Reduction of hypertension after liver disease

One-Year Mortality after Traumatic Brain Injury in Liver Cirrhosis Patients--A Ten-Year Population-Based Study

This study investigated the 1-year mortality of patients who underwent brain surgery following traumatic brain injury (TBI) who also had alcoholic and/or nonalcoholic liver cirrhosis (LC) using a nationwide database in Taiwan. A longitudinal cohort study matched by propensity score with age, gender, length of ICU stay, HTN, DM, MI, stroke, HF, renal diseases, and year of TBI diagnosis in TBI patients with alcoholic and/or nonalcoholic LC and TBI patients without LC was conducted using the National Health Insurance Research Database in Taiwan between January 1997 and December 2007. The main outcome studied was 1-year mortality. In total, 7296 subjects (2432 TBI patients with LC and 4864 TBI patients without LC) were enrolled in this study. The main findings were (1) TBI patients with LC had a higher 1-year mortality (52.18% vs 30.61%) and a 1.75-fold increased risk of mortality (95% CI 1.61-1.90) compared with non-LC TBI patients, (2) renal diseases and HF are risk factors, but hypertension could be a protective factor in cirrhotic TBI patients, and (3) TBI patients with non-alcoholic LC and the coexistence of alcoholic and nonalcoholic LC had higher 1-year mortality compared with TBI patients with alcoholic cirrhosis. This study showed that patients with LC who have undergone brain surgery might have higher risk of 1-year mortality than those without LC. In addition, nonalcoholic and the coexistence of alcoholic and nonalcoholic LC show higher 1-year mortality risk than alcoholic in TBI patients with LC, especially in those with comorbidities of hypertension, diabetes mellitus, and stroke.

Arterial blood pressure is closely related to ascites development in compensated HCV-related cirrhosis

Background

Arterial blood pressure (BP) is a reliable marker of circulatory dysfunction in cirrhotic patients. There are no prospective studies evaluating the association between different levels of arterial BP and ascites development in compensated cirrhotic patients. Therefore, we evaluated the relationship between arterial BP and ascites development in compensated cirrhotic patients.

Materials and Methods

A total of 402 patients with compensated HCV-related cirrhosis were prospectively followed during 6 years to identify ascites development. At baseline, patients underwent systolic, diastolic and mean arterial pressure (MAP) measurements. Any history of arterial hypertension was also recorded. The occurrence of events such as bleeding, hepatocellular carcinoma, death and liver transplantation prior to ascites development were considered as competing risk events.

Results

Over a median of 156 weeks, ascites occurred in 54 patients (13%). At baseline, MAP was significantly lower in patients with ascites development (75.9 mm/Hg [95%CI, 70.3–84.3]) than those without ascites (93.6 mm/Hg [95% CI: 86.6–102.3]). After adjusting for covariates, the 6-year cumulative incidence of ascites was 40% (95%CI, 34%–48%) for patients with MAP<83.32 mm/Hg. In contrast, cumulative incidences of ascites were almost similar among patients with MAP values between 83.32 mm/Hg and 93.32 mm/Hg (7% [95% CI: 4%–12%]), between 93.32 mm/Hg and 100.31 mm/Hg (5% [95% CI: 4%–11%]) or higher than 100.31 mm/Hg (3% [95% CI: 1%–6%]). The MAP was an independent predictor of ascites development.

Conclusions

The MAP is closely related to the development of ascites in compensated HCV-related cirrhosis. The risk of ascites development increases in 4.4 fold for subjects with MAP values <83.32 mm/Hg.

The haemodynamic response to propranolol in cirrhosis with arterial hypertension: a comparative analysis with normotensive cirrhotic patients

BACKGROUND

Cirrhosis with arterial hypertension is not uncommon. Haemodynamic alterations in these patients and the effects of beta-blocker on hepatic venous pressure gradient (HVPG) and systemic haemodynamics have not been evaluated.

AIMS

To compare the systemic haemodynamic alterations in hypertensive and normotensive cirrhotics, and to investigate the effects of propranolol on these parameters.

METHODS

A retrospective analysis of consecutive hypertensive cirrhotic patients (n = 33) who underwent haemodynamic assessment and paired HVPG measurement was done. Normotensive cirrhotics (n = 50) served as controls.

