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Müller M, Grasshoff C. [The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:283-295. [PMID: 38759684 DOI: 10.1055/a-2152-7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.
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2
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Panackel C, Fawaz M, Jacob M, Raja K. Pulmonary Assessment of the Liver Transplant Recipient. J Clin Exp Hepatol 2023; 13:895-911. [PMID: 37693254 PMCID: PMC10483013 DOI: 10.1016/j.jceh.2023.04.003] [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: 12/22/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.
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Affiliation(s)
| | - Mohammed Fawaz
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Jacob
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Kaiser Raja
- King's College Hospital London, Dubai Hills, Dubai, United Arab Emirates
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3
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Tan YW, Agrawal RV, Pan TLT, Muthiah MD, Teo FSW, Wong WH. Pentoxifylline therapy for persistent hepatopulmonary syndrome after liver transplantation. Singapore Med J 2023:384046. [PMID: 37675673 DOI: 10.4103/singaporemedj.smj-2021-246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Yi Wei Tan
- Department of Anesthesia, National University Health System, Singapore
| | | | - Terry Ling Te Pan
- Department of Anesthesia, National University Health System, Singapore
| | - Mark Dhinesh Muthiah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Division of Gastroenterology and Hepatology, National University Hospital; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Felicia Su Wei Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Weng Hoa Wong
- Department of Anesthesia, National University Health System, Singapore
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4
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Chan SKT, Lim ZMJ, Tay SM. Navigating a complicated liver transplant in a patient with severe hepatopulmonary syndrome without extracorporeal membrane oxygenation: a case report. Singapore Med J 2023; 64:538-542. [PMID: 35082107 PMCID: PMC10476917 DOI: 10.11622/smedj.2022002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Steffi Kang Ting Chan
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | | | - Sook Muay Tay
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
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5
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Nassef NAA, Abd-El Hamid MS, Abusikkien SA, Ahmed AI. Quercetin ameliorates acute lung injury in a rat model of hepatopulmonary syndrome. BMC Complement Med Ther 2022; 22:320. [PMID: 36463144 PMCID: PMC9719635 DOI: 10.1186/s12906-022-03785-w] [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: 05/23/2022] [Accepted: 11/09/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Common bile duct ligation (BDL) is a rat experimental model to induce biliary cirrhosis. Lung fibrosis and pulmonary vascular angiogenesis and congestion are the most common complications of biliary cirrhosis that is known as hepatopulmonary syndrome. The aim of the present work is to investigate the acute lung injury in a BDL model and to investigate the possible protective effect of quercetin on this injury. METHODS Twenty-four adult male albino rats of the Wister strain (weighing 150-250 g). Animals were divided into 3 groups, with 8 rats each: Group I: Sham-operated group (control). Group II: Bile duct ligation group (BDL) sacrificed after 28 days from the surgery. Group III: Quercetin-treated bile duct ligation group (Q-BDL) was given orally by gastric gavage in a dose of 50 mg/kg/day, starting from the 4th day of the operation until the 28th day. At the end of the experiment, at day 28, all rats were sacrificed. Lung specimens were processed to measure Endothelin B receptor gene expression by PCR, lung surfactant by ELISA, "eNO" s by immunohistochemistry. Histological assessment was done using; H&E, Masson's trichrome, PAS, toluidine blue-stained semi-thin sections, transmission electron microscope. Histomorphometric and statistical studies were done. RESULTS BDL group showed significant increase in lung index together with mononuclear cellular infiltration denoting lung inflammatory state. Also, the significant increase in pulmonary endothelial nitric oxide synthase ("eNO" s) area percent and endothelin B receptor (ETB) gene expression indicates enhanced angiogenesis. Pulmonary surfactant concentration was significantly decreased together with thickening of interalveolar septa denoting lung injury and fibrosis. Quercetin led to significant decrease in lung index, pulmonary "eNO" s area percent, ETB gene expression and significant increase in pulmonary surfactant concentration. Quercetin treatment improved histological changes and morphometric measurements, limited mononuclear cellular infiltration and decreased perivascular and perialveolar collagen deposition. CONCLUSION Quercetin ameliorates the hepatopulmonary syndrome-induced lung injury through its anti-inflammatory, antioxidative and antifibrotic effects.
