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Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol 2022; 22:363. [PMID: 36435747 PMCID: PMC9701388 DOI: 10.1186/s12871-022-01904-1] [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: 09/06/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Essen, Hufeland 55, 45147, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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Stubbe B, Opitz CF, Halank M, Habedank D, Ewert R. Intravenous prostacyclin-analogue therapy in pulmonary arterial hypertension - A review of the past, present and future. Respir Med 2021; 179:106336. [PMID: 33647836 DOI: 10.1016/j.rmed.2021.106336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
Therapy with intravenous prostacyclin analogues in patients with pulmonary arterial hypertension (PAH) has been established for decades and is an integral component of the current guidelines for the treatment of pulmonary hypertension. Initially, these drugs were infused by external pump systems via tunnelled right atrial catheters with the need for cooling and frequent exchange of drug reservoirs. Associated complications included, among others, catheter-related infections. More recently, fully implantable pump systems have been developed with drug reservoirs that are filled transcutaneously, allowing intervals between refills of several weeks. This technique results in a low rate of infections. Epoprostenol, iloprost and treprostinil have all been used intravenously in PAH, but titration, dosing and dose escalation in long-term therapy are not standardized. Intravenous prostacyclin analogues are still under-used, despite available data suggesting that early and broad application of these therapies as part of risk-oriented, guideline-directed combination therapy for patients with PAH may lead to a survival benefit. This review provides a detailed overview of the drugs, infusion systems and dosing strategies used for intravenous therapy in patients with PAH.
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Affiliation(s)
- Beate Stubbe
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany.
| | - Christian F Opitz
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden, Germany
| | - Dirk Habedank
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
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Diagnosis, Treatment, and Management of Orthotopic Liver Transplant Candidates With Portopulmonary Hypertension. Cardiol Rev 2018; 26:169-176. [PMID: 29608499 DOI: 10.1097/crd.0000000000000195] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Onoe T, Tanaka A, Ishiyama K, Ide K, Tashiro H, Ohdan H. Perioperative management with phosphodiesterase type 5 inhibitor and prostaglandin E1 for moderate portopulmonary hypertension following adult-to-adult living-donor liver transplantation: a case report. Surg Case Rep 2018; 4:15. [PMID: 29417353 PMCID: PMC5803166 DOI: 10.1186/s40792-018-0423-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/30/2018] [Indexed: 01/15/2023] Open
Abstract
Background Portopulmonary hypertension (PPH) is a relatively rare but well-recognized complication of end-stage liver disease. Moderate or severe PPH (mean pulmonary artery pressure [mPAP] ≥ 35 mmHg) is usually a contraindication for liver transplantation due to high operation-related mortality. Here, we report on a patient with moderate PPH whose condition was successfully managed with a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) and prostaglandin E1, who experienced rapid improvement of PPH after living-donor liver transplantation (LDLT). Case presentation A 63-year-old woman with alcoholic decompensated cirrhosis was referred to our hospital for LDLT. She had mild dyspnea on exertion as well as fatigue. Echocardiography and subsequent cardiac catheterization revealed a high mPAP (35 mmHg), and she was diagnosed with moderate PPH. We commenced treatment with oral tadalafil for the PPH. A second preoperative echocardiography demonstrated improved PPH, and she underwent LDLT. An intravenous infusion of prostaglandin E1 was introduced instead of tadalafil during and after the operation. The mPAP value showed a rapid decrease in mPAP value to 22 mmHg in 2 days. After discontinuation of the prostaglandin E1, the mPAP value remained 23 mmHg. Postoperative catheterization 2 months after LDLT showed no exacerbation of PPH. She was discharged on foot 70 days after LDLT in good condition and has shown a good clinical condition more than 2 years after LDLT. Conclusion LDLT could be a radical treatment for PPH with careful management and adequate patient selection. PDE5 inhibitor and PGE1 is effective and feasible for perioperative management of the patient with moderate portopulmonary hypertension in LDLT.
