[Hepatopulmonary syndrome]

The hepatopulmonary syndrome (HPS) is one of the lung diseases associated with cirrhosis and portal hypertension. It should be discussed for any dyspnea in cirrhotic patients. HPS is a pulmonary vascular disease characterized by intrapulmonary vascular dilatations (IPVD). The pathogenesis is complex and seems to rely on communications between the portal and pulmonary circulations. The diagnosis is based on a triad of liver disease and portal hypertension, evidence of IPVDs, and impaired gas exchange (alveolar-arterial oxygen difference [A-aO2]≥15mmHg). HPS impairs prognosis (23% survival at 5years) and patients' quality of life. Liver transplantation (LT) allows regression of IPDVD in almost 100% of cases, normalization of gas exchange and improves survival with a 5-year post-LT survival between 76 and 87%. It is the only curative treatment, indicated in patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60mmHg. When LT is not indicated or feasible, long-term oxygen therapy may be proposed as a palliative treatment. A better understanding of the pathophysiological mechanisms is needed to improve the therapeutic possibilities in a near future.

Pulmonary vascular disease and exercise hemodynamics in chronic liver disease

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.

[Hepatopulmonar syndrome and liver transplantation: experience in the transplantation department of the Guillermo Almenara Irigoyen National Hospital - EsSalud]

INTRODUCTION

Hepatopulmonary syndrome (HPS) is a serious complication of liver disease, which is characterized by the presence of intrapulmonary vasodilation and progressive hypoxemia. Liver transplantation is the only effective treatment.

OBJECTIVE

To show our results of patients with hepatopulmonary syndrome undergoing liver transplantation.

MATERIALS AND METHODS

Retrospective, descriptive and cross-sectional study. From March 2000 to December 2016; 226 liver transplants were performed. Of the total, 25 patients were excluded: 12 retransplantation, 9 liver-kidney combined transplants, 2 transplants for acute liver failure, 2 transplants in non-cirrhotic patients. Of the 201 patients with pretransplant diagnosis of liver cirrhosis, 19 filled criteria for SHP; who were distributed according to age, sex, hypoxemia level (pO2), Child-Pugh score and MELD score. The reversibility hypoxemia after liver trasplantation was measured with a cut-off of p02 >75 mmHg.

RESULTS

The prevalence of SHP in our series was 9.45%. The average age was 41 years (14-65); the M / F ratio of 1.65. The 78.94% (15/19) were adults. 89.5% (17/19) were Score of Child-Pugh B and C, and 68.4% had severe and very severe SHP. In 94.11% of patients, reversibility SHP founded. The early mortality rate (30 days) in patients with SHP was 10.4%.

CONCLUSIONS

The prevalence of HPS in our series was 9.45%. Transplanted patients with and without SHP had similar survival.

Review article: Update on current and emergent data on hepatopulmonary syndrome

Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of end-stage liver disease, characterized by impaired arterial oxygenation induced by intrapulmonary vascular dilatation. Its prevalence ranges from 4% to 47% in patients with cirrhosis due to the different diagnostic criteria applied among different studies. Nitric oxide overproduction and angiogenesis seem to be the hallmarks of a complicated pathogenetic mechanism, leading to intrapulmonary shunting and ventilation-perfusion mismatch. A classification of HPS according to the severity of hypoxemia has been suggested. Contrast-enhanced echocardiography represents the gold standard method for the detection of intrapulmonary vascular dilatations which is required, in combination with an elevated alveolar arterial gradient to set the diagnosis. The only effective treatment which can modify the syndrome’s natural history is liver transplantation. Although it is usually asymptomatic, HPS imparts a high risk of pretransplantation mortality, independently of the severity of liver disease, while there is variable data concerning survival rates after liver transplantation. The potential of myocardial involvement in the setting of HPS has also gained increasing interest in recent research. The aim of this review is to critically approach the existing literature of HPS and emphasize unclear points that remain to be unraveled by future research.

Chronic liver disease is universal in children with biliary atresia living with native liver

AIM

To examine the medical status of children with biliary atresia (BA) surviving with native livers.

METHODS

In this cross-sectional review, data collected included complications of chronic liver disease (CLD) (cholangitis in the preceding 12 mo, portal hypertension, variceal bleeding, fractures, hepatopulmonary syndrome, portopulmonary hypertension) and laboratory indices (white cell and platelet counts, total bilirubin, albumin, international normalized ratio, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase). Ideal medical outcome was defined as absence of clinical evidence of CLD or abnormal laboratory indices.

