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Melo-Silva CA, Nunes WMC, Nascimento ESP, Guerra EM, Roza MR, Silva-Costa S, Machado-Silva W, Avelar GG, Nóbrega OT, Amado VM. Modulating respiratory mechanics and inflammation in hepatopulmonary syndrome: Aerobic exercise as a therapeutic strategy. Respir Physiol Neurobiol 2025; 335:104410. [PMID: 39947455 DOI: 10.1016/j.resp.2025.104410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Revised: 02/03/2025] [Accepted: 02/09/2025] [Indexed: 02/16/2025]
Abstract
INTRODUCTION Aerobic exercise training positively modulates the immune system and improves lung function; however, its effects on respiratory system's elastic, resistive properties and interleukin-10 (IL-10) concentration in hepatopulmonary syndrome (HPS) remains unexplored. This study aimed to assess whether moderate-intensity aerobic (AE) training altered exercise capacity, respiratory mechanics and lung inflammation. MATERIAL AND METHODS Wistar rats were randomly assigned to SHAM, HPS, HPS + AE4, and HPS + EA8 groups. The EA4 group represents AE training for 4 weeks starting 7 days after HPS induction, whereas EA8 accounts for AE training for 4 weeks before and after HPS induction, both protocols practiced 3 times weekly. Exercise capacity, respiratory mechanics, lung and systemic inflammation, and lung morphology were assessed. RESULTS Moderate aerobic exercise significantly increased the maximal running capacity of the HPS animals. The training decreased tissue elastance by 19 % (p = 0.01 compared to SHAM) and reduced frequency-dependent respiratory reactance at 0.5 Hz, 0.75 Hz, and 1.25 Hz frequencies compared to HPS animals (p < 0.05 for all). For the HPS + EA4 and HPS + EA8 groups IL-10 plasma concentration increased by 23 % and 31 % compared to SHAM (p < 0.001 both) and by 38 % and 47 % compared to HPS (p < 0.01 both). Nonetheless, AE did not alleviate lung tissue remodeling induced by HPS. CONCLUSIONS Moderate-intensity aerobic training improved maximum running capacity, reduced HPS-induced respiratory mechanics derangements at the lung regional level, and increased systemic IL-10 concentration, although it did not ameliorate lung tissue remodeling.
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Affiliation(s)
- César Augusto Melo-Silva
- Laboratory of Respiratory Physiology, University of Brasilia, Brasília, DF, Brazil; Division of Physical Therapy, Brasilia University Hospital, Brasília, DF, Brazil; Graduate Program in Medical Sciences, School of Medicine, University of Brasilia, Brasília, DF, Brazil.
| | | | | | | | | | - Suellen Silva-Costa
- Laboratory of Respiratory Physiology, University of Brasilia, Brasília, DF, Brazil
| | - Wilcelly Machado-Silva
- Graduate Program in Medical Sciences, School of Medicine, University of Brasilia, Brasília, DF, Brazil
| | - Gleiciane Gontijo Avelar
- Graduate Program in Medical Sciences, School of Medicine, University of Brasilia, Brasília, DF, Brazil
| | - Otávio Toledo Nóbrega
- Graduate Program in Medical Sciences, School of Medicine, University of Brasilia, Brasília, DF, Brazil
| | - Veronica Moreira Amado
- Laboratory of Respiratory Physiology, University of Brasilia, Brasília, DF, Brazil; Graduate Program in Medical Sciences, School of Medicine, University of Brasilia, Brasília, DF, Brazil; Division of Pulmonology, Brasilia University Hospital, Brasília, DF, Brazil
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Chen J, Guo Y, Zhang X, Zhou D, Zhou Y, Pan Q, Chai J, Gao J. Disruption of Hepatic Sinusoidal Homeostasis Leads to Hepatopulmonary Syndrome. J Cell Mol Med 2025; 29:e70585. [PMID: 40344298 PMCID: PMC12061640 DOI: 10.1111/jcmm.70585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Revised: 04/22/2025] [Accepted: 04/26/2025] [Indexed: 05/11/2025] Open
Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of liver disease and/or portal hypertension. HPS manifests as impaired gas exchange and hypoxemia due to intrapulmonary vascular dilatations and shunts. In response to primary liver disease, the abnormal adaptation of respiratory epithelial cells, pulmonary endothelial cells and immune cells leads to pulmonary microenvironment disequilibrium and HPS. In this review, we explore the pathophysiologic mechanisms of HPS, including vascular dilation, angiogenesis and alveolar dysfunction. The liver is the primary contributor to HPS, and liver transplantation is the only treatment that generally reverses HPS. We then discuss how disruption of hepatic sinusoidal homeostasis may impact the progression of HPS, mainly focusing on hepatocytes, cholangiocytes, LSECs and macrophages. As HPS occurs more commonly in advanced liver cirrhosis, we also discuss that normalisation of liver dysfunction and portal hypertension is crucial for the resolution of HPS. In conclusion, liver-targeted therapies may be effective in treating HPS.
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Affiliation(s)
- Jiaxin Chen
- Department of Gastroenterology, Lab of Gastroenterology and HepatologyWest China Hospital, Sichuan UniversityChengduChina
| | - Yangkun Guo
- Department of Gastroenterology, Lab of Gastroenterology and HepatologyWest China Hospital, Sichuan UniversityChengduChina
| | - Xiaoxun Zhang
- Department of Gastroenterology, Institute of Digestive Disease of PLA, Cholestatic Liver Diseases Center and Center for Metabolic Associated Fatty Liver DiseaseThe First Affiliated Hospital (Southwest Hospital), Third Military Medical University (Army Medical University)ChongqingChina
| | - Dengcheng Zhou
- Key Laboratory of Birth Defects of MOE, State Key Laboratory of Biotherapy, West China Second Hospital, College of Life SciencesSichuan UniversityChengduChina
| | - Yongfang Zhou
- Department of Respiratory CareWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Qiong Pan
- Department of Gastroenterology, Institute of Digestive Disease of PLA, Cholestatic Liver Diseases Center and Center for Metabolic Associated Fatty Liver DiseaseThe First Affiliated Hospital (Southwest Hospital), Third Military Medical University (Army Medical University)ChongqingChina
| | - Jin Chai
- Department of Gastroenterology, Institute of Digestive Disease of PLA, Cholestatic Liver Diseases Center and Center for Metabolic Associated Fatty Liver DiseaseThe First Affiliated Hospital (Southwest Hospital), Third Military Medical University (Army Medical University)ChongqingChina
| | - Jinhang Gao
- Department of Gastroenterology, Lab of Gastroenterology and HepatologyWest China Hospital, Sichuan UniversityChengduChina
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3
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Wu ZP, Wang YF, Shi FW, Cao WH, Sun J, Yang L, Ding FP, Hu CX, Kang WW, Han J, Yang RH, Song QK, Jin JW, Shi HB, Ma YM. Predictive models and clinical manifestations of intrapulmonary vascular dilatation and hepatopulmonary syndrome in patients with cirrhosis: Prospective comparative study. World J Gastroenterol 2025; 31:105720. [PMID: 40309225 PMCID: PMC12038555 DOI: 10.3748/wjg.v31.i15.105720] [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: 02/12/2025] [Revised: 03/13/2025] [Accepted: 03/26/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Patients with cirrhosis with hepatopulmonary syndrome (HPS) have a poorer prognosis. The disease has a subtle onset, symptoms are easily masked, clinical attention is insufficient, and misdiagnosis rates are high. AIM To compare the clinical characteristics of patients with cirrhosis, cirrhosis combined with intrapulmonary vascular dilatation (IPVD), and HPS, and to establish predictive models for IPVD and HPS. METHODS Patients with cirrhosis were prospectively screened at a liver-specialized university teaching hospital. Clinical information and blood samples were collected, and biomarker levels in blood samples were measured. Patients with cirrhosis were divided into three groups: Those with pure cirrhosis, those with combined IPVD, and those with HPS based on contrast-enhanced transthoracic echocardiography results and the pulmonary alveolar-arterial oxygen gradient values. Univariate logistic regression and Least Absolute Shrinkage and Selection Operator (LASSO) regression methods were utilized to identify risk factors for IPVD and HPS, and nomograms were constructed to predict IPVD and HPS. RESULTS A total of 320 patients were analyzed, with 101 diagnosed with IPVD, of whom 54 were diagnosed with HPS. There were statistically significant differences in clinical parameters among these three groups of patients. Among the tested biomarkers, sphingosine 1 phosphate, angiopoietin-2, and platelet-derived growth factor BB were significantly associated with IPVD and HPS in patients with cirrhosis. Following LASSO logistic regression screening, prediction models for IPVD and HPS were established. The area under the receiver operating characteristic curve for IPVD prediction was 0.792 (95% confidence interval [CI]: 0.737-0.847), and for HPS prediction was 0.891 (95%CI: 0.848-0.934). CONCLUSION This study systematically compared the clinical characteristics of patients with cirrhosis, IPVD, and HPS, and constructed predictive models for IPVD and HPS based on clinical parameters and laboratory indicators. These models showed good predictive value for IPVD and HPS in patients with cirrhosis. They can assist clinicians in the early prognosis assessment of patients with cirrhosis, ultimately benefiting the patients.
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Affiliation(s)
- Zhi-Peng Wu
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Ying-Fei Wang
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Feng-Wei Shi
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Wen-Hui Cao
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Jie Sun
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Liu Yang
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Fang-Ping Ding
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Cai-Xia Hu
- Hepatic Disease and Tumor Interventional Treatment Center, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Wei-Wei Kang
- Fourth Department of Liver Disease, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Jing Han
- Ultrasound and Functional Diagnosis Center, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Rong-Hui Yang
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Qing-Kun Song
- Division of Clinical Epidemiology and Evidence-Based Medicine, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Jia-Wei Jin
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100043, China
| | - Hong-Bo Shi
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Ying-Min Ma
- Beijing Institute of Hepatology, Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing 100069, Beijing, China
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Robert F, Benchenouf F, Ha MN, Cuomo A, Ottaviani M, Surbier M, Thuillet R, Normand C, Dumont F, Verstuyft C, Fiore F, Guinut F, Humbert M, Coilly A, Gonzales E, Sitbon O, Tu L, Guignabert C, Savale L. Placental growth factor modulates endothelial NO production and exacerbates experimental hepatopulmonary syndrome. JHEP Rep 2025; 7:101297. [PMID: 39980753 PMCID: PMC11840504 DOI: 10.1016/j.jhepr.2024.101297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 11/27/2024] [Accepted: 12/05/2024] [Indexed: 02/22/2025] Open
Abstract
Background & Aims Hepatopulmonary syndrome (HPS) results from portal hypertension, with or without cirrhosis, and is marked by pulmonary vascular dilations leading to severe hypoxemia. Although placental growth factor (PlGF) is important for vascular growth and endothelial function, its role in HPS is unclear. This study investigated the involvement of PlGF in experimental models of HPS and in patients. Methods Circulating PlGF levels were measured in 64 controls and 137 patients with liver disease, with or without HPS. Two rat models, common bile duct ligation (CBDL) and long-term partial portal vein ligation (PPVL), were used. Plgf-knockout (Plgf -/-) rats were generated using CRISPR-Cas9. Lung RNA-sequencing analysis was performed in the CBDL model. The effects of PlGF on endothelial nitric oxide synthase (eNOS) activity in human pulmonary microvascular endothelial cells were also investigated. Results Circulating PlGF levels were significantly higher in patients with cirrhosis compared with healthy controls (29.4 ± 1.2 vs. 20.2 ± 0.8 pg/ml, p <0.0001), but no difference were found between patients with and without HPS. PlGF levels were not elevated in patients with extrahepatic portal hypertension. In Plgf -/- rats, there was a protective effect against CBDL-induced HPS, whereas PPVL-induced HPS severity remained unchanged. RNA sequencing coupled with ingenuity pathway analysis identified significant interactions between PlGF and pulmonary eNOS activity. Following CBDL, Plgf -/- rats showed decreased pulmonary eNOS activity and reduced circulating nitric oxide metabolites. In vitro, PlGF stimulation enhanced eNOS activity in human pulmonary microvascular endothelial cells, whereas PlGF knockdown led to a decrease. Conclusions These findings indicate that PlGF aggravates cirrhosis-induced HPS through modulation of pulmonary eNOS activity, and is not involved in HPS from extrahepatic portal hypertension. Impact and implications This study identified PlGF as a significant contributor to the exacerbation of HPS associated with cirrhosis, through its regulation of pulmonary nitric oxide production. Our findings demonstrated that PlGF deficiency mitigates the severity of both cirrhosis and HPS in the CBDL model, highlighting its potential as a therapeutic target in cirrhosis-induced HPS. Notably, this protective effect was absent in the PPVL model, which induces HPS associated with portal hypertension without cirrhosis. These results open avenues for novel pharmacological interventions aiming to improve outcomes for patients with cirrhosis-induced HPS.