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Affiliation(s)
- Noha Abdel-Aziz Nassef
- grid.7269.a0000 0004 0621 1570Assistant Professor of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Manal S. Abd-El Hamid
- grid.7269.a0000 0004 0621 1570Assistant Professor of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Samy A. Abusikkien
- grid.7269.a0000 0004 0621 1570Lecturer of Anatomy, Rabigh Faculty of Medicine, King Abdulaziz University, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Asmaa Ibrahim Ahmed
- grid.7269.a0000 0004 0621 1570Assistant Professor of Anatomy, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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6
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Morita Y, Williams B, Yamada Y, Kariya T. Effect of Anesthesia Machine Ventilator and ICU Ventilator on Intraoperative Oxygenation and Ventilation. J Cardiothorac Vasc Anesth 2022; 36:3175-3186. [PMID: 35624038 DOI: 10.1053/j.jvca.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/21/2022] [Accepted: 03/17/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Yoshihisa Morita
- Department of Anesthesiology, University of Maryland, Baltimore, MD.
| | | | - Yoshitsugu Yamada
- Department of Anesthesiology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Taro Kariya
- Department of Anesthesiology, University of Tokyo, Tokyo, Japan
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7
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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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Okumura K, Schluger A, Dhand A, Bodin R, Nishida S. Hepatopulmonary Syndrome: Unique Radiological Association with Portal Vein Thrombosis and Porto-systemic Shunting. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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9
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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: 2.0] [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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10
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Kadry Z, Schaefer E, Krok K, Faust A, Stine JG, Schreibman IR, Bezinover D, Riley TR. Excellent outcomes with liver transplantation in hepatopulmonary syndrome across pre-transplant PaO 2 spectrum. JHEP Rep 2021; 3:100351. [PMID: 34604726 PMCID: PMC8473556 DOI: 10.1016/j.jhepr.2021.100351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Significantly worse survival has been reported in patients with hepatopulmonary syndrome (HPS) and partial pressure of arterial oxygen (PaO2) <45 mmHg undergoing liver transplantation. Long-term pre- and post-transplant outcomes based on degree of hypoxaemia were re-examined. Methods A retrospective analysis of 1,152 HPS candidates listed with an approved HPS model for end-stage liver disease (MELD) exception was performed. A Fine and Gray competing risks model was utilised to evaluate pre-transplant outcomes for PaO2 thresholds of <45, 45 to <60, and ≥60 mmHg. Post-transplant survival was analysed using the Kaplan-Meier method. Results Patients with a PaO2 <45 mmHg were significantly more likely to undergo transplantation (hazard ratio [HR] 1.51; 95% CI 1.12-2.03), whereas patients with higher MELD scores had lower hazard of transplant (HR 0.80, 95% CI 0.67-0.95, p = 0.011) and higher hazard of pre-transplant death (HR 2.29, 95% CI 1.55-3.37, p <0.001). Post-transplantation, patients with a PaO2 <45 mmHg had lower survival (p = 0.04) compared with patients with a PaO2 ≥45 to <50 mmHg, with survival curves significantly different at 2.6 years (75% survival compared with 86%) and median survival of 11.5 and 14.1 years, respectively. Cardiac arrest was a more likely (p = 0.025) cause of death for these patients. Cardiac arrest incidence in patients who died with a PaO2 >50 mmHg was 6.2%. Conclusions Patients with a PaO2 <45 mmHg had a significantly higher rate of transplantation, and higher calculated MELD scores were associated with significantly higher pre-transplant mortality. Although post-transplant survival was lower in patients with a PaO2 <45 mmHg, the median survival was 11.5 years, and survival curves only became significantly different at 2.6 years. This suggests that patients with HPS do benefit from transplantation up to 2-3 years post-transplant regardless of the severity of pre-transplant hypoxaemia. Lay summary A total of 1,152 patients with hepatopulmonary syndrome listed for liver transplant were analysed. Patients with a low PaO2 <45 mmHg had a high likelihood of transplantation. If associated with advanced liver disease, the mortality risk was higher for patients with hepatopulmonary syndrome on the wait list. After liver transplantation, patients with a PaO2 <45 mmHg had a lower survival, but this only became significant after 2.6 years, and the median survival was 11.5 years. This suggests that patients with hepatopulmonary syndrome do benefit from transplantation.
