Prevalence and Prognosis of Portopulmonary Hypertension in 223 Liver Transplant Recipients

Echocardiography Screening of Consecutive Patients With Portal Hypertension Referred to Mayo Clinic for Liver Transplant Evaluation

OBJECTIVE

To determine the prevalence of portopulmonary hypertension in patients referred for liver transplant evaluation.

METHODS

Medical records were reviewed for 986 consecutive patients referred for liver transplant evaluation who were screened for pulmonary hypertension with echocardiography from February 1, 2021, to January 31, 2022, across 3 liver transplant centers.

RESULTS

Of 934 patients eligible for analysis, mean (SD) age was 57 (11) years, 558 (59.7%) were men, and 859 (92.0%) were White. Alcoholic cirrhosis and nonalcoholic steatohepatitis represented 640 (68.5%) of the liver diseases. Right ventricular systolic pressure estimated by echocardiography was 35 mm Hg or greater in 147 (15.7%) and less than 35 mm Hg in 475 (50.9%; unable to estimate in 312 [33.4%]). Right-sided heart catheterization was performed in 42 (4.5%) patients; hemodynamic profiles revealed that 12 (28.6%) did not have pulmonary hypertension, 15 (35.7%) had postcapillary venous pulmonary hypertension, 7 (16.7%) had portopulmonary hypertension, 6 (14.3%) had unclassifiable pulmonary hypertension, and 2 (4.8%) had combined pre- and postcapillary pulmonary hypertension.

CONCLUSION

The percentage of portopulmonary hypertension in patients referred for liver transplant was considerably lower, 7 of 934 (0.7%), than in previous studies, but the reason was unclear.

Addition of a Loop Diuretic to Norepinephrine During Treatment of Hepatorenal Syndrome Type 1

Introduction

Diuretics are commonly discontinued in patients with cirrhosis with acute kidney injury (AKI) because they are presumed to trigger hepatorenal syndrome type 1 (HRS-1). We hypothesized that if HRS-1 is adequately treated with a vasoconstrictor (mean arterial pressure [MAP] effectively increased), diuretics are safe and effective.

Methods

Records of hospitalized patients with cirrhosis who received i.v. furosemide while receiving i.v. norepinephrine as a vasoconstrictor to treat HRS-1 were examined. We assessed change in urine output (UOP), trajectory of serum creatinine (sCr), and impact of portopulmonary hypertension (PoPHTN) on the therapeutic response.

Results

Twenty-six patients with HRS-1 received i.v. furosemide (median: 2 days, 160 mg boluses every 6-24 hours) added to i.v. norepinephrine. Median age was 51 years; 91% were of White race, 36% were women, and median model for end-stage liver disease score was 32. The median initial sCr was 4.0 mg/dl. Before treatment, median UOP was 358 ml/d. Norepinephrine alone led to a median increase in UOP to 850 ml/d. Addition of furosemide to norepinephrine induced a subsequent increase in median UOP to 2072 ml/d (P < 0.0001), which was not observed in a control group (n = 22) who did not receive furosemide. Nineteen patients (73%) treated with norepinephrine plus furosemide (median MAP increase, 16 mm Hg) either maintained or improved their sCr trajectory. The magnitude of norepinephrine-induced increase in MAP correlated with the norepinephrine plus furosemide-induced UOP (r = 0.67, P = 0.0002), and the correlation coefficient was numerically stronger among those with PoPHTN.

Conclusion

In patients with HRS-1 who are adequately treated with norepinephrine and achieved an optimal MAP increment, addition of i.v. furosemide enhances diuresis without negatively affecting renal recovery.