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Affiliation(s)
- Fabien Robert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Feriel Benchenouf
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - My Ngoc Ha
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Alessandra Cuomo
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Mina Ottaviani
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Maxime Surbier
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Raphaël Thuillet
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Corinne Normand
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Florent Dumont
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Céline Verstuyft
- Université Paris-Saclay, Centre de Ressource Biologique Paris-Saclay, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Frederic Fiore
- Centre d'Immunophénomique (CIPHE), Aix Marseille Université, INSERM, CNRS, CELPHEDIA, PHENOMIN, Marseille, France
| | | | - Marc Humbert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de L’hypertension Pulmonaire (PulmoTension), AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Audrey Coilly
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
- INSERM UMR_S 1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Emmanuel Gonzales
- INSERM UMR_S 1193, Hepatinov, University Paris-Saclay, Orsay, France
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de L’hypertension Pulmonaire (PulmoTension), AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Ly Tu
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- INSERM, UMR_S 999 Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT), Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de L’hypertension Pulmonaire (PulmoTension), AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Rolim MM, Farsoun LG, Luna CF, Markman-Filho B, Querette P, Lopes EP, Domingues AL. Survival of patients with hepatopulmonary syndrome related to cirrhotic and non-cirrhotic (schistosomiasis) portal hypertension. World J Hepatol 2025; 17:99134. [PMID: 40027571 PMCID: PMC11866160 DOI: 10.4254/wjh.v17.i2.99134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 12/19/2024] [Accepted: 12/25/2024] [Indexed: 02/20/2025] Open
Abstract
BACKGROUND The hepatosplenic schistosomiasis (HSS) with portal hypertension can cause vascular complications such as hepatopulmonary syndrome (HPS). HPS increases the risk of mortality in patients with cirrhosis; however, there is no data on the mortality of patients with HSS and HPS. AIM To perform a survival analysis of patients with HPS related to cirrhotic and non-cirrhotic (schistosomiasis) portal hypertension. METHODS From August 2023 to January 2024, medical records and the official mortality information service of 121 patients who participated in a cross-sectional study on HPS between 2010 and 2012 were analyzed. Survival curves were created using the Kaplan-Meier method, and comparisons were performed using the log-rank test. Cox regression models estimated the hazard ratios (HR). RESULTS Overall, data of 113 patients were analyzed; most (55.8%) had HSS and concomitant cirrhosis (HSS/cirrhosis). Meanwhile, HPS was present in 39 (34.5%) patients. Death occurred in 65 patients [57.5%; 95% confidence interval (CI): 48%-67%. The average time to death was lower in those with HPS when compared to those without HPS (3.37 years vs 5.65 years; P = 0.017). According to the cause of liver disease, patients with HSS/cirrhosis died earlier, and their risk of death was twice as high compared with patients with HSS without cirrhosis (HR: 2.17; 95%CI: 1.3-3.60; P = 0.003). Meanwhile, there were no differences when comparing the two groups with and without HPS (HR: 1.01; 95%CI: 0.59-1.73; P = 0.967). CONCLUSION Patients with HSS and concomitant cirrhosis had a lower survival rate, but there was no difference in survival regardless of the presence of HPS.
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Affiliation(s)
- Melissa M Rolim
- Postgraduate Program in Tropical Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil.
| | - Liana G Farsoun
- Faculdade de Medicina UniNassau, Grupo Ser Educacional, Recife 50100220, Pernambuco, Brazil
| | - Carlos F Luna
- Statistics and Geoprocessing Center, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife 50740465, Pernambuco, Brazil
| | - Brivaldo Markman-Filho
- Department of Cardiology Division, Hospital das Clínicas/EBSERH-Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
- Department of Internal Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
| | - Paulo Querette
- Postgraduate Program in Translational Health, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
| | - Edmundo P Lopes
- Postgraduate Program in Tropical Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
- Department of Internal Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
- Department of Gastroenterology Division, Hospital das Clínicas/EBSERH-Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
| | - Ana L Domingues
- Postgraduate Program in Tropical Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
- Department of Internal Medicine, Center of Medical Sciences, Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
- Department of Gastroenterology Division, Hospital das Clínicas/EBSERH-Universidade Federal de Pernambuco, Recife 50670901, Pernambuco, Brazil
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6
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Mohammadi M, Hasjim BJ, Balbale SN, Polineni P, Huang AA, Paukner M, Banea T, Dentici O, Vitello DJ, Obayemi JE, Duarte-Rojo A, Nadig SN, VanWagner LB, Zhao L, Mehrotra S, Ladner DP. Disease trajectory and competing risks of patients with cirrhosis in the US. PLoS One 2025; 20:e0313152. [PMID: 39951428 PMCID: PMC11828360 DOI: 10.1371/journal.pone.0313152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 10/19/2024] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Cirrhosis is a dynamic disease process leading to liver-related death, which has increased by over 65% over the last decade. Unpredictable hepatic decompensation complications are a major source of morbidity and mortality. Thus, accurately characterizing disease progression through discrete stages of cirrhosis is critical towards implementing timely intervention and liver transplant (LT) waitlisting. METHODS A retrospective, longitudinal, population-cohort study of adult patients with cirrhosis from a US metropolitan area (2006-2012) was conducted. Clinical diagnoses were defined by ICD-9 and CPT codes. Cirrhosis stages were defined as: compensated without portal hypertension (Stage 1), compensated with portal hypertension (Stage 2), variceal bleeding (Stage 3), hepatic encephalopathy (Stage 4a), ascites (Stage 4b), and ≥2 different decompensating complications (Stage 5). Multivariate Fine-Gray competing risk survival analysis adjusted for clinicodemographic covariates. RESULTS Among 12,196 patients with cirrhosis, the mean (±SD) age was 56.8 (±11.7) years with a follow-up time of 2.35 (±1.81) years. A novel 5-stage disease progression framework was used. The 1-year mortality rates for each stage were 7.3% for Stage 1, 5.4% for Stage 2, 11.4% for Stage 3, 10.0% for Stage 4a, 20.2% for Stage 4b, and 43.8% for Stage 5. Compared to those in Stage 1, Stage 3 (sHR:1.83, 95% CI:1.36-2.48, P<0.001), Stage 4b (sHR:1.45, 95% CI:1.23-1.70, P<0.001), and Stage 5 (sHR:1.95, 95% CI:1.71-2.23, P<0.001) patients had higher risks of mortality. Additional disease progression rates were identified. CONCLUSION Even among patients with compensated cirrhosis, the 1-year mortality rate was as high as 7.3% and subsequently increases with each decompensation complication. This one-year mortality rate is higher than 5-years mortality rate reported in previously known non-US studies. The highest associated risk of death was observed among patients with ≥2 different decompensating complications (95.2%), variceal bleeding (83.2%) and ascites (44.9%). Overall, patients in advanced stages of cirrhosis were more likely to die than they were to receive a LT, suggesting that patients should be referred and waitlisted for LT earlier in the disease process.
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Affiliation(s)
- Mohsen Mohammadi
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, IL, United States of America
| | - Bima J. Hasjim
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Salva N. Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL, United States of America
- Department of Surgery, Center for Health Services and Outcomes Research, Institute of Public Health and Medicine & Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, United States of America
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Alexander A. Huang
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Mitchell Paukner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University, Chicago, IL, United States of America
| | - Therese Banea
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Oriana Dentici
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Dominic J. Vitello
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Joy E. Obayemi
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Andrés Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Satish N. Nadig
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, IL, United States of America
| | - Lisa B. VanWagner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Lihui Zhao
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University, Chicago, IL, United States of America
| | - Sanjay Mehrotra
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, IL, United States of America
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, IL, United States of America
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7
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Zaka AZ, Mangoura SA, Ahmed MA. New updates on hepatopulmonary syndrome: A comprehensive review. Respir Med 2025; 236:107911. [PMID: 39662637 DOI: 10.1016/j.rmed.2024.107911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 11/28/2024] [Accepted: 12/08/2024] [Indexed: 12/13/2024]
Abstract
Hepatopulmonary syndrome (HPS) is a serious pulmonary vascular complication that causes arterial hypoxemia in the setting of liver disease. HPS has a progressive course and is associated with a two-fold increased risk of mortality relative to cirrhotic patients without HPS. It primarily affects patients with portal hypertension. The key pathological features of HPS include intrapulmonary angiogenesis and vascular dilations (IPVDs). The prevalence of HPS varies widely due to inconsistent diagnostic criteria and a lack of standardized protocols. Despite advances in understanding its pathophysiology, no effective curative treatments for HPS exist. Liver transplantation remains the only definitive treatment, improving survival and altering the disease natural course. This review explores the pathophysiology, clinical features, and therapeutic strategies for HPS, highlighting recent advances in the literature.
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Affiliation(s)
- Andrew Z Zaka
- Department of Medical Pharmacology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt.
| | - Safwat A Mangoura
- Department of Medical Pharmacology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt; Department of Pharmacology and Toxicology, Faculty of Pharmacy, Badr University in Cairo (BUC), Badr, Cairo, 11829, Egypt.
| | - Marwa A Ahmed
- Department of Medical Pharmacology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
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8
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Chan SK, Buitrago Blanco MM, Feduska NJ, Agopian VG, Ebaid SS, Wang T, Tamhaney A, Barjaktarevic I. Cerebrovascular Accidents After Orthotopic Liver Transplantation in Patients with Hepatopulmonary Syndrome: A Case Series. Clin Pract 2024; 15:5. [PMID: 39851788 PMCID: PMC11764223 DOI: 10.3390/clinpract15010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 11/22/2024] [Accepted: 12/25/2024] [Indexed: 01/26/2025] Open
Abstract
Background: Hepatopulmonary syndrome (HPS), defined by the presence of pulmonary vascular dilatations that cause right-to-left transpulmonary shunting of venous blood with a consequential increase in the alveolar-arterial oxygen gradient, is a relatively frequent complication of chronic liver disease. While orthotopic liver transplantation (OLT) is indicated and often curative in HPS patients with end-stage liver disease (ESLD), little is known about the peri- and post-operative-period risks of CVA in OLT recipients with HPS. Case Presentation: We report a case series of five non-consecutive OLT recipients with HPS who developed ischemic and/or hemorrhagic CVAs during or shortly after OLT, raising concern that the risks of neurological complications remain increased even after OLT. Conclusions: Our case series hopes to highlight the importance of close vigilance in this subset of patients, at a time when there may be multiple issues to be addressed in facilitating post-operative recovery.
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Affiliation(s)
- Steffi K. Chan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | | | - Nicholas J. Feduska
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; (N.J.F.)
| | - Vatche G. Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; (N.J.F.)
| | - Samer S. Ebaid
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; (N.J.F.)
