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Imai Y, Koizumi Y, Hiasa Y, Hirooka M, Tokumoto Y, Yoshida O, Chikamori F. Standard technique in Japan for measuring hepatic venous pressure gradient. J Gastroenterol 2025; 60:24-31. [PMID: 39652102 PMCID: PMC11717883 DOI: 10.1007/s00535-024-02182-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 11/13/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND Direct measurement of portal venous pressure (PVP) is invasive, so the hepatic venous pressure gradient (HVPG) is commonly measured to evaluate portal hypertension (PH). HVPG is the gold standard for estimating PVP but few reports have covered standardized measurement techniques. METHODS This study validated standardized techniques for PVP measurement. RESULTS In Western countries, electronic transducers are commonly used to measure PVP, whereas the water column method is still frequently applied in Japan. Setting a reference point for accurate PVP measurement is important but complicated. According to Japanese guidelines, the reference point for PVP measurement is 10 cm above the dorsal surface or in the midaxillary line. For simpler determination, the anterior axillary point, defined as the point of convergence between the proximal pectoralis major muscle and arm when both arms are positioned against the trunk in a supine position, can be used as the reference point. New methods, such as endoscopic ultrasound-guided portal pressure gradient, offer less invasive alternatives. Non-invasive methods like elastography measure liver and spleen stiffness, which correlate with HVPG. The Baveno VII criteria incorporate measurements of liver and splenic stiffness for risk stratification. Biomarkers such as type IV collagen, M2BPGi, and FIB-4 score also predict HVPG. The Baveno VII consensus emphasizes the status of HVPG as the gold standard while advocating for non-invasive alternative methods to improve patient care and monitor treatment efficacy. CONCLUSIONS Continued development of non-invasive tests is crucial for safer, more convenient PH management.
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Affiliation(s)
- Yusuke Imai
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Yoshio Tokumoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Osamu Yoshida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon City, Ehime, 791-0295, Japan
| | - Fumio Chikamori
- Department of Surgery, Japanese Red Cross Kochi Hospital, Hadaminami-Machi, Kochi City, Kochi, 780-8562, Japan.
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Shah KP, Kuruvada S, Gopalakrishnan M, Latchireddy B, Prathima T, Patra N. The Assessment of Cardiovascular Abnormalities in Patients With Chronic Liver Disease: A Cross-Sectional Study. Cureus 2024; 16:e73311. [PMID: 39655150 PMCID: PMC11626255 DOI: 10.7759/cureus.73311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2024] [Indexed: 12/12/2024] Open
Abstract
Background Chronic liver disease (CLD) is associated with a wide range of systemic complications, including cardiovascular abnormalities. This study aimed to assess the prevalence of cardiac abnormalities and to correlate with the severity of liver disorder. Materials and methods A cross-sectional analysis comprising 120 adult subjects diagnosed with CLD was performed. Data were collected through clinical assessments, including liver function tests, echocardiography, and electrocardiograms (ECG). The severity of CLD was determined using the Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scoring systems. Results In this study, 85 (70.8%) were men, and the major cause of CLD was alcoholism in 89 (66.7%) of the patients. Regarding CLD severity, the majority of patients were in MELD stage 2, and 70 (58.3%) and 76 (63.3%) were in CTP class C. The prevalence of various cardiac abnormalities was as follows: left ventricular systolic dysfunction (LVSD) in 25 (20.8%), left ventricular diastolic dysfunction (LVDD) in 76 (63.3%), and prolonged corrected QT (QTc) in 52 (43.3%) of the CLD patients. The values of the QTc interval were higher in MELD stage 3, and it was significant (p=0.001). The association between LVSD (p=0.004) and LVDD (p=0.001) was significant, and the proportion of CLD subjects with cardiac dysfunction was greater in CTP class C compared to classes B and A. Conclusion The present study highlights a concerning prevalence of cardiovascular abnormalities among chronic liver disease patients, underscoring the need for routine cardiovascular assessment in this population.
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Affiliation(s)
- Kunjan PareshKumar Shah
- Department of General Medicine, Dr. N.D. Desai Faculty of Medical Science and Research, Nadiad, IND
| | - Sailaja Kuruvada
- Department of General Medicine, University College London, London, GBR
| | | | | | - Talla Prathima
- Department of General Medicine, Hebei Medical University, Shijiazhuang, CHN
| | - Niyati Patra
- Department of Emergency Medicine, Caboolture Hospital, Caboolture, AUS
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Bile acid predicts congenital portosystemic venous shunt in patients with pulmonary arterial hypertension. Eur J Med Res 2023; 28:74. [PMID: 36774505 PMCID: PMC9921690 DOI: 10.1186/s40001-023-01039-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
The etiology of pulmonary arterial hypertension (PAH) is complex, especially the investigation of rare pathogeny is difficult. Congenital portosystemic venous shunt (CPSS) is a rare congenital anomaly in which the portal blood completely or partially bypasses the liver through a congenital portosystemic shunt, and drains directly into the inferior vena cava (IVC) (Howard and Davenport in J Pediatr Surg 32:494-497, 1997).CPSS is an uncommon cause of PAH (Christiane et al. in J Pediatr Gastroenterol Nutr 56:675-681, 2013), and often covered by other pathogenic factors. The clinical manifestations of CPSS-associated PAH are not specific, thus making it difficult to distinguish from PAH caused by other pathogenetic factors based on clinical presentations alone. This is a retrospective analysis of data from six patients with CPSS at a single center. Of these, five were diagnosed as PAH: four were also associated with other predisposing factors of pulmonary hypertension (PH). All patients had high serum bile concentration and high cardiac output. The aim of this retrospective study was to investigate the clinical recognition of PAH secondary to CPSS. The concentration of serum bile acid and cardiac output can be used as two important non-invasive indicators in clinical practice. Thus far, few studies have reported the clinical outcomes of CPSS-associated PAH specifically (Anna et al. in Hepatology 71:658-669, 2020;Franchi-Abella et al. in J Pediatr Gastroenterol Nutr 51:322-330, 2010;Uike et al. in Pediatr Pulmonol 53:505-511, 2018;). In the current study, such patients carried a poor prognosis if left untreated, or treated with pulmonary vasodilators alone.