RESULTS

Fifty-two children [females = 32, 62%; median age 7.4 years, n = 35 (67%) older than 5 years] with BA (median age at surgery 60 d, range of 30 to 148 d) survived with native liver. Common complications of CLD noted were portal hypertension (40%, n = 21; 2 younger than 5 years), cholangitis (36%) and bleeding varices (25%, n = 13; 1 younger than 5 years). Fifteen (29%) had no clinical complications of CLD and three (6%) had normal laboratory indices. Ideal medical outcome was only seen in 1 patient (2%).

CONCLUSION

Clinical or laboratory evidence of CLD are present in 98% of children with BA living with native livers after hepatoportoenterostomy. Portal hypertension and variceal bleeding may be seen in children younger than 5 years of age, underscoring the importance of medical surveillance for complications of BA starting at a young age.

[Prevalence and severity of the hepatopulmonar syndrome in patients with liver cirrhosis attended at Cayetano Heredia Hospital, between January and December 2015]

INTRODUCTION

The hepatopulmonary syndrome (HPS) is a rare complication of liver cirrhosis (LC) which significantly diminishes the quality of life for people who suffer.

OBJECTIVES

To determine the prevalence and severity of HPS in patients with CH treated at the Cayetano Heredia (HCH) Hospital in the period from January to December 2015.

MATERIALS AND METHODS

Cross-sectional study with sample size needed to determine the point prevalence calculated in 297 patients.

RESULTS

The prevalence of HPS in 0.7% and the identified cases were classified as mild and severe SHP.

CONCLUSION

The prevalence of HPS is very low in the population of patients with liver cirrhosis treated at the Cayetano Heredia Hospital.

CHARACTER AND FREQUENCY OF THE VARIATIONS OF CO- AND POLYMORBID SYNTROPIC EXTRAHEPATIC LESIONS AND THEIR DEPENDENCE ON THE HEPATOPULMONARY SYNDROME SEVERITY DEGREE IN CIRRHOTIC PATIENTS

In this study, we comprehensively examined 93 patients with liver cirrhosis, selected in a randomized manner, with the preliminary stratification by the presence of hepatopulmonary syndrome with the aim to study the nature and frequency of extrahepatic syntropic lesions of organs and systems and their dependence on the severity of lung injury that is necessary for the appointment of the most effective individualized comprehensive treatment. The results of our calculations showed that with the increasing of the hepatopulmonary syndromeseverity degree, the nature and the frequency of the syntropic co- and polymorbid functional and organic extrahepatic lesions of the organs and body systems was significantly (p<0.05) changing. Also some polymorbid disorders' combinations and/or combined variants of the syndromes and nosologies have been increasing in case of growing the severity of the hepatopulmonary syndrome, that shows their significant (p<0.05) dependency.

Hepatopulmonary syndrome: What we know and what we would like to know

Hepatopulmonary syndrome (HPS) is characterized by abnormalities in blood oxygenation caused by the presence of intrapulmonary vascular dilations (IPVD) in the context of liver disease, generally at a cirrhotic stage. Knowledge about the subject is still only partial. The majority of the information about the etiopathogenesis of HPS has been obtained through experiments on animals. Reported prevalence in patients who are candidates for a liver transplantation (LT) varies between 4% and 32%, with a predominance of mild or moderate cases. Although it is generally asymptomatic it does have an impact on their quality of life and survival. The diagnosis requires taking an arterial blood gas sample of a seated patient with alveolar-arterial oxygen gradient (AaO₂) ≥ 15 mm Hg, or ≥ 20 mm Hg in those over 64 years of age. The IPVD are identified through a transthoracic contrast echocardiography or a macroaggregated albumin lung perfusion scan (^99mTc-MAA). There is currently no effective medical treatment. LT has been shown to reverse the syndrome and improve survival rates, even in severe cases. Therefore the policy of prioritizing LT would appear to increase survival rates. This paper takes a critical and clinical look at the current understanding of HPS, as well as the controversies surrounding it and possible future research.

Portopulmonary hypertension and hepatopulmonary syndrome

Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are two frequent complications of liver disease, with prevalence among liver transplant candidates of 6% and 10%, respectively. Both conditions result from a lack of hepatic clearance of vasoactive substances produced in the splanchnic territory. Subsequently, these substances cause mainly pulmonary vascular remodeling and some degree of vasoconstriction in POPH with resulting elevated pulmonary pressure and right ventricular dysfunction. In HPS the vasoactive mediators cause intrapulmonary shunts with hypoxemia. Medical treatment is disappointing overall. Whereas liver transplantation (LT) results in the disappearance of HPS within six to twelve months, its effect on POPH is highly unpredictable. Modern strategies in managing HPS and POPH rely on a thorough screening and grading of the disease’s severity, in order to tailor the appropriate therapy and select only the patients who will benefit from LT. The anesthesiologist plays a central role in managing these high-risk patients. Indeed, the important hemodynamic and respiratory modifications of the perioperative period must be avoided through continuation of the preoperatively initiated drugs, appropriate intraoperative monitoring and proper hemodynamic and respiratory therapies.