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Ami Tamhaney
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
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9
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Hui Y, Wang H, Guo G, Yang W, Wang X, Cui B, Fan X, Sun C. Health-related quality of life and frailty in liver cirrhosis. BMJ Support Palliat Care 2024; 14:e2880-e2887. [PMID: 38471790 DOI: 10.1136/spcare-2024-004839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND OBJECTIVES There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort. METHODS This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses. RESULTS More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty. CONCLUSIONS Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Han Wang
- Tianjin Hospital, Hexi District, Tianjin, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
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10
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Lai Y, Hung HC, Lee JC, Wang YC, Cheng CH, Wu TH, Wu TJ, Chou HS, Chan KM, Lee WC, Lee CF. Hepatopulmonary Syndrome and Liver Transplantation: Impact on Survival and Postoperative Complications. Ann Transplant 2024; 29:e945297. [PMID: 39623708 PMCID: PMC11624605 DOI: 10.12659/aot.945297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 10/04/2024] [Indexed: 12/09/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) is the preferred treatment for patients with cirrhosis who have hepatopulmonary syndrome (HPS). However, the effect of HPS on LT remains controversial. We assessed the correlation between HPS severity and LT survival and compared the incidence of postoperative complications between patients with and without HPS undergoing LT. MATERIAL AND METHODS We retrospectively reviewed the recipients who received living-donor LT in our institute between January 2016 and July 2019. Patients with HPS (HPS group) and patients without HPS (non-HPS group) were included in our study. HPS is defined as a defect in arterial oxygenation caused by the presence of intrapulmonary vascular dilatations, which is found by transthoracic echocardiography with pre-existing liver cirrhosis. HPS severity was graded according to the value of partial pressure of arterial oxygen. The demographic characteristics and clinical outcomes between the HPS and non-HPS groups were compared. RESULTS A total of 181 patients were enrolled. Among them, 104 patients (57.5%) had HPS. The mean overall survival of HPS and non-HPS groups was 69.82±3.1 vs 63.36±3.8 months, with no significant difference (P=0.332). The overall survival between different degrees of HPS was also compared, and showed no significant difference (P=0.466). The HPS group had a higher incidence of delayed extubation (22.1% vs 10.4%, P=0.028) and chest pigtail catheter insertion (16.3% vs 10.4%, P=0.012). Nevertheless, it did not lead to a longer Intensive Care Unit/hospital stay or higher risk of short-term mortality. CONCLUSIONS Patients with HPS tend to have more post-LT pulmonary complications, but the overall survival is not adversely influenced, regardless of the severity of HPS.
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Affiliation(s)
- Yin Lai
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Hao-Chien Hung
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Jin-Chiao Lee
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Chao Wang
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Hsien Cheng
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-Han Wu
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Ting-Jung Wu
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Hong-Shiue Chou
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Kun-Ming Chan
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chen Lee
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chen-Fang Lee
- Division of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang-Gung University College of Medicine, Taoyuan, Taiwan
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11
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Chen JY, Chang MH, Ho MC, Peng SF, Hsu WM, Lin WH, Wu JF. Hepatopulmonary syndrome in biliary atresia children increased postoperative complications after liver transplantation. Pediatr Neonatol 2024:S1875-9572(24)00199-2. [PMID: 39580337 DOI: 10.1016/j.pedneo.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/10/2024] [Accepted: 06/04/2024] [Indexed: 11/25/2024] Open
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is a complication in biliary atresia (BA) children following hepatoportoenterostomy. Liver transplantation (LT) was the definitive treatment of HPS. However, little was known about the risk factors between HPS and mortalities. We aimed to evaluate the role of HPS and the predictors of complications after LT in BA children. METHODS One hundred and twenty (54 males and 66 females) children with BA receiving LT were retrospectively enrolled. The primary outcome was postoperative biliary/vascular complication rates and the secondary outcome was post-LT mortality rates. RESULTS Among 120 BA children receiving LT, six (5%) children were diagnosed with HPS before LT. The overall survival rate of LT in BA children was 80% and the overall survival rate of LT in BA children with and without HPS was 17% and 83%, respectively. Vascular complications and HPS were predictors for poor overall survival rates both in univariate logistic regression analyses (hazard ratio [HR], 11.63 and 5.96; P < 0.0001 and P = 0.001, respectively) and multivariate logistic regression analyses (HR, 10.02 and 4.16; P < 0.0001 and P = 0.007, respectively). Kaplan-Meier analysis indicated the predictive role of HPS on poor overall survival rates (P < 0.0001), higher risks of biliary complications (P < 0.0001), and higher risks of jaundice (P < 0.01) post-LT. CONCLUSION The present study comprising children over long-term follow-up revealed that the development of pre-LT HPS had a poor impact on overall survival rates and higher risks of biliary complications in BA children receiving LT.
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Affiliation(s)
- Ju-Yin Chen
- Department of Pediatrics, Taipei City Hospital Women and Children Campus, Taipei, Taiwan; Departments of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwei Chang
- Departments of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chih Ho
- Departments of Surgery, National Taiwan University Hospital Hsin-Chu Biomedical Park Branch, Hsinchu, Taiwan
| | - Shinn-Forng Peng
- Departments of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ming Hsu
- Departments of Pediatric Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Hsi Lin
- Departments of Pediatric Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Departments of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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12
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Gualandro DM, Fornari LS, Caramelli B, Abizaid AAC, Gomes BR, Tavares CDAM, Fernandes CJCDS, Polanczyk CA, Jardim C, Vieira CLZ, Pinho C, Calderaro D, Schreen D, Marcondes-Braga FG, Souza FD, Cardozo FAM, Tarasoutchi F, Carmo GAL, Kanhouche G, Lima JJGD, Bichuette LD, Sacilotto L, Drager LF, Vacanti LJ, Gowdak LHW, Vieira MLC, Martins MLFM, Lima MSM, Lottenberg MP, Aliberti MJR, Marchi MFDS, Paixão MR, Oliveira Junior MTD, Yu PC, Cury PR, Farsky PS, Pessoa RS, Siciliano RF, Accorsi TAD, Correia VM, Mathias Junior W. Guideline for Perioperative Cardiovascular Evaluation of the Brazilian Society of Cardiology - 2024. Arq Bras Cardiol 2024; 121:e20240590. [PMID: 39442131 DOI: 10.36660/abc.20240590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024] Open
Affiliation(s)
- Danielle Menosi Gualandro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- University Hospital Basel, Basel - Suíça
| | - Luciana Savoy Fornari
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - Bruno Caramelli
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Alexandre Antonio Cunha Abizaid
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Carisi Anne Polanczyk
- Hospital de Clínicas da Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre, RS - Brasil
| | - Carlos Jardim
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Claudio Pinho
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, SP - Brasil
- Clinica Pinho, Campinas, SP - Brasil
| | - Daniela Calderaro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Dirk Schreen
- Hospital São Carlos, Rede D'Or, Fortaleza, CE - Brasil
- Hospital Universitário Walter Cantidio da Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
- Instituto de Medicina Nuclear, Fortaleza, CE - Brasil
| | - Fabiana Goulart Marcondes-Braga
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Fábio de Souza
- Escola de Medicina e Cirurgia da Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ - Brasil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Gabriel Assis Lopes Carmo
- Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Evangélico de Belo Horizonte, Belo Horizonte, MG - Brasil
- Hospital Orizonti, Belo Horizonte, MG - Brasil
| | | | - José Jayme Galvão de Lima
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Dornfeld Bichuette
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Sacilotto
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - Luciano Ferreira Drager
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | - Luis Henrique Wolff Gowdak
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Márcio Silva Miguel Lima
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Marcos Pita Lottenberg
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Felippi de Sá Marchi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Milena Ribeiro Paixão
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Pai Ching Yu
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Rinaldo Focaccia Siciliano
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Tarso Augusto Duenhas Accorsi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Vinícius Machado Correia
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
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13
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Verstraeten M, Lefere S, Raevens S. Pulmonary vascular complications of cirrhosis: hepatopulmonary syndrome and portopulmonary hypertension. Acta Clin Belg 2024; 79:384-391. [PMID: 39873530 DOI: 10.1080/17843286.2025.2456697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2024] [Accepted: 01/13/2025] [Indexed: 01/30/2025]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are two distinct pulmonary vascular complications seen in patients with liver disease and/or portal hypertension. HPS is characterized by disturbed gas exchange and hypoxemia because of intrapulmonary vascular dilatations. POPH is defined by pulmonary arterial hypertension, which might lead to right heart failure. HPS affects up to 30% of patients with end-stage liver disease requiring liver transplantation. POPH is rarer and affects 1-5% of this patient population. If not recognized and left untreated, these disorders result in significant mortality. This review provides an update on HPS and POPH and discusses their clinical characteristics, screening and diagnostic modalities, and management, including the place of liver transplantation.
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Affiliation(s)
- Maïté Verstraeten
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center, Ghent University, Ghent, Belgium
| | - Sander Lefere
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center, Ghent University, Ghent, Belgium
| | - Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center, Ghent University, Ghent, Belgium
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14
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Abdelwahed AH, Aboeldahb M, Wu GY. Effects of Transjugular Intrahepatic Portosystemic Shunt on Renal and Pulmonary Function in Hepatic Decompensation with and without Hepatorenal and Hepatopulmonary Syndromes: A Review. J Clin Transl Hepatol 2024; 12:780-791. [PMID: 39280072 PMCID: PMC11393845 DOI: 10.14218/jcth.2024.00188] [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: 06/09/2024] [Revised: 07/07/2024] [Accepted: 07/28/2024] [Indexed: 09/18/2024] Open
Abstract
Cirrhosis is often characterized by decreased liver function, ranging from a compensated, typically asymptomatic phase to a decompensated phase characterized by the appearance of ascites or variceal bleeding, and ultimately hepatorenal syndrome (HRS) or hepatopulmonary syndrome (HPS). The latter two complications are associated with a poor prognosis and limited treatment efficacy. In cases of ascites or variceal bleeding resistant to medical therapy, transjugular intrahepatic portosystemic shunt (TIPS) is effective and safe. Shunting blood by TIPS diverts portal blood to the systemic circulation, potentially increasing systemic blood volume and benefiting renal function. However, TIPS could also divert nitric oxide to the systemic circulation, potentially worsening systemic hypotension and perfusion, which could be detrimental to renal function. Available evidence indicates that TIPS often improves renal function in patients with portal hypertension, with or without HRS. No studies have shown persistently decreased renal function after TIPS. However, these data are insufficient to support a recommendation for the use of TIPS specifically for HRS. In patients without pre-existing HPS, TIPS does not appear to significantly affect pulmonary gas exchange. Results of TIPS in HPS have been inconsistent; some studies have shown improvement, but effects were transient. No studies have shown a persistent decline in pulmonary function after TIPS. The evidence supports the need for large randomized controlled trials to investigate the beneficial effects of TIPS for HRS. Similar pulmonary function data are less clear regarding TIPS for HPS. The aim of the current report was to review the literature regarding the effects of TIPS on renal and pulmonary function in hepatic decompensation, with or without the development of HRS or HPS.
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Affiliation(s)
- Ahmed H Abdelwahed
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Moataz Aboeldahb
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - George Y Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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15
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Alam A, Ozturk NB, Akyuz F. Hepatopulmonary syndrome unveiled: Exploring pathogenesis, diagnostic approaches, and therapeutic strategies. HEPATOLOGY FORUM 2024; 6:29-33. [PMID: 40255956 PMCID: PMC12008457 DOI: 10.14744/hf.2024.2024.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 04/22/2025]
Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary complication of liver cirrhosis that causes an oxygenation defect. Many patients are asymptomatic at diagnosis or may have non-specific symptoms such as dyspnea. Since the diagnostic criteria for HPS have been established, its prevalence has been better estimated. HPS is an important prognostic indicator for patients undergoing evaluation for liver transplant. The implementation of the Model for End-stage Liver Disease exception policy has improved the outcomes of HPS; however, the mortality remains high. Here, we discuss the pathophysiology, diagnostic criteria, and recent experimental studies in HPS.