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Impact of Cirrhotic Cardiomyopathy Diagnosed According to Different Criteria on Patients with Cirrhosis Awaiting Liver Transplantation: A Retrospective Cohort Study. Dig Dis Sci 2022; 67:5315-5326. [PMID: 35150344 DOI: 10.1007/s10620-022-07412-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/23/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recently, the Cirrhotic Cardiomyopathy Consortium (Consortium) proposed criteria to replace the World Congress of Gastroenterology (WGO) criteria for cirrhotic cardiomyopathy (CCM) using contemporary echocardiography parameters. We assessed the impact of substituting WGO by Consortium criteria on the frequency of diagnosis and clinical outcomes in patients with cirrhosis awaiting liver transplantation (LT). METHODS Consecutive adults with cirrhosis approved for LT with echocardiography evaluation from January 2014 to December 2016 were screened. Patients with structural heart diseases were excluded. Two primary outcomes were: (1) frequency of CCM; (2) association of CCM with pre-transplant mortality. The secondary outcomes were pre-LT complications of acute kidney injury (AKI) and/or hepatic encephalopathy (HE), and post-LT mortality. RESULTS Of 386 patients screened, 278 were included. 238 (85.6%) and 208 (74.8%) patients met Consortium and WGO criteria, respectively; 180 (64.7%) patients fulfilled both the criteria, while 12 (4.3%) patients had no evidence of CCM by either criterion. Pre-LT mortality rates in Consortium-CCM group were similar to the other groups (19.3% vs 20.2% vs 25.0%). The patients with advanced diastolic dysfunction (DD) per Consortium-CCM criteria had higher mortality than the other groups. The rates of pre-LT AKI/HE rates and post-LT mortality were similar in Consortium-CCM and WGO-CCM groups. CONCLUSION The Consortium criteria do not impact the prevalence of CCM compared to WGO criteria and have similar predictive accuracy. Presence of advanced DD per the Consortium criteria increases the risk of pre-LT mortality and complications of AKI/HE. The patients with advanced DD could benefit from further monitoring and treatment.
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Yokoyama K, Fukuda H, Yamauchi R, Higashi M, Miyayama T, Higashi T, Uchida Y, Shibata K, Tsuchiya N, Fukunaga A, Umeda K, Takata K, Tanaka T, Shakado S, Sakisaka S, Hirai F. Long-Term Effects of Rifaximin on Patients with Hepatic Encephalopathy: Its Possible Effects on the Improvement in the Blood Ammonia Concentration Levels, Hepatic Spare Ability and Refractory Ascites. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091276. [PMID: 36143954 PMCID: PMC9501622 DOI: 10.3390/medicina58091276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/09/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022]
Abstract
Background and Objectives: To investigate the long-term efficacy of rifaximin (RFX) for hyperammonemia and efficacy for refractory ascites in patients with cirrhosis. Materials and Methods: We enrolled 112 patients with liver cirrhosis who were orally administered RFX in this study. Changes in the clinical data of patients were evaluated up to 36 months after RFX administration. The primary endpoint was a change in blood ammonia levels. Secondary endpoints included changes in clinical symptoms, Child−Pugh (CP) score, number of hospitalizations, degree of refractory ascites, adverse events, and the relationship between RFX administration and the renin-angiotensin-aldosterone system. Results: An improved rate of overt hepatic encephalopathy (HE) of 82.7% was observed 3 months after RFX administration, which significantly induced a progressive decrease in blood ammonia concentration and an improved CP score up to 36 months. No serious RFX treatment-related adverse events were observed. 36.5% in patients after RFX administration improved refractory ascites. After RFX administration, patients with satisfactory control of hepatic ascites without addition of diuretic had lower renin concentration than those with poor control (p < 0.01). At less than 41 pg/mL renin concentration, the control of refractory ascites was significantly satisfactory (p < 0.0001). Conclusions: RFX reduced blood ammonia concentration and improved hepatic spare ability and the quality of life of patients with long-term HE to up to 36 months. Our study revealed the effects of RFX against refractory ascites, suggesting that renin concentration may be a predictive marker for assessing ascites control.