Respiratory system involvement in chronic liver diseases

Liver diseases are often associated with respiratory complications. They may manifest as pleural effusion, interstitial lung disease, as well as various combinations of symptoms affecting the pulmonary vasculature. The duration and severity of liver disease is not always reflected by the degree of lung function impairment. On the other hand, progressive damage to the lungs significantly worsens prognosis in the course of severe liver disease. The diagnosis is difficult and often requires multidisciplinary cooperation. The effects of pharmacological treatment are not always satisfactory. In numerous cases, liver transplantation proves to be the best option.

Screening of hepatopulmonary syndrome (HPS) with CEUS and pulse-oximetry in liver cirrhosis patients eligible for liver transplant

BACKGROUND AND AIM

The prevalence of hepatopulmonary syndrome (HPS) in the setting of cirrhosis ranges between 4%-47%. We aimed to detect a correlation between heart and lungs findings on contrast-enhanced ultrasound (CEUS)and pulse-oximetry, in order to early detect HPS and thus to improve patients referral to orthotopic liver transplantation(OLT).

METHODS

We considered at risk for HPS all patients with delayed left ventricle (LV) enhancement of the contrast agent,at least 3 systolic beats after it appears in the right ventricle(RV). We correlated CEUS results with pulse-oximetry findings,considering to have a positive HPS diagnosis in all patients with both CEUS findings and SaO2 95%.

RESULTS

From 186 patients diagnosed with liver cirrhosis, 56 patients (30.10%) had delayed LV enhancement of the contrast agent. Pulse-oximetry showed alterations, such as SaO2 95%and PaO2 70 mmHg in 62 patients (33.33%). Pearson index showed a good correlation between lung and heart CEUS findings and pulse-oximetry (r=0.99) in HPS diagnosis. CONCLUSIONS. Two non-invasive, simple and rapid methods such as CEUS and pulse-oximetry can easily diagnose HPS, a highly fatal complication of liver cirrhosis, and can also guide the future treatment by speeding up OLT recommendations.

[Gaseous disorders and their role in the development of hepatopulmonary syndrome in liver cirrhosis associated with COPD]

OBJECTIVE

To evaluate the indicators of arterial blood gasometry and levels of nitric oxide (NO) in exhaled breath of patients with liver cirrhosis (LC) in combination with COPD, and determine frequency of occurrence of hepatopulmonary syndrome (HPS). The comparison group consisted of 20 patients with COPD, control - 15 volunteers. Gas measurement was estimated by ABL 725 radiometer (Denmark).

MATERIAL AND METHODS

We examined 57 patients with liver cirrhosis. The patients were divided into 2 groups: 1st--Patients with liver cirrhosis (n = 48), 2nd group--the CPU and COPD (n = 9). Comparison group consisted of 20 patients with COPD, control - 15 volunteers. The gasometry was evaluated by ABL 725 radiometer (Denmark). NO levels in exhaled air was estimated using the NIOX MINO (Sweden). Contrast electrocardiography was performed on ATL HDI 5000 (Bothell, WA, USA).

RESULTS

We found that the PaO2 was lower in the 2nd group compared with the control and with the 1st group (81.4 +/- 5.2; 95.5 +/- 5.3 and 94.5 +/- 5.1 mm Hg; p < 0.05), but the lowest PaO2 was in the group with COPD (68.4 mm Hg). AaDO2 was higher in the group with COPD (37.7 mm Hg). In the 2nd group this indicator was higher as compared with the control and with the 1st group (26.8 +/- 5.4; 8.2 +/- 4.5 and 14.9 +/- 5.2 mm Hg; p < 0.05). A strong negative correlation in the 1st and the 2nd groups between AaDO2 and PaO2 (r = -0.67 and r = -0.93; p < 0.05) was obtained. Content of NO in exhaled air was higher in the 1st and 2nd groups compared with control (18.7 +/- 4.1; 18,9 +/- 4.5 and 11.0 +/- 3.3 ppb; p < 0.05). Intrapulmonary shunts were detected in 3 patients in the 1st and 2nd groups.

CONCLUSION

The relationship between measures of blood gas composition showed the leading role of hypoxemia in increasing the risk of formation of HPS in the LC, especially when combined with COPD.

