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Elsabaawy MM, Assem M, Badran H, Mahmoud A, Elsabaawy D, Ragab A. Impacts of rifaximin and midodrine on morbidity, mortality, and quality of life in patients with decompensated liver cirrhosis. Eur J Gastroenterol Hepatol 2024; 36:1022-1028. [PMID: 38973543 DOI: 10.1097/meg.0000000000002797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
BACKGROUND Vasodilatation and bacterial dislocation are the main contributors to the catastrophic events in patients with decompensated liver cirrhosis (DLC). AIM The aim of this study was to evaluate the impacts of adding midodrine and rifaximin on morbidity, mortality, and quality of life in patients with DLC. METHODS This interventional clinical study included 100 consecutively enrolled DLC patients randomized 1 : 1 into two groups. Group A received oral midodrine (5 mg/8 h) and rifaximin (550 mg/12 h) with standard diuretic therapy, while group B received only standard diuretic therapy. Clinical and laboratory data, including the McGill Quality of Life Questionnaire, were evaluated over a 3-month treatment period. RESULTS In the study group, there was a significant reduction in Child-Pugh and Model for End-Stage Liver Disease scores, international normalized ratio, and mean arterial blood pressure at 2, 6, and 12 weeks (P < 0.05). Ascites, spontaneous bacterial peritonitis incidence, hematemesis, paracentesis need, and hepatic encephalopathy showed improvement after 12 weeks compared with the control group. McGill Quality of Life Questionnaire significantly improved after 6 and 12 weeks (P < 0.05). Survival rates demonstrated a noteworthy improvement (P = 0.014), substantiated by evidence in both univariate and multivariate regression analyses. CONCLUSION Combined midodrine with rifaximin represents an endowment to patients with DLC with spectacular improvements in synthetic liver functions, along with improved quality of life, and survival.
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Affiliation(s)
- Maha Mohammad Elsabaawy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
| | - Medhat Assem
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
- Internal Medicine Department, Faculty of Medicine, Bisha University, Saudi Arabia
| | - Hanaa Badran
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
| | - Asmaa Mahmoud
- Internal medicine Department, Banha Teaching Hospital, Banha
| | - Dalia Elsabaawy
- Clinical Pharmacy Department, Pharmacy College, Menoufia University, Shebeen El-Koom, Egypt
| | - Amr Ragab
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
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2
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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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3
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Sakiani S, Heller T, Koh C. Current and investigational drugs in early clinical development for portal hypertension. Front Med (Lausanne) 2022; 9:974182. [PMID: 36300180 PMCID: PMC9589453 DOI: 10.3389/fmed.2022.974182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The development of portal hypertension leads to a majority of complications associated with chronic liver disease. Therefore, adequate treatment of portal hypertension is crucial in the management of such patients. Current treatment options are limited and consist mainly of medications that decrease the hyperdynamic circulation, such as non-selective beta blockers, and treatment of hypervolemia with diuretics. Despite these options, mortality rates have not improved over the last two decades. Newer, more effective treatment options are necessary to help improve survival and quality of life in these patients. Areas covered Multiple preclinical models and clinical studies have demonstrated potential efficacy of a variety of new treatment modalities. We introduce treatment options including the use of vasodilation promotors, vasoconstriction inhibitors, anticoagulants, antiangiogenics, and anti-inflammatory drugs. We examine the most recent studies for treatment options within these drug classes and offer insights as to which show the most promise in this field. Methodology Published studies that identified novel medical treatment options of portal hypertension were searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/). Clinical trials listed in Clinicaltrials.gov were also searched with a focus on more recent and ongoing studies, including those with completed recruitment. Searching with key terms including "portal hypertension" as well as individually searching specific treatment medications that were listed in other publications was carried out. Finally, current societal guidelines and recent review articles relevant to the management of portal hypertension were evaluated, and listed references of interest were included. Conclusion Many ongoing early phase studies demonstrate promising results and may shape the field of portal hypertension management in future. As concrete results become available, larger RCTs will be required before making definitive conclusions regarding safety and efficacy and whether or not they can be incorporated into routine clinical practice. Statins, anticoagulants, and PDE inhibitors have been among the most studied and appear to be most promising.