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Affiliation(s)
- Keiji Yokoyama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
- Correspondence: ; Tel.: +81-92-801-1011 (ext. 3355)
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Masashi Higashi
- Higashi Hospital, 593-1 Hirotsu, Yositomi-machi, Chikujo-gun 871-0811, Fukuoka, Japan
| | - Takashi Miyayama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Tomotaka Higashi
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Yotaro Uchida
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Kumiko Shibata
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Naoaki Tsuchiya
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Atsushi Fukunaga
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Kaoru Umeda
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Kazuhide Takata
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka-shi 814-0180, Fukuoka, Japan
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Ridjab DA, Ivan I, Budiman F, Tenggara R. Evaluation of subclinical ventricular systolic dysfunction assessed using global longitudinal strain in liver cirrhosis: A systematic review, meta-analysis, and meta-regression. PLoS One 2022; 17:e0269691. [PMID: 35671306 PMCID: PMC9173645 DOI: 10.1371/journal.pone.0269691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/25/2022] [Indexed: 11/24/2022] Open
Abstract
Global longitudinal strain (GLS) can identify subclinical myocardial dysfunction in patients with cirrhosis. This systematic review aims to provide evidence of a possible difference in GLS values between patients with cirrhosis and patients without cirrhosis. Studies from inception to August 11, 2021, were screened and included based on the inclusion criteria. The Newcastle Ottawa Scale was used to assess the quality of nonrandomized studies. Meta-analyses were conducted with subsequent sensitivity and subgroup analyses according to age, sex, cirrhosis etiology, and severity. Publication bias was evaluated using Begg’s funnel plot, Egger’s test, and rank correlation test with subsequent trim-and-fill analysis. The systematic database search yielded 20 eligible studies. Random effect showed a significant reduction of left ventricular (LV) GLS (MD:-1.43;95%; 95%CI,-2.79 to -0.07; p = 0.04; I2 = 95% p<0.00001) and right ventricular (RV) GLS (MD:-1.95; 95%CI,-3.86 to -0.05, p = 0.04; I2 = 90%, p<0.00001) in the group with cirrhosis. A sensitivity test on subgroup analysis based on the study design showed a -1.78% lower LV-GLS in the group with cirrhosis (I2 = 70%, p = 0.0003). Meta-regression analysis showed that the severity of cirrhosis was significantly related to GLS reduction. This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors. The study protocol was registered at PROSPERO (CRD42020201630). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement guidelines.
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Affiliation(s)
- Denio A. Ridjab
- Department of Medical Education Unit, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
- * E-mail:
| | - Ignatius Ivan
- Fifth Year Medical Student, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Fanny Budiman
- Fifth Year Medical Student, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Riki Tenggara
- Department of Internal Medicine, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
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Kokubo R, Saito K, Yamada T, Tanaka T, Tajima Y, Suzuki K. Comparison of Liver Fibrosis and Function Indices with Extracellular Volume using Dual-Energy CT: A Retrospective Study. Curr Med Imaging 2022; 18:1180-1185. [PMID: 35392787 DOI: 10.2174/1573405618666220407100237] [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: 10/13/2021] [Revised: 01/05/2022] [Accepted: 01/31/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dual-energy computed tomography (DECT) enables the direct measurement of iodine accumulation in the extracellular space. OBJECTIVE To compare measures of liver fibrosis and function with extracellular volume (ECV) from iodine/water images using DECT. METHODS Data was obtained from 119 consecutive patients who underwent abdominal DECT. A region of interest was set in the right lobe of the liver, pancreas, spleen, and aorta on iodine density images. ECV was calculated using the following formula: ECV = (1 hematocrit) × [iodine concentration in the liver (or pancreas, spleen) / iodine concentration in the aorta]. The severity of liver fibrosis was estimated using the aminotransferase/platelet ratio index (APRI) and the Fibrosis-4 (FIB-4) index. Liver function was assessed by the Child-Pugh classification and albumin-bilirubin (ALBI) grade. Data were analyzed by Spearman rank correlation coefficient, one-way analysis of variance, and post hoc analysis. RESULTS The correlation between ECV and fibrosis indices (APRI and FIB-4) was only significant and with a weak magnitude for the liver ECV quantification at the equilibrium phase (r=0.25 and r=0.20, respectively). The correlations between liver function index and ECV quantification were more robust than with fibrosis index. The highest correlations (r=0.50) were found between ALBI grade and liver ECV at the equilibrium phase. Liver ECV value at the equilibrium phase were significant difference between ALBI grade 1 vs. 2 and grade 1 vs. 3. CONCLUSION Liver ECV quantification by DECT is more suitable for evaluating liver function than liver fibrosis severity.
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Affiliation(s)
- Reiji Kokubo
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Saito
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Takafumi Yamada
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Taro Tanaka
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Yu Tajima
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Kunihito Suzuki
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
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9
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [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: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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10
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Sharma S, Sonny A, Dalia AA, Karamchandani K. Acute heart failure after liver transplantation: A narrative review. Clin Transplant 2020; 34:e14079. [PMID: 32941661 DOI: 10.1111/ctr.14079] [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: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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11
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Mottelson MN, Lundsgaard CC, Møller S. Mechanisms in fluid retention - towards a mutual concept. Clin Physiol Funct Imaging 2019; 40:67-75. [PMID: 31823451 DOI: 10.1111/cpf.12615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/04/2019] [Indexed: 12/12/2022]
Abstract
Fluid retention is a common and challenging condition in daily clinical practice. The normal fluid homoeostasis in the human body is based on accurately counter-balanced physiological mechanisms. When compromised fluid retention occurs and is seen in pathophysiologically different conditions such as liver cirrhosis, heart and kidney failure, and in preeclampsia. These conditions may share pathophysiological mechanisms such as functional arterial underfilling, which seems to be a mutual element in cirrhosis, cardiac failure, cardiorenal and hepatorenal syndromes, and in pregnancy. However, there are also distinct differences and it is still unclear whether kidney dysfunction or arterial underfilling is the initiating factor of fluid retention or if they happen simultaneously. This review focuses on similarities and differences in water retaining conditions and points to areas where important knowledge is still needed.