Portopulmonary hypertension: peculiarities of diagnosis and treatment

Portopulmonary hypertension is defined as the development of pulmonary hypertension secondary to portal one. Its exact prevalence is difficult to determine due to the lack of routine screening in patients with portal hypertension. Hemodynamic changes associated with portal hypertension, including the hyperdynamic state, portosystemic shunts, and splanchnic vasodilation, cause significant disturbances in the pulmonary vasculature and play a key role in the pathogenesis of the disease. Without treatment, portopulmonary hypertension leads to progressive right ventricular failure with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and candidates for liver transplant, right heart catheterization remains the gold standard for disease diagnosis. Treatment of patients with portopulmonary hypertension is aimed at improving cardiac function, reducing pulmonary vascular resistance, and optimizing functional capacity. Pulmonary hypertension-specific therapy, which includes prostacyclin and its receptor agonists, endothelin receptor antagonists, phosphodiesterase inhibitors, and guanylate cyclase stimulators, plays a key role in the treatment of patients with portopulmonary hypertension. Small uncontrolled and recent single randomized controlled trials have reported promising results of vasodilator therapy in terms of clinical and hemodynamic improvement in patients, allowing certain patients to undergo liver transplantation. This review discusses the epidemiology, approach to diagnosis and treatment of patients with portopulmonary hypertension. We used MEDLINE database on the PubMed platform and the Cochrane library to search for literature sources using the keywords: portopulmonary hypertension, portal hypertension, pulmonary hypertension, liver cirrhosis, pulmonary complications.

[Pulmonary Complications in Patients with Liver Cirrhosis]

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.

Portopulmonary Hypertension: An Updated Review

Portal hypertension may have major consequences on the pulmonary vasculature due to the complex pathophysiological interactions between the liver and lungs. Portopulmonary hypertension (PoPH), a subset of group 1 pulmonary hypertension (PH), is a serious pulmonary vascular disease secondary to portal hypertension, and is the fourth most common subtype of pulmonary arterial hypertension. It is most commonly observed in cirrhotic patients; however, patients with noncirrhotic portal hypertension can also develop it. On suspicion of PoPH, the initial evaluation is by a transthoracic echocardiogram in which, if elevated pulmonary pressures are shown, patients should undergo right heart catheterization to confirm the diagnosis. The prognosis is extremely poor in untreated patients; therefore, management includes pulmonary arterial hypertension therapies with the aim of improving pulmonary hemodynamics and moving patients to orthotopic liver transplantation (OLT). In this article, we review in detail the epidemiology, pathophysiology, process for diagnosis, and most current treatments including OLT and prognosis in patients with PoPH. In addition, we present a diagnostic algorithm that includes the current criteria to properly select patients with PoPH who are candidates for OLT.

Current clinical understanding and effectiveness of portopulmonary hypertension treatment

Portopulmonary hypertension (PoPH) is a rare subtype of Group 1 pulmonary arterial hypertension (PAH) with a poor prognosis. According to the most up-to-date definition, PoPH is characterized by a mean pulmonary arterial pressure (PAP) of &gt;20 mmHg at rest, a pulmonary artery wedge pressure of ≤15 mmHg, and a pulmonary vascular resistance (PVR) of &gt;2 Wood units with portal hypertension. Like PAH, PoPH is underpinned by an imbalance in vasoactive substances. Therefore, current guidelines recommend PAH-specific therapies for PoPH treatment; however, descriptions of the actual treatment approaches are inconsistent. Given the small patient population, PoPH is often studied in combination with idiopathic PAH; however, recent evidence suggests important differences between PoPH and idiopathic PAH in terms of hemodynamic parameters, treatment approaches, survival, socioeconomic status, and healthcare utilization. Therefore, large, multi-center registry studies are needed to examine PoPH in isolation while obtaining statistically meaningful results. PoPH has conventionally been excluded from clinical drug trials because of concerns over hepatotoxicity. Nevertheless, newer-generation endothelin receptor antagonists have shown great promise in the treatment of PoPH, reducing PVR, PAP, and World Health Organization functional class without causing hepatotoxicity. The role of liver transplantation as a treatment option for PoPH has also been controversial; however, recent evidence shows that this procedure may be beneficial in this patient population. In the future, given the shortage of liver donors, predictors of a favorable response to liver transplantation should be determined to select the most eligible patients. Collectively, advances in these three areas could help to standardize PoPH treatment in the clinic.

Risk factors for portopulmonary hypertension in patients with cirrhosis: a prospective, multicenter study

BACKGROUND

Tricuspid regurgitation pressure gradient (TRPG) measurement by echocardiography is recommended as the most objective examination to detect portopulmonary hypertension (PoPH). This study aimed to identify factors associated with a high TRPG in patients with cirrhosis and develop a scoring model for identifying patients who are most likely to benefit from echocardiography investigations.