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Affiliation(s)
- Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Baltimore, MD, United States
| | - Theo Heller
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Christopher Koh
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
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4
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Cellular and mitochondrial taurine depletion in bile duct ligated rats: a justification for taurine supplementation in cholestasis/cirrhosis. Clin Exp Hepatol 2022; 8:195-210. [PMID: 36685263 PMCID: PMC9850306 DOI: 10.5114/ceh.2022.119216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/05/2022] [Indexed: 01/25/2023] Open
Abstract
Taurine (TAU) is a free amino acid abundant in the human body. Various physiological roles have been attributed to TAU. At the subcellular level, mitochondria are the primary targets for TAU function. Meanwhile, it has been found that TAU depletion is associated with severe pathologies. Cholestasis is a severe clinical complication that can progress to liver fibrosis, cirrhosis, and hepatic failure. Bile duct ligation (BDL) is a reliable model for assessing cholestasis/cirrhosis and related complications. The current study was designed to investigate the effects of cholestasis/cirrhosis on tissue and mitochondrial TAU reservoirs. Cholestatic rats were monitored (14 and 42 days after BDL surgery), and TAU levels were assessed in various tissues and isolated mitochondria. There was a significant decrease in TAU in the brain, heart, liver, kidney, skeletal muscle, intestine, lung, testis, and ovary of the BDL animals (14 and 42 days after surgery). Mitochondrial levels of TAU were also significantly depleted in BDL animals. Tissue and mitochondrial TAU levels in cirrhotic animals (42 days after the BDL operation) were substantially lower than those in the cholestatic rats (14 days after BDL surgery). These data indicate an essential role for tissue and mitochondrial TAU in preventing organ injury induced by cholestasis/cirrhosis and could justify TAU supplementation for therapeutic purposes.
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5
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Rodrigues SG, Mendoza YP, Bosch J. Investigational drugs in early clinical development for portal hypertension. Expert Opin Investig Drugs 2022; 31:825-842. [PMID: 35758843 DOI: 10.1080/13543784.2022.2095259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Advanced chronic liver disease is considered a reversible condition after removal of the primary aetiological factor. This has led to a paradigm shift in which portal hypertension (PH) is a reversible complication of cirrhosis. The pharmacologic management of PH is centered on finding targets to modify the natural history of cirrhosis and PH. AREAS COVERED This paper offers an overview of the use of pharmacological strategies in early clinical development that modify PH. Papers included were selected from searching clinical trials sites and PubMed from the last 10 years. EXPERT OPINION A paradigm shift has generated a new concept of PH in cirrhosis as a reversible complication of a potentially curable disease. Decreasing portal pressure to prevent decompensation and further complications of cirrhosis that may lead liver transplantation or death is a goal. Therapeutic strategies also aspire achieve total or partial regression of fibrosis thus eliminating the need for treatment or screening of PH.