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Affiliation(s)
- Mathis N Mottelson
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Internal Medicine, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Christoffer C Lundsgaard
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Centre of Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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12
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Park J, Lee SH, Kim J, Park SJ, Park MS, Choi GS, Lee SK, Kim GS. Predictive Value of Intraoperative Pulmonary Vascular Resistance in Liver Transplantation. Liver Transpl 2018; 24:1680-1689. [PMID: 30240130 DOI: 10.1002/lt.25341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/04/2018] [Indexed: 01/13/2023]
Abstract
We aimed to evaluate the association between intraoperative pulmonary vascular resistance (PVR) and clinical outcome of liver transplantation (LT). Cardiovascular involvement of end-stage liver disease is relatively common, and hemodynamic instability during LT can be fatal to recipients. However, the clinical impact of intraoperative PVR in LT remains undetermined. A total of 363 adult recipients with intraoperative right heart catheterization from January 2011 to May 2016 were analyzed. Patients were divided into 2 groups according to PVR. Two separate analyses were performed according to the time point of measurement: at the beginning and at the end of LT. The primary outcome was all-cause death or graft failure during the follow-up period. Increased PVR was observed in 11.8% (43/363) of recipients at the beginning and 12.7% (46/363) of recipients at the end of LT. PVR at the beginning of LT had no significant effect on the rate of death or graft failure in the multivariate analysis (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.64-2.38; P = 0.52). In contrast, PVR at the end of LT was significantly associated with death or graft failure during the overall follow-up period (HR, 2.00; 95% CI, 1.13-3.54; P = 0.02). In conclusion, PVR at the end of LT, rather than the beginning, is associated with clinical outcome. Larger trials are needed to support this finding.
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Affiliation(s)
- Jungchan Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo Jung Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Myung Soo Park
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk-Koo Lee
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
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13
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Lin SY, Lin CL, Lin CC, Wang IK, Hsu WH, Kao CH. Risk of acute coronary syndrome and peripheral arterial disease in chronic liver disease and cirrhosis: A nationwide population-based study. Atherosclerosis 2018; 270:154-159. [PMID: 29425961 DOI: 10.1016/j.atherosclerosis.2018.01.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS Until now, no study has investigated the risks of acute coronary syndrome (ACS) and peripheral arterial disease (PAD) in cirrhosis. METHODS In this study, 57,214 patients diagnosed with cirrhosis between 2000 and 2010 were identified from the Taiwan National Health Insurance claims data. Each patient was randomly selected and frequency-matched with an individual without cirrhosis by age, sex, and index year. RESULTS The overall incidence rates of ACS and PAD were 2.81 and 2.97 per 1000 person-years, respectively, in the cirrhosis cohort. The cirrhosis cohort had a higher risk of ACS [adjusted subhazard ratio (aSHR) = 1.12, 95% confidence interval (CI) = 1.03-1.22] and PAD (aSHR = 1.11, 95% CI = 1.02-1.21). The risk of ACS was highest among members of the cirrhosis cohort with ascites (aSHR = 1.09, 95% CI = 1.11-1.19). CONCLUSIONS Patients with chronic liver disease and cirrhosis have higher risks of ACS and PAD than those without chronic liver disease and cirrhosis.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - I-Kuan Wang
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Pulmonary and Critical Care Medicine, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Department of Nuclear Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan.
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14
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Isaak RS, Kumar PA, Arora H. PRO: Transesophageal Echocardiography Should Be Routinely Used for All Liver Transplant Surgeries. J Cardiothorac Vasc Anesth 2017; 31:2282-2286. [DOI: 10.1053/j.jvca.2016.11.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Indexed: 11/11/2022]
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Tandon M, Karna ST, Pandey CK, Chaturvedi R. Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series. World J Hepatol 2017; 9:1253-1260. [PMID: 29312528 PMCID: PMC5745586 DOI: 10.4254/wjh.v9.i33.1253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/18/2017] [Accepted: 10/15/2017] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.
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Affiliation(s)
- Manish Tandon
- Institute of Liver and Biliary Sciences, New Delhi 110070, India
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16
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Cardiac echoparameters (geometry and dimensions), interleukin 6, and anthropometric measurements in Egyptian adolescents with hepatitis C and hepatocellular carcinoma. EGYPTIAN LIVER JOURNAL 2017. [DOI: 10.1097/01.elx.0000526967.41371.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Desai M, Mathur B, Eblimit Z, Vasquez H, Taegtmeyer H, Karpen S, Penny DJ, Moore DD, Anakk S. Bile acid excess induces cardiomyopathy and metabolic dysfunctions in the heart. Hepatology 2017; 65:189-201. [PMID: 27774647 PMCID: PMC5299964 DOI: 10.1002/hep.28890] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 09/07/2016] [Accepted: 09/30/2016] [Indexed: 12/31/2022]
Abstract
UNLABELLED Cardiac dysfunction in patients with liver cirrhosis is strongly associated with increased serum bile acid concentrations. Here we show that excess bile acids decrease fatty acid oxidation in cardiomyocytes and can cause heart dysfunction, a cardiac syndrome that we term cholecardia. Farnesoid X receptor; Small Heterodimer Partner double knockout mice, a model for bile acid overload, display cardiac hypertrophy, bradycardia, and exercise intolerance. In addition, double knockout mice exhibit an impaired cardiac response to catecholamine challenge. Consistent with this decreased cardiac function, we show that elevated serum bile acids reduce cardiac fatty acid oxidation both in vivo and ex vivo. We find that increased bile acid levels suppress expression of proliferator-activated receptor-γ coactivator 1α, a key regulator of fatty acid metabolism, and that proliferator-activated receptor-γ coactivator 1α overexpression in cardiac cells was able to rescue the bile acid-mediated reduction in fatty acid oxidation genes. Importantly, intestinal bile acid sequestration with cholestyramine was sufficient to reverse the observed heart dysfunction in the double knockout mice. CONCLUSIONS Decreased proliferator-activated receptor-γ coactivator 1α expression contributes to the metabolic dysfunction in cholecardia so that reducing serum bile acid concentrations may be beneficial against the metabolic and pathological changes in the heart. (Hepatology 2017;65:189-201).