RESULTS

A total of 486 patients who underwent echocardiography were randomly allocated to the derivation and validation sets at a ratio of 2:1. Of the patients, 51 (10.5%) had TRPG ≥ 35 mmHg. The median brain natriuretic peptide (BNP) was 39.5 pg/mL. Shortness of breath (SOB) was reported by 91 (18.7%) patients. In the derivation set, multivariate analysis identified female gender, shortness of breath, and BNP ≥ 48.9 pg/mL as independent factors for TRPG ≥ 35 mmHg. The risk score for predicting TRPG ≥ 35 mmHg was calculated as follows: - 3.596 + 1.250 × gender (female: 1, male: 0) + 1.093 × SOB (presence: 1, absence: 0) + 0.953 × BNP (≥ 48.9 pg/mL: 1, < 48.9 pg/mL: 0). The risk score yielded sensitivity of 66.7%, specificity of 75.3%, positive predictive value of 25.5%, negative predict value of 94.3%, and predictive accuracy of 74.4% for predicting TRPG ≥ 35 mmHg. These results were almost similar in the validation set, indicating the reproducibility and validity of the risk score.

CONCLUSIONS

This study clarified the characteristics of patients with suspected PoPH and developed a scoring model for identifying patients at high risk of PoPH, which may be used in selecting patients that may benefit from echocardiography.

Struggling Between Liver Transplantation and Portopulmonary Hypertension

Portopulmonary hypertension (PoPH) is a progressive, ultimately fatal cardiopulmonary disease that occurs exclusively in patients with underlying portal hypertensive liver disease. PoPH outcomes are driven by both the severity of underlying liver disease and the degree of cardiac adaptation to elevated pulmonary pressures. The mainstay of treatment in PoPH is targeted pulmonary vascular therapy. Liver transplantation (LT) can be beneficial in some patients, but is associated with considerable risks in the PoPH population, and outcomes are variable. The optimal management strategy for PoPH, LT, or medical therapy alone, is unclear, and further research is needed to help guide clinical decision-making.

Clinical Management and Outcomes of Patients With Portopulmonary Hypertension Enrolled in the Japanese Multicenter Registry

Background: Portopulmonary hypertension (PoPH) is one of the major underlying causes of pulmonary arterial hypertension (PAH). However, PoPH, especially treatment strategies, has been poorly studied. Therefore, this study evaluated current treatments for PoPH, their efficacy, and clinical outcomes of patients with PoPH. Methods and Results: Clinical data were collected for patients with PoPH who were enrolled in the Japan Pulmonary Hypertension Registry between 2008 and 2021. Hemodynamic changes, functional class, and clinical outcomes were compared between patients with PoPH treated with monotherapy and those treated with combination therapies. Clinical data were analyzed for 62 patients with PoPH, including 25 treatment-naïve patients, from 21 centers in Japan. In more than half the patients, PAH-specific therapy improved the New York Heart Association functional class by at least one class. The 3- and 5-year survival rates of these patients were 88.5% (95% confidence interval [CI] 76.0-94.7) and 80.2% (95% CI 64.8-89.3), respectively. Forty-one (66.1%) patients received combination therapy. Compared with patients who had received monotherapy, the mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac index were significantly improved in patients who had undergone combination therapies. Conclusions: Combination therapy was commonly used in patients with PoPH with a favorable prognosis. Combination therapies resulted in significant hemodynamic improvement without an increased risk of side effects.

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.

Portopulmonary Hypertension: A Review of the Current Literature

Portopulmonary hypertension is defined as the development of pulmonary arterial hypertension in the setting of portal hypertension with or without liver cirrhosis. Portal hypertension-associated haemodynamic changes, including hyperdynamic state, portosystemic shunts and splanchnic vasodilation, induce significant alterations in pulmonary vascular bed and play a pivotal role in the pathogenesis of the disease. If left untreated, portopulmonary hypertension results in progressive right heart failure, with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and liver transplantation candidates, right heart catheterisation remains the gold standard for the diagnosis of the disease. Severe portopulmonary hypertension exerts a prohibitive risk to liver transplantation by conferring an elevated perioperative mortality risk. It is important for haemodynamic parameters to correspond with non-severe portopulmonary hypertension before patients can proceed with the liver transplantation. Small uncontrolled studies and a recent randomised controlled trial have reported promising results with vasodilatory therapies in clinical and haemodynamic improvement of patients, allowing a proportion of patients to undergo liver transplantation. In this review, the epidemiology, pathogenesis, diagnostic approach and management of portopulmonary hypertension are discussed. We also highlight fields of ongoing investigation pertinent to risk stratification and optimal patient selection to maximise long-term benefit from currently available treatments.