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Affiliation(s)
- Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Department for BioMedical Research, Visceral Surgery and Medicine, University of Bern, Switzerland
| | - Yuly P Mendoza
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Department for BioMedical Research, Visceral Surgery and Medicine, University of Bern, Switzerland.,Graduate School for Health Sciences (GHS), University of Bern
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Department for BioMedical Research, Visceral Surgery and Medicine, University of Bern, Switzerland
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6
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The Hepatic Sinusoid in Chronic Liver Disease: The Optimal Milieu for Cancer. Cancers (Basel) 2021; 13:cancers13225719. [PMID: 34830874 PMCID: PMC8616349 DOI: 10.3390/cancers13225719] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary During the development of chronic liver disease, the hepatic sinusoid undergoes major changes that further compromise the hepatic function, inducing persistent inflammation and the formation of scar tissue, together with alterations in liver hemodynamics. This diseased background may induce the formation and development of hepatocellular carcinoma (HCC), which is the most common form of primary liver cancer and a major cause of mortality. In this review, we describe the ways in which the dysregulation of hepatic sinusoidal cells—including liver sinusoidal cells, Kupffer cells, and hepatic stellate cells—may have an important role in the development of HCC. Our review summarizes all of the known sinusoidal processes in both health and disease, and possible treatments focusing on the dysregulation of the sinusoid; finally, we discuss how some of these alterations occurring during chronic injury are shared with the pathology of HCC and may contribute to its development. Abstract The liver sinusoids are a unique type of microvascular beds. The specialized phenotype of sinusoidal cells is essential for their communication, and for the function of all hepatic cell types, including hepatocytes. Liver sinusoidal endothelial cells (LSECs) conform the inner layer of the sinusoids, which is permeable due to the fenestrae across the cytoplasm; hepatic stellate cells (HSCs) surround LSECs, regulate the vascular tone, and synthetize the extracellular matrix, and Kupffer cells (KCs) are the liver-resident macrophages. Upon injury, the harmonic equilibrium in sinusoidal communication is disrupted, leading to phenotypic alterations that may affect the function of the whole liver if the damage persists. Understanding how the specialized sinusoidal cells work in coordination with each other in healthy livers and chronic liver disease is of the utmost importance for the discovery of new therapeutic targets and the design of novel pharmacological strategies. In this manuscript, we summarize the current knowledge on the role of sinusoidal cells and their communication both in health and chronic liver diseases, and their potential pharmacologic modulation. Finally, we discuss how alterations occurring during chronic injury may contribute to the development of hepatocellular carcinoma, which is usually developed in the background of chronic liver disease.
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7
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Turaga RC, Satyanarayana G, Sharma M, Yang JJ, Wang S, Liu C, Li S, Yang H, Grossniklaus H, Farris AB, Gracia-Sancho J, Liu ZR. Targeting integrin αvβ3 by a rationally designed protein for chronic liver disease treatment. Commun Biol 2021; 4:1087. [PMID: 34531529 PMCID: PMC8445973 DOI: 10.1038/s42003-021-02611-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/26/2021] [Indexed: 12/22/2022] Open
Abstract
Chronic Liver Diseases (CLD) are characterized by abnormal accumulation of collagen fibrils, neo-angiogenesis, and sinusoidal remodeling. Collagen deposition along with intrahepatic angiogenesis and sinusoidal remodeling alters sinusoid structure resulting in portal hypertension, liver failure, and other complications. Efforts were made to develop treatments for CLDs. However, the success of such treatments is limited and unpredictable. We report a strategy for CLD treatment by induction of integrin αvβ3 mediated cell apoptosis using a rationally designed protein (ProAgio). ProAgio is designed to target integrin αvβ3 at a novel site. Integrin αvβ3 is highly expressed in activated Hepatic Stellate Cells (HSC), angiogenic endothelium, and capillarized Liver Sinusoidal Endothelial Cells (LSEC). ProAgio induces apoptosis of these disease causative cells. Tests with liver fibrosis mouse models demonstrate that ProAgio reverses liver fibrosis and relieves blood flow resistance by depleting activated HSC and capillarized LSEC. Our studies demonstrate an effective approach for CLD treatment.
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Affiliation(s)
- Ravi Chakra Turaga
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA
| | | | - Malvika Sharma
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA
| | - Jenny J Yang
- Department of Chemistry, Georgia State University, Atlanta, USA
| | | | | | - Sun Li
- Department of Chemistry, Georgia State University, Atlanta, USA
| | - Hua Yang
- Department Ophthalmology, Emory University, Atlanta, GA, 30322, USA
| | | | | | | | - Zhi-Ren Liu
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA.
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Bochnakova T. Hepatic Venous Pressure Gradient. Clin Liver Dis (Hoboken) 2021; 17:144-148. [PMID: 33868655 PMCID: PMC8043695 DOI: 10.1002/cld.1031] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/10/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Teodora Bochnakova
- Dotter Institute of Interventional RadiologyOregon Health & Science UniversityPortlandOR
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9
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Abstract
Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.