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Affiliation(s)
- Moreshwar Desai
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Bhoomika Mathur
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Zeena Eblimit
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Hernan Vasquez
- Dept. of Cardiology University of Texas Health Sciences Center, Houston, TX
| | | | - Saul Karpen
- Pediatric Gastroenterology, Emory School of Medicine, Atlanta, GA
| | - Daniel J. Penny
- Department of Pediatric Cardiology, Baylor College of Medicine, Houston, TX
| | - David D. Moore
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX
| | - Sayeepriyadarshini Anakk
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL
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18
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Umbro I, Tinti F, Scalera I, Evison F, Gunson B, Sharif A, Ferguson J, Muiesan P, Mitterhofer AP. Acute kidney injury and post-reperfusion syndrome in liver transplantation. World J Gastroenterol 2016; 22:9314-9323. [PMID: 27895419 PMCID: PMC5107695 DOI: 10.3748/wjg.v22.i42.9314] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/10/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose.
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Abstract
PURPOSE Acid-base disturbances were investigated in patients with cirrhosis in relation to hemodynamic derangement to analyze the hyperventilatory effects and the metabolic compensation. METHODS A total of 66 patients with cirrhosis and 44 controls were investigated during a hemodynamic study. RESULTS Hyperventilatory hypocapnia was present in all patients with cirrhosis and progressed from Child class A to C (P<0.01). Arterial pH increased significantly from class A to C (P<0.001) and was correlated inversely to the mean arterial blood pressure (r=-0.30, P<0.02), systemic vascular resistance (r=-0.25, P<0.05), indocyanine green clearance (r=-0.37, P<0.005), and serum sodium (r=-0.38, P<0.002). Metabolic compensation was shown by a reduced standard base excess in all patients (P<0.001). Standard base excess contained elements related to changes in serum albumin, water dilution, and effects of unidentified ions (all P<0.001). A significant hepatic component in the acid-base disturbances could not be identified. CONCLUSION Hypocapnic alkalosis is related to disease severity and hyperdynamic systemic circulation in patients with cirrhosis. The metabolic compensation includes alterations in serum albumin and water retention that may result in a delicate acid-base balance in these patients.
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20
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Chikamori F, Okamoto H, Kuniyoshi N. Relationships between splenorenal shunt/portal vein diameter ratio and systemic hemodynamics in patients with liver cirrhosis. Digestion 2014; 89:133-8. [PMID: 24513698 DOI: 10.1159/000357494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/22/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the relationships between the splenorenal shunt (SRS)/portal vein (PV) diameter ratio (SRS/PV ratio) and systemic hemodynamics in patients with liver cirrhosis. PATIENTS AND METHODS Thirty-seven patients with SRS due to liver cirrhosis were included in this study. SRS was evaluated in the retropancreatic space on contrast-enhanced CT and the diameter was measured at the maximum point. Systemic hemodynamics was studied using a thermodilution catheter. RESULTS The SRS/PV ratio showed a significant correlation with the cardiac index (p < 0.01), and showed an inverse correlation with the systemic vascular resistance index and the arteriovenous oxygen content difference [C(a-v)O2] (p < 0.01). The Child-Pugh score showed a correlation with the SRS/PV ratio (p < 0.01). The SRS/PV ratio was 0.89 ± 0.52, 1.02 ± 0.51, and 1.74 ± 0.50 in the Child-Pugh A, B, and C classes, respectively. The SRS/PV ratio in the Child-Pugh C class was significantly higher than those in classes A and B (p < 0.01). The plasma ammonia level was 75.3 ± 23.2 in the group with an SRS/PV ratio <1.0 (n = 19) versus 102.6 ± 34.8 in the group with an SRS/PV ratio ≥1.0 (n = 18), and the ratio of encephalopathy was 5% (1/19) in the group with an SRS/PV ratio <1.0 (n = 19) versus 50% (9/18) in the group with an SRS/PV ratio ≥1.0 (n = 18), respectively. The differences between the two groups were statistically significant (p < 0.01). CONCLUSIONS We conclude that the increase in the SRS/PV ratio is accompanied by deteriorated liver function, hyperdynamic status, and narrowed C(a-v)O2.
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Affiliation(s)
- Fumio Chikamori
- Department of Surgery, Kuniyoshi Hospital, Kuniyoshi Hospital, Kochi, Japan
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21
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James S, Waterhouse D, McDonald K, O'Hanlon R. Dilated cardiomyopathy and progressive familial intrahepatic cholestasis. BMJ Case Rep 2014; 2014:bcr-2013-202950. [PMID: 24654243 DOI: 10.1136/bcr-2013-202950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case is of a 29-year-old man with progressive familial intrahepatic cholestasis type 1 also known as Byler's disease. At the age of 21, our patient developed non-ischaemic dilated cardiomyopathy. Cardiac MRI demonstrated global wall thinning, with significant areas of myocardial fibrosis in the mid and epicardial walls from base to apex on postgadolinium late contrast enhanced images. No shared genetic loci between dilated cardiomyopathy and Byler's or cholestatic liver disease have yet been found. This presents the first documented case of non-ischaemic dilated cardiomyopathy, with evidence of mid wall fibrosis, in association with an established diagnosis of progressive familial intrahepatic cholestasis type 1 since childhood.
