and management in the current treatment era - results from the REHAP registry. Intern Med J 2021; 51:355-365. [PMID: 31943676 DOI: 10.1111/imj.14751] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Portopulmonary hypertension (PoPH) is a rare condition with poorer survival compared to idiopathic/familial pulmonary arterial hypertension (IPAH/FPAH). AIMS To compare the characteristics, survival, prognostic factors and management of PoPH and IPAH/FPAH patients and to assess the impact of treatment on survival of PoPH patients. METHODS Analysis of data of prevalent and incident PoPH patients enrolled in the Spanish registry of PAH (REHAP) from January 1998 to December 2017 and comparison with IPAH/FPAH patients. Variables analysed: patient and disease (PAH and liver) characteristics, first-line PAH-targeted therapy, causes of death, prognostic factors and survival (according to aetiology and treatment in PoPH patients). RESULTS Compared to IPAH/FPAH patients (n = 678), patients with PoPH (n = 237) were predominantly men, older and had better functional class and higher prevalence of ascites. Haemodynamics were better. Biomarkers for heart failure were worse. Age- and sex-adjusted 5-year survival rate from diagnosis was 49.3% for PoPH patients and 68.7% for IPAH patients (P < 0.001). Treated PoPH had better survival than non-treated. PAH- and liver-related causes accounted for 30.2% and 24.7% of deaths in PoPH patients. PoPH patients were less likely to receive first-line PAH-targeted therapy and this was associated with greater mortality. Increasing age, worse exercise capacity and ascites were independent prognostic factors of poorer survival; first-line oral monotherapy was associated with improved survival. Eight (3.4%) PoPH patients underwent liver transplantation. CONCLUSIONS PoPH patients are undertreated and show poorer survival than IPAH/FPAH patients. First-line treatment with PAH-targeted therapy was associated with better survival. Presence of ascites was a predictor of mortality.
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Affiliation(s)
| | | | | | - Joan A Barberá
- Pulmonary Medicine Department, Hospital Clínic de Barcelona/Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel López-Meseguer
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Pneumology Department, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Raquel López-Reyes
- Pneumology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ernest Sala-Llinas
- Pneumology Department, Hospital Universitario Son Espases, Islas Baleares, Spain
| | - Sergio Alcolea
- Pneumology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Isabel Blanco
- Pulmonary Medicine Department, Hospital Clínic de Barcelona/Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pilar Escribano-Subías
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Instituto de Salud Carlos III, Madrid, Spain
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Abstract
Increased life expectancy and advances in the care of chronic liver disease has increased the number of elderly patients needing liver transplant. Organ donation policies prioritize transplant to the sickest. There is an ongoing debate with regard to balancing the principles of equity and utility. Several hospitals have adopted center-specific policies and there has been an increased trend of transplant in elderly patients since 2002. Appropriate patient selection and long-term outcomes in the setting of limited organ availability pose several challenges. This article reviews the data and discusses the pros and cons of transplants in the elderly.
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Affiliation(s)
- Claudia Cottone
- Department of Internal Medicine at Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, 4309 West Medical Center Drive, McHenry, IL 60050, USA.
