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Wu TW, Hou TY, Yang JCS, Wang CC. First report of successful liver transplantation following supermicrosurgical lymphaticovenous anastomoses for lymphorrhea with intractable infection: A case report. World J Transplant 2025; 15:101496. [DOI: 10.5500/wjt.v15.i3.101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 12/30/2024] [Accepted: 02/06/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Liver transplant (LT) candidates face a heightened risk of infection both pre- and post-transplant, owing to immunosuppressive therapy and complications from chronic liver disease. Infections during the pre-transplant period, such as lymphorrhea-induced cellulitis, can cause significant delays in transplantation and increase mortality while on the waiting list. Lymphorrhea, characterized by substantial lymphatic leakage and recurrent skin infections, presents a significant challenge in managing patients who are already immunocompromised. Effective preoperative infection control is critical to enhancing the prospects for a successful liver transplantation.
CASE SUMMARY We report the case of a 50-year-old female diagnosed with Hepatitis C virus-related cirrhosis (Child-Pugh C) and recurrent cellulitis due to lymphorrhea in her left lower leg. She suffered repeated episodes of cellulitis over five years, which prevented her from undergoing LT. Initial conservative treatments were unsuccessful in managing the lymphatic leakage and accompanying infections. In February 2019, she underwent supermicrosurgical lymphaticovenous anastomoses (LVA) to address her lymphorrhea. This procedure, which created multiple lymphatic-venous connections in the lower limb, led to significant improvements in her condition. After the LVA, she experienced no further episodes of cellulitis. Eighteen months later, she successfully underwent a deceased donor liver transplantation. Postoperative complications, including a wound hematoma, were effectively managed, and she was discharged 3 months post-operation. At her 3-year follow-up, her liver function was stable, with no recurrence of cellulitis.
CONCLUSION Despite numerous challenges, the patient achieved a successful recovery with satisfactory graft function and was free from lymphorrhea/lymphedema in her left lower limb 3 years post-transplantation. This case underscores the importance of robust infection control during both the pre- and post-transplantation phases and highlights the potential of LVA as a treatment option for managing lymphorrhea and infections in patients with liver cirrhosis.
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Affiliation(s)
- Tse-Wei Wu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan
| | - Teng-Yuan Hou
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833401, Taiwan
| | - Johnson Chia-Shen Yang
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833401, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833401, Taiwan
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Juneja P, Yadav R, Tripathi DM, Kaur S. The interplay between lymphatic system and portal hypertension: a comprehensive review. Hepatol Int 2025:10.1007/s12072-025-10815-5. [PMID: 40178721 DOI: 10.1007/s12072-025-10815-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 02/28/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND The pathophysiology of portal hypertension revolves around numerous structural and functional changes in the intra- and extra-hepatic vascular compartments. In recent years, a dysfunction of the lymphatic system has garnered increasing attention as one of the key sequelae of portal hypertension. PURPOSE AND METHODS The review comprehensively deliberates about the anatomical and functional attributes of the hepatic lymphatic system during portal hypertension. Along with liver lymphatic system, important modifications that occur in extrahepatic lymphatics during advanced liver disease are discussed. RESULTS During progression of liver disease, elevated portal pressures cause increased sinusoidal blood and enhanced lymph flow, leading to dilation and proliferation of hepatic lymphatic vessels. In advanced liver disease, portal and central lymphatic systems also undergo profound changes to accommodate increased lymph flows. These changes in lymphatic system seem to have evolved as compensatory mechanisms to alleviate enhanced portal pressures. However, further increase in the splanchnic lymph production causes a complete failure of the drainage capacity of local and central lymphatic vessels, leading to maldistribution of extracellular fluid along with immune system anomalies aggravating ascites and pathological bacterial translocation. CONCLUSION Lymphatic dysfunction plays a crucial role in the progression and complications of portal hypertension. Development of routine imaging techniques for lymphatic vessels in clinics, protocols for measuring lymphovenous pressure gradient and in vitro and in vivo experimental studies are requisite to further our understanding in this field. Targeting lymphatic dysfunction could offer promising therapeutic options for managing cirrhosis, portal hypertension and related complications.
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Affiliation(s)
- Pinky Juneja
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajni Yadav
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Dinesh M Tripathi
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Savneet Kaur
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India.
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Pogorelova M, Sungur CM. Chylous ascites as an initial presentation of lupus nephritis. BMJ Case Rep 2025; 18:e264415. [PMID: 40107757 DOI: 10.1136/bcr-2024-264415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025] Open
Abstract
We report the case of a man in his 50s who presented with pleural and pericardial effusions, chylous ascites, lymphadenopathy, weight loss and fatigue. Extensive evaluation ruled out malignancy, infection and many autoimmune conditions, but test results were positive for antinuclear antibodies and anti-double-stranded DNA antibodies. A kidney biopsy showed evidence of lupus nephritis (class 5). He ultimately was diagnosed with systemic lupus erythematosus and lupus nephritis. The patient began immunosuppressive treatment, and the manifestations started to resolve. Recognition of systemic lupus erythematosus as the cause of chylous ascites was essential for identifying effective therapy.