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Affiliation(s)
- Stephanie James
- Department of Cardiology, St Vincent's University Hospital, Dublin, Ireland
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22
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Spruijt OA, Bogaard HJ, Vonk-Noordegraaf A. Pulmonary arterial hypertension combined with a high cardiac output state: Three remarkable cases. Pulm Circ 2013; 3:440-3. [PMID: 24015348 PMCID: PMC3757842 DOI: 10.4103/2045-8932.113185] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A congenital extrahepatic portosystemic venous shunt (CEPVS), also known as an Abernethy malformation, is a rare cause of pulmonary arterial hypertension (PAH). In this case series, we describe three male patients of 30, 23, and 27 years of age with PAH due to a CEPVS. In all three patients, a right heart catheterization revealed a high cardiac output. The aim of this case series is to make pulmonary hypertension physicians aware of the possibility of a CEPVS when PAH is accompanied with a high cardiac output state.
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Affiliation(s)
- Onno A Spruijt
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands
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23
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Choi SS, Yu J, Kim YK, Hwang GS. Severe hemodynamic instability in a patient with suspected hepatoadrenal syndrome during liver transplantation -A case report-. Korean J Anesthesiol 2013; 64:536-40. [PMID: 23814656 PMCID: PMC3695253 DOI: 10.4097/kjae.2013.64.6.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 08/09/2012] [Accepted: 08/10/2012] [Indexed: 11/17/2022] Open
Abstract
Adrenal insufficiency, which is related to hemodynamic instability and increased mortality, has been reported in patients with advanced liver disease regardless of the presence of septic conditions. In this regard, the hepatoadrenal syndrome has been recently proposed as adrenal insufficiency in critically ill patients with liver disease. We describe here a 67-year-old female patient with hepatic failure and adrenal insufficiency. The patient showed stable vital signs and no evidence of sepsis preoperatively. Despite hydrocortisone replacement and inotropics administration, severe intraoperative hemodynamic instability was observed. Hydrocortisone administration was continued postoperatively, nevertheless inotropics could not be tapered. On postoperative day 11, the patient died due to pneumonia and septic shock. Hepatoadrenal syndrome may have played a key role in her severe hemodynamic fluctuation and poor outcome, reinforcing the importance of adrenal function in the liver transplantation surgery.
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Affiliation(s)
- Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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24
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Gjesdal K. Challenges for a Nordic cardiovascular journal. SCAND CARDIOVASC J 2013. [DOI: 10.3109/14017431.2013.790995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Henriksen UL, Henriksen JH, Bendtsen F, Møller S. 99mTc-labelled human serum albumin cannot replace125I-labelled human serum albumin to determine plasma volume in patients with liver disease. Clin Physiol Funct Imaging 2012; 33:211-7. [DOI: 10.1111/cpf.12015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 11/28/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Ulrik Lütken Henriksen
- Clinical Physiology and Nuclear Medicine 239; Center of Functional and Diagnostic Imaging and Research; Hvidovre Hospital; University of Copenhagen; Copenhagen; Denmark
| | - Jens H. Henriksen
- Clinical Physiology and Nuclear Medicine 239; Center of Functional and Diagnostic Imaging and Research; Hvidovre Hospital; University of Copenhagen; Copenhagen; Denmark
| | - Flemming Bendtsen
- Faculty of Health Sciences; Department of Gastroenterology 439; Hvidovre Hospital; University of Copenhagen; Copenhagen; Denmark
| | - Søren Møller
- Clinical Physiology and Nuclear Medicine 239; Center of Functional and Diagnostic Imaging and Research; Hvidovre Hospital; University of Copenhagen; Copenhagen; Denmark
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26
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Henriksen JH, Fuglsang S, Bendtsen F. Arterial pressure profile in patients with cirrhosis: Fourier analysis of arterial pulse in relation to pressure level, stroke volume, and severity of disease: on the reduction of afterload in the hyperdynamic syndrome. Scand J Gastroenterol 2012; 47:580-90. [PMID: 22414026 DOI: 10.3109/00365521.2012.658856] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients with cirrhosis have cardiovascular dysfunction and altered mechanical properties of large and small arteries. This study was undertaken in order to analyze the arterial pressure curve in relation to mean arterial pressure level, stroke volume, and severity of liver disease. MATERIALS AND METHODS Forty-one patients with cirrhosis (Child-Turcotte classes A/B/C = 13/15/13) were studied during a hemodynamic investigation of portal hypertension. Fifteen patients without liver disease served as controls. We applied fast Fourier analysis to quantify the pressure components of the arterial curve, the harmonic Fourier coefficients (HFC). RESULTS Mean arterial pressure was significantly reduced (91 vs. 98 mmHg, p < 0.001) and stroke volume was significantly increased (94 vs. 78 ml, p < 0.001) in patients with cirrhosis versus controls. The HFC were significantly lower in patients with cirrhosis than in controls (-15 to -24%, p < 0.002), except for the fourth HFC, which was significantly increased (+28%, p < 0.02). In contrast to controls, which showed a highly significant effect of the level of arterial pressure on their HFC (p < 0.001), patients with cirrhosis did not show pressure or stroke volume dependence on their HFC, indicating an overall compliant and slow reflective arterial vascular bed. The initial rise in pulse pressure (dP/dt) was inversely related to the Child-Turcotte score (p < 0.05), and the HFC were borderline significantly related to this score (p = 0.07). CONCLUSIONS The arterial pulsation in cirrhosis is qualitatively changed with reduced pulse reflections, which may protect against manifest cardiac failure in patients with advanced cirrhosis.
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Affiliation(s)
- Jens H Henriksen
- Department of Clinical Physiology 239, Faculty of Health Sciences, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark.