| | - Nathalie A Pena Polanco
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Suite 1105, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Suite 1144, Miami, FL 33136, USA
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Al-Naamani N, Krowka MJ, Forde KA, Krok KL, Feng R, Heresi GA, Dweik RA, Bartolome S, Bull TM, Roberts KE, Austin ED, Hemnes AR, Patel MJ, Oh JK, Lin G, Doyle MF, Denver N, Andrew R, MacLean MR, Fallon MB, Kawut SM. Estrogen Signaling and Portopulmonary Hypertension: The Pulmonary Vascular Complications of Liver Disease Study (PVCLD2). Hepatology 2021; 73:726-737. [PMID: 32407592 PMCID: PMC8115214 DOI: 10.1002/hep.31314] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/18/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Portopulmonary hypertension (POPH) was previously associated with a single-nucleotide polymorphism (SNP) rs7175922 in aromatase (cytochrome P450 family 19 subfamily A member 1 [CYP19A1]). We sought to determine whether genetic variants and metabolites in the estrogen signaling pathway are associated with POPH. APPROACH AND RESULTS We performed a multicenter case-control study. POPH patients had mean pulmonary artery pressure >25 mm Hg, pulmonary vascular resistance >240 dyn-sec/cm-5 , and pulmonary artery wedge pressure ≤15 mm Hg without another cause of pulmonary hypertension. Controls had advanced liver disease, right ventricular (RV) systolic pressure <40 mm Hg, and normal RV function by echocardiography. We genotyped three SNPs in CYP19A1 and CYP1B1 using TaqMan and imputed SNPs in estrogen receptor 1 using genome-wide markers. Estrogen metabolites were measured in blood and urine samples. There were 37 patients with POPH and 290 controls. Mean age was 57 years, and 36% were female. The risk allele A in rs7175922 (CYP19A1) was significantly associated with higher levels of estradiol (P = 0.02) and an increased risk of POPH (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.12-4.91; P = 0.02) whereas other SNPs were not. Lower urinary 2-hydroxyestrogen/16-α-hydroxyestrone (OR per 1-ln decrease = 2.04; 95% CI, 1.16-3.57; P = 0.01), lower plasma levels of dehydroepiandrosterone-sulfate (OR per 1-ln decrease = 2.38; 95% CI, 1.56-3.85; P < 0.001), and higher plasma levels of 16-α-hydroxyestradiol (OR per 1-ln increase = 2.16; 95% CI, 1.61-2.98; P < 0.001) were associated with POPH. CONCLUSIONS Genetic variation in aromatase and changes in estrogen metabolites were associated with POPH.
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Affiliation(s)
- Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Kimberly A. Forde
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Karen L. Krok
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Raed A. Dweik
- Department of Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Todd M. Bull
- Department of Medicine, University of Colorado, Denver, CO
| | | | - Eric D. Austin
- Department of Pediatrics, Vanderbilt University, Nashville, TN
| | - Anna R. Hemnes
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Mamta J. Patel
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jae K. Oh
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Margaret F. Doyle
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT
| | - Nina Denver
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Ruth Andrew
- University/British Heart Foundation Centre for Cardiovascular Science and Edinburgh Mass Spectrometry Core, University of Edinburgh, Edinburgh, UK
| | - Margaret R. MacLean
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Subramani S, Sharma A, Arora L, Hanada S, Krishnan S, Ramakrishna H. Perioperative Right Ventricular Dysfunction: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:309-320. [PMID: 33593648 DOI: 10.1053/j.jvca.2021.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Abstract
Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.1 The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.
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Affiliation(s)
- Sudhakar Subramani
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lovkesh Arora
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Satoshi Hanada
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sundar Krishnan
- Department of Anesthesia, Duke University School of Medicine, Durham, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Savale L, Sitbon O. Reply to: "Management of portopulmonary hypertension: What is more important, PAH severity or liver disease severity?". J Hepatol 2021; 74:238-239. [PMID: 32972731 DOI: 10.1016/j.jhep.2020.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Laurent Savale
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin Bicêtre, France; AP-HP, Service de pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
| | - Olivier Sitbon
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin Bicêtre, France; AP-HP, Service de pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Thévenot T, Savale L, Sitbon O. Portopulmonary hypertension: An unfolding story. Clin Res Hepatol Gastroenterol 2021; 45:101492. [PMID: 32800529 DOI: 10.1016/j.clinre.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Thierry Thévenot
- Service d'hépatologie et de soins intensifs digestifs, hôpital Jean-Minjoz, 25030 Besançon cedex, France; CIC-1431 Inserm, CHU de Besançon, Besançon, France.
| | - Laurent Savale
- Service de pneumologie, centre de référence de l'hypertension pulmonaire, hôpital Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France; Faculté de médecine, université Paris-Saclay, Le-Kremlin-Bicêtre, France; Inserm, UMR S999, Le-Plessis-Robinson, France
| | - Olivier Sitbon
- Service de pneumologie, centre de référence de l'hypertension pulmonaire, hôpital Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France; Faculté de médecine, université Paris-Saclay, Le-Kremlin-Bicêtre, France; Inserm, UMR S999, Le-Plessis-Robinson, France
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Navarro-Vergara DI, Roldan-Valadez E, Cueto-Robledo G, Jurado-Hernandez MY. Portopulmonary Hypertension: Prevalence, Clinical and Hemodynamic Features. Curr Probl Cardiol 2020; 46:100747. [PMID: 33248724 DOI: 10.1016/j.cpcardiol.2020.100747] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 02/05/2023]
Abstract
Portopulmonary hypertension (PoPH) is a vascular complication of portal hypertension. This study aims to identify the prevalence and analyzing the clinical and hemodynamic features of patients with PoPH from a cohort of pulmonary arterial hypertension (PAH) patients. A retrospective transversal descriptive and analytical study. Patients with PoPH taken from a PAH cohort. We compare with those reported in the literature. We found prevalence of 6.1% of 244 consecutive patients with PAH, 11 females and 4 males. The mean age was 62 years and the main etiology of portal hypertension was primary biliary cirrhosis. Statistical differences were found in mean pulmonary arterial pressure, pulmonary vascular resistance, right atrial pressure; we found levels lower than reported. We found significant differences in clinical and hemodynamic characteristics such as older age and hemodynamic parameters of less severity in the group of patients analyzed compared with reported data.
