Hepatopulmonary syndrome caused by hypothalamic obesity and nonalcoholic fatty liver disease after surgery for craniopharyngioma: a case report

Risk Factors for MAFLD and Advanced Liver Fibrosis in Adult-Onset Craniopharyngioma Patients: A Cross-Sectional Study

Purpose

To investigate the prevalence of and risk factors for metabolic dysfunction-associated fatty liver disease (MAFLD) and advanced liver fibrosis (ALF) in postoperative adult-onset craniopharyngioma (AOCP) patients.

Patients and Methods

This cross-sectional study included 242 postoperative AOCP patients at Huashan Hospital (Shanghai, China). Clinical characteristics were compared between patients with and without MAFLD and ALF. Independent risk factors for MAFLD and ALF were identified using binary logistic regression analysis.

Results

The prevalence of MAFLD in postoperative AOCP patients was 67.4% (95% CI 61.2-73.0%), and 32.5% (95% CI 25.8-40.0%) of patients with MAFLD were diagnosed with ALF. Body mass index (BMI) was independently associated with MAFLD (OR = 1.51, 95% CI 1.33-1.72, P < 0.001). In patients with MAFLD, hypertension (OR = 2.33, 95% CI 1.04-5.20, P = 0.040), glycated hemoglobin (HbA1c) (OR = 1.34, 95% CI 1.01-1.78, P = 0.044), daily hydrocortisone dose (OR = 1.08, 95% CI 1.01-1.15, P = 0.026), and insulin-like growth factor-1 (IGF-1)(OR = 0.99, 95% CI 0.97-0.99, P = 0.011) were independently associated with the presence of ALF.

Conclusion

MAFLD is a common comorbidity in postoperative AOCP patients and is associated with a high risk of ALF. MAFLD is closely related to BMI, while ALF is significantly associated with hypertension, HbA1c levels, IGF-1 levels, and daily hydrocortisone dose. Strategies such as controlling weight gain, maintaining optimal blood glucose and blood pressure levels, appropriate hormone replacement, and avoiding excessive glucocorticoid use should be implemented to prevent and delay the onset and progression of MAFLD and ALF.

Risk factors and prediction model of metabolic disorders in adult patients with pituitary stalk interruption syndrome

Pituitary stalk interruption syndrome (PSIS) is an infrequently occurring congenital condition, and there exists a dearth of systematic investigative work focusing on the clinical features and long-term outcomes in adult patients. Individuals who have reached adulthood with PSIS are at an increased risk of developing metabolic disorders, including metabolic syndrome (MS) and non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction associated fatty liver disease (MAFLD), which are also one of the main factors for the poor prognosis of these patients. An analysis was conducted on the clinical data of adult PSIS patients who visited the endocrinology department of the First Medical Center of the People's Liberation Army General Hospital from January 2005 to August 2023. Patients were grouped based on their MAFLD and MS status, and the differences in clinical characteristics and risk factors between the groups were analyzed. Machine learning models were used to construct a prediction model for the occurrence of MAFLD in adult PSIS patients and to analyze high-risk predictors. Out of 136 PSIS adult patients, 93.3% were male. The prevalence of MAFLD was 55.5%, and MS was 22.3%. Patients with a history of growth hormone (GH) treatment were less likely to develop MAFLD (P = 0.032). MAFLD patients exhibited higher rates of hypertension, hyperuricemia, obesity, MS, and dyslipidemia. Multiple risk factors may contribute to MS, while no significant link was found between MS and hormone replacement. However, GH non-treatment may serve as the notable predictor of MAFLD in PSIS patients revealed by the Ridge regression model of machine learning model with the highest predictive performance of a mean area under the curve (AUC) of 0.82. The prevalence of MS and MAFLD is high among adult patients with PSIS. Multiple risk factors may contribute to these two diseases, and after constructing a predictive model, we found that MAFLD may be closely linked to the previous lack of GH treatment.