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Abstract
PURPOSE OF REVIEW The incidence of cirrhosis is growing steadily and this cohort of patients will present in ever-greater numbers to critical care with acute decompensation, usually secondary to an inter-current event or following elective surgery. This review examines the evidence for treatment options and outcomes. RECENT FINDINGS Outcome of cirrhotics presenting with end-organ dysfunction is steadily improving and their outcomes are not as poor as sometimes suggested. Treatment options for variceal bleeding and renal dysfunction are evolving and outcomes improving. SUMMARY Critical care support should be offered to patients with cirrhosis and in high-risk variceal bleed patients transhepatic portosystemic shunt should be considered.
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Chung IS, Kim HY, Shin YH, Ko JS, Gwak MS, Sim WS, Kim GS, Lee SK. Incidence and predictors of post-reperfusion syndrome in living donor liver transplantation. Clin Transplant 2011; 26:539-43. [PMID: 22168355 DOI: 10.1111/j.1399-0012.2011.01568.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A characteristic pattern of hemodynamic changes that may occur in reperfusion phase of liver transplantation (LT) is known as post-reperfusion syndrome (PRS). In this study, we determined the frequency of PRS and evaluated possible predictors of PRS. The medical records of 152 patients who underwent living donor LT were reviewed. PRS was defined as a decrease in mean arterial pressure of more than 30% from the baseline value for more than one min during the first five min after reperfusion. The frequency of PRS was determined, and patients were divided into two groups: PRS group and non-PRS group. Donor factors, preoperative and intraoperative recipient factors, and postoperative outcomes were compared between the two groups. PRS occurred in 58 recipients (34.2%). Preoperative model for end-stage liver disease scores of recipients and percentage of graft steatotic changes were higher in PRS group. PRS group showed higher heart rates and lower hemoglobin values preoperatively. Before reperfusion, PRS group received more transfusion and their urine output was less than that of non-PRS group. Postoperatively, peak bilirubin during the first five d after LT was higher in PRS group. In conclusion, both severity of liver disease and graft steatosis may increase risk for PRS in LT. Further prospective studies of PRS in its relationship to outcome are indicated.
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Affiliation(s)
- In S Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-Gu, Seoul, South Korea
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Abstract
Cardiac dysfunction in patients with cirrhosis and potential clinical implications have long been known, but the pathophysiology and potential targets for therapeutic intervention are still under investigation and are only now becoming understood. The pathophysiological changes result in systolic dysfunction, diastolic dysfunction, and electrophysiological changes. Here, we aim to review cirrhotic cardiomyopathy from a cellular and physiological model and how these patients develop overt heart failure in the setting of stress, such as infection, ascites, and procedures including transjugular intrahepatic portosystemic shunt, portocaval shunts, and orthotopic liver transplantation. We will also review the most current, although limited, available therapeutic modalities.
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30
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George A, Figueredo VM. Alcoholic cardiomyopathy: a review. J Card Fail 2011; 17:844-9. [PMID: 21962423 DOI: 10.1016/j.cardfail.2011.05.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 05/06/2011] [Accepted: 05/16/2011] [Indexed: 02/08/2023]
Abstract
Alcohol abuse can cause cardiomyopathy indistinguishable from other types of dilated nonischemic cardiomyopathy. Most heavy drinkers remain asymptomatic in the earlier stages of disease progression, and many never develop the familiar clinical manifestations that typify heart failure. We review the current thinking on the pathophysiology, clinical characteristics, and treatments available for alcoholic cardiomyopathy. The relationship of alcohol to heart disease is complicated by the fact that in moderation, alcohol has been shown to afford a certain degree of protection against cardiovascular disease.
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Affiliation(s)
- Anil George
- Einstein Institute for Heart and Vascular Health, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
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Saleh A, Matsumori A, Negm H, Fouad H, Onsy A, Shalaby M, Hamdy E. Assessment of cardiac involvement of hepatitis C virus; tissue Doppler imaging and NTproBNP study. J Saudi Heart Assoc 2011; 23:217-23. [PMID: 23960652 DOI: 10.1016/j.jsha.2011.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/25/2011] [Accepted: 04/30/2011] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Hepatitis C disease burden is substantially increasing in Egyptian community, it is estimated that prevalence of Hepatitis C virus (HCV) in Egyptian community reach 22% of total population. Recently there is a global alert of HCV cardiovascular complications. OBJECTIVE To evaluate LV diastolic functions of HCV patients using tissue Doppler Imaging and NTPBNP. METHODS 30 HCV patients of 30 years, sex & BMI matched controls were evaluated by PCR, ECG, Echocardiography "conventional Doppler, pulsed wave tissue Doppler (PW-TD), strain rate imaging" & NTPBNP to assess LV diastolic functions. Mean age was 32.8 years ± 5.1 in HCV group, 29.8 years ± 6.6 in control group. Cardiovascular anomalies and predisposing factors were excluded. RESULTS HCV group has shown significant increase in QTc interval, significant statistical increase in A wave, deceleration time; (p < 0.05), highly significant decrease in tissue Doppler E a (p < 0.001), highly significant decrease in A a (p < 0.001), highly significant increased E/E a ratio (p value < 0.001), significant decrease in E a/A a ratio and significant increase in SRa (p < 0.05). NTPBNP levels showed highly significant increase with mean value 222 pg/ml ± 283 in HCV group and 32.7 pg/ml ± 21.2 in control group (p value < 0.001). The best cut-off value of NTPBNP to detect diastolic dysfunction in HCV group was 213 pg/ml. No statistical differences in SRe/SRa and E/SRe ratios were observed, however they had significant correlation with NTPBNP level and tissue Doppler parameters. The best cut-off value of E/SRe ratio to detect diastolic dysfunction in HCV group was 0.91, with 75% sensitivity and 100% specificity. CONCLUSION AND RECOMMENDATION This data show the first direct evidence that HCV infection causes diastolic dysfunction without any other predisposing factors, probably due to chronic inflammatory reaction with mild fibrosis in the heart. Previous studies did not follow strict inclusion and exclusion criteria that confirm the independent role of HCV to cause diastolic dysfunction. Tissue Doppler was more sensitive to diagnose diastolic dysfunction than conventional Doppler.