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Key Words
- CIF, cumulative incidence function
- ECMO, extracorporeal membrane oxygenation
- HPS, hepatopulmonary syndrome
- HR, hazard ratio
- Hepatopulmonary syndrome
- Hypoxia
- Liver transplantation
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- OPTN, Organ Procurement and Transplant Network
- POPH, portopulmonary hypertension
- PaO2, partial pressure of arterial oxygen
- STAR, Standard Transplant Analysis and Research
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Zakiyah Kadry
- Division of Transplantation, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Eric Schaefer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Karen Krok
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Alison Faust
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Jonathan Gibson Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ian Roy Schreibman
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Dmitri Bezinover
- Department of Anesthesiology, Penn State College of Medicine, Hershey, PA, USA
| | - Thomas Roberts Riley
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
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Anesthetic Management Using Low Fraction of Inspiratory Oxygen for Living Donor Liver Transplantation in a Patient With Hepatopulmonary Syndrome Complicated by Interstitial Pneumonia: A Case Report. Transplant Proc 2021; 53:2556-2558. [PMID: 34465421 DOI: 10.1016/j.transproceed.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome frequently complicates end-stage liver disease. It causes hypoxemia and requires oxygen administration. Additionally, interstitial pneumonia causes hypoxemia; however, it is known to be aggravated by high-concentration oxygen administration. CASE PRESENTATION A 71-year-old woman with hepatopulmonary syndrome and interstitial pneumonia underwent living donor liver transplantation, requiring conflicting management in terms of the inspiratory oxygen concentration. We achieved a low intraoperative fraction of inspiratory oxygen by increasing the cardiac output with intravenous catecholamines. As a result, the transplanted liver functioned well postoperatively, and the patient was discharged without exacerbation of the interstitial pneumonia. CONCLUSION We suggest that patients with hepatopulmonary syndrome complicated with interstitial pneumonia can undergo successful living donor liver transplantation without the use of high inspiratory oxygen concentration by using catecholamines to maintain a high mixed venous oxygen saturation.
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12
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Raevens S, Boret M, De Pauw M, Fallon MB, Van Vlierberghe H. Pulmonary Abnormalities in Liver Disease: Relevance to Transplantation and Outcome. Hepatology 2021; 74:1674-1686. [PMID: 33636019 DOI: 10.1002/hep.31770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/17/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Pulmonary disease in liver cirrhosis and portal hypertension (PH) constitutes a challenging clinical scenario and may have important implications with regard to prognosis, liver transplantation (LT) candidacy, and post-LT outcome. Pre-LT evaluation should include adequate screening for pulmonary diseases that may occur concomitantly with liver disease as well as for those that may arise as a complication of end-stage liver disease and PH, given that either may jeopardize safe LT and successful outcome. It is key to discriminate those patients who would benefit from LT, especially pulmonary disorders that have been reported to resolve post-LT and are considered "pulmonary indications" for transplant, from those who are at increased mortality risk and in whom LT is contraindicated. In conclusion, in this article, we review the impact of several pulmonary disorders, including cystic fibrosis, alpha 1-antitrypsin deficiency, hereditary hemorrhagic telangiectasia, sarcoidosis, coronavirus disease 2019, asthma, chronic obstructive pulmonary disease, pulmonary nodules, interstitial lung disease, hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension, on post-LT survival, as well as the reciprocal impact of LT on the evolution of lung function.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Maxine Boret
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
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13
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Gupta S, Tang R, Al-Hesayen A. Inhaled nitric oxide improves the hepatopulmonary syndrome: a physiologic analysis. Thorax 2021; 76:1142-1145. [PMID: 33859047 DOI: 10.1136/thoraxjnl-2020-216128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/10/2020] [Accepted: 03/05/2021] [Indexed: 01/30/2023]
Abstract
The hepatopulmonary syndrome (HPS) is defined by liver dysfunction, intrapulmonary vasodilatation and abnormal oxygenation. Hypoxaemia is progressive and liver transplant is the only effective treatment. Severe hypoxaemia is a life-threatening HPS complication, particularly after transplant. We evaluated gas-exchange and haemodynamic effects of invasive therapies in a consecutive sample of 26 pre-transplant patients. Inhaled nitric oxide significantly improved partial pressure of oxygen (12.4 mm Hg; p=0.001) without deleterious effects on cardiac output. Trendelenburg positioning resulted in a small improvement, and methylene blue did not, though individual responses were variable. Future studies should prospectively evaluate these strategies in severe post-transplant hypoxaemia.