Case report: Pediatric hepatopulmonary syndrome despite strict weight control after craniopharyngioma surgery

Childhood-onset craniopharyngiomas, though rare, are intracranial malformations that can cause obesity by disrupting the hypothalamus, a condition that often persists even after tumor resection. This severe obesity increases the risk of diabetes and fatty liver disease in childhood. Concurrently, panhypopituitarism, including growth hormone (GH) deficiency, may develop. Notably, some individuals with GH deficiency may exhibit a normal growth rate, making GH therapy unnecessary for growth purposes. However, in these cases, GH therapy may still be beneficial in preventing the progression of nonalcoholic fatty liver disease or nonalcoholic steatohepatitis. Although weight management is traditionally considered the gold standard for preventing liver cirrhosis, its effectiveness can be limited by hypothalamic dysfunction and the difficulty of achieving successful weight control. Our case study highlights a patient with normal growth despite GH deficiency, who did not receive GH replacement therapy and continued to struggle with hypothalamic obesity. Despite effective body weight control, the patient developed hepatopulmonary syndrome, indicating that relying solely on weight management may not be sufficient to prevent liver complications. This case underscores the importance of addressing GH deficiency even when growth is normal. Our findings suggest that GH replacement therapy could be beneficial for preventing liver cirrhosis in such cases.

Hepatopulmonary syndrome secondary to metabolic associated fatty liver disease in childhood - novel treatment with growth hormone replacement therapy: a case report and systematic review of literature

Objective

Hepatopulmonary syndrome (HPS) is a rare complication of metabolic associated fatty liver disease (MAFLD) occurring subsequent to hypopituitarism, often developing after resection of hypothalamic or pituitary tumors. The aim of this study is to report an illustrative case of an HPS patient who was successfully treated with growth hormone replacement therapy, without liver transplantation which is conventionally regarded as the only treatment option. Additionally, we conducted a comprehensive review of published case reports of HPS in the pediatric population.

Methods

We systematically searched literature databases to identify case reports and case series of HPS associated with hypopituitarism diagnosed in childhood. The search included MEDLINE/PubMed, Scopus, Embase, and Google Scholar from 1990 to 2023. The review process adhered to the PRISMA checklist for comprehensive reporting and methodological transparency.

Results

An 18-year-old female, who had been followed up for MAFLD after craniopharyngioma resection, presented with cyanosis and progressive dyspnea. She was diagnosed with severe degree of HPS. The patient began treatment with recombinant human growth hormone, leading to a significant improvement in respiratory symptoms within 3 months, and normalization of lung shunt ratio after 6 months of therapy. In our systematic review, nine patients from nine studies across six countries were identified. The median age at diagnosis of hypopituitarism was 10.5 years (range 1-16 years), and HPS was diagnosed at a median interval of 7 years later (range 0-26 years). Half of the patients had not received growth hormone therapy after being diagnosed with hypopituitarism, which subsequently led to the diagnosis of HPS. Three patients underwent liver transplantation, but non-alcoholic steatohepatitis recurred in all cases. Six patients were successfully treated with growth hormone replacement therapy without undergoing liver transplantation.

Conclusions

HPS can occur in pediatric patients with MAFLD who have undergone resection of the tumor in the hypothalamus or pituitary gland. Our findings suggest that growth hormone replacement therapy can be a possible alternative to liver transplantation for HPS patients. However, further investigations need to be performed to validate the efficacy of growth hormone treatment in different causes of HPS cases.

Nonalcoholic fatty liver disease and adult growth hormone deficiency: An under-recognized association?

Growth hormone (GH) plays an essential role not only in promoting growth in children, but also in many important metabolic processes in adults. One of the major metabolic functions of GH is its stimulatory effects on the liver in generating approximately 80% of circulating insulin-like growth factor 1 (IGF-1). Adult growth hormone deficiency (GHD) is an established clinical entity defined as a defect in endogenous GH secretion that is frequently associated with central obesity, loss of muscle mass, decreased bone mass, and impaired quality of life. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are conditions that are often under-recognized in adults with GHD, and accordingly some studies have shown that GH and IGF-1 levels are decreased in patients with NAFLD. Furthermore, it has been reported that it can progress to end-stage liver cirrhosis in some adults and children with GHD. Due to their underlying mechanisms of action, GH and IGF-1 can act on hepatocytes, macrophages, and hepatic stellate cells to mitigate progression to steatosis and fibrosis. It is, thus, important to recognize NAFLD/NASH as important complications in adult and childhood GHD. Therefore, careful and thorough evaluation of NAFLD/NASH in adults with GHD and the consideration for GH replacement therapy is crucial in these patients, together with management of other metabolic risk factors, such as obesity and dyslipidemia. This review will focus on recent reports on the role of GH and IGF-1 in the liver and its clinical significance in the regulation of hepatic function.

Growth hormone ameliorates hepatopulmonary syndrome and nonalcoholic steatohepatitis secondary to hypopituitarism in a child: A case report

BACKGROUND

Craniopharyngioma is a benign tumor that usually develops in children; however, it is located in the center and close to sensitive structures, such as the pituitary gland and hypothalamus. As the hypothalamus plays a crucial role in the homeostasis of anterior pituitary hormone synthesis, damage to the hypothalamus leads to multiple pituitary hormone deficiencies and non-alcoholic fatty liver disease, including hepatopulmonary syndrome (HPS). HPS has limited treatment and poor prognosis.