Portopulmonary hypertension: Current developments and future perspectives

Portopulmonary hypertension (POPH) is a severe pulmonary vascular disease secondary to portal hypertension and a subset of Group 1 pulmonary hypertension (PH). The pathological changes of POPH are indistinguishable from other PH phenotypes, including endothelial dysfunction, pulmonary vasoconstriction, and vascular remodeling. These changes cause a progressive increase in pulmonary vascular resistance and afterload of the right ventricle, eventually leading to severe right heart failure. The prognosis of POPH is extremely poor among untreated patients. POPH is associated with a high risk of death after liver transplantation (LT), and severe POPH is considered an absolute contraindication for LT. However, pulmonary arterial hypertension (PAH)-targeted therapies are administered to patients with POPH, and aggressive drug treatment significantly optimizes pulmonary hemodynamics and reduces the risk of death. Therefore, early diagnosis, aggressive PAH-targeted therapies, and proper selection of liver transplant candidates are vital to reduce the risk of surgery and improve clinical outcomes. This article aims to review the results of previous studies and describe biological mechanisms, epidemiology, potential risk factors, and diagnostic approaches of POPH. Moreover, we introduce recent therapeutic interventions for the early diagnosis of POPH and efficient clinical management decisions.

Evaluation of Predisposing Metabolic Risk Factors for Portopulmonary Hypertension in Patients with NASH Cirrhosis

PURPOSE

Metabolic parameters are important for the development of portopulmonary hypertension (PoPH) during nonalcoholic steatohepatitis (NASH)-associated cirrhosis. This study evaluated patients with NASH-associated cirrhosis to determine metabolic risk factors for portopulmonary hypertension.

PATIENTS AND METHODS

Data on 171 patients (120 men and 51 women) with NASH-associated cirrhosis who were seen in Florence Nightingale Hospital's gastroenterology Clinic from 2009 to 2018 was obtained from the Hospital database. A pulmonary artery systolic pressure >35 mmHg was defined as PH (pulmonary hypertension) according to standard transthoracic echocardiography. Portal hypertension was diagnosed from clinical symptoms and dilated portal veins shown by abdominal ultrasound or computed tomography (CT). Pulmonary patients with portal hypertension were diagnosed with portopulmonary hypertension (PoPH).

RESULTS

A total of 171 patients with NASH-associated cirrhosis were included in this study. Of these, 43 patients had PoPH. These patients had increased TSH (p=0.004), bilirubin (p=0.023) and triglyceride (p=0.048) levels, higher MELD scores (p=0.018) and decreased hemoglobin (p=0.05). MELD score and hemoglobin, total bilirubin, TSH, and triglyceride levels were all included in a multivariate logistic regression model and TSH levels were independently associated with increased risk of PoPH.

CONCLUSION

Increased TSH is an independent risk factor for PoPH.

Pulmonary Vascular Resistance Predicts Mortality and Graft Failure in Transplantation Patients With Portopulmonary Hypertension

Portopulmonary hypertension (POPH) is a pulmonary vascular disease associated with significant morbidity and mortality in those with liver disease, conferring a higher mortality in patients awaiting liver transplantation (LT). Although not a transplant indication, patients with POPH can experience significant clinical improvement following LT, and those maintaining a mean pulmonary artery pressure (MPAP) <35mm Hg and a pulmonary vascular resistance (PVR) <5 Woods units (WU) are granted additional listing points to expedite LT. The effect of POPH on posttransplant outcomes such as mortality and graft failure, however, is not well defined. We performed a retrospective cohort study of the US Organ Procurement and Transplantation Network database of all adult patients who underwent LT between January 1, 2006, and December 1, 2020. Using adjusted accelerated failure time models, we examined the relationship between a diagnosis of POPH and outcomes following LT and the relationship between pre-LT hemodynamics and post-LT survival (alive with a functioning graft) in patients with POPH. Compared with those undergoing transplants without exception points, patients with POPH had comparable post-LT survival rates but were significantly more likely to have graft failure. Both pre-LT MPAP and PVR predicted post-LT survival in POPH, with a pre-LT PVR of ≥1.6 WU, more than doubling the hazard for mortality (death or a nonfunctioning graft; coefficient, 2.01; standard error, 0.85; hazard ratio, 2.21; P = 0.02). POPH may confer a significantly higher risk of post-LT graft failure compared with patients with cirrhosis without POPH, and a pre-LT PVR of ≥1.6 WU may predict post-LT survival. Further investigation into the relationship between pre-LT hemodynamics, right ventricular function, and post-LT outcomes of mortality and graft failure in POPH is needed.