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Affiliation(s)
- Samir Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Rosalind Tang
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada.,Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Abdul Al-Hesayen
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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14
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Kartha A, Sawant A, Kesavan R, Kumar L. Hypoxemia with stress cardiomyopathy following liver transplant: Is there a role for nitric oxide? - A case report. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_52_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Hamada S, Okamoto T, Ogawa E, Sonoda M, Okajima H, Hirai T, Handa T, Uemoto S, Chin K. High-flow nasal cannula oxygen therapy: Alternative respiratory therapy for severe post-transplant hypoxemia in children with hepatopulmonary syndrome. Pediatr Transplant 2020; 24:e13813. [PMID: 33099865 DOI: 10.1111/petr.13813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Severe post-transplant hypoxemia, which is defined as <50 mm Hg of the partial pressure of oxygen in arterial blood/fraction of inspired oxygen (P/F) ratio, is a major post-operative complication with high mortality rates in patients with hepatopulmonary syndrome (HPS). Non-invasive positive pressure ventilation therapy and mechanical ventilation are options for respiratory support of patients with severe post-transplant hypoxemia. However, these therapies are associated with several problems, such as compliance, ventilator-associated pneumonia, and lung injury. We here firstly described two children with HPS who developed severe post-transplant hypoxemia (lowest post-operative P/F ratio, 49.7 and 34.0 mm Hg, respectively) that was successfully managed with high-flow nasal cannula (HFNC) oxygen therapy and vasodilation drugs without adverse complications or necessity of reintubation. We consider that HFNC oxygen therapy could become a safe alternative respiratory therapy or be added to the other such as inhaled nitric oxide (iNO), methylene blue (MB), inhaled epoprostenol, embolization of abnormal pulmonary vessels, and combination of iNO and MB for severe post-transplant hypoxemia in children with HPS.