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10
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Yoshida H, Shimizu T, Yoshioka M, Taniai N. Management of portal hypertension based on portal hemodynamics. Hepatol Res 2021; 51:251-262. [PMID: 33616258 DOI: 10.1111/hepr.13614] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 12/13/2022]
Abstract
Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.
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Affiliation(s)
- Hiroshi Yoshida
- Department of GI and HBP Surgery, Nippon Medical School, Tokyo, Japan
| | - Tetsuya Shimizu
- Department of GI and HBP Surgery, Nippon Medical School, Tokyo, Japan
| | - Masato Yoshioka
- Department of GI and HBP Surgery, Nippon Medical School, Tokyo, Japan
| | - Nobuhiko Taniai
- Department of GI and HBP Surgery, Nippon Medical School, Tokyo, Japan
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11
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Novel therapeutics for portal hypertension and fibrosis in chronic liver disease. Pharmacol Ther 2020; 215:107626. [DOI: 10.1016/j.pharmthera.2020.107626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
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12
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Guixé-Muntet S, Ortega-Ribera M, Wang C, Selicean S, Andreu I, Kechagia JZ, Fondevila C, Roca-Cusachs P, Dufour JF, Bosch J, Berzigotti A, Gracia-Sancho J. Nuclear deformation mediates liver cell mechanosensing in cirrhosis. JHEP Rep 2020; 2:100145. [PMID: 32939447 PMCID: PMC7479345 DOI: 10.1016/j.jhepr.2020.100145] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Liver stiffness is increased in advanced chronic liver disease (ACLD) and accurately predicts prognosis in this population. Recent data suggest that extracellular matrix stiffness per se may modulate the phenotype of liver cells. We aimed at investigating the effect of matrix stiffness on the phenotype of liver cells of rats with cirrhosis, assessing its influence on their response to antifibrotic strategies and evaluating associated molecular mechanisms. METHODS Hepatocytes, hepatic stellate cells, and liver sinusoidal endothelial cells were isolated from healthy rats or rats with cirrhosis (carbon tetrachloride or thioacetamide), and cultured on polyacrylamide gels with different physiologically relevant stiffness for 72 h. RESULTS All cell types of rats with cirrhosis cultured at low stiffness showed a significant phenotype amelioration vs. rigid matrix (assessed by quantitative morphology, mRNA expression, protein synthesis, and electron microscopy imaging). Additionally, stiffness modified the antifibrotic effects of liraglutide in stellate cells of rats with cirrhosis. Finally, evaluation of nuclear morphology revealed that high stiffness induced nuclei deformation in all cell types, an observation confirmed in cells from human livers. Disconnecting the nucleus from the cytoskeleton by cytoskeleton disruption or a defective form of nesprin 1 significantly recovered spherical nuclear shape and quiescent phenotype of cells. CONCLUSIONS The environment's stiffness per se modulates the phenotype of healthy rats and liver cells of rats with cirrhosis by altering the nuclear morphology through cytoskeleton-derived mechanical forces. The reversibility of this mechanism suggests that targeting the stiffness-mediated intracellular mechanical tensions may represent a novel therapeutic strategy for ACLD. LAY SUMMARY During cirrhosis, the liver becomes scarred, stiff, and unable to perform its normal functions efficiently. In this study, we demonstrated that cells from diseased (stiff) livers recovered their functionality when placed in a soft environment (as that of a healthy liver). Furthermore, treatments aimed at tricking liver cells into believing they are in a healthy, soft liver improved their function and could potentially contribute to treat cirrhosis.