CASE SUMMARY

A girl aged 13 years and 6 mo underwent surgery for craniopharyngioma 6 years prior. Right craniotomy was performed with total resection via the corpus callosum approach, and the tumor at the base was approximately 3.5 cm × 3.5 cm × 4.0 cm. At 1 year postoperatively, she exhibited abdominal distension and weakness, and the laboratory tests revealed fatty liver disease. Thereafter, she had not visited the outpatient clinic for 2 years. Two years ago, she developed decreased activity endurance, severe cyanosis, chest tightness, wheezing, and intermittent and recurrent low fever after mild physical labor. Hepatobiliary ultrasonography, liver biopsy, and contrast echocardiography of the right heart showed cirrhosis and multiple pituitary hormone deficiencies, indicating HPS. After 1 year of treatment with recombinant human growth hormone, the liver function and oxygenation improved; she did not undergo liver transplantation.

CONCLUSION

Craniopharyngioma surgery can easily cause hypopituitarism, which can lead to nonalcoholic steatohepatitis and HPS in children. Early growth hormone therapy is important to improve the prognosis of these diseases.

[Hepatopulmonary syndrome: a rare manifestation of cirrhosis in patient with diencephalic obesity and nonalcoholic fatty liver disease after surgery for craniopharyngioma]

We describe a 15-year girl, who developed panhypopituitarism and diencephalic obesity after surgical excision of craniopharyngioma, followed by nonalcoholic fatty liver disease and cirrhosis 5 years after surgery. Cirrhosis in this case manifested by hypoxia due to hepatopulmonary syndrome, and despite cure of craniopharyngioma by surgery and radiosurgery treatment and adequate hormonal substitution therapy patient died 9 years after surgery. Growth hormone substitutional therapy in patients with hypopituitarism, and steatohepatitis may decrease liver triglyceride accumulation and prevent end-stage liver disease.

Liver epigenome changes in patients with hepatopulmonary syndrome: A pilot study

The hepatopulmonary syndrome (HPS) is defined by the presence of pulmonary gas exchange abnormalities due to intrapulmonary vascular dilatations in patients with chronic liver disease. Changes in DNA methylation reflect the genomic variation. Since liver transplant (LT) reverts HPS we hypothesized that it may be associated with specific liver epigenetic changes. Thus, the aim of this study was to investigate the role of the liver epigenome in patients with HPS. We extracted DNA from paraffin embedded liver tissue samples from 10 patients with HPS and 10 age-, sex- and MELD (Model for End-stage Liver Disease)-matched controls. DNA methylation was determined using the 850K array (Illumina). Weighted Gene Co-expression Network Analysis (WGCNA) was used to identify modules related to defining physiologic characteristics of HPS. Only 12 out of the 20 liver biopsies (7 HPS and 5 controls) had sufficient quality to be analyzed. None of the 802,688 DNA probes analyzed in the case control comparison achieved a significant False Discovery Rate (FDR). WGCNA identified 5 co-methylated gene-modules associated to HPS markers, mainly related to nervous and neuroendocrine system, apoptotic processes, gut bacterial translocation, angiogenesis and vascular remodeling ontologies. To conclude, HPS is associated with nervous/neuroendocrine system and vascular remodeling related liver epigenetic changes.

Pediatric Fatty Liver and Obesity: Not Always Justa Matter of Non-Alcoholic Fatty Liver Disease

Obesity-related non-alcoholic fatty liver disease (NAFLD) represents the most common cause of pediatric liver disease due to overweight/obesity large-scale epidemics. In clinical practice, diagnosis is usually based on clinical features, blood tests, and liver imaging. Here, we underline the need to make a correct differential diagnosis for a number of genetic, metabolic, gastrointestinal, nutritional, endocrine, muscular, and systemic disorders, and for iatrogenic/viral/autoimmune hepatitis as well. This is all the more important for patients who are not in the NAFLD classical age range and for those for whom a satisfactory response of liver test abnormalities to weight loss after dietary counseling and physical activity measures cannot be obtained or verified due to poor compliance. A correct diagnosis may be life-saving, as some of these conditions which appear similar to NAFLD have a specific therapy. In this study, the characteristics of the main conditions which require consideration are summarized, and a practical diagnostic algorithm is discussed.