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Affiliation(s)
- Satoshi Hamada
- Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuya Okamoto
- Divison of Hepato-Biliary-Pancreatic and Transplant/Pediatric Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Divison of Hepato-Biliary-Pancreatic and Transplant/Pediatric Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mari Sonoda
- Divison of Hepato-Biliary-Pancreatic and Transplant/Pediatric Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Divison of Hepato-Biliary-Pancreatic and Transplant/Pediatric Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Pediatric Surgery, Kanazawa Medical University Hospital, Ishikawa, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiro Handa
- Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Divison of Hepato-Biliary-Pancreatic and Transplant/Pediatric Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuo Chin
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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16
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Weinfurtner K, Forde K. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Current Status and Implications for Liver Transplantation. CURRENT HEPATOLOGY REPORTS 2020; 19:174-185. [PMID: 32905452 PMCID: PMC7473417 DOI: 10.1007/s11901-020-00532-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are both pulmonary vascular complications of advanced liver disease; however, these syndromes have distinct pathophysiology, clinical implications, and management. RECENT FINDINGS While both conditions are associated with portal hypertension, HPS results from diffuse pulmonary capillary vasodilation and PoPH results from vasoconstriction and vascular remodeling of pulmonary arteries. In HPS, no medical therapies clearly improve outcomes; however, patients have excellent post-LT outcomes with near uniform reversal of hypoxemia. In PoPH, several medical therapies used in idiopathic pulmonary hypertension have been shown improve pulmonary hemodynamics, symptoms, and potentially LT outcomes; however, further study is needed to determine best treatment regimens, long-term outcomes on medical therapy, and role of LT. SUMMARY While HPS results in severe hypoxemia that is usually reversible by LT, PoPH patients develop progressive pulmonary hypertension that may improve with medical therapy.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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17
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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18
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Sheckley M, Calderon E, Patel BM, Sen A, Giorgakis E, Hewitt WR, Singer AL, Reddy KS, Moss AA, Mathur AK. Utilization of Veno-Arterial Extracorporeal Life Support for Acute Respiratory Distress Syndrome After Liver Transplant. EXP CLIN TRANSPLANT 2020; 20:616-620. [PMID: 32778014 DOI: 10.6002/ect.2020.0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this report, we present a case of successful long-term salvage of a patient with transfusion-related acute lung injury associated with acute respiratory distress syndrome immediately after a liver transplant. The patient was a 29-year-old man with end-stage liver disease due to sclerosing cholangitis who underwent liver transplant. After organ reperfusion, there was evidence of liver congestion, acidosis, coagulopathy, and acute kidney injury. He received 61 units of blood products. Continuous renal replacement therapy was initiated intraoperatively. On arrival to the intensive care unit, the patient was on high-dose pressors, and the patient developed respiratory failure and was immediately placed on veno-arterial extracorporeal membrane oxygenation via open femoral exposure. The patient presented with severe coagulopathy and early allograft dysfunction; therefore, no systemic heparin was administered and no thrombotic events occurred. He required extracorporeal membrane oxygenation support until posttransplant day 4, when resolution of the respiratory and cardiac dysfunction was noted. At 2 years after liver transplant, the patient has normal liver function, normal cognitive function, and stage V chronic kidney disease. We conclude that extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with cardiorespiratory failure after liver transplant.
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Affiliation(s)
- Marwan Sheckley
- From the Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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19
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Amaral B, Vicente M, Pereira CSM, Araújo T, Ribeiro A, Pereira R, Perdigoto R, Marcelino P. Approach to the liver transplant early postoperative period: an institutional standpoint. Rev Bras Ter Intensiva 2020; 31:561-570. [PMID: 31967233 PMCID: PMC7009000 DOI: 10.5935/0103-507x.20190076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022] Open
Abstract
The liver transplant program in our center started in 1992, and post-liver transplant patients are still admitted to the intensive care unit. For the intensive care physician, a learning curve started then, skills were acquired, and a specific practice was established. Throughout this time, several concepts changed, improving the care of these patients. The practical approach varies between liver transplant centers, according to local specificities. Hence, we wanted to present our routine practice to stimulate the debate between dedicated teams, which can allow the introduction of new ideas and potentially improve each local standard of care.