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Affiliation(s)
- Takashi Onoe
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan. .,Institute for Clinical Research, National Hospital Organization Kure Medical Center/Chugoku Cancer Center, Kure, Japan.
| | - Asuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan.,Institute for Clinical Research, National Hospital Organization Kure Medical Center/Chugoku Cancer Center, Kure, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan
| | - Hirotaka Tashiro
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan.,Institute for Clinical Research, National Hospital Organization Kure Medical Center/Chugoku Cancer Center, Kure, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-0037, Japan
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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: 251] [Impact Index Per Article: 35.9] [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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Abstract
Portopulmonary hypertension (PoPH) refers to the condition that pulmonary arterial hypertension (PAH) occur in the stetting of portal hypertension. The development of PoPH is thought to be independent of the severity of portal hypertension or the etiology or severity of liver disease. PoPH results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. Untreated PoPH is associated with a poor prognosis. As PoPH is frequently asymptomatic or symptoms are generally non-specific, patients should be actively screened for the presence of PoPH. Two-dimensional transthoracic echocardiography is a useful non-invasive screening tool, but a definitive diagnosis requires invasive hemodynamic confirmation by right heart catheterization. Despite a dearth of randomized, prospective data, an ever-expanding clinical experience shows that patients with PoPH benefit from therapy with PAH-specific medications including with endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and/or prostanoids. Due to high perioperative mortality, transplantation should be avoided in those patients who have severe PoPH that is refractory to medical therapy.
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Affiliation(s)
- Yong Lv
- a Department of Liver Diseases and Digestive Interventional Radiology , Xijing Hospital of Digestive Diseases, Fourth Military Medical University , Xi'an , China
| | - Guohong Han
- a Department of Liver Diseases and Digestive Interventional Radiology , Xijing Hospital of Digestive Diseases, Fourth Military Medical University , Xi'an , China
| | - Daiming Fan
- b State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Xi'an , China
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Saleemi S, Idrees MM. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Portopulmonary hypertension. Ann Thorac Med 2014; 9:S42-6. [PMID: 25076996 PMCID: PMC4114279 DOI: 10.4103/1817-1737.134021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 12/13/2022] Open
Abstract
Portopulmonary hypertension (POPH) is defined as pulmonary arterial hypertension (PAH) complicated by portal hypertension, with or without advanced hepatic disease. Significant percentage of patients with cirrhotic liver disease has high cardiac output and subsequently elevated pulmonary arterial pressures (PAP). However, patients with POPH develop a progressive increase in pulmonary vascular resistance (PVR), which is generally lower than that observed in other forms of PAH. The prognosis of untreated patients with POPH is very poor and the outcome of liver transplant (LT) in those patients is determined by the degree of severity of the associated pulmonary hemodynamics. In this narrative review, we describe the clinical presentation of POPH, the pathobiology, and the clinical implication of pulmonary hemodynamics. We also provide evidence-based recommendations for the diagnosic and management approaches of POPH.
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Affiliation(s)
- Sarfraz Saleemi
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Prince Sultan Medical Military City, Riyadh, Saudi Arabia
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Aldenkortt F, Aldenkortt M, Caviezel L, Waeber JL, Weber A, Schiffer E. Portopulmonary hypertension and hepatopulmonary syndrome. World J Gastroenterol 2014; 20:8072-8081. [PMID: 25009379 PMCID: PMC4081678 DOI: 10.3748/wjg.v20.i25.8072] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are two frequent complications of liver disease, with prevalence among liver transplant candidates of 6% and 10%, respectively. Both conditions result from a lack of hepatic clearance of vasoactive substances produced in the splanchnic territory. Subsequently, these substances cause mainly pulmonary vascular remodeling and some degree of vasoconstriction in POPH with resulting elevated pulmonary pressure and right ventricular dysfunction. In HPS the vasoactive mediators cause intrapulmonary shunts with hypoxemia. Medical treatment is disappointing overall. Whereas liver transplantation (LT) results in the disappearance of HPS within six to twelve months, its effect on POPH is highly unpredictable. Modern strategies in managing HPS and POPH rely on a thorough screening and grading of the disease’s severity, in order to tailor the appropriate therapy and select only the patients who will benefit from LT. The anesthesiologist plays a central role in managing these high-risk patients. Indeed, the important hemodynamic and respiratory modifications of the perioperative period must be avoided through continuation of the preoperatively initiated drugs, appropriate intraoperative monitoring and proper hemodynamic and respiratory therapies.