A review of liver dysfunction in the lung transplant patient

Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.

Prevalence and Associated Factors of Portopulmonary Hypertension in Patients with Portal Hypertension: A Case-Control Study

Background and Aims

There are few studies on the prevalence and clinical characteristics of portopulmonary hypertension (POPH) in patients with portal hypertension. In addition, invasive right heart catheterization further limits the clinical diagnosis of POPH patients.

Methods

From January 2018 to December 2019, 1004 patients with portal hypertension were treated in the Department of Hepatology, the First Hospital of Jilin University. Based on the inclusion and exclusion criteria, 188 patients with portal hypertension were finally included. We collected complete clinical data, laboratory examinations, and imaging examinations. Patients were divided into a POPH group and a non-POPH group based on echocardiographic results. We calculated the prevalence of POPH in patients with portal hypertension. The differences in clinical characteristics of the two groups of patients were compared.

Results

The prevalence of POPH in patients with portal hypertension was 2.8%. Among the 188 patients with portal hypertension with fingertip oxygen saturation < 95% at rest, 28 patients had POPH (12 males and 16 females), with an average age of 63 ± 8, and 160 patients did not have POPH (110 males, 50 women), with an average age of 59 ± 11. The proportion of women in the POPH group (P < 0.01) and patients without liver cancer (P = 0.044) was high. Compared to patients without POPH, patients with POPH had lower hemoglobin (related to the severity of anemia, P < 0.01), higher creatinine (P < 0.05), and lower partial pressure of oxygen and carbon dioxide (P < 0.05). Patients with POPH had a higher incidence of atrial enlargement, ventricular enlargement, mitral valve regurgitation, tricuspid regurgitation, pulmonary artery widening, pericardial effusion, and aortic regurgitation than those without POPH. The risk of POPH did not increase with the aggravation of the Child-Pugh classification.

Conclusion

The prevalence of POPH in patients with portal hypertension is 2.8%. The proportion of women and nonliver cancer in POPH patients was higher than that in non-POPH patients. In addition, the POPH group had higher creatinine and lower hemoglobin, and echocardiography showed that POPH patients had more cardiac structural changes. In patients with portal hypertension, the risk in patients with POPH has nothing to do with the Child-Pugh classification and MELD score.

The clinical characteristics, treatment, and survival of portopulmonary hypertension in Japan

Background

Portopulmonary hypertension (PoPH) refers to the simultaneous presentation of pulmonary arterial and portal hypertension. However, few reports have included the characteristics and treatments for patients with PoPH of Asian population; thus, we investigated the clinical characteristics, treatment, and survival of these patients in a Japanese cohort.

Methods

Pulmonary arterial hypertension (PAH) has been included in the National Research Project on Intractable Disease in Japan; therefore, we extracted data of patients with PoPH from the forms of newly registered cases of the project from 2012 to 2013 (for 2 years), and updated cases of the project in 2013 (Study 1, n = 36 newly registered forms, n = 46 updated forms). Additionally, for Study 2, we performed a retrospective, observational cohort study at Chiba University Hospital (n = 11). We compared the characteristics between patients with PoPH and those with idiopathic/heritable PAH (I/H-PAH).

Results

Both studies showed higher cardiac outputs (COs) and cardiac indexes (CIs), lower pulmonary vascular resistance (PVR), and less treated with combination therapy in patients with PoPH than those with I/H-PAH. In Study 2, the overall and disease-specific survival between PoPH and I/H-PAH were similar. Conversely, many patients (45%) had to change their PAH-specific medicine because of adverse effects.

Conclusion

As seen in western countries, Japanese patients with PoPH showed higher COs and CIs, better exercise tolerance, and lower PVRs than patients with I/H-PAH. Further studies are needed to improve PoPH treatments.

Pulmonary manifestations of chronic liver disease: a comprehensive review

Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.