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Affiliation(s)
- Anusha Alam
- Department of Internal Medicine, Beaumont Hospital, Michigan, United States
| | - Nazli Begum Ozturk
- Department of Internal Medicine, Beaumont Hospital, Michigan, United States
| | - Filiz Akyuz
- Department of Gastroenterology and Hepatology, Istanbul University School of Medicine, Istanbul, Turkiye
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16
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Shaikh S. Highlighting Hepatopulmonary Syndrome: An Important Consideration in Decompensated Cirrhosis [Letter]. Hepat Med 2024; 16:79-80. [PMID: 39247514 PMCID: PMC11380880 DOI: 10.2147/hmer.s492882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Accepted: 08/31/2024] [Indexed: 09/10/2024] Open
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Dandavate V, Bolshette N, Van Drunen R, Manella G, Bueno-Levy H, Zerbib M, Kawano I, Golik M, Adamovich Y, Asher G. Hepatic BMAL1 and HIF1α regulate a time-dependent hypoxic response and prevent hepatopulmonary-like syndrome. Cell Metab 2024; 36:2038-2053.e5. [PMID: 39106859 DOI: 10.1016/j.cmet.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/28/2024] [Accepted: 07/05/2024] [Indexed: 08/09/2024]
Abstract
The transcriptional response to hypoxia is temporally regulated, yet the molecular underpinnings and physiological implications are unknown. We examined the roles of hepatic Bmal1 and Hif1α in the circadian response to hypoxia in mice. We found that the majority of the transcriptional response to hypoxia is dependent on either Bmal1 or Hif1α, through shared and distinct roles that are daytime determined. We further show that hypoxia-inducible factor (HIF)1α accumulation upon hypoxia is temporally regulated and Bmal1 dependent. Unexpectedly, mice lacking both hepatic Bmal1 and Hif1α are hypoxemic and exhibit increased mortality upon hypoxic exposure in a daytime-dependent manner. These mice display mild liver dysfunction with pulmonary vasodilation likely due to extracellular signaling regulated kinase (ERK) activation, endothelial nitric oxide synthase, and nitric oxide accumulation in lungs, suggestive of hepatopulmonary syndrome. Our findings indicate that hepatic BMAL1 and HIF1α are key time-dependent regulators of the hypoxic response and can provide molecular insights into the pathophysiology of hepatopulmonary syndrome.
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Affiliation(s)
- Vaishnavi Dandavate
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Nityanand Bolshette
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Rachel Van Drunen
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Gal Manella
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Hanna Bueno-Levy
- Department of the Veterinary Resources, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Mirie Zerbib
- Department of the Veterinary Resources, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Ippei Kawano
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Marina Golik
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Yaarit Adamovich
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel
| | - Gad Asher
- Department of Biomolecular Sciences, Weizmann Institute of Science, 7610001 Rehovot, Israel.
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Alberto LD, Fagundes EDT, Rodrigues AT, Queiroz TCN, Castro GVD, Ferreira AR. HEPATOPULMONARY SYNDROME IN PEDIATRIC PATIENTS WITH PORTAL HYPERTENSION - AN INTEGRATIVE REVIEW. ARQUIVOS DE GASTROENTEROLOGIA 2024; 61:e24040. [PMID: 39230090 DOI: 10.1590/s0004-2803.24612024-040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/23/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is characterized by the triad of abnormal arterial oxygenation caused by intrapulmonary vascular dilatations (IPVD) in the setting of advanced liver disease or portal hypertension, impacting the patient's quality of life and survival. There are still many gaps in the literature on this topic, especially in pediatrics, with practices frequently based on extrapolation of data obtained from adults. OBJECTIVE Provide a synthesis of the current knowledge about HPS in children. METHODS The research was carried out through narrative review. The databases used for the search include Medline, Embase, Elsevier, Lilacs and Scielo. The keywords used were "hepatopulmonary syndrome" AND child, children, infant, preschool, pediatric. RESULTS In cirrhotic children, the prevalence of HPS can reach up to 42.5%, and it is even more common in those whose underlying condition is biliary atresia, reaching up to 63%. Screening with pulse oximetry (O2 saturation <96%), unlike in adults, has low sensitivity in the pediatric age group. Management involves supportive care with oxygen therapy; liver transplantation is the only definitive treatment to reverse the condition and HPS is considered an exceptional criterion for waitlist. The waitlist mortality is similar among children listed by HPS as a special criterion when compared to those listed for other reasons. The reported rates of complete resolution of hypo-xemia after liver transplantation are close to 100% in children. The post-liver transplantation survival is similar or slightly lower in children with HPS when compared to those without HPS. Contrary to findings from adults, no differences were found in post- liver transplantation mortality between children of different hypoxemia ranges, although longer mechanical ventilation time and hospital stay were observed in children with PaO2 <50 mmHg. CONCLUSION HPS is not an uncommon complication of cirrhosis in children and adolescents, particularly when biliary atresia is the underlying condition. There are still many gaps to be filled regarding the condition, and this article demonstrates that not all data obtained in studies with adults reflects the disease's behavior in pediatrics, especially concerning prognosis.
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Affiliation(s)
- Letícia Drumond Alberto
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
| | - Eleonora Druve Tavares Fagundes
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Adriana Teixeira Rodrigues
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Thaís Costa Nascentes Queiroz
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
| | | | - Alexandre Rodrigues Ferreira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Mauz JB, Rieland H, Berliner D, Tiede A, Stockhoff L, Hinrichs JB, Wedemeyer H, Meyer BC, Olsson KM, Maasoumy B, Tergast TL. High Prevalence and Clinical Relevance of Intrapulmonary Vascular Dilatations in Patients Undergoing TIPS Implantation. Clin Gastroenterol Hepatol 2024; 22:1867-1877.e4. [PMID: 38729401 DOI: 10.1016/j.cgh.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Considerate patient selection is vital to ensure the best possible outcomes after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, data regarding the impact of intrapulmonary vascular dilatations (IPVDs) or hepatopulmonary syndrome (HPS) on the clinical course after TIPS implantation is lacking. Hence, this study aimed to investigate the relevance of IPVD and HPS in patients undergoing TIPS implantation. METHODS Contrast enhanced echocardiography and blood gas analysis were utilized to determine presence of IPVD and HPS. Multivariable competing risk analyses were performed to evaluate cardiac decompensation (CD), hepatic decompensation (HD), and liver transplant (LTx)-free survival within 1 year of follow-up. RESULTS Overall, 265 patients were included, of whom 136 had IPVD and 71 fulfilled the HPS criteria. Patients with IPVD had lower Freiburg index of post-TIPS survival (FIPS) scores, lower creatinine, and more often received TIPS because of variceal bleeding. Presence of IPVD was associated with a significantly higher incidence of CD (hazard ratio [HR], 1.756; 95% confidence interval [CI], 1.011-3.048; P = .046) and HD (HR, 1.841; 95% CI, 1.255-2.701; P = .002). However, LTx-free survival was comparable between patients with and without IPVD (HR, 1.081; 95% CI, 0.630-1.855; P = .780). Patients with HPS displayed a trend towards more CD (HR, 1.708; 95% CI, 0.935-3.122; P = .082) and HD (HR, 1.458; 95% CI, 0.934-2.275; P = .097) that failed to reach statistical significance. LTx-free survival did not differ in those with HPS compared with patients without HPS, respectively (HR, 1.052; 95% CI, 0.577-1.921; P = .870). CONCLUSION Screening for IPVD before TIPS implantation could help to further identify patients at higher risk of CD and HD.
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Affiliation(s)
- Jim B Mauz
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Hannah Rieland
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Dominik Berliner
- Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - Anja Tiede
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany
| | - Lena Stockhoff
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Jan B Hinrichs
- St Bernward Hospital, Department of Radiology, Hildesheim, Germany
| | - Heiner Wedemeyer
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany; Excellence Cluster Resist, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Hannover Medical School, Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Karen M Olsson
- Hannover Medical School, Department of Respiratory Medicine and Infectious Diseases, Hannover, Germany; German Center for Lung Research (DZL), Hannover, Germany
| | - Benjamin Maasoumy
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany.
| | - Tammo L Tergast
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany.
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Robert F, Certain MC, Baron A, Thuillet R, Duhaut L, Ottaviani M, Chelgham MK, Normand C, Berrebeh N, Ricard N, Furlan V, Desroches-Castan A, Gonzales E, Jacquemin E, Sitbon O, Humbert M, Bailly S, Coilly A, Guignabert C, Tu L, Savale L. Disrupted BMP-9 Signaling Impairs Pulmonary Vascular Integrity in Hepatopulmonary Syndrome. Am J Respir Crit Care Med 2024; 210:648-661. [PMID: 38626313 DOI: 10.1164/rccm.202307-1289oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/16/2024] [Indexed: 04/18/2024] Open
Abstract
Rationale: Hepatopulmonary syndrome (HPS) is a severe complication of liver diseases characterized by abnormal dilation of pulmonary vessels, resulting in impaired oxygenation. Recent research highlights the pivotal role of liver-produced BMP-9 (bone morphogenetic protein-9) in maintaining pulmonary vascular integrity. Objectives: This study aimed to investigate the involvement of BMP-9 in human and experimental HPS. Methods: Circulating BMP-9 levels were measured in 63 healthy control subjects and 203 patients with cirrhosis with or without HPS. Two animal models of portal hypertension were employed: common bile duct ligation with cirrhosis and long-term partial portal vein ligation without cirrhosis. Additionally, the therapeutic effect of low-dose BMP activator FK506 was investigated, and the pulmonary vascular phenotype of BMP-9-knockout rats was analyzed. Measurements and Main Results: Patients with HPS related to compensated cirrhosis exhibited lower levels of circulating BMP-9 compared with patients without HPS. Patients with severe cirrhosis exhibited consistently low levels of BMP-9. HPS characteristics were observed in animal models, including intrapulmonary vascular dilations and an increase in the alveolar-arterial gradient. HPS development in both rat models correlated with reduced intrahepatic BMP-9 expression, decreased circulating BMP-9 level and activity, and impaired pulmonary BMP-9 endothelial pathway. Daily treatment with FK506 for 2 weeks restored the BMP pathway in the lungs, alleviating intrapulmonary vascular dilations and improving gas exchange impairment. Furthermore, BMP-9-knockout rats displayed a pulmonary HPS phenotype, supporting its role in disease progression. Conclusions: The study findings suggest that portal hypertension-induced loss of BMP-9 signaling contributes to HPS development.
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Affiliation(s)
- Fabien Robert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Marie-Caroline Certain
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Audrey Baron
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Raphaël Thuillet
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Léa Duhaut
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
| | - Mina Ottaviani
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Mustapha Kamel Chelgham
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Corinne Normand
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Nihel Berrebeh
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Nicolas Ricard
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Valerie Furlan
- Service de pharmacologie-toxicologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Agnès Desroches-Castan
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Emmanuel Gonzales
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Emmanuel Jacquemin
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabine Bailly
- Biosanté Unit UMR_S 1292, Grenoble Alpes University, INSERM, Commissariat à l'énergie atomique et aux énergies alternative (CEA), Grenoble, France
| | - Audrey Coilly
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
- Université Paris-Saclay, INSERM, UMR_S 1193, Hepatinov, Orsay, France
| | - Christophe Guignabert
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Ly Tu
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Université Paris-Saclay, Unité Mixte de Recherche en Santé (UMR_S) 999 "Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique (HPPIT)", Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR_S 999 "HPPIT", Le Kremlin-Bicêtre, France
- Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire (PulmoTension), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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22
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Bommena S, Fallon MB. Pulmonary Complications of Portal Hypertension. Clin Liver Dis 2024; 28:467-482. [PMID: 38945638 DOI: 10.1016/j.cld.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, 475 North 5th Street, Phoenix, AZ 85004, USA.
