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Harris SJ, Stine JG. Frailty in liver transplantation: Exploring prescribing exercise as medicine to improve patient outcomes. Liver Int 2024. [PMID: 38899635 DOI: 10.1111/liv.15986] [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: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024]
Abstract
Liver transplantation (LT) represents a curative avenue for individuals with advanced chronic liver disease. Given the inherent illness severity of LT candidates, identifying patients at greater risk for adverse outcomes before and after transplantation is paramount. Approximately 50% of cirrhotic patients are frail and have considerable functional impairment. Various measures have been used to assess frailty, including performance-based tests and functional status evaluations. Frailty carries significant prognostic implications and predicts both mortality and pre- and post-LT complications. Contributing factors to frailty in this population include sarcopenia, malnutrition, inflammation, and psychosocial factors. Recognizing the prevalence of frailty among LT candidates, exercise interventions have been developed to improve physical frailty and offer potential to improve patient outcomes. While many interventions have demonstrated efficacy without notable adverse events, the absence of a universally accepted standard for exercise prescription underscores the variability in intervention elements and patient adherence. Given the safety profile of exercise interventions, there remains a critical need for standardized protocols and guidelines to optimize exercise regimens for LT candidates. This review delves into the landscape of frailty among LT candidates, elucidating its etiological underpinnings, impact on outcomes, utilization of exercise interventions, and the efficacy of exercise programs in reducing the burden frailty in those awaiting LT.
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Affiliation(s)
- Sara J Harris
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Jonathan G Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Fatty Liver Program, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Liver Center, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, The Pennsylvania State University - College of Medicine, Hershey, Pennsylvania, USA
- Cancer Institute, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Wu R, Kokabi N, Adler JM, Bhave AD, Morris CS, Saad WE, Majdalany DS, Majdalany BS. Paradoxical Cerebral Embolization during Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Sclerotherapy. Semin Intervent Radiol 2024; 41:220-225. [PMID: 38993595 PMCID: PMC11236452 DOI: 10.1055/s-0044-1786539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Affiliation(s)
- Richard Wu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Jonah M. Adler
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Anant D. Bhave
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Christopher S. Morris
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Wael E. Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Utah Hospital, Salt Lake City, Utah
| | | | - Bill S. Majdalany
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
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Elsheikh M, El Sabagh A, Mohamed IB, Bhongade M, Hassan MM, Jalal PK. Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management. World J Gastroenterol 2023; 29:6028-6048. [PMID: 38130738 PMCID: PMC10731159 DOI: 10.3748/wjg.v29.i46.6028] [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: 09/13/2023] [Revised: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 12/13/2023] Open
Abstract
Frailty and sarcopenia are frequently observed in patients with end-stage liver disease. Frailty is a complex condition that arises from deteriorations across various physiological systems, including the musculoskeletal, cardiovascular, and immune systems, resulting in a reduced ability of the body to withstand stressors. This condition is associated with declined resilience and increased vulnerability to negative outcomes, including disability, hospitalization, and mortality. In cirrhotic patients, frailty is influenced by multiple factors, such as hyperammonemia, hormonal imbalance, malnutrition, ascites, hepatic encephalopathy, and alcohol intake. Assessing frailty is crucial in predicting morbidity and mortality in cirrhotic patients. It can aid in making critical decisions regarding patients' eligibility for critical care and transplantation. This, in turn, can guide the development of an individualized treatment plan for each patient with cirrhosis, with a focus on prioritizing exercise, proper nutrition, and appropriate treatment of hepatic complications as the primary lines of treatment. In this review, we aim to explore the topic of frailty in liver diseases, with a particular emphasis on pathophysiology, clinical assessment, and discuss strategies for preventing frailty through effective treatment of hepatic complications. Furthermore, we explore novel assessment and management strategies that have emerged in recent years, including the use of wearable technology and telemedicine.