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Thomas C, Glinskii V, de Jesus Perez V, Sahay S. Portopulmonary Hypertension: From Bench to Bedside. Front Med (Lausanne) 2020; 7:569413. [PMID: 33224960 PMCID: PMC7670077 DOI: 10.3389/fmed.2020.569413] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
Portopulmonary hypertension (PoPH) is defined as pulmonary arterial hypertension (PAH) associated with portal hypertension and is a subset of Group 1 pulmonary hypertension (PH). PoPH is a cause of significant morbidity and mortality in patients with portal hypertension with or without liver disease. Significant strides in elucidating the pathogenesis, effective screening algorithms, accurate diagnoses, and treatment options have been made in past 20 years. Survival of PoPH has remained poor compared to IPAH and other forms of PAH. Recently, the first randomized controlled trial was done in this patient population and showed promising results with PAH specific therapy. Despite positive effects on hemodynamics and functional outcomes, it is unclear whether PAH specific therapy has a beneficial effect on long term survival or transplant outcomes. In this review, we will discuss the epidemiology, pathophysiology, clinical and hemodynamic characteristics of PoPH. Additionally, this review will highlight the lacunae in our current management strategy, challenges faced and will provide direction to potentially useful futuristic management strategies.
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Affiliation(s)
- Christopher Thomas
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Vladimir Glinskii
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Vinicio de Jesus Perez
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Sandeep Sahay
- Houston Methodist Hospital Lung Center, Houston Methodist Hospital, Houston, TX, United States
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Deroo R, Trépo E, Holvoet T, De Pauw M, Geerts A, Verhelst X, Colle I, Van Vlierberghe H, Fallon MB, Raevens S. Vasomodulators and Liver Transplantation for Portopulmonary Hypertension: Evidence From a Systematic Review and Meta-Analysis. Hepatology 2020; 72:1701-1716. [PMID: 32017176 DOI: 10.1002/hep.31164] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Untreated portopulmonary hypertension (PoPH) carries a poor prognosis. Previous reports have described vasomodulator (VM) therapy and liver transplantation (LT) as treatment options. We aimed to provide summary estimates on the endpoints of pulmonary hemodynamics and survival in patients with PoPH, treated with different modalities. APPROACH AND RESULTS We performed a systematic review with meta-analysis of mainly observational and case-control studies describing no treatment, VM, LT, or VM + LT in patients with PoPH. Twenty-six studies (1,019 patients) were included. Both VM and VM + LT improve pulmonary hemodynamics. A substantial proportion of patients treated with VM become eligible for LT (44%; 95% confidence interval [CI], 31-58). Pooled estimates for 1-, and 3-year postdiagnosis survival in patients treated with VM were 86% (95% CI, 81-90) and 69% (95% CI, 50-84) versus 82% (95% CI, 52-95) and 67% (95% CI, 53-78) in patients treated with VM + LT. Of note, studies reporting on the effect of VM mainly included Child-Pugh A/B patients, whereas studies reporting on VM + LT mainly included Child-Pugh B/C. Seven studies (238 patients) included both patients who received VM only and patients who received VM + LT. Risk of death in VM-only-treated patients was significantly higher than in patients who could be transplanted as well (odds ratio, 3.5; 95% CI, 1.4-8.8); however, importantly, patients who proceeded to transplant had been selected very strictly. In 50% of patients, VM can be discontinued post-LT (95% CI, 38-62). CONCLUSIONS VM and VM + LT both improve pulmonary hemodynamics and prognosis in PoPH. In a strictly selected subpopulation of cases where LT is indicated based on severe liver disease and where LT is considered safe and feasible, treatment with VM + LT confers a better prognosis. Considering successful VM, 44% can proceed to LT, with half being able to postoperatively stop medication.