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23
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Zheng S, Xue C, Li S, Zao X, Li X, Liu Q, Cao X, Wang W, Qi W, Du H, Zhang P, Ye Y. Liver cirrhosis: current status and treatment options using western or traditional Chinese medicine. Front Pharmacol 2024; 15:1381476. [PMID: 39081955 PMCID: PMC11286405 DOI: 10.3389/fphar.2024.1381476] [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: 02/03/2024] [Accepted: 06/28/2024] [Indexed: 08/02/2024] Open
Abstract
Liver cirrhosis arises from liver fibrosis and necroinflammation caused by various mechanisms of hepatic injury. It is a prevalent condition in clinical practice characterized by hepatocellular dysfunction, portal hypertension, and associated complications. Despite its common occurrence, the etiology and pathogenesis of liver cirrhosis remain incompletely understood, posing a significant health threat. Effective prevention of its onset and progression is paramount in medical research. Symptoms often include discomfort in the liver area, while complications such as sarcopenia, hepatic encephalopathy, ascites, upper gastrointestinal bleeding, and infection can arise. While the efficacy of Western medicine in treating liver cirrhosis is uncertain, Chinese medicine offers distinct advantages. This review explores advancements in liver cirrhosis treatment encompassing non-pharmacological and pharmacological modalities. Chinese medicine interventions, including Chinese medicine decoctions, Chinese patent medicines, and acupuncture, exhibit notable efficacy in cirrhosis reversal and offer improved prognoses. Nowadays, the combination of Chinese and Western medicine in the treatment of liver cirrhosis also has considerable advantages, which is worthy of further research and clinical promotion. Standardized treatment protocols based on these findings hold significant clinical implications.
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Affiliation(s)
- Shihao Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Chengyuan Xue
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Size Li
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Xiaobin Zao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoke Li
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Liver Diseases Academy of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Qiyao Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Xu Cao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Liver Diseases Academy of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Wenying Qi
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Hongbo Du
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Liver Diseases Academy of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Peng Zhang
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yongan Ye
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Liver Diseases Academy of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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24
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Qasim A, Jyala A, Shrivastava S, Allena N, Ghazanfar H, Bhatt V, Ali HR, Vakde T, Patel H. Hepatopulmonary Syndrome: A Comprehensive Review. Cureus 2024; 16:e65204. [PMID: 39176346 PMCID: PMC11340781 DOI: 10.7759/cureus.65204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 08/24/2024] Open
Abstract
Hepatopulmonary syndrome (HPS) is defined by abnormally dilated blood vessels and shunts within the lungs, leading to impaired oxygen exchange. This condition results from intricate interactions between the liver, the gastrointestinal system, and the lungs. This complex system primarily affects pulmonary endothelial, immunomodulatory, and respiratory epithelial cells. Consequently, this contributes to pathological pulmonary changes characteristic of HPS. A classification system based on the severity of oxygen deficiency has been proposed for grading the physiological dysfunction of HPS. Contrast-enhanced echocardiography is considered the primary radiological evaluation for identifying abnormal blood vessel dilations within the lungs, which, combined with an elevated alveolar-arterial gradient, is essential for making the diagnosis. Liver transplantation is the sole effective definitive treatment that can reverse the course of the condition. Despite often being symptomless, HPS carries a significant risk of mortality before transplantation, regardless of the severity of liver disease. Meanwhile, there is varying data regarding survival rates following liver transplantation. The adoption of the model for end-stage liver disease (MELD) standard exception policy has notably improved the results for individuals with HPS compared to the period before MELD was introduced. This review offers a summary of the present understanding, highlighting recent advancements in the diagnosis and treatment of HPS. Furthermore, it aims to augment comprehension of the condition's fundamental mechanisms through insights derived from experimental models and translational research.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, New York, USA
| | | | | | - Nishant Allena
- Pulmonary Medicine, BronxCare Health System, New York, USA
| | | | | | - Husnain R Ali
- Medicine, American University of the Caribbean School of Medicine, Miramar, USA
| | - Trupti Vakde
- Pulmonary and Critical Care, BronxCare Health System, New York, USA
| | - Harish Patel
- Internal Medicine, BronxCare Health System, New York, USA
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25
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Zhao X, Kotha S, Nayyar D, Ma X, Lilly L, Castel H, Gupta S. Physiologic changes in the hepatopulmonary syndrome before and after liver transplant: A longitudinal and predictor analysis. Hepatology 2024; 79:636-649. [PMID: 37732952 PMCID: PMC10871618 DOI: 10.1097/hep.0000000000000605] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. APPROACH AND RESULTS This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: -3.7 (-6.4, -0.96) mm Hg/year for partial pressure of arterial oxygen (PaO 2 ); -26 (-96, 44) m/year for 6-minute walk distance, and 3.3% (-6.6, -0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO 2 decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO 2 deterioration classes-"very severe disease, slow decliners" (PaO 2 45.0 mm Hg; -1.0 mm Hg/year); and "moderate disease, steady decliners" (PaO 2 65.5 mm Hg; -2.5 mm Hg/year). PaO 2 increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO 2 was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. CONCLUSIONS We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO 2 decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, McGill University, Montreal, Canada
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Dhruv Nayyar
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xiayi Ma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hélène Castel
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
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26
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Sayadi A, Duhaut L, Robert F, Savale L, Coilly A. [Hepatopulmonary syndrome]. Rev Med Interne 2024; 45:156-165. [PMID: 37005097 DOI: 10.1016/j.revmed.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
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.
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Affiliation(s)
- A Sayadi
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - L Duhaut
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - F Robert
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France
| | - L Savale
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France; Service de pneumologie, hôpital Bicêtre, université Paris-Saclay, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - A Coilly
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France.
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Yang C, Yang Y, Chen Y, Huang J, Li D, Tang X, Ning J, Gu J, Yi B, Lu K. Cholangiocyte-derived exosomal long noncoding RNA PICALM-AU1 promotes pulmonary endothelial cell endothelial-mesenchymal transition in hepatopulmonary syndrome. Heliyon 2024; 10:e24962. [PMID: 39822730 PMCID: PMC11737509 DOI: 10.1016/j.heliyon.2024.e24962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/19/2025] Open
Abstract
Hepatopulmonary syndrome (HPS) is a severe lung injury caused by chronic liver disease, with limited understanding of the disease pathology. Exosomes are important mediators of intercellular communication that modulates various cellular functions by transferring a variety of intracellular components to target cells. Our recent studies have indicated that a new long noncoding RNA (lncRNA), PICALM-AU1, is mainly expressed in cholangiocytes, and is dramatically induced in the liver during HPS. However, the mechanism by which cholangiocyte-derived PICALM-AU1 regulates Endothelial-mesenchymal transition (EndMT) in HPS remains unclear. Here, we observed that PICALM-AU1 was synthesized in the cholangiocytes of the liver and then, secreted as exosomes into the serum; serum exosomal PICALM-AU1 levels were positively correlated with the severity of HPS in a rat model and in human patients. PICALM-AU1 carrying serum exosomes induced the EndMT of pulmonary microvascular endothelial cells (PMVECs) and promoted lung injury in vivo and in vitro. Furthermore, PICALM-AU1 acted as a molecular sponge for microRNA 144-3p (miR144-3p), resulting in the up-regulation of Zinc Finger E-Box Binding Homeobox 1 (ZEB1), a known target of EndMT and enhancement of EndMT, proliferation and migration of PMVECs. Taken together, our findings indicate that the cholangiocyte-derived exosomal lncRNA PICALM-AU1 plays a critical role in the EndMT in HPS lungs. Thus, it represents a potential therapeutic target for the treatment of HPS.
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Affiliation(s)
- Congwen Yang
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
- Chongqing Key Laboratory of Traditional Chinese Medicine for Prevention and Cure of Metabolic Diseases, Chongqing Medical University, Chongqing, 400016, China
| | - Yihui Yang
- Department of Anesthesia, The Third Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, 563000 China
| | - Yang Chen
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Jian Huang
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Dan Li
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Xi Tang
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Jiaolin Ning
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Jianteng Gu
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Bin Yi
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Kaizhi Lu
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
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28
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Chooklin S, Chuklin S. Hepatopulmonary syndrome: diagnosis and treatment. EMERGENCY MEDICINE 2024; 19:511-518. [DOI: 10.22141/2224-0586.19.8.2023.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Hepatopulmonary syndrome (HPS) is one of the lung diseases associated with liver cirrhosis and portal hypertension. The diagnosis is based on the triad: liver disease and portal hypertension, evidence of intrapulmonary vascular dilatation and impaired gas exchange. HPS impairs prognosis (23 % survival after 5 years) and patients’ quality of life, so early diagnosis and timely treatment are of great importance. Liver transplantation allows for regression of intrapulmonary vascular dilatation in almost 100 % of cases, normalization of gas exchange and improves a 5-year survival after transplantation from 76 to 87 %. This is the only treatment method indicated for patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60 mm Hg. However, in the face of a global shortage of transplants, it is necessary to develop medical therapies to delay or even defer liver transplantation. This goal seems possible due to the growing understanding of the HPS pathophysiology and the development of therapies targeting key mechanisms, mainly inflammatory and angiogenic. This article provides an overview of the clinical manifestations, diagnosis and treatment of HPS based on literature sources from the MEDLINE database on the PubMed platform.
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29
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Han SK, Baik SK, Kim MY. [Pulmonary Complications in Patients with Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:213-223. [PMID: 37997217 DOI: 10.4166/kjg.2023.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023]
Abstract
Portal hypertension is a clinical syndrome defined by an increased portal venous pressure. The most frequent cause of portal hypertension is liver cirrhosis, and many of the complications of cirrhosis, such as ascites and gastroesophageal variceal bleeding, are related to portal hypertension. Portal hypertension is a pathological condition caused by the accumulation of blood flow in the portal system. This blood flow retention reduces the effective circulation volume. To compensate for these changes, neurotransmitter hormone changes and metabolic abnormalities occur, which cause complications in organs other than the liver. A hepatic hydrothorax is fluid accumulation in the pleural space resulting from increased portal pressure. Hepatopulmonary syndrome and portopulmonary hypertension are the pulmonary complications in cirrhosis by deforming the vascular structure. Symptoms, such as dyspnea and hypoxia, affect the survival and the quality of life of patients. These lung complications are usually underestimated in the management of cirrhosis. This review briefly introduces the type of lung complications of cirrhosis.
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Affiliation(s)
- Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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30
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Li YJ, Wu XF, Wang DD, Li P, Liang H, Hu XY, Gan JQ, Sun YZ, Li JH, Li J, Shu X, Song AL, Yang CY, Yang ZY, Yu WF, Yang LQ, Wang XB, Belguise K, Xia ZY, Yi B. Serum Soluble Vascular Endothelial Growth Factor Receptor 1 as a Potential Biomarker of Hepatopulmonary Syndrome. J Clin Transl Hepatol 2023; 11:1150-1160. [PMID: 37577229 PMCID: PMC10412700 DOI: 10.14218/jcth.2022.00421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/02/2023] [Accepted: 02/28/2023] [Indexed: 07/03/2023] Open
Abstract
Background and Aims The results of basic research implicate the vascular endothelial growth factor (VEGF) family as a potential target of hepatopulmonary syndrome (HPS). However, the negative results of anti-angiogenetic therapy in clinical studies have highlighted the need for markers for HPS. Therefore, we aimed to determine whether VEGF family members and their receptors can be potential biomarkers for HPS through clinical and experimental studies. Methods Clinically, patients with chronic liver disease from two medical centers were enrolled and examined for HPS. Patients were divided into HPS, intrapulmonary vascular dilation [positive contrast-enhanced echocardiography (CEE) and normal oxygenation] and CEE-negative groups. Baseline information and perioperative clinical data were compared between HPS and non-HPS patients. Serum levels of VEGF family members and their receptors were measured. In parallel, HPS rats were established by common bile duct ligation. Liver, lung and serum samples were collected for the evaluation of pathophysiologic changes, as well as the expression levels of the above factors. Results In HPS rats, all VEGF family members and their receptors underwent significant changes; however, only soluble VEGFR1 (sFlt-1) and the sFlt-1/ placental growth factor (PLGF) ratio were changed in almost the same manner as those in HPS patients. Furthermore, through feature selection and internal and external validation, sFlt-1 and the sFlt-1/PLGF ratio were identified as the most important variables to distinguish HPS from non-HPS patients. Conclusions Our results from animal and human studies indicate that sFlt-1 and the sFlt-1/PLGF ratio in serum are potential markers for HPS.