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Houlihan DD, Holt A, Elliot C, Ferguson JW. Review article: liver transplantation for the pulmonary disorders of portal hypertension. Aliment Pharmacol Ther 2013; 37:183-94. [PMID: 23146100 DOI: 10.1111/apt.12140] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 09/18/2012] [Accepted: 10/24/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver transplantation is potentially a life-saving therapeutic intervention for patients with portopulmonary hypertension and hepatopulmonary syndrome. However, due to limited data, listing criteria for patients with these conditions have not been clearly established. Indeed, this has led some to speculate that transplantation may not be appropriate in cases of moderate-to-severe portopulmonary hypertension and severe hepatopulmonary syndrome. AIM To critically discuss the utility of LT for the treatment of hepatopulmonary syndrome and portopulmonary hypertension. METHODS A literature search was conducted in 2012 on PubMed, Ovid Embase, Ovid Medline and Scopus using the following search terms: hepatopulmonary syndrome, portopulmonary hypertension, pulmonary arterial hypertension, liver transplantation. Relevant manuscripts were included in the review. RESULTS Liver transplantation has established itself as an effective treatment for selected patients with hepatopulmonary syndrome and portopulmonary hypertension. A multidisciplinary team approach incorporating focused strategies (both pre- and post-operatively) aimed at improving oxygenation in patients with hepatopulmonary syndrome has led to a dramatic improvement in patient outcomes. Additionally, careful patient selection and the use of targeted pulmonary vascular therapies are successfully being used to treat portopulmonary hypertension and 'bridge' patients to successful liver transplantation. CONCLUSIONS Liver transplantation is an effective therapy for patients with hepatopulmonary syndrome and portopulmonary hypertension. However, rigorous screening and early identification of these conditions allied with aggressive pre-operative optimisation of physiology and diligent post-operative care are imperative to ensuring a good outcome.
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Affiliation(s)
- D D Houlihan
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
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12
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John J, Palevsky H. Clinical pharmacology and efficacy of inhaled iloprost for the treatment of pulmonary arterial hypertension. Expert Rev Clin Pharmacol 2012; 4:197-205. [PMID: 22115402 DOI: 10.1586/ecp.10.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Similar to other prostanoids, iloprost is a potent vasodilator with considerable antiproliferative and anti-thrombotic properties, although the relevance of its ability to affect platelet aggregation in this subset of patients is unrecognized. The pathogenesis of pulmonary arterial hypertension (PAH) is a multifactorial and complex process secondary to an innate deficiency of substances that induce vasodilation and an overproduction of substances producing vasoconstriction. The production of endothelial vasoactive mediators such as nitric oxide, prostacyclin, endothelin-1, thromboxane and serotonin affect the growth of smooth muscle cells, which facilitate the development of structural remodeling changes that are characteristic of PAH. There have been remarkable advances in understanding the pathologic processes that are responsible for increasing pulmonary vascular resistance and that result in elevated pulmonary artery pressures in order to reverse and prevent progression of the disease process. The goals of treatment in these patients are to alleviate the patients' symptoms, to improve functional capacity and to prevent the progression of the disease. The prostacyclin analogs, such as iloprost, have given hope to these patients who struggle under the burdens of this complex disease.