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Affiliation(s)
- Beatriz Amaral
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Madalena Vicente
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | | | - Teresa Araújo
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Ana Ribeiro
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Pereira
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Perdigoto
- Unidade de Transplante Hepático, Hospital Curry Cabral - Lisboa, Portugal
| | - Paulo Marcelino
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
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20
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Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU. Crit Care Med 2020; 48:e173-e191. [DOI: 10.1097/ccm.0000000000004192] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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21
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Diosmin enhances the anti-angiogenic activity of sildenafil and pentoxifylline against hepatopulmonary syndrome via regulation of TNF-α/VEGF, IGF-1/PI3K/AKT, and FGF-1/ANG-2 signaling pathways. Eur J Pharmacol 2020; 873:173008. [PMID: 32050083 DOI: 10.1016/j.ejphar.2020.173008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 02/08/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a severe complication of hepatic cirrhosis, which is characterized by hypoxia, intrapulmonary vasodilation, inflammation, and angiogenesis. In this study, we aimed to investigate the regulatory effects of diosmin (DS) on selected phosphodiesterase inhibitors against chronic bile duct ligation (CBDL)-induced HPS. Experimentally, Wistar Albino rats were used and HPS was induced by CBDL for 28 days. DS (100 mg/kg, daily, P.O.), sildenafil (Sild; 10 mg/kg, twice daily, P.O.), and pentoxifylline (PTX; 50 mg/kg, daily, P.O.) were evaluated either alone or in combinations for their anti-angiogenic activity. CBDL significantly altered oxidative stress biomarkers and up-regulated pulmonary mRNA expressions of VEGF, IGF-1, ET-1, iNOS, eNOS, and ANG-2 as well as the protein expressions of vWF, FGF-1, PI3K, AKT, p-AKT, TGF-β, HYP, MPO activity and circulating TNF-α. Treatment with DS, Sild, PTX, and their combinations significantly attenuated molecular and cellular changes due to CBDL. Improvement of histopathological changes was also observed after drug treatment which further supported our results. Furthermore, DS combination with Sild or PTX exhibited an improvement in HPS in comparison to each drug alone. Collectively, DS can augment the anti-angiogenic activity of Sild and PTX during HPS through regulation of TNF-α/VEGF, IGF-1/PI3K/AKT, and FGF-1/ANG-2 signaling pathways.
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22
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Hirata Y, Sakamoto S, Yoshimura S, Takeda M, Uchida H, Shimizu S, Kitamura M, Irie R, Miyazaki O, Yoshioka T, Nosaka S, Kasahara M. Outcomes of 50 Cases of Pediatric Liver Transplantation for Intrapulmonary Shunt While Considering the Deteriorated Prognosis of Severe Intrapulmonary Shunt Patients. Transplant Proc 2019; 51:2793-2797. [PMID: 31563247 DOI: 10.1016/j.transproceed.2019.03.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/12/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intrapulmonary shunt (IPS) is recognized in 10% of chronic liver disease patients. Liver transplantation (LT) is associated with a high risk of morbidity and mortality in patients with IPS. PATIENTS AND METHODS Of 519 pediatric LT cases between November 2005 and October 2018, 50 patients with IPS were enrolled in this study. The patients were divided into 3 groups, according to the shunt ratio, calculated by scintigraphy: mild (15%-20%, n = 26), moderate (20%-40%, n = 19), and severe (> 40%, n = 5). We compared the patients' characteristics before LT and the outcomes of LT between these groups. RESULTS The major original disease resulting in LT in the mild and moderate groups was biliary atresia (73.1% and 52.6%, respectively), while that in the severe group was congenital portosystemic shunt (60%). The median ages at LT were 7.5, 6.1, and 8.3 years in the mild, moderate, and severe groups, respectively. All of the mild and moderate IPS patients lived; however, 3 patients with severe IPS (60.0%) died within 3 months. The shunt ratios of the mild and moderate IPS patients normalized within 2 years after LT, while the 2 surviving severe IPS patients showed a slight improvement. The autopsy findings of the lung in 1 deceased severe IPS patient showed medial hypertrophy and proliferation of intimal cells of the pulmonary arteries, suggesting a diagnosis of portopulmonary hypertension. CONCLUSIONS LT can be safely performed for mild and moderate IPS patients; however, LT for severe IPS patients should be carefully indicated because concomitant portopulmonary hypertension may be masked by IPS.