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Affiliation(s)
- Yu-Jie Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xian-Feng Wu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan-Dan Wang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Peng Li
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Hao Liang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiao-Yan Hu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jia-Qi Gan
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Yi-Zhu Sun
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun-Hong Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xin Shu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ai-Lin Song
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chun-Yong Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zhi-Yong Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wei-Feng Yu
- Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Li-Qun Yang
- Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Bo Wang
- LBCMCP, Centre de Biologie Intégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Karine Belguise
- LBCMCP, Centre de Biologie Intégrative (CBI), Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Zheng-Yuan Xia
- Department of Anesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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31
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Igata S, Kono Y, Van Houten T, Hang CT, Cotter BR, Strachan MG, Morikawa N, DeMaria AN. Role of Quantitation of Saline Bubble Studies in Patients with Liver Cirrhosis. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1804-1810. [PMID: 37198087 DOI: 10.1016/j.ultrasmedbio.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Microbubble contrast echocardiography with a late positive signal enables the detection of intrapulmonary vascular dilation, including hepatopulmonary syndrome, in patients with end-stage liver disease. We assessed the relationship between the severity of bubble study and clinical outcome. METHODS We retrospectively analyzed 163 consecutive patients with liver cirrhosis who underwent an echocardiogram with bubble study from 2018 to 2021. Patients who were diagnosed with a late positive signal were divided into three groups: grade 1 (1-9 bubbles), grade 2 (10-30 bubbles) and grade 3 (>30 bubbles). RESULTS Fifty-six percent of the patients had a late positive bubble study (grade 1: 31%, grade 2: 23%, grade 3: 46%). Patients with grade 3 had a significantly higher international normalized ratio, model for end-stage liver disease score and Child-Pugh score and a lower peripheral oxygen saturation compared with patients with a negative study. In patients undergoing liver transplant (LT), survival rates were similar among the groups (3-mo: >87%, 1-y: >87%, 2-y: >83%). However, survival rate was lower in grade 3 patients without LT (3-mo: 81%, 1-y: 64%, 2-y: 39%). CONCLUSION Patients with grade 3 had much worse mortality without LT compared with other groups. However, after LT, all grades had equal survival. Therefore, patients with grade 3 may be considered as higher priority for LT.
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Affiliation(s)
- Sachiyo Igata
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA.
| | - Yuko Kono
- Division of Hepatology, Department of Medicine, University of California, San Diego, CA, USA
| | - Thomas Van Houten
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Calvin T Hang
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Bruno R Cotter
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Monet G Strachan
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
| | - Nagisa Morikawa
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Anthony N DeMaria
- Division of Cardiology, Department of Medicine, University of California, Sulpizio Cardiovascular Center at UC San Diego Health, San Diego, CA, USA
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DuBrock HM, Forde K, Krok K, Patel M, Al-Naamani N, Lin G, Oh JK, Fallon MB, Kawut SM, Krowka MJ. Cardiac index and hepatopulmonary syndrome in liver transplantation candidates: The pulmonary vascular complications of liver disease study. Liver Transpl 2023; 29:467-475. [PMID: 36862505 PMCID: PMC11929963 DOI: 10.1097/lvt.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/17/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) and a hyperdynamic circulation are common complications of advanced liver disease, but the relationship between HPS and cardiac index (CI) is poorly understood. We sought to compare CI in patients with and without HPS and to assess the relationship between CI and symptoms, quality of life, gas exchange, and exercise capacity among liver transplantation (LT) candidates. We performed a cross-sectional analysis within the Pulmonary Vascular Complications of Liver Disease 2 study, a multicenter prospective cohort study of patients being evaluated for LT. We excluded patients with obstructive or restrictive lung disease, intracardiac shunting, and portopulmonary hypertension. We included 214 patients (81 with HPS and 133 controls without HPS). Compared with controls, patients with HPS had a higher CI (least square mean 3.2 L/min/m 2 , 95% CI 3.1-3.4 vs. 2.8 L/min/m 2 , 95% CI 2.7-3.0, p < 0.001) after adjustment for age, sex, Model for End-stage Liver Disease-Sodium (MELD-Na) score and beta-blocker use, and a lower systemic vascular resistance. Among all LT candidates, CI was correlated with oxygenation (Alveolar-arterial oxygen gradient r =0.27, p < 0.001), intrapulmonary vasodilatation severity ( p < 0.001), and biomarkers of angiogenesis. Higher CI was independently associated with dyspnea and worse functional class and physical quality of life after adjusting for age, sex, MELD-Na, beta-blocker use, and HPS status. HPS was associated with a higher CI among LT candidates. Independent of HPS, higher CI was associated with increased dyspnea and worse functional class, quality of life, and arterial oxygenation.
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Affiliation(s)
- Hilary M. DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kimberly Forde
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Krok
- Division of Gastroenterology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jae K. Oh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Steven M. Kawut
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael J. Krowka
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Singh SA, Shrivastava P, Agarwal A, Nandakumar K, Nasa VK, Premkumar G, Rajakumar A, Panchwagh A, Vohra V, Ranade S, Kumar L, Saraf N, Shah V, Sudhidharan S. LTSI Consensus Guidelines: Preoperative Pulmonary Evaluation in Adult Liver Transplant Recipients. J Clin Exp Hepatol 2023; 13:523-531. [PMID: 37250889 PMCID: PMC10213854 DOI: 10.1016/j.jceh.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/20/2022] [Indexed: 05/31/2023] Open
Abstract
The relationship between chronic liver disease and respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease (CLD) have been characterized: hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. Apart from that coexisting pulmonary disease like chronic obstructive lung disease and interstitial lung disease also complicate the outcomes after liver transplantation (LT). Assessment for evaluation of underlying pulmonary disorders is essential to improve outcomes in patients with CLD, posted for LT. This consensus guideline of the Liver Transplant Society of India (LTSI) provides a comprehensive review of pulmonary issues in CLD, related and unrelated to underlying liver disease and gives recommendations for pulmonary screening in specific clinical scenarios in adults with chronic liver disease planned for LT. This document also aims to standardize the strategies for preoperative evaluation of these pulmonary issues in this subset of patients. Proposed recommendations were based on selected single case reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Additionally, this review will highlight the lacunae in our current evaluation strategy, challenges faced, and will provide direction to potentially useful futuristic preoperative evaluation strategies.
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Affiliation(s)
- Shweta A. Singh
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Anil Agarwal
- Liver Transplant Anaesthesia, Fortis Hospital, Noida, India
| | - K. Nandakumar
- Liver Transplant Anaesthesia, Apollo Main Hospital, Greams Road, Chennai, India
| | - Vaibhav K. Nasa
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Akila Rajakumar
- Dr. Rela Institute and Medical Centre, Chromepet, Chennai, Tamil Nadu, India
| | | | - Vijay Vohra
- Medanta - The Medicity Hospital, Gurugram, India
| | - Sharmila Ranade
- Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, India
| | - Lakshmi Kumar
- Amrita Institute of Medical Sciences & Research Centre, Kochi, India
| | - Neeraj Saraf
- Medanta - The Medicity Hospital, Gurugram, India
| | - V.R. Shah
- Institute of Kidney Disease and Research Centre-ITS, Ahmedabad, Gujarat, India
| | - S. Sudhidharan
- HPB and LT Surgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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34
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Raza MH, Kwon Y, Kobierski P, Misra AC, Lim A, Goldbeck C, Etesami K, Kohli R, Emamaullee J. Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception policy and outcomes in pediatric patients with hepatopulmonary syndrome requiring liver transplantation. Liver Transpl 2023; 29:134-144. [PMID: 37160070 PMCID: PMC9868062 DOI: 10.1002/lt.26548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 01/29/2023]
Abstract
Hepatopulmonary syndrome (HPS) is associated with increased waitlist mortality in liver transplantation (LT) candidates. Children with HPS are granted Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) exception points for waitlist prioritization in the United States based on criterion developed for adults. In this study, the impact of this MELD/PELD exception policy on post-LT survival in children was examined. A retrospective cohort of patients aged younger than 18 years with a MELD/PELD exception request who underwent LT between 2007 and 2018 were identified in the Scientific Registry of Transplant Recipients. Patients were stratified by waitlist partial pressure of arterial oxygen (PaO 2 ) to assess risk factors for waitlist mortality and post-LT survival. Among 3082 pediatric LT recipients included in the study, 124 patients (4%) received MELD/PELD exception points for HPS. Patients with HPS were a median age of 9 years (interquartile range: 6, 12 years), 54.8% were girls, and 54% were White. Most patients (87.9%) were listed with laboratory MELD/PELD scores <15. Waitlist mortality for patients with HPS exception points was rare and not different from patients without HPS. When stratified by pre-LT PaO 2 , hypoxemia severity was not associated with differences in 1-, 3-, or 5-year survival rates after LT ( p = 0.13). However, patients with HPS showed a slightly lower survival rate at 5 years compared with patients without HPS (88.7% vs. 93.4%; p = 0.04). MELD/PELD exceptions for children with HPS mitigated waitlist mortality, and recipients with HPS experienced excellent 5-year survival after LT, although slightly lower than in patients without HPS. Unlike adults with HPS, the severity of pre-LT hypoxemia in children does not impact post-LT survival. These data suggest that adult criteria for granting MELD/PELD exception points may not appropriately capture HPS severity in pediatric patients. Further prospective multicenter studies to examine the risk factors predicting negative survival outcomes in children with HPS are warranted.
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Affiliation(s)
- Muhammad H Raza
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Yong Kwon
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Pierre Kobierski
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Asish C Misra
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Angelina Lim
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA
| | - Cameron Goldbeck
- Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA
| | - Kambiz Etesami
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
| | - Rohit Kohli
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA.,Department of Pediatrics , University of Southern California , Los Angeles , California , USA
| | - Juliet Emamaullee
- Keck School of Medicine , University of Southern California , Los Angeles , California , USA.,Division of Hepatobiliary and Abdominal Transplant Surgery, Department of Surgery , University of Southern California , Los Angeles , California , USA.,Liver Transplant Program , Children's Hospital-Los Angeles , Los Angeles , California , USA
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Gera A, Pant D. Preoperative Assessment and Optimization of Liver Transplant Patients: Pulmonary Issues. PERI-OPERATIVE ANESTHETIC MANAGEMENT IN LIVER TRANSPLANTATION 2023:147-161. [DOI: 10.1007/978-981-19-6045-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Chen J, Gao F, Li D, Wang J. MiR26-5p inhibits pathological pulmonary microvascular angiogenesis via down-regulating WNT5A. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2023; 26:812-819. [PMID: 37396938 PMCID: PMC10311967 DOI: 10.22038/ijbms.2023.68856.15006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/19/2023] [Indexed: 07/04/2023]
Abstract
Objectives Pathological micro angiogenesis is a key pathogenic factor in pulmonary diseases such as pulmonary hypertension and hepatopulmonary syndrome. More and more pieces of evidence show that excessive proliferation of pulmonary microvascular endothelial cells is the key event of pathological micro angiogenesis. The purpose of this research is to reveal the mechanism of miR26-5p regulating pulmonary microvascular hyperproliferation. Materials and Methods Hepatopulmonary syndrome rat model was made by common bile duct ligation. HE and IHC staining were used for analysis of the pathology of the rat. CCK8, transwell, and wound healing assay were used to assess miR26-5p or target gene WNT5A functioned toward PMVECs. microRNA specific mimics and inhibitors were used for up/down-regulated miR26-5p expression in PMVECs. Recombinant lentivirus was used for overexpression/knockdown WNT5A expression in PMVECs. And the regulation relationship of miR26-5p and WNT5A was analyzed by dual-luciferase reporter assay. Results qPCR showed that miR26-5p was significantly down-regulated in the course of HPS disease. Bioinformatics data showed that WNT5A was one of the potential key target genes of miR26-5p. Immunohistochemistry and qPCR analysis showed that WNT5A was largely expressed in pulmonary microvascular endothelial cells, in addition, this molecule was significantly up-regulated with the progression of the disease. Furthermore, dual luciferase reporter assay showed that miR26-5p could bind to WNT5A 3 'UTR region to inhibit WNT5A synthesis. Conclusion The results suggested MiR26-5p negatively regulated PMVECs proliferation and migration by WNT5A expression. Overexpression of miR26-5p may be a potentially beneficial strategy for HPS therapy.