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Affiliation(s)
- Rebecca Deroo
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Tom Holvoet
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Isabelle Colle
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
| | - Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
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Atsukawa M, Tsubota A, Hatano M, Kondo C, Shioda K, Ohno H, Kawano T, Hayama K, Arai T, Nakagawa-Iwashita A, Itokawa N, Kaneko K, Yoshida Y, Koeda M, Okubo T, Yamamoto T, Yamamoto T, Taniai N, Yoshida H, Kanazawa H, Shimizu W, Iwakiri K. Prevalence and characteristics of portopulmonary hypertension in cirrhotic patients who underwent both hepatic vein and pulmonary artery catheterization. Hepatol Res 2020; 50:1244-1254. [PMID: 32822521 DOI: 10.1111/hepr.13560] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/31/2020] [Accepted: 08/14/2020] [Indexed: 12/12/2022]
Abstract
UNLABELLED Portopulmonary hypertension (PoPH) is a well-known complication of liver cirrhosis. The aim of this study was to clarify the pulmonary hemodynamics and the prevalence and characteristics of PoPH in patients with portal hypertension. METHODS The subjects were 335 patients with portal hypertension diagnosed by hepatic vein pressure gradient (HVPG). Among them, 186 patients received measurements of pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance (PVR). PoPH was diagnosed by PAP >20 mmHg, PVR ≥3 Wood units (WU) and PAWP ≤15 mmHg. RESULTS The Child-Pugh classification was class A in 53, B in 92 and C in 41 patients. Median (range) values of HVPG, PAP, PVR and PAWP were 18.4 (5.5-39.0) mmHg, 12.9 (6.6-40.8) mmHg, 0.8 (0.1-4.5) WU and 7.5 (2.2-15.4) mmHg, respectively. Of six patients with PAP >20 mmHg, four had autoimmune hepatitis or primary biliary cholangitis, with the prevalence being significantly higher than that in patients with PAP ≤20 mmHg. Meanwhile, no significant difference was noted in the hepatic functional reserve or HVPG between patients with PAP >20 mmHg and ≤20 mmHg. Only two patients met the diagnostic criteria of PoPH and both patients were Child-Pugh B. The Child-Pugh score and HVPG were not associated with PoPH. CONCLUSIONS Our study demonstrated that only two patients were complicated by PoPH. High PAP values were noted in patients with primary biliary cholangitis or autoimmune hepatitis. However, the presence of PoPH and high PAP were not associated with the degree of hepatic functional reserve or HVPG.
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Affiliation(s)
- Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Akihito Tsubota
- Core Research Facilities, The Jikei University School of Medicine, 3-9-18, Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Masaru Hatano
- Department of therapeutic strategy for heart failure, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Chisa Kondo
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Kaori Shioda
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Ohno
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Tadamichi Kawano
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Korenobu Hayama
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Ai Nakagawa-Iwashita
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Norio Itokawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Keiko Kaneko
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Yuji Yoshida
- Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, 1715, kamakari, Inzai, Chiba, Japan
| | - Mai Koeda
- Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, 1715, kamakari, Inzai, Chiba, Japan
| | - Tomomi Okubo
- Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, 1715, kamakari, Inzai, Chiba, Japan
| | - Teppei Yamamoto
- Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, 1715, kamakari, Inzai, Chiba, Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Hidenori Kanazawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Wataru Shimizu
- Division of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
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Razavi-Khorasani N, Moazzami B, Dooghaie Moghadam A, Eslami P, Farokhi E, Mehrvar A, Saeedi S, Iravani S, Aghajanpoor Pasha M, Nassiri Toosi M. Pulmonary Complications in Candidates for Liver Transplantation. Middle East J Dig Dis 2020; 12:145-153. [PMID: 33062219 PMCID: PMC7548088 DOI: 10.34172/mejdd.2020.176] [Citation(s) in RCA: 2] [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] [Indexed: 12/17/2022] Open
Abstract
The liver plays a pivotal role in maintaining the homeostasis of various organ systems. Also, end-stage liver disease and its complications are major causes of morbidity and mortality among adults. Individuals who develop a chronic liver disease are at increased risk of progression to multi-organ dysfunction, including the pulmonary system. The clinical complications of pulmonary problems related to the presence of liver disease range from mild (such as hypoxemia) to life-threatening diseases (such as portopulmonary hypertension and hepatopulmonary syndrome). Herein, the major pulmonary complications related to liver cirrhosis and considerations for performing liver transplantation are reviewed.