RESULTS

Hypertensive patients had a significantly higher heart rate, systemic (SVRI), and pulmonary vascular resistance. There was a significant reduction in mean arterial pressure (MAP) in the hypertensive cirrhotic group from 112 (107-130) mmHg to 95 (77-114) mmHg (P < 0.01), but no change in the normotensives. SVRI remained the same in the hypertensive cirrhotic group, but it increased in the normotensives. There was no correlation between MAP reduction and HVPG reduction.

CONCLUSIONS

The frequency of HVPG response with propranolol treatment in hypertensive cirrhotics is similar to normotensive cirrhotics. Propranolol treatment reduces MAP significantly in hypertensive patients with cirrhosis. Treatment with a nonselective beta-blocker is a good strategy for hypertensive cirrhotic patients.

Liver cirrhosis and arterial hypertension

Characteristic findings in patients with cirrhosis are vasodilatation with low overall systemic vascular resistance, high arterial compliance, increased cardiac output, secondary activation of counter-regulatory systems (renin-angiotensin-aldosterone system, sympathetic nervous system, release of vasopressin), and resistance to vasopressors. The vasodilatory state is mediated through adrenomedullin, calcitonin gene-related peptide, nitric oxide, and other vasodilators, and is most pronounced in the splanchnic area. This constitutes an effective (although relative) counterbalance to increased arterial blood pressure. This review considers the alterations in systemic hemodynamics in patients with cirrhosis in relation to essential hypertension and arterial hypertension of the renal origin. Subjects with arterial hypertension (essential, secondary) may become normotensive during the development of cirrhosis, and arterial hypertension is rarely manifested in patients with cirrhosis, even in cases with renovascular disease and high circulating renin activity. There is much dispute as to the understanding of homoeostatic regulation in cirrhotic patients with manifest arterial hypertension. This most likely includes the combination of vasodilatation and vasoconstriction in parallel.

Hypertension and liver disease

Arterial hypertension is a common disorder with a frequency of 10% to 15% in subjects in the 40- to 60-year age group. Yet most reports find the prevalence of arterial hypertension in patients with chronic liver disease (cirrhosis) much lower. In this review, we consider the alterations in systemic hemodynamics in cirrhosis. The most characteristic findings in cirrhotic patients are vasodilatation with low systemic vascular resistance, increased cardiac output, high arterial compliance, secondary activation of counterregulatory systems (sympathetic nervous system, renin-angiotensin-aldosterone system, neuropituitary release of vasopressin), and resistance to vasopressors. The vasodilatory state is mediated through nitric oxide, calcitonin gene-related peptide, adrenomedullin, and other vasodilators, and is most pronounced in the splanchnic area. This constitutes an effective (although relative) counterbalance to increased arterial blood pressure. Subjects with established arterial hypertension (essential, secondary) may become normotensive during the development of cirrhosis, and arterial hypertension is rarely manifested in patients with cirrhosis, even in cases with renovascular disease and high circulating renin activity. There is much dispute as to the understanding of homeostatic regulation in cirrhotic patients with manifest arterial hypertension. This is a topic for future research.

Cardiovascular and renal function in normotensive and hypertensive patients with compensated cirrhosis: effects of posture

BACKGROUND/AIMS

The aim of this study was to evaluate cardiovascular and renal function in patients with compensated cirrhosis and essential hypertension in the supine position and in response to standing up.

METHODS

Twenty-four patients with compensated cirrhosis (12 with elevated arterial pressure) and 20 healthy volunteers underwent echocardiographic evaluation of left ventricular end-diastolic and stroke volumes, ejection fraction, cardiac index, arterial pressure, peripheral resistance, creatinine clearance and sodium excretion in both the supine and the standing position.

RESULTS

When supine, only normotensive patients had a hyperdynamic circulation, with increased left ventricular end-diastolic and stroke volumes, cardiac index, and ejection fraction, and reduced peripheral resistance. Creatinine clearance and sodium excretion were comparable in patients and controls. Standing induced a decrease in end-diastolic volume in all subjects. Healthy volunteers maintained cardiovascular homeostasis by increasing ejection fraction and heart rate, while both normotensive and hypertensive cirrhotic patients experienced a fall in stroke volume and cardiac index, despite a marked activation of the renin-aldosterone and sympathetic nervous system. Creatinine clearance decreased only in normotensive patients, who experienced the greatest reduction in sodium excretion.