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Key Words
- ACLD, advanced chronic liver disease
- Cd, cytoskeleton disruptor
- Chronic liver disease
- DN-KASH, dominant negative nesprin peptide containing a KASH domain
- ECM, extracellular matrix
- HNF4α, hepatocyte nuclear factor 4α
- HSC
- HSC, hepatic stellate cell
- Hepatocyte
- KASH, Klarsicht/abnormal nuclear anchorage-1/Syne homology
- LSEC
- LSEC, liver sinusoidal endothelial cell
- Lamb1, laminin b1
- Stiffness
- TAA, thioacetamide
- eNOS, endothelial nitric oxide synthase
- α-SMA, α-smooth muscle actin
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Affiliation(s)
- Sergi Guixé-Muntet
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Martí Ortega-Ribera
- Liver Vascular Biology Research Group, Hepatic Hemodynamic Laboratory, IDIBAPS Biomedical Research Institute, CIBEREHD, Barcelona, Spain
| | - Cong Wang
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Sonia Selicean
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Ion Andreu
- Institute for Bioengineering of Catalonia, Barcelona Institute of Technology, University of Barcelona, Barcelona, Spain
| | - Jenny Z. Kechagia
- Institute for Bioengineering of Catalonia, Barcelona Institute of Technology, University of Barcelona, Barcelona, Spain
| | | | - Pere Roca-Cusachs
- Institute for Bioengineering of Catalonia, Barcelona Institute of Technology, University of Barcelona, Barcelona, Spain
| | - Jean-François Dufour
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Jaime Bosch
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Liver Vascular Biology Research Group, Hepatic Hemodynamic Laboratory, IDIBAPS Biomedical Research Institute, CIBEREHD, Barcelona, Spain
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Annalisa Berzigotti
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Jordi Gracia-Sancho
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Liver Vascular Biology Research Group, Hepatic Hemodynamic Laboratory, IDIBAPS Biomedical Research Institute, CIBEREHD, Barcelona, Spain
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
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Oxidative Stress in Chronic Liver Disease and Portal Hypertension: Potential of DHA as Nutraceutical. Nutrients 2020; 12:nu12092627. [PMID: 32872239 PMCID: PMC7551786 DOI: 10.3390/nu12092627] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic liver disease constitutes a growing public health issue worldwide, with no safe and effective enough treatment clinical scenarios. The present review provides an overview of the current knowledge regarding advanced chronic liver disease (ACLD), focusing on the major contributors of its pathophysiology: inflammation, oxidative stress, fibrosis and portal hypertension. We present the benefits of supplementation with docosahexaenoic acid triglycerides (TG-DHA) in other health areas as demonstrated experimentally, and explore its potential as a novel nutraceutical approach for the treatment of ACLD and portal hypertension based on published pre-clinical data.
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14
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Nevzorova YA, Boyer-Diaz Z, Cubero FJ, Gracia-Sancho J. Animal models for liver disease - A practical approach for translational research. J Hepatol 2020; 73:423-440. [PMID: 32330604 DOI: 10.1016/j.jhep.2020.04.011] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
Animal models are crucial for improving our understanding of human pathogenesis, enabling researchers to identify therapeutic targets and test novel drugs. In the current review, we provide a comprehensive summary of the most widely used experimental models of chronic liver disease, starting from early stages of fatty liver disease (non-alcoholic and alcoholic) to steatohepatitis, advanced cirrhosis and end-stage primary liver cancer. We focus on aspects such as reproducibility and practicality, discussing the advantages and weaknesses of available models for researchers who are planning to perform animal studies in the near future. Additionally, we summarise current and prospective models based on human tissue bioengineering.
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Affiliation(s)
- Yulia A Nevzorova
- Department of Genetics, Physiology and Microbiology, Faculty of Biology, Complutense University, Madrid, Spain; 12 de Octubre Health Research Institute (imas12), Madrid, Spain; Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoe Boyer-Diaz
- Liver Vascular Biology Research Group, Barcelona Hepatic Hemodynamic Unit, IDIBAPS Biomedical Research Institute, Barcelona, Spain; Barcelona Liver Bioservices, Barcelona, Spain
| | - Francisco Javier Cubero
- 12 de Octubre Health Research Institute (imas12), Madrid, Spain; Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, Madrid, Spain.
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, Barcelona Hepatic Hemodynamic Unit, IDIBAPS Biomedical Research Institute, Barcelona, Spain; Barcelona Liver Bioservices, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland.