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Affiliation(s)
- Mazen Elsheikh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ahmed El Sabagh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Islam B Mohamed
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Megha Bhongade
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Manal M Hassan
- Department of Epidemiology, Division of Cancer Prevention and Population Sciences, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Prasun Kumar Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
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Bai X, Liu X, Shi Y, Li W, Li Q, Du W. Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study. Front Med (Lausanne) 2023; 10:1165604. [PMID: 37332757 PMCID: PMC10268603 DOI: 10.3389/fmed.2023.1165604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
Aims and background Hepatic hydrothorax, which presents as an unexplained pleural effusion, is one of the important complications in patients with end-stage cirrhosis. It has a significant correlation with prognosis and mortality. The aim of this clinical study was to detect the risk factors for hepatic hydrothorax in patients with cirrhosis and to better understand potentially life-threatening complications. Methods Retrospectively, 978 cirrhotic patients who were hospitalized at the Shandong Public Health Clinical Center from 2013 to 2021 were involved in this study. They were divided into the observation group and the control group based on the presence of hepatic hydrothorax. The epidemiological, clinical, laboratory, and radiological characteristics of the patients were collected and analyzed. ROC curves were used to evaluate the forecasting ability of the candidate model. Furthermore, 487 cases in the experimental group were divided into left, right, and bilateral groups, and the data were analyzed. Results The patients in the observation group had a higher proportion of upper gastrointestinal bleeding (UGIB), a history of spleen surgery, and a higher model for end-stage liver disease (MELD) scores compared with the control group. The width of the portal vein (PVW) (P = 0.022), prothrombin activity (PTA) (P = 0.012), D-dimer (P = 0.010), immunoglobulin G (IgG) (P = 0.007), high-density lipoprotein cholesterol (HDL) (P = 0.022), and the MELD score were significantly associated with the occurrence of the hepatic hydrothorax. The AUC of the candidate model was 0.805 (P < 0.001, 95% CI = 0.758-0.851). Portal vein thrombosis was more common in bilateral pleural effusion compared with the left and right sides (P = 0.018). Conclusion The occurrence of hepatic hydrothorax has a close relationship with lower HDL, PTA, and higher PVW, D-dimer, IgG, and MELD scores. Portal vein thrombosis is more common in cirrhotic patients with bilateral pleural effusion compared to those with unilateral pleural effusion.
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Affiliation(s)
- Xue Bai
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyan Liu
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Yanhui Shi
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Qiang Li
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Wenjun Du
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
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Ma B, Shang T, Huang J, Tu Z, Wang Y, Han Y, Wen X, Jin Q. Analysis of clinical features and prognostic factors in patients with hepatic hydrothorax: a single-center study from China. BMC Gastroenterol 2022; 22:333. [PMID: 35799114 PMCID: PMC9264701 DOI: 10.1186/s12876-022-02412-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background The clinical features and factors affecting the prognostic survival of hepatic hydrothorax (HH) are currently unknown. Methods We conducted a retrospective cohort study of 131 patients with HH using the Kaplan–Meier method and Cox proportional hazards regression analysis to assess factors influencing the prognosis of HH. Results A total of 131 patients were enrolled: the male to female ratio was 80:51 (1.59:1), and the mean age was 52.76 ± 11.88 years. Hepatitis B cirrhosis was the main cause of HH, and abdominal distention and dyspnea were the most common clinical signs. Ascites was present in varying amounts in all patients and was the most common decompensated complication, with pleural effusions mostly seen on the right side (107/131; 82%), followed by the left side (16/131; 12%) and bilateral effusions (8/131; 6%). For overall survival without transplantation, the estimated median survival time was 21 (95% confidence interval [CI]:18–25) months, and survival rates at 6 months, 1 year, and 2 years were 77.2%, 62.4%, and 29.7%, respectively. After controlling for covariates that were associated with liver-related mortality in the univariate analysis, males (hazard ratio [HR]: 1.721, 95% CI: 1.114–2.658, P = 0.005) and combined hepatic encephalopathy (HR: 2.016, 95% CI: 1.101–3.693, P = 0.001) were found to be associated with an increase in liver-related mortality. Conclusions In this cohort of HH patients without liver transplantation, male sex and hepatic encephalopathy were associated with a higher risk of liver-related death.