Pulmonary complications of cirrhosis

Pulmonary vascular complications of liver disease comprise two distinct clinical entities: hepatopulmonary syndrome (HPS-microvascular dilatation and angiogenesis) and portopulmonary hypertension (POPH-vasoconstriction and remodeling in resistance vessels). These complications occur in similar pathophysiologic environments and may share pathogenic mechanisms. HPS is found in 15% to 30% of patients with cirrhosis and its presence increases mortality and the risks of liver transplantation, particularly when hypoxemia is present. Contrast echocardiography and arterial blood gas analysis are required to establish the diagnosis. No medical therapies are available, although liver transplantation is effective in reversing the syndrome. POPH is found in 4% to 8% of patients undergoing liver transplantation evaluation, and the presence of moderate to severe disease significantly increases perioperative transplant mortality. Transthoracic echocardiography is recommended for screening and right-heart catheterization is required to establish the diagnosis. Medical therapies are increasingly effective in improving pulmonary vascular hemodynamics in POPH and may result in better perioperative outcomes.

Hepatopulmonary syndrome: prevalence and predictors in Egyptian cirrhotic patients

BACKGROUND

The reported prevalence of hepatopulmonary syndrome (HPS) in cirrhotic patients is heterogeneous. Although the prevalence of chronic liver diseases is high in Egypt, however, scanty data is available about HPS.

AIM

To assess the frequency of HPS and factors predictive of diagnosis of HPS in Egyptian patients with liver cirrhosis.

METHODS

Fifty cirrhotic patients were evaluated for the presence of HPS. Orthodeoxia was measured by arterial blood gas test. The patients positive for diagnostic criteria of HPS (the presence of A-a O2 > or = 15 mmHg and pulmonary vascular dilatation assessed by contrast enhanced echocardiography) were defined as clinical HPS cases and those manifesting with intrapulmonary arterial dilation but no other criteria were defined as subclinical HPS cases.

RESULTS

Subclinical HPS and clinical HPS was observed in 10 (20%) and 17 (34%) of the patients, respectively. The presence of HPS was significantly associated with severity of liver disease assessed by the Child-Pugh score (CP) or MELD score. Portal vein diameter (mm) (OR 3.3; 95% C.I 1.3-8.2; p=0.01) was the only independent predictor for HPS; the specificity of orthodeoxia for diagnosis of HPS was 100%.

CONCLUSIONS

HPS and intrapulmonary vein dilation are relatively frequent in patients with liver cirrhosis and occur in 34% and 20% of cirrhosis patients, respectively. They are associated with disease severity according to the MELD and CP score. Alveolar arterial oxygen gradient is the most valuable negative and positive diagnostic predictor for presence of HPS in cirrhotic patients.

[Pulmonary affection in advanced liver disease - hepatepulonary syndrome and portopulmonary hypertension]

Patients suffering from severe chronic liver disease, in particular cirrhosis, are at risk for pulmonary complications. The leading clinical symptom is shortness of breath, which can accompany the actual disease as indirect effect because of anemia, faint muscles or ascites. On the other hand, dyspnea can have multiple additive causes in case of accompanying cardial or pulmonary disease. The hepatopulmonary syndrome (HPS) and the portopulmonary hypertension (PoPH) belong to the most relevant pulmonary complications in liver cirrhosis. HPS appears to be more common than PoPH and the presence of either entity increases morbidity and mortality in patients with liver disease. The two diseases have to be strictly distinguished, as they have opposed histological and pathophysiological origin. While the HPS is a dilatative pulmonary- vascular disease, the PoPH is a constrictive or obliterative pulmonary-vascular disease in the context of a liver disease or a portal hypertension. Therefore, these diseases are separate entities also when it comes to diagnostics and therapy.

[Assessment of prevalence of intrapulmonary arterio-venous shunt in cirrhotic patients qualified to liver transplantation]

INTRODUCTION

Hepatopulmonary syndrome (HPS) is the clinical relationship between hepatic dysfunction and the arterial hypoxygenation caused by significant intrapulmonary arteriovenous blood leakage. HPS is responsible for increased peritransplant mortality. Data on prevalence of HPS are contradictory and its clinical risk factors are still unknown. Aim of the study was assessment of prevalence of HPS in cirrhotic patients qualified to liver transplantation and determination of clinical risk factors of this syndrome.

MATERIAL AND METHODS

The study involved 30 patients with advanced liver cirrhosis of different etiology, qualified to liver transplantation. In all patients the laboratory hepatic examinations, pulmonary function tests (spirometry, gasometry) and albumin lungs-brain scintigraphy were performed.

RESULTS

We did not find symptomatic HPS in the investigated group, but 2 patients (6.6%) with alcoholic cirrhosis showed arterio-venous intrapulmonary shunt. No significant differences in demographic and clinical data were found between patients with and without intrapulmonary shunt.

CONCLUSIONS

Symptomatic HPS is rare complication of advanced cirrhosis. Symptom free intrapulmonary shunt occurs in less than 10% of patients, however, significance and clinical risk factors of this phenomenon remain unknown.