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15
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Ortega‐Ribera M, Hunt NJ, Gracia‐Sancho J, Cogger VC. The Hepatic Sinusoid in Aging and Disease: Update and Advances From the 20th Liver Sinusoid Meeting. Hepatol Commun 2020; 4:1087-1098. [PMID: 32626839 PMCID: PMC7327202 DOI: 10.1002/hep4.1517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/13/2022] Open
Abstract
This is a meeting report of the 2019 Liver Sinusoid Meeting, 20th International Symposium on Cells of the Hepatic Sinusoid, held in Sydney, Australia, in September 2019. The meeting, which was organized by the International Society for Hepatic Sinusoidal Research, provided an update on the recent advances in the field of hepatic sinusoid cells in relation to cell biology, aging, and liver disease, with particular focus on the molecular and cellular targets involved in hepatic fibrosis, nonalcoholic hepatic steatohepatitis, alcoholic liver disease, hepatocellular carcinoma, and cirrhosis. In addition, the meeting highlighted the recent advances in regenerative medicine, targeted nanotechnologies, therapeutics, and novel methodologies.
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Affiliation(s)
- Martí Ortega‐Ribera
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic UnitInstitut d’Investigacions Biomèdiques August Pi i SunyerCentro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasBarcelonaSpain
| | - Nicholas J. Hunt
- Centre for Education and Research on AgeingConcord Repatriation General HospitalANZAC Research InstituteAustralian Ageing and Alzheimers InstituteConcordSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Jordi Gracia‐Sancho
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic UnitInstitut d’Investigacions Biomèdiques August Pi i SunyerCentro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasBarcelonaSpain
- HepatologyDepartment of Biomedical ResearchUniversity of BernInselspitalBernSwitzerland
| | - Victoria C. Cogger
- Centre for Education and Research on AgeingConcord Repatriation General HospitalANZAC Research InstituteAustralian Ageing and Alzheimers InstituteConcordSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
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16
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Møller S, Kimer N, Barløse M, Bendtsen F. Pathophysiological-based treatments of complications of cirrhosis. Scand J Gastroenterol 2020; 55:383-394. [PMID: 32233873 DOI: 10.1080/00365521.2020.1744709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Detailed knowledge and understanding of the pathophysiological mechanisms and changes in hepatic and splanchnic function leading to the development of haemodynamic changes and portal hypertension in patients with cirrhosis are essential since it guides the search for targets to ameliorate liver-related abnormalities. Recent research has focused on the gut-liver axis, changes in intestinal permeability, translocation of bacterial products, and inflammation as important drivers of haemodynamic alterations and thereby targets for treatment. Additionally, treatment strategies should focus on microbiotic modulation, antiangiogenics, anti-inflammatory strategies, and modulation of bile acid metabolism. This paper aims to review contemporary pathophysiological-based treatment principles of the major complications of cirrhosis and portal hypertension and future targets for treatment.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Bridge Translational Excellence Programme, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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17
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Mandorfer M, Kozbial K, Schwabl P, Chromy D, Semmler G, Stättermayer AF, Pinter M, Hernández‐Gea V, Fritzer‐Szekeres M, Steindl‐Munda P, Trauner M, Peck‐Radosavljevic M, García‐Pagán JC, Ferenci P, Reiberger T. Changes in Hepatic Venous Pressure Gradient Predict Hepatic Decompensation in Patients Who Achieved Sustained Virologic Response to Interferon-Free Therapy. Hepatology 2020; 71:1023-1036. [PMID: 31365764 PMCID: PMC7155089 DOI: 10.1002/hep.30885] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Sustained virologic response (SVR) to interferon (IFN)-free therapies ameliorates portal hypertension (PH); however, it remains unclear whether a decrease in hepatic venous pressure gradient (HVPG) after cure of hepatitis C translates into a clinical benefit. We assessed the impact of pretreatment HVPG, changes in HVPG, and posttreatment HVPG on the development of hepatic decompensation in patients with PH who achieved SVR to IFN-free therapy. Moreover, we evaluated transient elastography (TE) and von Willebrand factor to platelet count ratio (VITRO) as noninvasive methods for monitoring the evolution of PH. APPROACH AND RESULTS The study comprised 90 patients with HVPG ≥ 6 mm Hg who underwent paired HVPG, TE, and VITRO assessments before (baseline [BL]) and after (follow-up [FU]) IFN-free therapy. FU