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Affiliation(s)
- Julie John
- Department of Medicine, Penn Presbyterian Medical Center, 51 N. 39th Street, Philadelphia, PA 19104, USA
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13
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Abstract
Hepatopulmonary syndrome (HPS) is a serious vascular complication of liver disease that occurs in 5-32% of patients with cirrhosis. The presence of HPS markedly increases mortality. No effective medical therapies are currently available and liver transplantation is the only established treatment option for HPS. The definition and diagnosis of HPS are established by the presence of a triad of liver disease with intrapulmonary vascular dilation that causes abnormal arterial gas exchange. Experimental biliary cirrhosis induced by common bile duct ligation in the rat reproduces the pulmonary vascular and gas exchange abnormalities of human HPS and serves as a pertinent animal model. Pulmonary microvascular dilation and angiogenesis are two central pathogenic features that drive abnormal pulmonary gas exchange in experimental HPS, and thus might underlie HPS in humans. Defining the mechanisms involved in the microvascular alterations of HPS has the potential to lead to effective medical therapies. This Review focuses on the current understanding of the pathogenesis, clinical features and management of HPS.
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Affiliation(s)
- Junlan Zhang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030-1501, USA
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Giusca S, Jinga M, Jurcut C, Jurcut R, Serban M, Ginghina C. Portopulmonary hypertension: from diagnosis to treatment. Eur J Intern Med 2011; 22:441-7. [PMID: 21925050 DOI: 10.1016/j.ejim.2011.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/30/2011] [Accepted: 02/19/2011] [Indexed: 01/10/2023]
Abstract
Portopulmonary hypertension is a form of pulmonary arterial hypertension that has gained interest in recent years with the development of liver transplantation techniques and new pulmonary vasodilator therapies. Portopulmonary hypertension is defined as pulmonary artery hypertension associated with portal hypertension with or without advanced hepatic disease. Echocardiography plays a major role in screening for portopulmonary hypertension but right heart catheterization remains the gold standard for diagnosis. The treatment of patients with portopulmonary hypertension consists of general measures that apply to all patients that carry the diagnosis of pulmonary hypertension and specific vasodilator therapies. These new therapies showed encouraging results in patients who would otherwise have a contraindication for liver transplantation. The review presents a summary of the current knowledge on the epidemiology, diagnosis, treatment and prognosis of patients with portopulmonary hypertension.
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Affiliation(s)
- Sorin Giusca
- Cardiology Department, Institute for Emergencies in Cardiovascular Diseases Prof Dr C. C. Iliescu, Bucharest, Romania.
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Abstract
OBJECTIVES To review the management of complications related to end-stage liver disease in the intensive care unit. The goal of this review is to address topics important to the practicing physician. DATA SOURCES We performed an organ system-based PubMed literature review focusing on the diagnosis and treatment of critical complications of end-stage liver disease. DATA SYNTHESIS AND FINDINGS: When available, preferential consideration was given to randomized controlled trials. In the absence of trials, observational and retrospective studies and consensus opinions were included. We present our recommendations for the neurologic, cardiovascular, pulmonary, gastrointestinal, renal, and infectious complications of end-stage liver disease. CONCLUSIONS Complications related to end-stage liver disease have significant morbidity and mortality. Management of these complications in the intensive care unit requires awareness and expertise among physicians from a wide variety of fields.
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Sawant P, Vashishtha C, Nasa M. Management of cardiopulmonary complications of cirrhosis. Int J Hepatol 2011; 2011:280569. [PMID: 21994850 PMCID: PMC3170746 DOI: 10.4061/2011/280569] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 05/12/2011] [Indexed: 12/22/2022] Open
Abstract
Advanced portal hypertension accompanying end-stage liver disease results in an altered milieu due to inadequate detoxification of blood from splanchnic circulation by the failing liver. The portosystemic shunts with hepatic dysfunction result in an increased absorption and impaired neutralisation of the gastrointestinal bacteria and endotoxins leads to altered homeostasis with multiorgan dysfunction. The important cardiopulmonary complications are cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension, and right-sided hydrothorax.