[Pulmonary complications of hepatic cirrhosis: portopulmonary hypertension and hepatopulmonary syndrome. The paradox of pulmonary vasoconstriction and vasodilation]

Cardiopulmonar complications in chronic liver diseases were described 100 years ago. Altough both hepatopulmonary sindrome and portopulmonary hypertension originates from liver damage, clinical findings and diagnosis are very different. These complications are important due to the highly deleterous impact on disease evolution and prognosis. Currently, there is not an ideal treatment for these diseases and liver transplantation should be adequately evaluated. In this review we analyze the most important issues on hepatopulmonary sindrome and portopulmonary hypertension. These complications,under the cornerstone of portal hypertension are characterized by pulmonary constriction and dilatation, respectively.

Pediatric hepatopulmonary syndrome is seen with polysplenia/interrupted inferior vena cava and without cirrhosis

Hepatopulmonary syndrome (HPS) is a triad of liver dysfunction, hypoxemia, and intrapulmonary vascular dilatation. We describe the prevalence and clinical features of HPS at a pediatric liver transplant center. Patients referred to Children's Healthcare of Atlanta/Emory University transplant program from February 1999 to May 2005 were reviewed. Oxygen saturation in room air was screened by percutaneous pulse oximetry. HPS cases were compared with similar age non-HPS recipients (n = 38) to determine differences in clinical characteristics, Pediatric End-Stage Liver Disease (PELD) scores, and posttransplantation survival. Of 211 patients referred and 114 patients transplanted, 7 met criteria for HPS (3.3% and 6.1%, respectively). Patients with HPS had lower PELD score (-0.4 +/- 5.9 vs. 11 +/- 11; P = 0.01) and total bilirubin (1.7 +/- 1.1 vs. 11.2 +/- 10.1; P = 0.02) at the time of transplantation. Four of 7 patients with HPS had polysplenia/interrupted inferior vena cava (PS/IVC) compared with 0 of 38 age-matched controls (P = 0.0002). Three patients with HPS did not have cirrhosis; 2 of these 3 had PS/IVC. All HPS cases normalized room air oxygen saturation by 6 months, and survival after transplantation in HPS cases was 100%. Marked hepatic synthetic or biochemical dysfunction may not be present, and cirrhosis is not a requirement for the development of HPS in children. HPS in children is frequently associated with PS/IVC. Histologic evidence of abnormal intrahepatic portal vein flow and the demonstration of portosystemic communications at any level should be sought in children presenting with unexplained intrapulmonary vascular dilatation. Liver transplantation for HPS in childhood may be appropriate even in the absence of cirrhosis.

Cost-effectiveness of screening for hepatopulmonary syndrome in liver transplant candidates

The hepatopulmonary syndrome (HPS) is present in 15-20% of patients with cirrhosis undergoing orthotopic liver transplantation (OLT) evaluation. Both preoperative and post-OLT mortality is increased in HPS patients particularly when hypoxemia is severe. Screening for HPS could enhance detection of OLT candidates with sufficient hypoxemia to merit higher priority for transplant and thereby decrease mortality. However, the cost-effectiveness of such an approach has not been assessed. Our objective was to perform a cost-effectiveness analysis from a third-party payer's perspective of screening for HPS in liver OLT candidates. The costs and outcomes of 3 different strategies were compared: (1) no screening, (2) screening patients with a validated dyspnea questionnaire, and (3) screening all patients with pulse oximetry. Arterial blood gas analyses and contrast echocardiography were performed in patients with dyspnea or a pulse oximetry (SpO(2)) < or =97% to define the presence of HPS. A Markov model was constructed simulating the natural history of cirrhosis in a cohort of patients 50 years old over a time horizon of their remaining life expectancy. Transition probabilities were obtained from published data available through Medline and U.S. vital statistics. Costs represented Medicare reimbursement data at our institution. Costs and health effects were discounted at a 3% annual rate. No screening was associated with a total cost of 291,898 dollars and a life expectancy of 11.131 years. Screening with pulse oximetry was associated with a cost of 299,719 dollars and a life expectancy of 12.27 years. Screening patients with the dyspnea-fatigue index was associated with a cost and life expectancy of 300,278 dollars and 12.28 years, respectively. The incremental cost-effectiveness ratio of screening with pulse oximetry (compared to no screening) was 6,867 dollars per life year gained, whereas that of the dyspnea-fatigue index (compared to pulse oximetry) was 55,900 dollars per life year gained. The cost-effectiveness of screening depended on the prevalence and severity of HPS, and the choice of screening strategy was dependent on the sensitivity of the screening modality. In conclusion, screening for HPS, especially with pulse oximetry, is a cost-effective strategy that improves survival in transplant candidates predominantly by targeting the transplant to the subgroup of patients most likely to benefit. The utility of screening depends on the prevalence and severity of HPS in the target population.

