Cirrhotic Cardiomyopathy: A New Clinical Phenotype

Critically Ill COVID-19 Patient with Chronic Liver Disease - Insights into a Comprehensive Liver Intensive Care

The novel coronavirus-related coronavirus disease 2019 (COVID-19) pandemic has been relentless in disrupting and overwhelming healthcare the world over. Clinical outcomes of COVID-19 in patients with chronic comorbidities, especially in those with metabolic syndrome, are well documented. Chronic liver disease and cirrhosis patients are a special sub-group, among whom the management of COVID-19 is challenging. Understanding the pathophysiology of COVID-19 in patients with cirrhosis and portal hypertension improves our identification of at-risk patients for disease progression that will further help compartmentalize generalized and specialized treatment options in this special patient group. In this exhaustive review, we critically review the impact of COVID-19 on the liver and in chronic liver disease and cirrhosis patients. We further discuss common features associated with the pathophysiology of COVID-19 and cirrhosis, based on the renin-angiotensin system and deliberate current literature on guidelines for the treatment of COVID-19 and extrapolate the same to the cirrhosis population to provide a concise and stepwise, evidence-based management for cirrhosis patients with severe and critical COVID-19. There are no specific management guidelines for cirrhosis patients with COVID-19 and current recommendations for treatment are as per guidelines for general population. Nevertheless, specific issues like avoiding corticosteroids in decompensated patients with variceal bleeding, suspected sepsis, high grade hepatic encephalopathy and acute kidney injury, use of early mechanical ventilation strategies in those with severe ascites and hepatopulmonary syndrome, avoidance of remdesivir in advanced liver disease, and application of liver-specific severity scores for prognostication and identification of futility need to be highlighted.

Role of Anti-Beta-1-Adrenergic Receptor Antibodies in Cardiac Dysfunction in Patients with Cirrhotic Cardiomyopathy

Cirrhotic cardiomyopathy (CCM) is a recognized complication of cirrhosis and is associated with poor outcomes, especially under challenges such as surgery/liver transplantation. However, the mechanism is not clear, and the treatment is not specific. The present study aimed to evaluate the role of anti-β₁-adrenergic receptor antibodies (anti-β1-AR) in CCM. We enrolled 3 groups: healthy controls, cirrhotic patients without CCM, and patients with CCM. We found that the anti-β1-AR levels in the CCM group were significantly higher than that in the non-CCM group; anti-β1-AR was positively correlated to NT-proBNP, negatively correlated to left ventricular ejection fraction, fractional shortening ((r =  - 0.466, P < 0.05), and the ratio of peak early (E wave) and atrial (A wave) flow velocities (E/A (r =  - 0.475, P < 0.05) in CCM patients. Anti-β1-AR is a useful predictive biomarker for the presence of CCM and eventually may also have therapeutic implications. Clinical Trials Registration: Chinese Clinical Trials No. ChiCTR 2,000,037,730.

Syndecan-1: A Review on Its Role in Heart Failure and Chronic Liver Disease Patients' Assessment

The close connection and interaction between the cardiac and the liver functions are well-known, as cirrhotic cardiomyopathy is an important clinical entity which best describes the mutual pathogenical influence between these two organs. Due to the fact that cardiac dysfunction in patients with chronic hepatic disorders is oligosymptomatic or even asymptomatic, an early diagnosis represents a challenge for every physician. Syndecan-1—a transmembrane proteoglycan that exerts its functions mainly via its heparane sulfate chains—is a very promising biomarker, correlated not only with the degree of cardiac fibrosis but also with the severity of liver fibrosis. Many studies highlighted its role in the development of cardiac fibrosis or atherogenesis, being significantly correlated with the activity of angiotensin II. Multiple evidence revealed that syndecan-1 is also associated with tissue injury and may regulate inflammatory and regenerative responses, being considered a protective molecule that limits the inflammation and reduces cardiac remodelling and dysfunction after a myocardial infarction. Syndecan-1 may also be used as a reliable biomarker for the noninvasive assessment of liver fibrosis. Under various fibrogenetic conditions, shedding of syndecan's extracellular domain took place, becoming a soluble form that binds different growth factors and inhibits further fibrosis. This complex molecule is also involved in the lipid metabolism, by altering the clearance of cholesterol particles, and in chronic hepatitis, by enhancing the viral invasion of hepatocytes. Due to the growing interest in this biomarker, multiple studies aimed at revealing syndecan-1's potential benefits in the diagnosis and prognosis assessment in patients with heart failure or chronic liver disorders. In this review, we review the mechanisms by which syndecan-1 exerts its effects and the possible perspectives opened by its use as a dual cardio-hepatic biomarker.

Tei index for monitoring changes in left heart function in patients with cirrhosis before and after propranolol treatment

AIM

To investigate the clinical value of Tei index in monitoring the changes of left heart function in patients with cirrhosis before and after propranolol treatment.

METHODS

One hundred and forty-three patients with cirrhosis treated at Tongde Hospital of Zhejiang Province from March 2015 to November 2017 were divided into either a control group or a study group. The control group (n = 70), including 29 cases with Child-Pugh grade A liver function, 20 cases of grade B, and 21 cases of grade C, was given routine treatments (liver protection, diet control, and so on). The study group (n = 73), including 27 cases with Child-Pugh grade A liver function, 22 cases of grade B, and 24 cases of grade C, was given propranolol on the basis of routine treatments. Eighty healthy volunteers who received physical examination in the same period were included as a normal control group. Tei index was measured in all subjects before and 1 mo after treatment.

RESULTS

Before treatment, Tei index was significantly higher in the study group and control group than in the normal control group (0.48 ± 0.13, 0.49 ± 0.13 vs 0.32 ± 0.14, P < 0.05). After treatment, Tei index in the study group was significantly lower than that before treatment (0.39 ± 0.12 vs 0.48 ± 0.13, P < 0.05) and that in the control group (0.39 ± 0.12 vs 0.47 ± 0.10, P < 0.05). After treatment, Tei index in patients with Child-Pugh grade A and B liver function in the study group were significantly lower than those before treatment (0.33 ± 0.07 vs 0.46 ± 0.11, 0.34 ± 0.10 vs 0.48 ± 0.15, P < 0.05), while Tei index in patients with grade C liver function in the study group did not differ significantly between before and after treatment (0.49 ± 0.13 vs 0.51 ± 0.13, P > 0.05).

CONCLUSION

Tei index can objectively and sensitively reflect the change of left heart function in patients with cirrhosis, and is a simple and effective index to evaluate the efficacy of propranolol.