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Affiliation(s)
- Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai 400022, India
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Abstract
Portopulmonary hypertension is defined as the combination of pulmonary arterial hypertension with portal hypertension and presents management complications in patients awaiting liver transplantation. The combination of these vascular disorders has a marked impact on mortality. At present the recommendations for management are limited because of the paucity of definitive clinical trials. We have reviewed the available data on prevalence, diagnosis and treatment. It is clearly time to more formally approach the study of this patient population.
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Affiliation(s)
- Patrick J Troy
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
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Abstract
Portopulmoanry hypertension (POPH) is a form of pulmonary arterial hypertension (PAH) associated with portal hypertension with or without underlying chronic liver disease. POPH is increasingly recognized and recent evidence suggests that it is one of the leading causes of PAH. The pathophysiology of POPH is poorly understood although the pathological changes in pulmonary vasculature in advanced POPH are similar to those seen in idiopathic pulmonary hypertension. The prognosis in patients with liver disease who also suffer from significant POPH is considered to be poor. Higher degree of pulmonary artery pressure (PAP) may preclude a patient from liver transplant as mortality in these patients is high. The treatment with vasodilator therapy has shown to improve both hemodynamics and clinical outcome in POPH in retrospective studies and in some case series. The aim of medical management is to bring PAP <35 mmHg that may make a patient with POPH and advanced liver disease eligible for liver transplant, which otherwise would have been denied because of high PAP.
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Affiliation(s)
- Sarfraz Saleemi
- King Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia.
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Scouras NE, Matsusaki T, Boucek CD, Wells C, Cooper EA, Planinsic RM, Sullivan EA, Bermudez CA, Toyoda Y, Sakai T. Portopulmonary hypertension as an indication for combined heart, lung, and liver or lung and liver transplantation: literature review and case presentation. Liver Transpl 2011; 17:137-43. [PMID: 21280186 DOI: 10.1002/lt.22202] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.
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Affiliation(s)
- Nicole E Scouras
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Savale L, O’Callaghan DS, Magnier R, Le Pavec J, Hervé P, Jaïs X, Seferian A, Humbert M, Simonneau G, Sitbon O. Current management approaches to portopulmonary hypertension. Int J Clin Pract 2010. [DOI: 10.1111/j.1742-1241.2010.02600.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Fukazawa K, Poliac LC, Pretto EA. Rapid assessment and safe management of severe pulmonary hypertension with milrinone during orthotopic liver transplantation. Clin Transplant 2010; 24:515-9. [DOI: 10.1111/j.1399-0012.2009.01119.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Respiratory failure and hypoxemia in the cirrhotic patient including hepatopulmonary syndrome. Curr Opin Anaesthesiol 2010; 23:133-8. [PMID: 20019600 DOI: 10.1097/aco.0b013e328335f024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Liver cirrhosis and portal hypertension present with three unique pulmonary complications that are the subject of ongoing clinical research: hepatopulmonary syndrome, portopulmonary hypertension (POPH), and hepatic hydrothorax. The present article is based on a review of the current literature on how to manage these disorders, which are highly important to both anesthesiologists and intensive care physicians. RECENT FINDINGS Hepatopulmonary syndrome leads to progressive hypoxemia through diffuse vasodilatation of the pulmonary microcirculation. Liver transplantation, although associated with increased mortality, is the only viable treatment. POPH occurs when vascular remodeling triggers an increase in pulmonary artery pressure and resistance. The role of liver transplantation in POPH is controversial given the excessive mortality in patients with moderate to severe POPH. Medical treatment is able to decrease pulmonary artery pressures, though multicenter randomized controlled trials showing improved outcome are lacking to date. Ultrasound plays an increasingly important role in the diagnosis of all three conditions. SUMMARY Patients with end-stage liver disease are at risk for respiratory failure and hypoxemia and need to be screened for hepatopulmonary syndrome, POPH, and hepatic hydrothorax. Failure to timely recognize and adequately treat these complications of cirrhosis may have severe consequences.