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Affiliation(s)
| | - Bobak Moazzami
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Pegah Eslami
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ermia Farokhi
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Azim Mehrvar
- Research Center for Cancer Screening and Epidemiology, AJA University of Medical Sciences, Tehran, Iran
| | - Sandra Saeedi
- Gastroenterology and Hepatobiliary Research Center, AJA University of Medical Sciences, Tehran, Iran
| | - Shahrokh Iravani
- Research Center for Cancer Screening and Epidemiology, AJA University of Medical Sciences, Tehran, Iran
| | - Morteza Aghajanpoor Pasha
- Gastroenterology and Hepatobiliary Research Center, AJA University of Medical Sciences, Tehran, Iran
| | - Mohssen Nassiri Toosi
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Clinical Outcomes after Liver Transplantation in Patients with Portopulmonary Hypertension. Transplantation 2020; 105:2283-2290. [PMID: 33065725 DOI: 10.1097/tp.0000000000003490] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Portopulmonary hypertension (POPH) is the presence of pulmonary arterial (PA) hypertension in patients with portal hypertension and is associated with significant morbidity and mortality. In a cohort of POPH patients, we describe the clinical outcomes of POPH patients who underwent liver transplantation (LT). METHODS Retrospectively collected data from a prospectively assembled cohort of all consecutive POPH adults evaluated in three transplant centers from 1996 to 2019. RESULTS From a cohort of 228 POPH patients, 50 patients underwent LT. Significant hemodynamic improvement after PA-targeted therapy was observed, with 58% receiving only monotherapy pre-transplant. After LT, 21 (42%) patients were able to discontinue and remained off PA-targeted therapy. The 1, 3, and 5 year unadjusted survival rates after LT were 72%, 63% and 60%, respectively. An elevated pulmonary vascular resistance (PVR) before LT was associated with worse survival rate (HR 1.91, 95% CI 1.07-3.74, p=0.04). No survival difference was observed in those granted MELD exception or transplants performed before or after the year 2010. CONCLUSION Significant number of POPH patients discontinued PA-targeted therapy after LT. Higher PVR before LT was associated with worse survival, as was monotherapy use. Despite effective PA-targeted therapies, POPH survival outcomes after LT in our cohort were modest and may reflect the need for more aggressive therapy.
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Weinfurtner K, Forde K. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Current Status and Implications for Liver Transplantation. CURRENT HEPATOLOGY REPORTS 2020; 19:174-185. [PMID: 32905452 PMCID: PMC7473417 DOI: 10.1007/s11901-020-00532-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are both pulmonary vascular complications of advanced liver disease; however, these syndromes have distinct pathophysiology, clinical implications, and management. RECENT FINDINGS While both conditions are associated with portal hypertension, HPS results from diffuse pulmonary capillary vasodilation and PoPH results from vasoconstriction and vascular remodeling of pulmonary arteries. In HPS, no medical therapies clearly improve outcomes; however, patients have excellent post-LT outcomes with near uniform reversal of hypoxemia. In PoPH, several medical therapies used in idiopathic pulmonary hypertension have been shown improve pulmonary hemodynamics, symptoms, and potentially LT outcomes; however, further study is needed to determine best treatment regimens, long-term outcomes on medical therapy, and role of LT. SUMMARY While HPS results in severe hypoxemia that is usually reversible by LT, PoPH patients develop progressive pulmonary hypertension that may improve with medical therapy.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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44