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Affiliation(s)
- Ahmed Saleh
- Academy of Scientific Research and Technology, Cardiovascular and Ultrasonography Research Unit "CURU", Cairo, Egypt
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Saner FH, Neumann T, Canbay A, Treckmann JW, Hartmann M, Goerlinger K, Bertram S, Beckebaum S, Cicinnati V, Paul A. High brain-natriuretic peptide level predicts cirrhotic cardiomyopathy in liver transplant patients. Transpl Int 2011; 24:425-32. [PMID: 21276088 DOI: 10.1111/j.1432-2277.2011.01219.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cirrhotic cardiomyopathy may appear following liver transplantation. Brain-natriuretic peptide (BNP) values exceeding 391 pg/ml or 567 pg/ml may partially reflect ventricular stress because of cardiac dysfunction or indicate cirrhotic cardiomyopathy, respectively. The aim of the study was to assess cardiac dysfunction in liver transplant patients and its correlation with BNP as a biomarker. From 1/2008 to 7/2009, 157 adult liver transplant recipients with proven cirrhosis were recruited for the study. BNP and liver enzymes were recorded upon admission, on the first postoperative day (POD) and 1 week after transplantation. Patients with ischemic heart attacks were excluded from the study. We identified two groups of patients. Group 1 was characterized by a BNP <391 pg/ml and Group 2 by a BNP >391 pg/ml. Group 2 had a significantly higher model of end-stage liver disease score than Group 1 (median 30, range 10-40 versus median 22, range 10-40, respectively; P = 0.003), required significantly more dialysis treatments and had a significantly higher mortality rate. Postoperative echocardiography in patients with a BNP >391 pg/ml indicated diastolic dysfunction in all of the patients and systolic dysfunction in 10 of the patients. Increased serum-BNP was associated with an overall higher mortality rate.
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Affiliation(s)
- Fuat H Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany.
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Satapathy SK, Charlton MR. Posttransplant metabolic syndrome: new evidence of an epidemic and recommendations for management. Liver Transpl 2011; 17:1-6. [PMID: 21254337 DOI: 10.1002/lt.22222] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Current world literature. Curr Opin Anaesthesiol 2010; 23:283-93. [PMID: 20404787 DOI: 10.1097/aco.0b013e328337578e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Desai MS, Shabier Z, Taylor M, Lam F, Thevananther S, Kosters A, Karpen SJ. Hypertrophic cardiomyopathy and dysregulation of cardiac energetics in a mouse model of biliary fibrosis. Hepatology 2010; 51:2097-107. [PMID: 20512997 PMCID: PMC3678910 DOI: 10.1002/hep.23585] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
UNLABELLED Cardiac dysfunction is a major cause of morbidity and mortality in patients with end-stage liver disease; yet the mechanisms remain largely unknown. We hypothesized that the complex interrelated impairments in cardiac structure and function secondary to progression of liver diseases involve alterations in signaling pathways engaged in cardiac energy metabolism and hypertrophy, augmented by direct effects of high circulating levels of bile acids. Biliary fibrosis was induced in male C57BL/6J mice by feeding a 0.1% 3,5-diethoxycarbonyl-1,4-dihydroxychollidine (DDC) supplemented diet. After 3 weeks, mice underwent live imaging (dual energy x-ray absorptiometry [DEXA] scanning, two-dimensional echocardiography [2DE], electrocardiography, cardiac magnetic resonance imaging), exercise treadmill testing, and histological and biochemical analyses of livers and hearts. Compared with chow-fed mice, DDC-fed mice fatigued earlier on the treadmill, with reduced VO(2). Marked changes were identified electrophysiologically (bradycardia and prolonged QT interval) and functionally (hyperdynamic left ventricular [LV] contractility along with increased LV thickness). Hearts of DDC-fed mice showed hypertrophic signaling (activation of v-akt murine thymoma viral oncogene/protein kinase B [AKT], inhibition of glycogen synthase kinase-3beta [GSK3beta], a 20-fold up-regulation of beta myosin heavy chain RNA and elevated G(s)alpha/G(i)alpha ratio. Genes regulating cardiac fatty acid oxidation pathways were suppressed, along with a threefold increase in myocardial glycogen content. Treatment of mouse cardiomyocytes (which express the membrane bile acid receptor TGR5) with potent natural TGR5 agonists, taurochenodeoxycholic acid and lithocholic acid, activated AKT and inhibited GSK3beta, similar to the changes seen in DDC-fed mouse hearts. This provides support for a novel mechanism whereby circulating natural bile acids can induce signaling pathways in heart associated with hypertrophy. CONCLUSION Three weeks of DDC feeding-induced biliary fibrosis leads to multiple functional, metabolic, electrophysiological, and hypertrophic adaptations in the mouse heart, recapitulating some of the features of human cirrhotic cardiomyopathy.
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Affiliation(s)
- Moreshwar S. Desai
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX
| | - Zainuer Shabier
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX
| | - Michael Taylor
- Section of Pediatric Cardiology, Baylor College of Medicine, Houston TX
| | - Fong Lam
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX
| | - Sundararajah Thevananther
- Texas Children’s Liver Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Astrid Kosters
- Texas Children’s Liver Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Saul J. Karpen
- Texas Children’s Liver Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
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