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Rapid normalization of portopulmonary hypertension after living donor liver transplantation. Transplant Proc 2009; 41:1976-8. [PMID: 19545772 DOI: 10.1016/j.transproceed.2009.02.095] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 01/10/2009] [Accepted: 02/17/2009] [Indexed: 11/21/2022]
Abstract
Portopulmonary hypertension (PPHTN) is a relatively rare complication of end-stage liver disease, and a serious problem in the context of liver transplantation. Herein we have reported a case of decompensated liver cirrhosis with PPHTN, which rapidly resolved after adult-to-adult living donor liver transplantation (LDLT). A 54-year-old man was referred to our hospital with end-stage liver cirrhosis owing to chronic hepatitis C. Preoperative mean pulmonary artery pressure (mPAP), as assessed by right heart catheterization, was 38 mm Hg. Continuous infusion of epoprostenol decreased the mPAP to 24 mm Hg over 44 days. He underwent LDLT using a right hepatic lobe graft donated by his son. The postoperative course was uneventful, epoprostenol was weaned by postoperative day (POD) 21, and the mPAP normalized to 21 mm Hg on POD 28. The patient was discharged on POD 31 without any vasodilators. Our case revealed that liver transplantation can rapidly resolve PPTHN.
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Abstract
Advanced liver disease and portal hypertension produce various intrathoracic complications that involve the pleural space, the lung parenchyma, and the pulmonary circulation. Dyspnea and arterial hypoxemia are the most common symptoms and signs in patients with such complications. This article focuses on the diagnosis and management of hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. All are pulmonary processes associated with end-stage liver disease that lead to significant morbidity and affect the quality of life of patients who are suffering from liver cirrhosis.
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Affiliation(s)
- C Singh
- Santa Barbara Cottage Hospital, 675 Central Avenue, Apartment 5, Buellton, CA 93427, USA
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Sakai T, Planinsic RM, Mathier MA, de Vera ME, Venkataramanan R. Initial experience using continuous intravenous treprostinil to manage pulmonary arterial hypertension in patients with end-stage liver disease. Transpl Int 2008; 22:554-61. [PMID: 19175541 DOI: 10.1111/j.1432-2277.2008.00830.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Treprostinil is a prostacyclin analog and has been used on idiopathic pulmonary arterial hypertension (PAH). There is only limited clinical experience using treprostinil to manage PAH in patients with end-stage liver disease (ESLD). We report three ESLD patients with PAH, who were treated with continuous intravenous treprostinil. A 59-year-old woman with ESLD secondary to alcoholic hepatitis had portopulmonary hypertension with mean pulmonary arterial pressure (mPAP) of 44 mmHg and transpulmonary gradient (TPG) of 23 mmHg. Treprostinil at 45 ng/kg/min for 6 months decreased mPAP to 23 (TPG to 8). A 53-year-old man had ESLD secondary to alcoholic hepatitis with PAH caused by multiple pulmonary embolisms (mPAP of 32 and TPG of 23). Treprostinil at 36 ng/kg/min for 3 months decreased mPAP to 23 and TPG to 14. Both patients underwent uneventful liver transplantation. A 48-year-old man had ESLD secondary to hepatitis C and portopulmonary hypertension with mPAP of 60 and TPG of 44. Two years after intravenous treprostinil at 106 ng/kg/min, his mPAP decreased to 44 and TPG to 30. These results demonstrate that for a selected group of ESLD patients with PAH, a continuous intravenous infusion of treprostinil appears to be safe and effective.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Abstract
Epoprostenol and the structurally related compounds treprostinil, iloprost, and beraprost are collectively referred to as prostanoids. The discovery of epoprostenol in 1976 and unequivocal demonstration of its efficacy in 1996 dramatically altered the approach to therapy for pulmonary arterial hypertension (PAH). Development of prostanoids available through multiple routes of administration and the discovery and development of other agents acting through alternative pathways continue to expand the array of therapeutic options. The use of prostanoids in combination with other PAH drugs and for treating pulmonary hypertensive disorders outside of the PAH classification are areas of ongoing research.