Hepatopulmonary syndrome in patients with hypoxic hepatitis

BACKGROUND & AIMS

The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and widespread pulmonary vasodilatation. Hypoxic hepatitis, also known as ischemic hepatitis, is the leading cause of acute liver impairment in hospitals. It is unknown whether HPS occurs in hypoxic hepatitis. We assessed the prevalence and clinical consequences of HPS in patients with hypoxic hepatitis.

METHODS

Forty-four patients with hypoxic hepatitis were screened prospectively for HPS using established criteria: (1) presence of hepatic disease, (2) increased alveolar-arterial difference for the partial pressure of oxygen greater than the age-related threshold, and (3) intrapulmonary vasodilatation detected via contrast-enhanced echocardiography. Sixty-two critically ill patients with different cardiopulmonary diseases but without hepatic disease were screened for prevalence of intrapulmonary vasodilatation as a control group.

RESULTS

Criteria of HPS were fulfilled in 18 patients with hypoxic hepatitis. HPS-positive patients had a significantly decreased partial pressure of arterial oxygen (P = .001) and partial pressure of arterial oxygen/fraction of inspired oxygen ratio (P = .034) at the time of diagnosis of HPS, a significant decreased area under the curve of the partial pressure of arterial oxygen/fraction of inspired oxygen ratio during the first 48 hours after diagnosis of hypoxic hepatitis (P = .009), and a significantly increased peak serum aspartate transaminase level (P = .028), compared with patients without HPS. Complete resolution of intrapulmonary vasodilatation was observed during follow-up evaluation. Contrast-enhanced echocardiography was negative for intrapulmonary vasodilatation in all 62 control patients.

CONCLUSIONS

Intrapulmonary vasodilatation indicating HPS frequently occurs in patients with hypoxic hepatitis. It is reversible after normalization of the hepatic dysfunction. Clinicians should consider intrapulmonary vasodilatation and HPS in patients with hypoxic hepatitis.

Cirrhotic rats with bacterial translocation have higher incidence and severity of hepatopulmonary syndrome

BACKGROUND

Bacterial translocation, that is, extra-intestinal dissemination of gut bacteria, occurs in approximately 50% of humans and rats with cirrhosis and plays a significant role in enhanced tumor necrosis factor-alpha (TNF-alpha) production. The authors' previous studies have indicated that prevention of bacterial translocation with norfloxacine or inhibition of TNF-alpha with pentoxifylline treatment decreased both the incidence and severity of hepatopulmonary syndrome by attenuating the induction of pulmonary intravascular macrophages in cirrhotic rats. In the present study the hypothesis was tested that the cirrhotic rats with bacterial translocation had higher TNF-alpha production, higher level of sequestration of macrophages in pulmonary vessels, and increased incidence and severity of hepatopulmonary syndrome.

METHODS

Rats were studied 5 weeks after common bile duct ligation or sham operation. Bacterial translocation was defined by positive mesenteric lymph node cultures. Hepatopulmonary syndrome was assessed by measurements of alveoloarterial oxygen difference (AaPO(2)) and intrapulmonary shunt. The TNF-alpha concentration in plasma was measured by ELISA. Pulmonary intravascular macrophage sequestration was assessed by lung morphometric analysis.

RESULTS

Bacterial translocation occurred in 48% of cirrhotic rats. Plasma concentrations of TNF-alpha and the percentage of vessels with pulmonary intravascular macrophages were higher in the cirrhotic rats with bacterial translocation. Rats with bacterial translocation also had a higher incidence (9% vs 63%, P < 0.01) and severity of hepatopulmonary syndrome, as indicated by higher levels of both AaPO(2) and intrapulmonary shunt.

CONCLUSIONS

These results suggest that bacterial translocation may play a role in the pathogenesis of hepatopulmonary syndrome by inducing pulmonary intravascular macrophages through TNF-alpha upregulation.

Liver transplant in a patient with a ventriculoperitoneal shunt

There are no published accounts of patients with ventriculoperitoneal shunts undergoing liver transplantation in the literature. Because patients with ventriculoperitoneal shunts are prone to infections, this may be a theoretical contraindication to transplantation. We present a case of a patient with cirrhosis who had a ventriculoperitoneal shunt placed many years prior to transplantation. The patient had no neurological complications and the shunt was intact and functioning. Prior to transplantation, the patient underwent a ventriculoperitoneal to ventriculopleural shunt conversion that was reversed posttransplantation. Apart from some minor complications, the patient has done remarkably well from a graft and neurological perspective. In conclusion, patients who have ventriculoperitoneal shunts may be considered for liver transplantation as the risk of infectious and neurological complications is low and there are no deleterious effects on graft survival.