HVPG but not BL HVPG predicted hepatic decompensation (per mm Hg, hazard ratio, 1.18; 95% confidence interval, 1.08-1.28; P < 0.001). Patients with BL HVPG ≤ 9 mm Hg or patients who resolved clinically significant PH (CSPH) were protected from hepatic decompensation. In patients with CSPH, an HVPG decrease ≥ 10% was similarly protective (36 months, 2.5% vs. 40.5%; P < 0.001) but was observed in a substantially higher proportion of patients (60% vs. 24%; P < 0.001). Importantly, the performance of noninvasive methods such as TE/VITRO for diagnosing an HVPG reduction ≥ 10% was inadequate for clinical use (area under the receiver operating characteristic curve [AUROC], < 0.8), emphasizing the need for HVPG measurements. However, TE/VITRO were able to rule in or rule out FU CSPH (AUROC, 0.86-0.92) in most patients, especially if assessed in a sequential manner. CONCLUSIONS Reassessment of HVPG after SVR improved prognostication in patients with pretreatment CSPH. An "immediate" HVPG decrease ≥ 10% was observed in the majority of these patients and was associated with a clinical benefit, as it prevented hepatic decompensation. These results support the use of HVPG as a surrogate endpoint for interventions that lower portal pressure by decreasing intrahepatic resistance.
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Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
- Barcelona Hepatic Hemodynamic Lab, Liver UnitHospital ClínicBarcelonaSpain
| | - Karin Kozbial
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
| | - David Chromy
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
| | - Albert F. Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
| | - Virginia Hernández‐Gea
- Barcelona Hepatic Hemodynamic Lab, Liver UnitHospital ClínicBarcelonaSpain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | | | - Petra Steindl‐Munda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Markus Peck‐Radosavljevic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, and Nephrology with Centralized Emergency Service (ZAE)Klinikum Klagenfurt am WörtherseeKlagenfurtAustria
| | - Juan C. García‐Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver UnitHospital ClínicBarcelonaSpain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
- Vienna Hepatic Hemodynamic LabMedical University of ViennaViennaAustria
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18
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Abstract
Terlipressin, somatostatin, or octreotide are recommended as pharmacologic treatment of acute variceal hemorrhage. Nonselective β-blockers decrease the risk of variceal hemorrhage and hepatic decompensation, particularly in those 30% to 40% of patients with good hemodynamic response. Carvedilol, statins, and anticoagulants are promising agents in the management of portal hypertension. Recent advances in the pharmacologic treatment of portal hypertension have mainly focused on modifying an increased intrahepatic resistance through nitric oxide and/or modulation of vasoactive substances. Several novel pharmacologic agents for portal hypertension are being evaluated in humans.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand; Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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19
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A Nutraceutical Rich in Docosahexaenoic Acid Improves Portal Hypertension in a Preclinical Model of Advanced Chronic Liver Disease. Nutrients 2019; 11:nu11102358. [PMID: 31623374 PMCID: PMC6835927 DOI: 10.3390/nu11102358] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/25/2019] [Accepted: 09/29/2019] [Indexed: 02/06/2023] Open
Abstract
Inflammation and oxidative stress play a key role in the pathophysiology of advanced chronic liver disease (ACLD) and portal hypertension (PH). Considering the current lack of effective treatments, we evaluated an anti-inflammatory and antioxidant nutraceutical rich in docosahexaenoic acid (DHA) as a possible therapy for ACLD. We investigated the effects of two-week DHA supplementation (500 mg/kg) on hepatic fatty acids, PH, oxidative stress, inflammation, and hepatic stellate cell (HSC) phenotype in rats with ACLD. Additionally, the effects of DHA were evaluated in murine macrophages and human HSC. In contrast to vehicle-treated animals, cirrhotic rats receiving DHA reestablished a healthy hepatic fatty acid profile, which was associated with an improvement in PH. The mechanisms underlying this hemodynamic improvement included a reduction in oxidative stress and inflammation, as well as a marked HSC deactivation, confirmed in human HSC. Experiments with cultured macrophages showed that treatment with DHA protects against pro-inflammatory insults. The present preclinical study demonstrates that a nutraceutical rich in DHA significantly improves PH in chronic liver disease mainly by suppressing inflammation and oxidative stress-driven HSC activation, encouraging its evaluation as a new treatment for PH and cirrhosis.