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Affiliation(s)
- Wayne L Strauss
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Sciences University, Mail Code UHN67, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Hendrickse A, Azam F, Mandell MS. Hepatopulmonary syndrome and portopulmonary hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:127-36. [PMID: 17484815 DOI: 10.1007/s11936-007-0006-5] [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: 10/23/2022]
Abstract
The incidence of pulmonary vascular disorders is significantly increased in patients with liver disease. Intrapulmonary shunting with hypoxemia in patients with liver disease is diagnosed as hepatopulmonary syndrome (HPS), whereas precapillary pulmonary vessel obliteration is identified as portopulmonary hypertension (PPHTN). Because the symptoms of liver disease can mimic those of pulmonary vascular disease, all patients with hepatic failure should be screened for these two diseases. Pulse oximetry effectively screens for hypoxemia associated with HPS, whereas an elevated right ventricular systolic pressure estimated by echocardiography identifies patients at risk of having PPHTN. Liver transplantation is the only effective medical therapy for HPS. However, those who have a resting arterial oxygenation less than 50 mm Hg or a shunt measured by scintigraphic perfusion greater than 20% have an unacceptably high mortality rate following surgery. Compared with HPS, there are more therapeutic options that can bridge patients with PPHTN to transplantation. Drugs used to manage idiopathic pulmonary hypertension have shown promise in the treatment of PPHTN. Prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have improved transplant survival. Despite treatment, however, perioperative mortality for patients with PPHTN remains high. Even with successful transplantation, HPS and PPHTN can persist or develop de novo. Long-term follow-up and surveillance of liver transplant recipients is thus indicated to identify HPS and PPHTN following surgery.
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Affiliation(s)
- Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Abstract
Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.
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Affiliation(s)
- Priya Grewal
- The Division of Liver Diseases, Recanati-Miller Transplantation Institute, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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Abstract
Progress in understanding the basic biology and the development of new therapies for pulmonary arterial hypertension have led to improvements in survival. This article reviews clinically important changes in the classification of the pulmonary hypertensive diseases, as well as the epidemiology of various forms of pulmonary hypertension. The risk factors for the development of pulmonary arterial hypertension, prognostic markers, and the effects of current therapies on survival are discussed.
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Affiliation(s)
- Darren B Taichman
- University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, 441 PHI Building, Philadelphia, PA 19104, USA.
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Gabbay E, Reed A, Williams TJ. Assessment and treatment of pulmonary arterial hypertension: an Australian perspective in 2006. Intern Med J 2007; 37:38-48. [PMID: 17199843 DOI: 10.1111/j.1445-5994.2006.01242.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pulmonary arterial hypertension is a group of diseases which forms a small subset of those with elevated pulmonary artery pressure (pulmonary hypertension). The recent development of selective pulmonary vasodilator has lead to a substantial resurgence of interest in what have been previously regarded as rare and incurable diseases. This review aims to describe the spectrum of pulmonary vascular diseases, the evolving understanding as to pathogenesis, the evolving evidence of efficacy for drug therapies, trying to put this into a contemporary Australian context. Several key pathogenic pathways may be involved: prostacycline, Nitric Oxide-cGMP-phosphodiesterase 5 and endothelin- all of which are exploited for therapeutic benefit by newly available drug therapies. A recently modified classification system reasserts the importance of precise diagnosis. The cardinal symptom of exertional dyspnea warrants careful evaluation in an attempt to prevent (frequently occurring) substantial delay in diagnosis. Echocardiogram is the cornerstone of screening for pulmonary arterial hypertension; however, a detailed evaluation including a carefully performed right heart catheterisation with sufficient data to allow calculation of pulmonary vascular resistance is key to accurate diagnosis. These new approaches to therapy are already substantially improving quality of life and prognosis.