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Affiliation(s)
- Yoshihiro Hirata
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Shohei Yoshimura
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masayuki Kitamura
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Irie
- Division of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Division of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Syunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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23
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Shanmugam N, Valamparampil J, Vij M, Reddy M, Rela M. Ischemic Cholangiopathy: Insight From an Explant Liver Allograft Affected by Severe Post-transplant Hypoxemia Due to Hepatopulmonary Syndrome: A Case Report. Transplant Proc 2019; 51:1002-1005. [PMID: 30979439 DOI: 10.1016/j.transproceed.2018.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023]
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24
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Perioperative Management of Patients with Hepatopulmonary Syndrome. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0208-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Raevens S, Fallon MB. Potential Clinical Targets in Hepatopulmonary Syndrome: Lessons From Experimental Models. Hepatology 2018; 68:2016-2028. [PMID: 29729196 PMCID: PMC6204081 DOI: 10.1002/hep.30079] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/20/2018] [Accepted: 04/27/2018] [Indexed: 12/12/2022]
Abstract
Hepatopulmonary syndrome (HPS) is a relatively common and potentially severe pulmonary complication of cirrhosis with increased risk of mortality. In experimental models, a complex interaction between pulmonary endothelial cells, monocytes, and the respiratory epithelium, which produces chemokines, cytokines, and angiogenic growth factors, causes alterations in the alveolar microvasculature, resulting in impaired oxygenation. Model systems are critical for evaluating mechanisms and for preclinical testing in HPS, due to the challenges of evaluating the lung in the setting of advanced liver disease in humans. This review provides an overview of current knowledge and recent findings in the rodent common bile duct ligation model of HPS, which recapitulates many features of human disease. We focus on the concepts of endothelial derangement, monocyte infiltration, angiogenesis, and alveolar type II cell dysfunction as main contributors and potential targets for therapy.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology – Hepatology Research Unit, Ghent University – Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Michael B. Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, Arizona, USA
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26
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Herborn J, Lewis C, De Wolf A. Liver Transplantation: Perioperative Care and Update on Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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27
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Krynytska I, Marushchak M, Mikolenko A, Bob A, Smachylo I, Radetska L, Sopel O. Differential diagnosis of hepatopulmonary syndrome (HPS): Portopulmonary hypertension (PPH) and hereditary hemorrhagic telangiectasia (HHT). Bosn J Basic Med Sci 2017; 17:276-285. [PMID: 28759737 PMCID: PMC5708897 DOI: 10.17305/bjbms.2017.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is a severe complication of advanced liver disease associated with an extremely poor prognosis. HPS is diagnosed in 4-47% of patients with cirrhosis and in 15-20% of candidates for liver transplantation. In addition, severe hypoxia is associated with a high risk of complications of liver transplantation (a 30% chance during the first 90 days) and increases the gap between transplantation and improving arterial oxygenation. The pathogenesis of HPS is not fully understood, and no effective pharmacological treatment has been developed yet. Currently, the treatment of choice for HPS is orthotopic liver transplantation. Non-specific clinical criteria and the lack of standardized diagnostic criteria for determining HPS can lead to diagnostic errors. Portopulmonary hypertension and hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu syndrome, are pulmonary complications of liver disease which should be differentially diagnosed from HPS.
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Affiliation(s)
- Inna Krynytska
- Functional and Laboratory Diagnostics Department, I. Horbachevsky Ternopil State Medical University, Ternopil, Ukraine.
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28
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Kumar L, Balakrishnan D, Varghese R, Surendran S. Extracorporeal membrane oxygenation for post-transplant hypoxaemia following very severe hepatopulmonary syndrome. BMJ Case Rep 2017; 2017:bcr-2017-221381. [PMID: 29092970 DOI: 10.1136/bcr-2017-221381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) associated with end-stage liver disease has a high morbidity when room air PaO2 is less than 50 mm Hg. Safe levels of oxygenation to facilitate transplantation have not been defined despite advancement in care. Postoperatively, hypoxaemia worsens due to ventilation perfusion mismatch contributed by postoperative pulmonary vasoconstriction and due to decrease in endogenous nitric oxide. A 16-year-old boy with cirrhosis presented with HPS and a PaO2 of 37 mm Hg on room air and underwent living donor liver transplant. Although stable intraoperatively, he desaturated on the second postoperative day. Despite a number of interventions, oxygenation remained critically low on 100% inspired oxygen. Extracorporeal membrane oxygenator (ECMO) was established with instant improvement in oxygenation (PaO268 mm Hg), and the patient was eventually salvaged. We suggest that ECMO could be a means of managing refractory post-transplant hypoxaemia in patients with HPS.