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Affiliation(s)
- Bo Ma
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Tianling Shang
- Department of Neurology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Jianjie Huang
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Zhixin Tu
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Yan Wang
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Yujin Han
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Xiaoyu Wen
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China
| | - Qinglong Jin
- Department of Hepatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130000, Jilin Province, China. .,Department of Hepatology, The First Hospital of Jilin University, No. 1, Xinmin Street, Chaoyang District, Changchun, 130021, Jilin, China.
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Sobotka LA, Spitzer C, Hinton A, Michaels A, Hanje AJ, Mumtaz K, Conteh LF. Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission. J Gastroenterol Hepatol 2020; 35:641-647. [PMID: 31441096 DOI: 10.1111/jgh.14842] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Carleen Spitzer
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Anthony Michaels
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - A James Hanje
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Lanla F Conteh
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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Ilyas SZ, Tabassum R, Hamed H, Rehman SU, Qadri I. Hepatitis C Virus-Associated Extrahepatic Manifestations in Lung and Heart and Antiviral Therapy-Related Cardiopulmonary Toxicity. Viral Immunol 2017; 30:633-641. [PMID: 28953449 DOI: 10.1089/vim.2017.0009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Besides liver cirrhosis and hepatocellular carcinoma, chronic hepatitis C virus (HCV) infection is associated with many extrahepatic manifestations (EHMs). HCV exhibits lymphotropism that is responsible for various EHM. An important characteristic of HCV is escape from the immune system, which enables it to produce chronic infections and autoimmune disorders along with accumulation of circulating immune complexes. These EHMs have large spectrum, because they affect many organs such as heart, lungs, kidney, brain, thyroid, and skin. HCV-related cardiac and pulmonary manifestations include myocarditis, cardiomyopathies, cardiovascular diseases (i.e., Stroke, ischemic heart disease), chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, asthma, and interstitial lung diseases. This review discusses etiology and pathogenesis of HCV-associated cardiac and pulmonary manifestations and how different genes, immune system, indirectly linked factors (mixed cryoglobulinemia), liver cirrhosis, and antiviral treatment are involved in HCV-related heart and lung diseases, however, their exact mechanism is not clear.
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Affiliation(s)
- Syeda Zainab Ilyas
- 1 Department of Microbiology and Molecular Genetics, University of the Punjab , Lahore, Pakistan
| | - Rabia Tabassum
- 1 Department of Microbiology and Molecular Genetics, University of the Punjab , Lahore, Pakistan
| | - Haroon Hamed
- 2 Department of Biological Sciences, King Abdul Aziz University , Jeddah, Kingdom of Saudi Arabia
| | - Shafiq Ur Rehman
- 1 Department of Microbiology and Molecular Genetics, University of the Punjab , Lahore, Pakistan
| | - Ishtiaq Qadri
- 2 Department of Biological Sciences, King Abdul Aziz University , Jeddah, Kingdom of Saudi Arabia
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Al-Zoubi RK, Abu Ghanimeh M, Gohar A, Salzman GA, Yousef O. Hepatic hydrothorax: clinical review and update on consensus guidelines. Hosp Pract (1995) 2016; 44:213-223. [PMID: 27580053 DOI: 10.1080/21548331.2016.1227685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatic Hydrothorax (HH) is defined as a pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. It is an uncommon complication of cirrhosis, most frequently seen in association with decompensated liver disease. The development of HH remains incompletely understood and involves a complex pathophysiological process with the most acceptable explanation being the passage of the ascetic fluid through small diaphragmatic defects. Given the limited capacity of the pleural space, even the modest pleural effusion can result in significant respiratory symptoms. The diagnosis of HH should be suspected in any patient with established cirrhosis and portal hypertension presenting with unilateral pleural effusion especially on the right side. Diagnostic thoracentesis should be performed in all patients with suspected HH to confirm the diagnosis and rule out infection and alternative diagnoses. Spontaneous bacterial empyema and spontaneous bacterial pleuritis can complicate HH and increase morbidity and mortality. HH can be difficult to treat and in our review below we will list the therapeutic modalities awaiting the evaluation for the only definitive therapy, which is liver transplantation.