[Hepatopulmonary syndrome in liver transplantation candidates]

BACKGROUND

Hepatopulmonary syndrome is an important clinical problem associated with chronic liver disease. Liver transplantation can result in complete resolution of the arterial hypoxemia associated with this syndrome, even in its most severe presentation.

AIM

To determine the prevalence of hepatopulmonary syndrome in adult liver transplant candidates.

PATIENTS AND METHODS

Fifty-four consecutives adult patients (> or = 18 years) with severe liver disease waiting for liver transplant were screened for arterial hypoxemia (PaO2 < 70 mm Hg) while they were seated, at rest, and breathing room air. Patients with arterial hypoxemia underwent contrast-enhanced two-dimensional echocardiography and pulmonary function testing. Hypoxemia (PaO2 < 70 mm Hg) was present in 7 of 54 patients (12.9%), although only 1 of them complained of dyspnea. The Child's classification of the patients were: A = 1, B = 4, and C = 1. All seven hypoxemic patients had positive contrast-enhanced two-dimensional echocardiography, consistent with hepatopulmonary syndrome.

CONCLUSION

The prevalence of hepatopulmonary syndrome in adult liver transplant candidates is elevated. The screening for hepatopulmonary syndrome should be part of the routine evaluation of liver transplant candidates even in the absence of pulmonary symptoms.

Prevalence of hepatopulmonary syndrome in cirrhosis and extrahepatic portal venous obstruction

OBJECTIVE

Hepatopulmonary syndrome (HPS) is characterized by arterial hypoxemia in patients with chronic liver disease caused by abnormal intrapulmonary vasodilations. Data on its frequency vary from 5% to 29%. Most of these studies are from the West and in patients with cirrhosis. We, therefore, studied the prevalence of HPS in patients with liver cirrhosis and extrahepatic portal venous obstruction (EHPVO).

METHODS

We studied 54 consecutive patients with liver cirrhosis (42 men and 12 women; mean age = 44.2 +/- 13 yr; Child grade A: 13, B: 22, and C: 19) and 50 patients with EHPVO (31 men and 19 women; mean age = 23.3 +/- 7.8 yr) Diagnosis of cirrhosis was made by history, liver function abnormalities, endoscopy, and sonography, whereas EHPVO was diagnosed by demonstration of a block in the splenoportovenous axis on sonography. Each of the patients underwent chest x-ray, arterial blood gas analysis, contrast-enhanced echocardiography (CEE), and pulmonary function tests. HPS was diagnosed in a patient with positive CEE, in the presence of hypoxia (PaO2 < 70 mm Hg) and/or elevated alveolar arterial oxygen gradient of > 20 mm Hg in the absence of any underlying cardiopulmonary disease.

RESULTS

Ten of 54 patients (18.5%) with cirrhosis were positive on CEE compared with two of 50 patients (4%) with EHPVO. Six of the 10 patients positive with cirrhosis for CEE had associated hypoxia, whereas only one EHPVO patient with positive CEE had an elevated pulmonary alveolar arterial oxygen gradient of > 20 mm Hg. Thus, the incidence of HPS was 11.1% in patients with cirrhosis, compared with 2% in patients with EHPVO. One patient with HPS and cirrhosis had clinical cyanosis.

CONCLUSION

HPS occurs more commonly in patients with cirrhosis but can also be seen in patients with EHPVO.

Hepatopulmonary syndrome in poorly compensated postnecrotic liver cirrhosis by hepatitis B virus in Korea

BACKGROUND

Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV.

METHODS

Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease.

RESULTS

Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients.

CONCLUSIONS

The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). 'Subclinical' hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.

Hepatopulmonary syndrome in candidates for liver transplantation

BACKGROUND

Hepatopulmonary syndrome (HPS) has been defined as a clinical triad, including chronic liver disease, gas exchange defects (increased alveolar-arterial PO2 difference irrespective of the presence of arterial hypoxemia), and widespread intrapulmonary vascular dilatations. We determined the incidence and the clinical and pulmonary functional characteristics of HPS in candidates for orthotopic liver transplantation (OLT) and tested their predicted accuracy.

METHODS

We studied 80 patients with cirrhosis prospectively, and carried out contrast-enhanced (CE) echocardiography and lung function tests, including ventilation-perfusion (V(A)/Q) distributions.

RESULTS

Fourteen patients had HPS (incidence, 17.5%). Patients with HPS (49 +/- 12 (+/-SD) years) had more cutaneous spiders, finger clubbing and dyspnea (P < 0.05 each) and a lower diffusing capacity (DLCO, 56 +/- 18% predicted; P < 0.001) than non-HPS patients (n = 66). Mild to moderate V(A)/Q inequalities and increased intrapulmonary shunt were predominant in HPS patients, but oxygen diffusion impairment was observed in those with hypoxemia (n = 8) only. The DLCO showed a considerable area under the receiver operating characteristic curve (0.89).