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Affiliation(s)
- Lakshmi Kumar
- Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Dinesh Balakrishnan
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Rekha Varghese
- Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Sudhindran Surendran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
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29
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Iqbal S, Smith KA, Khungar V. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Implications for Liver Transplantation. Clin Chest Med 2017; 38:785-795. [PMID: 29128026 DOI: 10.1016/j.ccm.2017.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) represent serious pulmonary complications of advanced liver diseases. Orthotopic liver transplantation (OLT) is capable of completely resolving the underlying abnormalities associated with HPS. On the other hand, post-OLT response in patients with PoPH is less predictable, although heavily influenced by pre-OLT mean pulmonary arterial pressure. It remains the case that the opportunity to reverse 2 potentially fatal organ dysfunctions in the liver and the lung make HPS and PoPH more than worthy for further clinical investigations.
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Affiliation(s)
- Shaz Iqbal
- Department of Medicine, General Internal Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 834 West Gates Building, Philadelphia, PA 19104, USA
| | - Vandana Khungar
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street 2 Dulles, Philadelphia, PA 19104, USA.
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30
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International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2017; 100:1440-52. [PMID: 27326810 DOI: 10.1097/tp.0000000000001229] [Citation(s) in RCA: 246] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two distinct pulmonary vascular disorders, hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) may occur as a consequence of hepatic parenchymal or vascular abnormalities. HPS and POPH have major clinical implications for liver transplantation. A European Respiratory Society Task Force on Pulmonary-Hepatic Disorders convened in 2002 to standardize the diagnosis and guide management of these disorders. These International Liver Transplant Society diagnostic and management guidelines are based on that task force consensus and should continue to evolve as clinical experience dictates. Based on a review of over 1000 published HPS and POPH articles identified via a MEDLINE search (1985-2015), clinical guidelines were based on, selected single care reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Guidelines are presented in 5 parts; I. Definitions/Diagnostic criteria; II. Hepatopulmonary syndrome; III. Portopulmonary hypertension; IV. Implications for liver transplantation; and V. Suggestions for future clinical research.
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31
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Change of hepatic arterial systolic/diastolic ratio predicts ischemic type biliary lesion after orthotropic liver transplantation. Clin Imaging 2016; 40:419-24. [PMID: 27133679 DOI: 10.1016/j.clinimag.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/25/2015] [Accepted: 01/26/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND We conducted this prospective nested case-control study for the hepatic artery and portal vein hemodynamic changes after orthotopic liver transplantation. METHODS A total 128 cases of orthotropic liver transplantation were analyzed, including 25 cases of ischemic type biliary lesions (ITBL). The portal vein and hepatic artery flow velocities were detected by ultrasound on days 28, 42, and 84 after liver transplantation. In the GLM analysis of Lg(S/D), the P values of Group Effect, Time Effect, and Time×Group were 0.014, 0.376, and 0.008, respectively. CONCLUSION Our results show a relatively reduced hepatic artery S/D in ITBL, especially in extrahepatic ITBL.
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32
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Shah R, Gutsche JT, Patel PA, Fabbro M, Ochroch EA, Valentine EA, Augoustides JGT. CASE 6-2016Cardiopulmonary Bypass as a Bridge to Clinical Recovery From Cardiovascular Collapse During Graft Reperfusion in Liver Transplantation. J Cardiothorac Vasc Anesth 2015; 30:809-15. [PMID: 26738978 DOI: 10.1053/j.jvca.2015.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Ronak Shah
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Edward A Ochroch
- Liver Transplant Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth A Valentine
- Liver Transplant Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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