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Affiliation(s)
- Rana Khazar Al-Zoubi
- a School of Medicine Ringgold standard institution - Pulmonary & Critical Care , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Mouhanna Abu Ghanimeh
- b School of Medicine Ringgold standard institution - Internal Medicine , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Ashraf Gohar
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Gary A Salzman
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Osama Yousef
- d School of Medicine - Gastroenterology Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
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Predicting stroke volume and arterial pressure fluid responsiveness in liver cirrhosis patients using dynamic preload variables. Eur J Anaesthesiol 2016; 33:645-52. [DOI: 10.1097/eja.0000000000000479] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Badillo R, Rockey DC. Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature. Medicine (Baltimore) 2014; 93:135-142. [PMID: 24797168 PMCID: PMC4632908 DOI: 10.1097/md.0000000000000025] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hepatic hydrothorax is an important and difficult-to-manage complication of cirrhosis and portal hypertension. Here, we aimed to study its clinical features and natural history. Complete clinical data, including outcomes, were abstracted from hospital records of patients with cirrhosis and ascites admitted to University of Texas Southwestern University teaching hospitals from January 2001 to July 2012. Hepatic hydrothorax was diagnosed based on currently accepted clinical characteristics of the disease, including a known diagnosis of cirrhosis, the presence of portal hypertension, pleural fluid analysis, and the absence of primary cardiopulmonary disease.Seventy-seven of 495 (16%) hospitalized cirrhotic patients with pleural effusion (28 female; mean age, 52 yr) met the criteria for diagnosis of hepatic hydrothorax. Resting dyspnea and cough were the most prominent presenting symptoms, occurring in 34% and 22% of patients, respectively. Pleural effusions were most often right-sided (56/77; 73%), followed by left-sided only (13/77; 17%) and bilateral effusions (8/77; 10%); 7 (9%) patients did not have detectable ascites. The mean Model for End-Stage Liver Disease (MELD) score at presentation was 16. The serum to pleural fluid albumin gradient (SPAG) was ≥1.1 in all 48 patients in whom it was measured. Most patients (64/77; 83%) were managed with diuretics and/or thoracentesis, while 8 (10%) underwent transjugular intrahepatic portosystemic shunt (TIPS) and 5 (7%) underwent liver transplant. A total of 44 of 77 (57%) patients died during a mean follow-up of 12 months. The average time from presentation to death for all patients was 368 days, while for those after TIPS it was 845 days. No deaths were reported in the liver transplant group. The data indicate that a substantial number of patients with hepatic hydrothorax had what may be considered atypical presentations, including left-sided only effusions, or pleural effusion without ascites. Here, we propose that the term "serum to pleural fluid albumin gradient (SPAG)" be used to describe the gradient between serum and pleural fluid albumin levels and suggest that not only is it consistent with the portal hypertensive pathophysiology of hepatic hydrothorax, but also it is a useful criterion for diagnosis of hepatic hydrothorax. Finally, the overall outcome of hepatic hydrothorax was extremely poor, except in those undergoing TIPS or liver transplantation.