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Affiliation(s)
- Jie Chen
- Department of Anesthesiology, People’s Hospital of Chongqing Banan District, Chongqing 401320, China
- These authors contributed equally to this work
| | - Feng Gao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing 400038, China
- These authors contributed equally to this work
| | - Dan Li
- Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Jinquan Wang
- Department of Anesthesiology, The Ninth People’s Hospital of Chongqing, Chongqing 400700, China
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Zhao H, Tsauo J, Zhang X, Ma H, Weng N, Yang Z, Li X. Prevalence and prognostic impact of hepatopulmonary syndrome in patients with unresectable hepatocellular carcinoma undergoing transarterial chemoembolization: a prospective cohort study. Chin Med J (Engl) 2022; 135:2043-2048. [PMID: 36255217 PMCID: PMC9746741 DOI: 10.1097/cm9.0000000000002034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). METHODS Fifty-four patients with unresectable HCC undergoing TACE between December 2014 and December 2015 were prospectively screened for HPS and were followed up for a maximum of 2 years or until the end of this prospective study. RESULTS Nineteen of the 54 (35.2%) patients were considered to have HPS, including one (5.3%) with severe HPS, nine (47.4%) with moderate HPS, and nine (47.4%) with mild HPS. The median overall survival (OS) was 10.1 (95% confidence interval [CI], 3.9-16.3) months for patients with HPS and 15.1 (95% CI, 7.3-22.9) months for patients without HPS, which is not a significant difference ( P = 0.100). The median progression-free survival was also not significantly different between patients with and without HPS (5.2 [95% CI, 0-12.8] vs. 8.4 [95% CI, 3.6-13.1] months; P = 0.537). In the multivariable Cox regression analyses, carbon monoxide diffusing capacity (hazard ratio [HR] = 1.033 [95% CI, 1.003-1.064]; P = 0.028) and Child-Pugh class (HR = 1.815 [95% CI, 1.011-3.260]; P = 0.046) were identified to be the independent prognostic factors of OS. CONCLUSION Mild or moderate HPS is common in patients with unresectable HCC undergoing TACE, but it does not seem to have a significant prognostic impact.
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Affiliation(s)
- He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jiaywei Tsauo
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiaowu Zhang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Huaiyuan Ma
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ningna Weng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Zhengqiang Yang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Izzy M, DuBrock HM. CAQ Corner: Cardiovascular and pulmonary evaluation of liver transplantation candidates: What you need to know for the board exam. Liver Transpl 2022; 28:1529-1538. [PMID: 35470532 DOI: 10.1002/lt.26495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Zafar M, Patel A, Ashraf M, Tibble J. Shortness of breath due to portopulmonary hypertension and hepatopulmonary syndrome: diagnostic challenges and complex management approach in frail patients. Clin Med (Lond) 2022; 22:485-489. [PMID: 38589073 PMCID: PMC9595008 DOI: 10.7861/clinmed.2022-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 60-year-old woman with a background of frailty, non-alcoholic fatty liver disease (NAFLD), cirrhosis and type 2 diabetes mellitus (T2DM), presented with worsening shortness of breath and a drop in oxygen saturation on sitting and standing up. Her chest X-ray demonstrated evidence of upper lobe venous diversion. Given the hypoxia, she had a computed tomography pulmonary angiography (CTPA) to rule out a pulmonary embolism. The only finding from the CTPA was pulmonary hypertension in the absence of any clots in the lungs. An ultrasound of the abdomen confirmed portal hypertension with splenomegaly and a cirrhotic liver, therefore, an initial diagnosis of portopulmonary hypertension and hepatopulmonary syndrome was made. The patient declined an agitated saline contrast echocardiography. Based on frailty she was not deemed to be a suitable candidate for a liver transplant and was discharged with a package of care alongside home oxygen therapy with periodic review in the gastroenterology clinic. She was assessed as stable with no new concerns while on home oxygen and diuretics. This case highlights challenges in diagnosing and managing patients with cirrhosis, portopulmonary hypertension and hepatopulmonary syndrome with a background of complex comorbidities and frailty.
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Kawut SM, Krowka MJ, Forde KA, Al-Naamani N, Krok KL, Patel M, Bartoli CR, Doyle M, Moutchia J, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB. Impact of hepatopulmonary syndrome in liver transplantation candidates and the role of angiogenesis. Eur Respir J 2022; 60:2102304. [PMID: 34949701 PMCID: PMC10967655 DOI: 10.1183/13993003.02304-2021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome affects 10-30% of patients with cirrhosis and portal hypertension. We evaluated the serum angiogenic profile of hepatopulmonary syndrome and assessed the clinical impact of hepatopulmonary syndrome in patients evaluated for liver transplantation. METHODS The Pulmonary Vascular Complications of Liver Disease 2 study was a multicentre, prospective cohort study of adults undergoing their first liver transplantation evaluation. Hepatopulmonary syndrome was defined as an alveolar-arterial oxygen gradient ≥15 mmHg (≥20 mmHg if age >64 years), positive contrast-enhanced transthoracic echocardiography and absence of lung disease. RESULTS We included 85 patients with hepatopulmonary syndrome and 146 patients without hepatopulmonary syndrome. Patients with hepatopulmonary syndrome had more complications of portal hypertension and slightly higher Model for End-Stage Liver Disease-Na score compared to those without hepatopulmonary syndrome (median (interquartile range) 15 (12-19) versus 14 (10-17), p=0.006). Hepatopulmonary syndrome patients had significantly lower 6-min walk distance and worse functional class. Hepatopulmonary syndrome patients had higher circulating angiopoietin 2, Tie2, tenascin C, tyrosine protein kinase Kit (c-Kit), vascular cell adhesion molecule 1 and von Willebrand factor levels, and lower E-selectin levels. Patients with hepatopulmonary syndrome had an increased risk of death (hazard ratio 1.80, 95% CI 1.03-3.16, p=0.04), which persisted despite adjustment for covariates (hazard ratio 1.79, 95% CI 1.02-3.15, p=0.04). This association did not vary based on levels of oxygenation, reflecting the severity of hepatopulmonary syndrome. CONCLUSION Hepatopulmonary syndrome was associated with a profile of abnormal systemic angiogenesis, worse exercise and functional capacity, and an overall increased risk of death.
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Affiliation(s)
- Steven M Kawut
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kimberly A Forde
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen L Krok
- Dept of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Dept of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiothoracic Surgery, Dept of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Margaret Doyle
- Dept of Pathology, University of Vermont, Burlington, VT, USA
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
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Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
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Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
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Raevens S, Boret M, Fallon MB. Hepatopulmonary syndrome. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100527. [PMID: 36035361 PMCID: PMC9403489 DOI: 10.1016/j.jhepr.2022.100527] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of liver disease, which adversely affects prognosis. The disease is characterised by intrapulmonary vascular dilatations and shunts, resulting in impaired gas exchange. A complex interaction between the liver, the gut and the lungs, predominately impacting pulmonary endothelial cells, immune cells and respiratory epithelial cells, is responsible for the development of typical pulmonary alterations seen in HPS. Liver transplantation is the only therapeutic option and generally reverses HPS. Since the implementation of the model for end-stage liver disease (MELD) standard exception policy, outcomes in patients with HPS have been significantly better than they were in the pre-MELD era. This review summarises current knowledge and highlights what’s new regarding the diagnosis and management of HPS, and our understanding of pathogenesis based on experimental models and translational studies.
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Craciun R, Mocan T, Procopet B, Nemes A, Tefas C, Sparchez M, Mocan LP, Sparchez Z. Pulmonary complications of portal hypertension: The overlooked decompensation. World J Clin Cases 2022; 10:5531-5540. [PMID: 35979136 PMCID: PMC9258359 DOI: 10.12998/wjcc.v10.i17.5531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/22/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.
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Affiliation(s)
- Rares Craciun
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Tudor Mocan
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Andrada Nemes
- Intensiv Care Unit I, Cluj County Emergency Hosptial, Cluj-Napoca 400006, Romania
| | - Cristian Tefas
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Sparchez
- 2nd Paediatric Clinic, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Please enter the state or province, Romania
| | - Lavinia-Patricia Mocan
- Department of Histology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400349, Romania
| | - Zeno Sparchez
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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Iwasaki S, Ueno T, Toyama C, Deguchi K, Nomura M, Saka R, Watanabe M, Tazuke Y, Bessho K, Okuyama H. A Retransplant Case for Hepatopulmonary Syndrome Without Liver Cirrhosis or Portosystemic Shunt After Living-Donor Liver Transplantation: A Case Report. Transplant Proc 2022; 54:552-555. [PMID: 35074161 DOI: 10.1016/j.transproceed.2021.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a disease of gas exchange caused by intrapulmonary shunting secondary to liver disease-associated intrapulmonary vascular dilation. HPS is characterized by the triad of cirrhosis, chronic liver disease, or portosystemic shunting (PSS); arterial hypoxemia; and intrapulmonary arteriovenous shunting in the absence of a primary cardiopulmonary anomaly. We encountered a rare case of HPS without liver disease or PSS. The patient was an 8-year-old girl who underwent living donor liver transplantation (LDLT) shortly after developing fulminant hepatitis at 11 months of her age. Eight years after LDLT, hypoxemia and shortness of breath developed. The shunt ratio on 99mTc-macroaggregated albumin (MAA) lung perfusion scintigraphy (99mTc-MAA lung scan) was 32%. The patient had no cardiopulmonary disease, so we diagnosed her illness as HPS. We did not find cirrhosis, chronic liver disease, or PSS as a cause of HPS. We thought the graft was the cause of HPS. A second transplantation was planned. One year after the diagnosis of HPS, the shunt ratio on 99mTc-MAA lung scan worsened to 42%, digital clubbing appeared, and hypoxemia was worsening. Thus, we performed a second LDLT. After LDLT the shunt ratio on 99mTc-MAA lung scan normalized (6%) and cyanosis resolved. We determined that the graft was the cause of HPS; the typical causes of HPS were not clearly revealed in the histologic examination of the second liver explant. Acute rejection occurred twice after LDLT, so we speculated that HPS occurred because the graft became stressed over the long term.
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Affiliation(s)
- Shun Iwasaki
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Chiyoshi Toyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Deguchi
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Motonari Nomura
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryuta Saka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Miho Watanabe
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Hepatopulmonary syndrome delays postoperative recovery and increases pulmonary complications after hepatectomy. Eur J Gastroenterol Hepatol 2021; 33:e449-e457. [PMID: 33852512 DOI: 10.1097/meg.0000000000002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study attempted to investigate the impact of hepatopulmonary syndrome (HPS) on postoperative outcomes in hepatitis B virus-induced hepatocellular carcinoma (HBV-HCC) patients. METHODS HBV-HCC patients undergoing primary curative hepatectomy for HCC in our hospital were diagnosed with HPS by contrast-enhanced echocardiography (CEE) and arterial blood gas analysis. Patients were divided into HPS, intrapulmonary vascular dilation (IPVD) (patients with positive CEE results and normal oxygenation) and control (patients with negative CEE results) groups. Baseline information, perioperative clinical data and postoperative pulmonary complications (PPCs) were compared among all groups. Cytokines in patient serums from each group (n = 8) were also assessed. RESULTS Eighty-seven patients undergoing hepatectomy from October 2019 to January 2020 were analyzed. The average time in the postanaesthesia care unit (112.10 ± 38.57 min) and oxygen absorption after extubation [34.0 (14.5-54.5) min] in the HPS group was longer than in IPVD [81.81 ± 26.18 min and 16.0 (12.3-24.0) min] and control [93.70 ± 34.06 min and 20.5 (13.8-37.0) min] groups. There were no significant differences in oxygen absorption time after extubation between HPS and control groups. The incidence of PPCs, especially bi-lateral pleural effusions in the HPS group (61.9%), was higher than in IPVD (12.5%) and control (30.0%) groups. Increased serum levels of the growth-regulated oncogene, monocyte chemoattractant protein, soluble CD40 ligand and interleukin 8 might be related to delayed recovery in HPS patients. CONCLUSIONS HPS patients with HBV-HCC suffer delayed postoperative recovery and are at higher risk for PPCs, especially bi-lateral pleural effusions, which might be associated with changes in certain cytokines.