CONCLUSIONS

HPS in cirrhotic patient candidates for OLT shows a high incidence and these patients present with distinctive clinical and functional features compared with non-HPS individuals. The presence of a low DLCO may be of help for the diagnosis of HPS.

Hepatopulmonary syndrome: prevalence and clinical profile

BACKGROUND

The hepatopulmonary syndrome (HPS) is defined as a triad of liver dysfunction, intrapulmonary vascular dilatations (IPVD) and arterial hypoxemia. There is paucity of Indian studies regarding the prevalence of IPVD and arterial hypoxemia particularly amongst patients with non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO), where liver dysfunction is not a feature.

METHODS

All patients with portal hypertension and esophageal varices seen at a tertiary care hospital during 1995-98 were studied. Ultrasonography of abdomen, contrast-enhanced echocardiography (CEE), arterial blood gas analysis and assessment of alveolar-arterial oxygen gradient were done.

RESULTS

Of 138 patients with portal hypertension seen during the study period, 88 fulfilled the inclusion and exclusion criteria. These included 63 with cirrhosis, 15 with NCPF and 10 with EHPVO. CEE showed IPVD in 17 (27%) patients with cirrhosis, of which 11 (17.5%) fulfilled the criteria for HPS. IPVD were also noted in 4 (26.6%) cases of NCPF and 3 (30%) of EHPVO, though only 2 (13.3%) and 1 (10%) respectively had elevated alveolar-arterial gradient and liver dysfunction in addition. Age and sex distribution and duration of symptoms were not different in patients with HPS. Patients with HPS had higher incidence of dyspnea, platypnea, clubbing and spider nevi.

CONCLUSIONS

Hepatopulmonary syndrome is present in 17.5% of cirrhotics, 13.3% of patients with NCPF and 10% with EHPVO. Patients with HPS had significantly higher incidence of dyspnea, platypnea, clubbing and spider nevi.

Clinical and haemodynamic aspects of hepatopulmonary syndrome in Indian patients with cirrhosis

BACKGROUND

Hepatopulmonary syndrome consists of the triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatation and hypoxaemia, in the absence of detectable primary cardiopulmonary diseases. In the present study, we examined the frequency of hepatopulmonary syndrome among Indian patients with cirrhosis, and studied clinical predictors and pulmonary haemodynamic alterations.

METHODS

Forty-five patients with cirrhosis and no cardiopulmonary diseases were investigated by air-contrast echocardiography. Where patients were positive, arterial blood gas analysis was carried out. Positive contrast echocardiography with PO2 < 70 mmHg confirmed the diagnosis of hepatopulmonary syndrome. Three cases with the syndrome and 24 without were assessed for haemodynamic status by hepatic and pulmonary catheterization.

RESULTS

Four of 45 cases of cirrhosis (8.9%) had positive contrast echocardiographies, including three (6.7%) with hepatopulmonary syndrome and one 'subclinical' case (positive contrast echocardiography without hypoxaemia). Under haemodynamic study, the mean pulmonary arterial and pulmonary capillary wedge pressures appeared to be lower among those patients with hepatopulmonary syndrome.

CONCLUSIONS

In this small study, the frequency of hepatopulmonary syndrome was relatively low (6.7%). Cyanosis was the only reliable clinical indicator, and there was no clear relationship with the severity of cirrhosis by Child's grading.

High prevalence of pulmonary diffusion abnormalities without interstitial changes in long-term survivors of liver transplantation

Abnormalities in lung function are frequent findings in patients with terminal stage chronic liver disease. While spirometric parameters improve early after liver transplantation, a reduction in diffusion capacity has been reported up to 15 months after transplantation. It is unknown to what extent this disturbance in gas exchange occurs among long term survivors after liver transplantation. We assessed lung function in terms of spirometry, and gas exchange as well as pulmonary morphology by high resolution computed tomography (HRCT) in 40 patients 38 months (median, range 20-147 months) after liver transplantation. The prevalence of restrictive or obstructive changes was not different from predicted values. For the whole group of long-term survivors the carbon monoxide transfer coefficient (KCO) was reduced to 71.3 + 12.0% predicted (P < 0.05). HRCT revealed interstitial changes in only 2/40 (5.0%), emphysematous bullae in 2/40 (5.0%) and pleural thickening in 9/40 (22.5%). Diffusion abnormalities are prevalent in the majority of patients after liver transplantation, whereas spirometric abnormalities are absent also in the long term. The high prevalence of impaired gas exchange and the absence of interstitial lesions imply that changes in pulmonary blood vessels are the most likely cause.