CONCLUSIONS

Compensated cirrhotic patients with arterial hypertension had no evidence of hyperdynamic circulation. Like their normotensive counterparts, hypertensive patients had an impaired cardiovascular response to the postural challenge, but a lesser degree of renal dysfunction during standing.

Hormonal aspects of the relation of liver cirrhosis to essential hypertension

The association of liver cirrhosis with arterial essential hypertension has been previously described. The present study extends the previous reports by investigating the hormonal relationships that may occur in patients with established essential hypertension associated to liver cirrhosis. We studied the renin-angiotensin, the adrenergic systems and other vasoactive hormones such as arginine-vasopressin, atrial natriuretic peptide, endothelin and parathyroid hormone in cirrhotic patients with and without essential hypertension. The data suggested that the coincidence of arterial hypertension in cirrhotic patients was characterized by the following findings: a decreased renin-angiotensin activity; a reduced systemic vasodilatation; an increased peripheral pressor effect of vasoactive hormones and an increased effective blood volume.

Portal hypertension ameliorates arterial hypertension in spontaneously hypertensive rats

Systemic hemodynamic effects of portal hypertension in arterial hypertension and their relationship to serum bile acid levels were investigated using spontaneously hypertensive rats 2 and 15 weeks after partial portal vein ligation (SHR-PVL) or sham operation (SHR-SH) and normotensive controls. Mean arterial pressure in SHR-PVL at 2 weeks was decreased to normal due to a decrease in peripheral resistance. Mean arterial pressure and peripheral resistance in SHR-PVL at 15 weeks did not differ from SHR-SH. Resolution of this arterial hypotensive effect and systemic hyperdynamic circulation was associated with decreased portal-systemic shunting. Bile acid levels were increased in both SHR-PVL groups. These results suggest that an endogenous circulating vasodilator(s) associated with portal hypertension ameliorates the systemic vasoconstriction in SHR. Bile acids, while not direct mediators of these hemodynamic events, may be prototypic of this vasodilator. This arterial hypertensive model may aid further investigation of the mechanisms contributing to the hyperdynamic state in portal hypertension.

The role of renin substrate in hypertension

A positive correlation between blood pressure and renin substrate concentration is found in a wide variety of conditions in human beings and in animal experiments. The evidence concerning this relationship is reviewed and the exceptions are discussed. The frequent positive correlation between renin substrate and elevated blood pressure suggests that increased renin substrate concentration may be a causal factor in hypertension.

Skeletal muscle blood flow and neurovascular reactivity in liver disease

There was no significant difference in forearm muscle blood flow, measured by the clearance of (133)Xenon when 38 patients with liver disease were compared with 38 normal subjects. Patients with a clinically hyperdynamic circulation, finger clubbing, and previous portocaval anastomoses were included in the study. The changes in forearm skeletal muscle blood flow and pulse rate caused by a head-up tilt of 70 degrees were measured in 15 patients with chronic liver disease and 15 age-matched controls. Head-up tilting resulted in significantly less peripheral vasoconstriction and tachycardia in the group with liver disease than in the control group. These results suggest an impairment of baroreceptor-mediated sympathetic reactivity in liver disease. Such a defect might explain the relative rarity of hypertension in patients with cirrhosis.

O comportam en to da pressão arterial na esquistossomose hepática e outras hepatopatias

O estudo de 911 pacientes hospitalizados para tratamento de variados casos de patologia interna mostrou 26,8% de hipertensos e 34,7% de doentes com alteração hepática, 17,7% dêstes apresentando hepatopatia esquistossomótica. A análise das observações resultem, na seleção de seis casos em que havia a coexistência de hipertensão e hepatopatia e que são estudados em separado. Outros seis casos foram encontrados em que a necrópsia revelou alteração hepática e o "rim da hipertensão essencial", mas em cujas observações clinioas não constava qualquer evidência de doença hipertensiva. A comparação da média das pressões arteriais mostrou diferença estatisticamente significante para as pressões sistólicas e diastólicas, sendo mais altas entre os pacientes não hepatopatas. Fêz-se, também, minuciosa revisão da literatura.