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Jose A, Shah SA, Anwar N, Jones CR, McCormack FX, Sherman KE, Elwing JM. Predictors of outcomes following liver transplant in hepatopulmonary syndrome: An OPTN database analysis. Respir Med 2021; 190:106683. [PMID: 34784562 DOI: 10.1016/j.rmed.2021.106683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a type of pulmonary vascular disease occurring exclusively in those with underlying liver disease, associated with significant mortality in patients awaiting liver transplantation (LT). LT is curative in HPS, and these patients are granted Model for End Stage Liver Disease (MELD) exception points to expedite LT. The purpose of this study is to use multivariable competing risk Accelerated Failure Time models and propensity matching to examine the relationship between pre-LT hypoxemia and post-LT outcomes in HPS. We performed a retrospective cohort study of UNOS/OPTN database of all adult patients undergoing LT between January 1, 2006 and January 12, 2020. Pre-LT PaO2 was significantly associated with post-LT mortality in HPS, with each 1 mmHg increase in PaO2 significantly decreasing the risk of post-LT mortality (coefficient 0.039, HR = 0.95, p = 0.001). HPS patients with a pre-LT PaO2 < 54 mmHg demonstrated increased mortality following LT as compared to matched non-HPS cirrhotic patients. We conclude that HPS patients with a PaO2, 54 mmHg are at increased risk of post-LT mortality and may identify high-risk patients who would benefit from additional resources during LT, and that the effects of HPS MELD exception points to optimize post-LT outcomes should be continuously re-evaluated.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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Chen B, Yang Y, Yang C, Duan J, Chen L, Lu K, Yi B, Chen Y, Xu D, Huang H. M2 macrophage accumulation contributes to pulmonary fibrosis, vascular dilatation, and hypoxemia in rat hepatopulmonary syndrome. J Cell Physiol 2021; 236:7682-7697. [PMID: 34041750 DOI: 10.1002/jcp.30420] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 12/11/2022]
Abstract
Hepatopulmonary syndrome (HPS) markedly increases the mortality of patients. However, its pathogenesis remains incompletely understood. Rat HPS develops in common bile duct ligation (CBDL)-induced, but not thioacetamide (TAA)-induced cirrhosis. We investigated the mechanisms of HPS by comparing these two models. Pulmonary histology, blood gas exchange, and the related signals regulating macrophage accumulation were assessed in CBDL and TAA rats. Anti-polymorphonuclear leukocyte (antiPMN) and anti-granulocyte-macrophage colony stimulating factor (antiGM-CSF) antibodies, clodronate liposomes (CL), and monocyte chemoattractant protein 1 (MCP1) inhibitor (bindarit) were administrated in CBDL rats, GM-CSF, and MCP1 were administrated in bone marrow-derived macrophages (BMDMs). Pulmonary inflammatory cell recruitment, vascular dilatation, and hypoxemia were progressively developed by 1 week after CBDL, but only occurred at 4 week after TAA. Neutrophils were the primary inflammatory cells within 3 weeks after CBDL and at 4 week after TAA. M2 macrophages were the primary inflammatory cells, meantime, pulmonary fibrosis, GM-CSFR, and CCR2 were specifically increased from 4 week after CBDL. AntiPMN antibody treatment decreased neutrophil and macrophage accumulation, CL or the combination of antiGM-CSF antibody and bindarit treatment decreased macrophage recruitment, resulting in pulmonary fibrosis, vascular dilatation, and hypoxemia in CBDL rats alleviated. The combination treatment of GM-CSF and MCP1 promoted cell migration, M2 macrophage differentiation, and transforming growth factor-β1 (TGF-β1) production in BMDMs. Conclusively, our results highlight neutrophil recruitment mediates pulmonary vascular dilatation and hypoxemia in the early stage of rat HPS. Further, M2 macrophage accumulation induced by GM-CSF/GM-CSFR and MCP1/CCR2 leads to pulmonary fibrosis and promotes vascular dilatation and hypoxemia, as a result, HPS develops.
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Affiliation(s)
- Bing Chen
- Department of Anesthesia, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Yong Yang
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Congwen Yang
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Jiaxiang Duan
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Lin Chen
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Kaizhi Lu
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Bin Yi
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Yang Chen
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - Duo Xu
- Department of Anesthesia, Southwest Hospital, Army Medical University (The Third Military Medical University), Chongqing, China
| | - He Huang
- Department of Anesthesia, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Bommena S, Gerkin RD, Agarwal S, Raevens S, Glassberg MK, Fallon MB. Diagnosis of Hepatopulmonary Syndrome in a Large Integrated Health System. Clin Gastroenterol Hepatol 2021; 19:2370-2378. [PMID: 33007510 DOI: 10.1016/j.cgh.2020.09.050] [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: 06/24/2020] [Revised: 08/26/2020] [Accepted: 09/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Data on the accuracy of the diagnosis of hepatopulmonary syndrome (HPS) in cirrhosis is limited. We evaluated the clinical characteristics of patients with International Classification of Diseases (ICD) codes for hepatopulmonary syndrome (HPS) in a large integrated health system. METHODS A retrospective review of encounters was performed of all patients with ICD-9-CM and/or ICD-10-CM diagnosis of cirrhosis and HPS from 2014-2019 in a multi-state health system. Demographics and cardiopulmonary testing closest to the time of HPS diagnosis were recorded. HPS was defined using standard criteria. RESULTS A total of 42,749 unique individuals with cirrhosis were identified. An ICD diagnosis of HPS was found in 194 patients (0.45%), of which 182 had clinically confirmed cirrhosis. 143 (78.5%) underwent contrast-enhanced transthoracic echocardiography, and 98 (54%) had delayed shunting. Among them, 61 patients had a documented arterial blood gas, with 53 showing abnormal oxygenation (A-a gradient of >15 mm Hg). 12 were excluded due to significant pulmonary function test abnormalities and abnormal oxygenation from other cardiopulmonary diseases. Ultimately, 41 (22.5%) fulfilled the criteria for HPS. When stratifying those with an ICD code diagnosis of HPS into HPS, no HPS and indeterminate HPS groups, based on standard diagnostic criteria for HPS, we found that the confirmed HPS patients had similar complications except for less portopulmonary hypertension, worse gas exchange, less cardiopulmonary disease and were more often diagnosed in transplant centers. CONCLUSIONS The diagnosis of HPS by ICD code is made in an extremely small subset of a sizeable cirrhotic cohort. When made, only a minority of these patients meet diagnostic criteria. Our findings highlight the need for improved education and more effective screening algorithms.
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Affiliation(s)
- Shoma Bommena
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona.
| | - Richard D Gerkin
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Sumit Agarwal
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Sarah Raevens
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Marilyn K Glassberg
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Michael B Fallon
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Department of Internal Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona
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Li YJ, Zhong KH, Bai XH, Tang X, Li P, Yang ZY, Zhi HY, Li XJ, Chen Y, Deng P, Qin XL, Gu JT, Ning JL, Lu KZ, Zhang J, Xia ZY, Chen YW, Yi B. A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning. J Clin Transl Hepatol 2021; 9:682-689. [PMID: 34722183 PMCID: PMC8516848 DOI: 10.14218/jcth.2020.00184] [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: 12/28/2020] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 12/04/2022] Open
Abstract
Background and Aims Screening for hepatopulmonary syndrome in cirrhotic patients is limited due to the need to perform contrast enhanced echocardiography (CEE) and arterial blood gas (ABG) analysis. We aimed to develop a simple and quick method to screen for the presence of intrapulmonary vascular dilation (IPVD) using noninvasive and easily available variables with machine learning (ML) algorithms. Methods Cirrhotic patients were enrolled from our hospital. All eligible patients underwent CEE, ABG analysis and physical examination. We developed a two-step model based on three ML algorithms, namely, adaptive boosting (termed AdaBoost), gradient boosting decision tree (termed GBDT) and eXtreme gradient boosting (termed Xgboost). Noninvasive variables were input in the first step (the NI model), and for the second step (the NIBG model), a combination of noninvasive variables and ABG results were used. Model performance was determined by the area under the curve of receiver operating characteristics (AUCROCs), precision, recall, F1-score and accuracy. Results A total of 193 cirrhotic patients were ultimately analyzed. The AUCROCs of the NI and NIBG models were 0.850 (0.738–0.962) and 0.867 (0.760–0.973), respectively, and both had an accuracy of 87.2%. For both negative and positive cases, the recall values of the NI and NIBG models were both 0.867 (0.760–0.973) and 0.875 (0.771–0.979), respectively, and the precisions were 0.813 (0.690–0.935) and 0.913 (0.825–1.000), respectively. Conclusions We developed a two-step model based on ML using noninvasive variables and ABG results to screen for the presence of IPVD in cirrhotic patients. This model may partly solve the problem of limited access to CEE and ABG by a large numbers of cirrhotic patients.
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Affiliation(s)
- Yu-Jie Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Kun-Hua Zhong
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Xue-Hong Bai
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xi Tang
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Peng Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Zhi-Yong Yang
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Hong-Yu Zhi
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xiao-Jun Li
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Yang Chen
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Peng Deng
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Xiao-Lin Qin
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Jian-Teng Gu
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Jiao-Lin Ning
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Kai-Zhi Lu
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
| | - Ju Zhang
- University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Zheng-Yuan Xia
- Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yu-Wen Chen
- Chengdu Institute of Computer Applications, Chinese Academy of Sciences, Chengdu, Sichuan, China.,University of Chinese Academy of Sciences, Beijing, China.,Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Bin Yi
- Department of Anaesthesiology, Southwest Hospital, Third Military Medical University (First Affiliated Hospital of Army Medical University), Chongqing, China
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Del Valle K, DuBrock HM. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Pulmonary Vascular Complications of Liver Disease. Compr Physiol 2021; 11:3281-3302. [PMID: 34636408 DOI: 10.1002/cphy.c210009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary vascular disease is a frequent complication of chronic liver disease and portal hypertension, affecting up to 30% of patients. There are two distinct pulmonary vascular complications of liver disease: hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS affects 25% of patients with chronic liver disease and is characterized by intrapulmonary vasodilatation and abnormal arterial oxygenation. HPS negatively impacts quality of life and is associated with a 2-fold increased risk of death compared to controls with liver disease without HPS. Angiogenesis, endothelin-1 mediated endothelial dysfunction, monocyte influx, and alveolar type 2 cell dysfunction seem to play important roles in disease pathogenesis but there are currently no effective medical therapies. Fortunately, HPS resolves following liver transplant (LT) with improvements in hypoxemia. POPH is a subtype of pulmonary arterial hypertension (PAH) characterized by an elevated mean pulmonary arterial pressure and pulmonary vascular resistance in the setting of normal left-sided filling pressures. POPH affects 5% to 6% of patients with chronic liver disease. Although the pathogenesis has not been fully elucidated, endothelial dysfunction, inflammation, and estrogen signaling have been identified as key pathways involved in disease pathogenesis. POPH is typically treated with PAH targeted therapy and may also improve with liver transplantation in selected patients. This article highlights what is currently known regarding the diagnosis, management, pathobiology, and outcomes of HPS and POPH. Ongoing research is needed to improve understanding of the pathophysiology and outcomes of these distinct and often misunderstood pulmonary vascular complications of liver disease. © 2021 American Physiological Society. Compr Physiol 11:1-22, 2021.
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