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Affiliation(s)
- Ricardo Badillo
- From the Department of Medicine (RB), University of Texas Southwestern, and Parkland Memorial Hospital (RB), Dallas, Texas; and Department of Medicine (DCR), Medical University of South Carolina, Charleston, South Carolina
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Hoerning A, Raub S, Neudorf U, Müntjes C, Kathemann S, Lainka E, Stehling F, Hoyer PF, Gerner P. Pulse oximetry is insufficient for timely diagnosis of hepatopulmonary syndrome in children with liver cirrhosis. J Pediatr 2014; 164:546-52.e1-2. [PMID: 24321540 DOI: 10.1016/j.jpeds.2013.10.070] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 09/17/2013] [Accepted: 10/24/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To prospectively investigate the prevalence of hepatopulmonary syndrome (HPS), the importance of pulse oximetry in diagnosing HPS, and the longitudinal course after liver transplantation in children with cirrhosis referred for liver transplantation. STUDY DESIGN Fifty-six patients aged 1-17 years (mean age, 4.6 ± 5.0 years) with liver cirrhosis were screened for HPS by hyperemic capillary blood gas (CBG) analysis and contrast-enhanced transthoracic echocardiography. Eleven patients were excluded owing to conditions that can produce cardiopulmonary dysfunction, including 5 with cystic fibrosis, 1 with pulmonary arterial hypertension, and 5 with an intracardial shunt. HPS was classified in accordance with the European Respiratory Society Task Force criteria on pulmonary-hepatic disorders. Patient groups were compared for biochemical and clinical characteristics. RESULTS Eighteen children (40%) with cirrhosis were intrapulmonary vasodilatation (IPVD)-positive and had a pulse oximetry oxygen saturation level >98%. Two of these patients (11%) exhibited moderate HPS with an elevated alveolar arterial oxygen gradient >15 mm Hg and PaO2 <70 mm Hg; they died before undergoing liver transplantation. The sensitivity and specificity of CBG analysis for detecting elevated alveolar arterial oxygen gradient in children with IPVD was 94% and 53%, respectively. HPS was associated with late hepatoportoenterostomy (P < .04). Liver transplantation led to resolution of HPS in all patients. CONCLUSION IPVD is frequent in children with liver cirrhosis (40%). Pulse oximetry is insufficient for timely HPS diagnosis. Pathological CBG analysis data indicate IPVD in the majority of cases, but are imprecise in children aged <2 years. Contrast-enhanced transthoracic echocardiography and CBG analysis are recommended for evaluation of HPS in children with cirrhosis, regardless of liver synthesis capacity and clinical chemistry data.
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Affiliation(s)
- André Hoerning
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Simon Raub
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Neudorf
- Clinic for Pediatrics III, Department of Pediatric Cardiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Carsten Müntjes
- Clinic for Pediatrics III, Department of Pediatric Cardiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Simone Kathemann
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Clinic for Pediatrics III, Department of Pediatric Pulmonology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Peter F Hoyer
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Patrick Gerner
- Clinic for Pediatrics II, Department of Pediatric Nephrology, Gastroenterology, Endocrinology, and Transplant Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Aller MA, Blanco-Rivero J, Arias JI, Balfagon G, Arias J. The wound-healing response and upregulated embryonic mechanisms: brothers-in-arms forever. Exp Dermatol 2012; 21:497-503. [PMID: 22716244 DOI: 10.1111/j.1600-0625.2012.01525.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The cutaneous wound-healing reaction occurs in overlapping but inter-related phases, which ultimately result in fibrosis. The pathophysiological mechanisms involved in fibrotic diseases, including organ-related and even systemic diseases, such as systemic sclerosis, could represent the successive systemic upregulation of extraembryonic-like phenotypes, that is, amniotic and vitelline phenotypes. These two extraembryonic-like phenotypes act on the injured tissue to induce a process similar to gastrulation, which occurs during the early phases of embryo development. The amniotic-like phenotype plays a leading role in the development of neurogenic responses with significant hydroelectrolytic alterations that essentially represent the development of open microcirculation within the injured tissue. In turn, through the overlapping expression of a vitelline-like phenotype, a bone marrow-related response is produced. Interstitial infiltration by molecular and cellular mediators contributed by amniotic- and vitelline-like functions provides the functional and metabolic autonomy needed for inducing new tissue formation through mechanisms similar to those that act in gastrulation during the early phases of embryonic development. Thus, while a new tissue is formed, it quickly evolves into fibrotic tissue because of premature senescence. Mechanisms related to extraembryonic-like functions have been suggested in the following physiological and pathological processes: embryonic development; wound-healing reactions occurring during adult life; and senescence. The existence of this sort of basic self-organizing fractal-like functional pattern is an essential characteristic of our way of life.
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Affiliation(s)
- María-Angeles Aller
- Department of Surgery I, School of Medicine, Complutense University of Madrid, Madrid, Spain
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