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Portopulmonary hypertension in the current era of pulmonary hypertension management. J Hepatol 2020; 73:130-139. [PMID: 32145258 DOI: 10.1016/j.jhep.2020.02.021] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Long-term outcomes in portopulmonary hypertension (PoPH) are poorly studied in the current era of pulmonary hypertension management. We analysed the effect of pulmonary arterial hypertension (PAH)-targeted therapies, survival and predictors of death in a large contemporary cohort of patients with PoPH. METHODS Data from patients with PoPH consecutively enrolled in the French Pulmonary Hypertension Registry between 2007 and 2017 were collected. The effect of initial treatment strategies on functional class, exercise capacity and cardiopulmonary haemodynamics were analysed. Survival and its association with PAH- and hepatic-related characteristics were also examined. RESULTS Six hundred and thirty-seven patients (mean age 55 ± 10 years; 58% male) were included. Fifty-seven percent had mild cirrhosis, i.e. Child-Pugh stage A. The median model for end-stage liver disease (MELD) score was 11 (IQR 9-15). Most patients (n = 474; 74%) were initiated on monotherapy, either with a phosphodiesterase-5 inhibitor (n = 336) or with an endothelin-receptor antagonist (n = 128); 95 (15%) were initiated on double oral combination therapy and 5 (1%) on triple therapy. After a median treatment time of 4.5 months, there were significant improvements in functional class (p <0.001), 6-minute walk distance (6MWD) (p <0.0001) and pulmonary vascular resistance (p <0.0001). Overall survival rates were 84%, 69% and 51% at 1, 3 and 5 years, respectively. Baseline 6MWD, sex, age and MELD score or Child-Pugh stage were identified as independent prognostic factors. Survival from PoPH diagnosis was significantly better in the subgroup of patients who underwent liver transplantation (92%, 83% and 81% at 1, 3 and 5 years, respectively). CONCLUSION Survival of patients with PoPH is strongly associated with the severity of liver disease. Patients who underwent liver transplantation had the best long-term outcomes. LAY SUMMARY Portopulmonary hypertension is defined by the presence of pulmonary arterial hypertension in the context of chronic liver disease and is characterized by progressive shortness of breath and exercise limitation. The presence of severe pulmonary arterial hypertension in liver transplant candidates represents a contraindication for such a surgery; however, treatments targeting pulmonary arterial hypertension are efficacious, allowing for safe transplantation and conferring good survival outcomes in those who undergo liver transplantation.
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45
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Yin X, Shao Y, Zhang Y, Gao H, Qin T, Wen X, Yang C. Role of echocardiography in screening for portopulmonary hypertension in liver transplant candidates: a meta-analysis. PeerJ 2020; 8:e9243. [PMID: 32518736 PMCID: PMC7261122 DOI: 10.7717/peerj.9243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/06/2020] [Indexed: 01/22/2023] Open
Abstract
Objectives To demonstrate the screening value of echocardiography for portopulmonary hypertension (POPH) in liver transplant candidates. Design Systematic review and meta-analysis. Background POPH is a complication of end-stage liver disease that adversely affects the outcome of orthotopic liver transplant. There are no specific symptoms in the early stage of POPH. POPH reduce the survival rate of patients with end-stage liver disease specially if they are not diagnosed. Therefore, early detection may improve prognosis. The objective of this study is to explore the screening value of echocardiography on liver transplant candidates for screening of POPH compared to right heart catheterization (RHC). Method PubMed, EMBASE and the Cochrane Library were searched by two independent reviewers for potentially eligible studies published up to 30 June 2019 to retrieve data based on per-patient analysis. STATA, Meta-DiSc, and RevMan were applied to perform this meta-analysis. Results Our search yielded 1576 studies, of which 11 satisfied the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and area under the summary receiver operating characteristic (SROC) curve (AUC) of echocardiography for POPH were 0.85 (95% CI [0.65–0.94]), 0.83 (95% CI [0.73–0.90]), 4.99 (95% CI [3.03–8.21]), 0.19 (95% CI [0.07–0.46]), and 0.91 (95% CI [0.88–0.93]), respectively. Deeks’ funnel plot did not indicate the existence of publication bias (P = 0.66). Conclusions Echocardiography, a noninvasive modality, provides superior screening for POPH, but the diagnosis of POPH still requires RHC. PROSPERO registration number CRD42019144589.