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Affiliation(s)
- E Gabbay
- Advanced Lung Disease Program, Department Respiratory Medicine and Asthma and Allergy Research Institute, Royal Perth Hospital, Perth, Western Australia, Australia
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Krowka MJ, Fallon MB, Mulligan DC, Gish RG. Model for end-stage liver disease (MELD) exception for portopulmonary hypertension. Liver Transpl 2006; 12:S114-6. [PMID: 17123283 DOI: 10.1002/lt.20975] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sussman N, Kaza V, Barshes N, Stribling R, Goss J, O'Mahony C, Zhang E, Vierling J, Frost A. Successful liver transplantation following medical management of portopulmonary hypertension: a single-center series. Am J Transplant 2006; 6:2177-82. [PMID: 16796721 DOI: 10.1111/j.1600-6143.2006.01432.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Severe portopulmonary hypertension (POPH) is an absolute contraindication to orthotopic liver transplantation (OLT). Vasodilators have been used, but the safety of subsequent transplantation and the reversibility of pulmonary hypertension after transplantation are uncertain. This study examined the feasibility and post-transplant effects of liver transplantation following medical control of POPH. Eight consecutive patients (three females and five males, ages 39-51) with POPH as their only contraindication to transplantation were treated with continuous intravenous epoprostenol. Liver transplantation was considered if the mean pulmonary artery pressure (PAM) was lowered to <35 mmHg. Epoprostenol 2-8 ng/kg/min successfully improved hemodynamics in seven of eight patients, usually within 6.5 months of initiating therapy. PAM declined from an average of 43-33 mmHg (p=0.03); mean pulmonary vascular resistance declined from 410 to 192 dyn s cm-5 (p=0.01) and cardiac output increased from 6.6 to 10 L/min (p=0.02). Six of the seven responders were actively listed for liver transplantation. Two died on the waiting list; the remaining four were transplanted and remain alive and well 9-18 months post-OLT-two without vasodilators, and two on oral medication. We conclude that pulmonary vasodilators permit safe liver transplantation in some cases, and that POPH may be reversible after transplantation.
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Affiliation(s)
- N Sussman
- Department of Medicine, Surgery, Baylor College of Medicine, Houston, Texas, USA.
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Abstract
Pulmonary arterial hypertension (PAH) is found in 2-20% of cirrhosis patients who have portal hypertension (portopulmonary hypertension, PPHT). Endothelin (ET), a potent vasoconstrictor, is likely to play a role in the pathogenesis of portal hypertension. We describe the long-term successful use of the dual ET(A)/ET(B) receptor antagonist bosentan in a 43-year-old male with alcohol-related cirrhosis (Child-Pugh A), right ventricular enlargement and dysfunction, respectively, and moderate PAH. Elevated pulmonary arterial pressure was substantially reduced and exercise capacity increased. Improvement was maintained over 2 years, and bosentan treatment continues in this patient. Our report is in line with a series of current reports in PPHT that support the use of bosentan in this subset of PAH patients.
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Affiliation(s)
- G Stähler
- Medical Clinic I, Klinik Löwenstein, Germany.
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Pearl RG. Perioperative Management of PH: Covering All Aspects From Risk Assessment to Postoperative Considerations. ACTA ACUST UNITED AC 2005. [DOI: 10.21693/1933-088x-4.4.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ronald G. Pearl
- Professor and Chair, Department of Anesthesia, Stanford University School of Medicine, Stanford, California
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Krowka MJ. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Implications for Liver Transplantation. Clin Chest Med 2005; 26:587-97, vi. [PMID: 16263398 DOI: 10.1016/j.ccm.2005.06.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are uncommon pulmonary vascular consequences of advanced liver disease. HPS, characterized by arterial hypoxemia caused by pulmonary vascular dilatation, may resolve completely after liver transplantation. POPH, caused by vasoproliferation/constriction and obstruction of pulmonary arterial blood flow, is associated with higher risk for liver transplantation and increased post-transplantation mortality. With or without transplantation, survival in patients who have these syndromes is associated with specific oxygenation and hemodynamic variables.
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Affiliation(s)
- Michael J Krowka
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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