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20
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Gracia‐Sancho J, Manicardi N, Ortega‐Ribera M, Maeso‐Díaz R, Guixé‐Muntet S, Fernández‐Iglesias A, Hide D, García‐Calderó H, Boyer‐Díaz Z, Contreras PC, Spada A, Bosch J. Emricasan Ameliorates Portal Hypertension and Liver Fibrosis in Cirrhotic Rats Through a Hepatocyte-Mediated Paracrine Mechanism. Hepatol Commun 2019; 3:987-1000. [PMID: 31304452 PMCID: PMC6601324 DOI: 10.1002/hep4.1360] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/27/2019] [Indexed: 12/12/2022] Open
Abstract
In cirrhosis, liver microvascular dysfunction is a key factor increasing hepatic vascular resistance to portal blood flow, which leads to portal hypertension. De-regulated inflammatory and pro-apoptotic processes due to chronic injury play important roles in the dysfunction of liver sinusoidal cells. The present study aimed at characterizing the effects of the pan-caspase inhibitor emricasan on systemic and hepatic hemodynamics, hepatic cells phenotype, and underlying mechanisms in preclinical models of advanced chronic liver disease. We investigated the effects of 7-day emricasan on hepatic and systemic hemodynamics, liver function, hepatic microcirculatory function, inflammation, fibrosis, hepatic cells phenotype, and paracrine interactions in rats with advanced cirrhosis due to chronic CCl4 administration. The hepato-protective effects of emricasan were additionally investigated in cells isolated from human cirrhotic livers. Cirrhotic rats receiving emricasan showed significantly lower portal pressure than vehicle-treated animals with no changes in portal blood flow, indicating improved vascular resistance. Hemodynamic improvement was associated with significantly better liver function, reduced hepatic inflammation, improved phenotype of hepatocytes, liver sinusoidal endothelial cells, hepatic stellate cells and macrophages, and reduced fibrosis. In vitro experiments demonstrated that emricasan exerted its benefits directly improving hepatocytes' expression of specific markers and synthetic capacity, and ameliorated nonparenchymal cells through a paracrine mechanism mediated by small extracellular vesicles released by hepatocytes. Conclusion: This study demonstrates that emricasan improves liver sinusoidal microvascular dysfunction in cirrhosis, which leads to marked amelioration in fibrosis, portal hypertension and liver function, and therefore encourages its clinical evaluation in the treatment of advanced chronic liver disease.
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Affiliation(s)
- Jordi Gracia‐Sancho
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- CIBEREHDMadridSpain
- Hepatology, Department of Biomedical ResearchInselspital – University of BernBernSwitzerland
| | - Nicolò Manicardi
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
| | - Martí Ortega‐Ribera
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
| | - Raquel Maeso‐Díaz
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
| | - Sergi Guixé‐Muntet
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- Hepatology, Department of Biomedical ResearchInselspital – University of BernBernSwitzerland
| | - Anabel Fernández‐Iglesias
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- CIBEREHDMadridSpain
| | - Diana Hide
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- CIBEREHDMadridSpain
| | - Héctor García‐Calderó
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- CIBEREHDMadridSpain
| | | | | | | | - Jaime Bosch
- Liver Vascular Biology Research GroupBarcelona Hepatic Hemodynamic Lab, IDIBAPS Biomedical Research InstituteBarcelonaSpain
- CIBEREHDMadridSpain
- Hepatology, Department of Biomedical ResearchInselspital – University of BernBernSwitzerland
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21
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Mandorfer M, Hernández-Gea V, Reiberger T, García-Pagán JC. Hepatic Venous Pressure Gradient Response in Non-Selective Beta-Blocker Treatment—Is It Worth Measuring? ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s11901-019-00469-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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