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Affiliation(s)
- Xin Yin
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China.,Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan Province, China
| | - Yueming Shao
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yu Zhang
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Hui Gao
- Department of Digestive System, The Hospital of Tai'an Municipal, Tai'an, Shandong Province, China
| | - Tingting Qin
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xiaoyu Wen
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chen Yang
- Department of Bone and Joint Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, China
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Owen NE, Alexander GJ, Sen S, Bunclark K, Polwarth G, Pepke-Zaba J, Davenport AP, Morrell NW, Upton PD. Reduced circulating BMP10 and BMP9 and elevated endoglin are associated with disease severity, decompensation and pulmonary vascular syndromes in patients with cirrhosis. EBioMedicine 2020; 56:102794. [PMID: 32454407 PMCID: PMC7248419 DOI: 10.1016/j.ebiom.2020.102794] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022] Open
Abstract
Background BMP9, originating from the liver, and BMP10 are circulating BMPs that preserve vascular endothelial integrity. We assessed BMP9, BMP10 and soluble endoglin (sEng) levels and their relationships to liver disease severity and associated pulmonary vascular syndromes in a cohort of well-characterised liver disease patients. Methods Plasma samples from patients with liver disease (n = 83) and non-disease controls (n = 21) were assayed for BMP9, BMP10 and sEng. Levels were also assessed in a separate cohort of controls (n = 27) and PoPH patients (n = 8). Expression of mRNA and immunohistochemical staining was undertaken in liver biopsy specimens. Plasma BMP activity was assessed using an endothelial cell bioassay. Findings Plasma BMP9 and BMP10 levels were normal in patients with compensated cirrhosis or fibrosis without cirrhosis, but markedly reduced in patients with decompensated cirrhosis, including those with hepatopulmonary syndrome (HPS) or portopulmonary hypertension (PoPH). Liver biopsy specimens revealed reduced mRNA expression and immunostaining for these ligands. Patient plasma samples with reduced BMP9 and BMP10 levels exhibited low BMP activity that was restored with exogenous BMP9. Endoglin mRNA expression was increased in cirrhotic livers and elevated circulating sEng levels in PoPH and HPS patients suggested increased endothelial sEng shedding in these syndromes. Interpretation Plasma BMP9 and BMP10 levels are reduced in decompensated cirrhosis, leading to reduced circulating BMP activity on the vascular endothelium. The pulmonary complications of cirrhosis, PoPH and HPS, are associated with markedly reduced BMP9 and BMP10 and increased sEng levels, suggesting that supplementation with exogenous ligands might be a therapeutic approach for PoPH and HPS.
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Affiliation(s)
- Nicola E Owen
- Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Graeme J Alexander
- Institute for Liver and Digestive Health, University College London, Royal Free Hospital Pond St, Hampstead, London NW3 2QG, UK, Royal Free Hospital, London, United Kingdom
| | - Sambit Sen
- Luton and Dunstable Hospital NHS Foundation Trust, Luton, United Kingdom
| | | | - Gary Polwarth
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Anthony P Davenport
- Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, United Kingdom.
| | - Paul D Upton
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, United Kingdom.
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Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
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48
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Krowka MJ. Hepatopulmonary Syndrome and Portopulmonary Hypertension: The Pulmonary Vascular Enigmas of Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:S13-S24. [PMID: 32140210 PMCID: PMC7050952 DOI: 10.1002/cld.846] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael J. Krowka
- Department of Medicine, Division of Pulmonary and Critical Care, Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
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49
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Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU. Crit Care Med 2020; 48:e173-e191. [DOI: 10.1097/ccm.0000000000004192] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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50
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Jha AK, Lata S. Liver transplantation and cardiac illness: Current evidences and future directions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:225-241. [PMID: 31975575 DOI: 10.1002/jhbp.715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Contraindications to liver transplantation are gradually narrowing. Cardiac illness and chronic liver disease may manifest independently or may be superimposed on each other due to shared pathophysiology. Cardiac surgery involving the cardiopulmonary bypass in patients with Child-Pugh Class C liver disease is associated with a high risk of perioperative morbidity and mortality. Liver transplantation involves hemodynamic perturbations, volume shifts, coagulation abnormalities, electrolyte disturbances, and hypothermia, which may prove fatal in patients with cardiac illness depending upon the severity. Additionally, cardiovascular complications are the major cause of adverse postoperative outcomes after liver transplantation even in the absence of cardiac pathologies. Clinical decision-making has remained an unsettled issue in these clinical scenarios. The absence of randomized clinical studies has further crippled our endeavours for a consensus on the management of patients with end-stage liver disease with cardiac illness. This review seeks to address this complex clinical setting by gathering information from published literature. The management algorithm in this review may facilitate clinical decision making and augur future research.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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