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Airola C, Varca S, Del Gaudio A, Pizzolante F. The Covert Side of Ascites in Cirrhosis: Cellular and Molecular Aspects. Biomedicines 2025; 13:680. [PMID: 40149656 PMCID: PMC11940454 DOI: 10.3390/biomedicines13030680] [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: 12/21/2024] [Revised: 02/25/2025] [Accepted: 03/07/2025] [Indexed: 03/29/2025] Open
Abstract
Ascites, a common complication of portal hypertension in cirrhosis, is characterized by the accumulation of fluid within the peritoneal cavity. While traditional theories focus on hemodynamic alterations and renin-angiotensin-aldosterone system (RAAS) activation, recent research highlights the intricate interplay of molecular and cellular mechanisms. Inflammation, mediated by cytokines (interleukin-1, interleukin-4, interleukin-6, tumor necrosis factor-α), chemokines (chemokine ligand 21, C-X-C motif chemokine ligand 12), and reactive oxygen species (ROS), plays a pivotal role. Besides pro-inflammatory cytokines, hepatic stellate cells (HSCs), sinusoidal endothelial cells (SECs), and smooth muscle cells (SMCs) contribute to the process through their activation and altered functions. Once activated, these cell types can worsen ascites accumulationthrough extracellular matrix (ECM) deposition and paracrine signals. Besides this, macrophages, both resident and infiltrating, through their plasticity, participate in this complex crosstalk by promoting inflammation and dysregulating lymphatic system reabsorption. Indeed, the lymphatic system and lymphangiogenesis, essential for fluid reabsorption, is dysregulated in cirrhosis, exacerbating ascites. The gut microbiota and intestinal barrier alterations which occur in cirrhosis and portal hypertension also play a role by inducing inflammation, creating a vicious circle which worsens portal hypertension and fluid accumulation. This review aims to gather these aspects of ascites pathophysiology which are usually less considered and to date have not been addressed using specific therapy. Nonetheless, it emphasizes the need for further research to understand the complex interactions among these mechanisms, ultimately leading to targeted interventions in specific molecular pathways, aiming towards the development of new therapeutic strategies.
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Affiliation(s)
- Carlo Airola
- CEMAD Centro Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.V.); (A.D.G.)
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Simone Varca
- CEMAD Centro Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.V.); (A.D.G.)
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Angelo Del Gaudio
- CEMAD Centro Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.V.); (A.D.G.)
- Facoltà di Medicina e Chirurgia, Università Cattolica Sacro Cuore, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Fabrizio Pizzolante
- CEMAD Centro Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.V.); (A.D.G.)
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Itkin M, Horak J, Pascual JL, Chang CWJ, Lile D, Tomita B, Bass GA, Kovach SJ, Kaplan LJ. Disorders of Lymphatic Architecture and Flow in Critical Illness. Crit Care Med 2025; 53:e665-e682. [PMID: 39791972 DOI: 10.1097/ccm.0000000000006561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
Abstract
OBJECTIVES To provide a narrative review of disordered lymphatic dynamics and its impact on critical care relevant condition management. DATA SOURCES Detailed search strategy using PubMed and Ovid Medline for English language articles (2013-2023) describing congenital or acquired lymphatic abnormalities including lymphatic duct absence, injury, leak, or obstruction and their associated clinical conditions that might be managed by a critical care medicine practitioner. STUDY SELECTION Studies that specifically addressed abnormalities of lymphatic flow and their management were selected. The search strategy time frame was limited to the last 10 years to enhance relevance to current practice. DATA EXTRACTION Relevant descriptions or studies were reviewed, and abstracted data were parsed into structural or functional etiologies, congenital or acquired conditions, and their management within critical care spaces in an acute care facility. DATA SYNTHESIS Abnormal lymph flow may be identified stemming from congenital lymphatic anomalies including lymphatic structure absence as well as acquired obstruction or increased flow from clinical entities or acute therapy. Macro- and microsurgical as well as interventional radiological techniques may address excess, inadequate, or obstructed lymph flow. Patients with deranged lymph flow often require critical care, and those who require critical care may concomitantly demonstrate deranged lymph flow that adversely impacts care. CONCLUSIONS Critical care clinicians ideally demonstrate functional knowledge of conditions that are directly related to, or are accompanied by, deranged lymphatic dynamics to direct timely diagnostic and therapeutic interventions during a patient's ICU care episode.
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Affiliation(s)
- Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jose L Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cherylee W J Chang
- Department of Neurology, Division of Neurocritical Care, Duke University, Durham, NC
| | - Deacon Lile
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Beverly Tomita
- Carle Illinois College of Medicine, University of Illinois Urbana-Champlain, Urbana, IL
| | - Gary Alan Bass
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Chen ZQ, Zeng SJ, Xu C. Management of chylous ascites after liver cirrhosis: A case report. World J Hepatol 2025; 17:100797. [PMID: 39871904 PMCID: PMC11736487 DOI: 10.4254/wjh.v17.i1.100797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 10/15/2024] [Accepted: 11/18/2024] [Indexed: 01/06/2025] Open
Abstract
BACKGROUND Chylous ascites is an uncommon condition, occurring in less than 1% of ascites cases. It results from traumatic or obstructive disruption of the lymphatic system, causing the leakage of thoracic or intestinal lymph into the abdominal cavity. This leads to the accumulation of a milky, triglyceride-rich fluid. In adults, malignancy and cirrhosis are the primary causes of chylous ascites. Notably, chylous ascites accounts for only 0.5% to 1% of all cirrhosis-related ascites cases. At present, there is a limited understanding of this condition, and effective timely management in clinical practice remains challenging. CASE SUMMARY This case report presents a patient with hepatic cirrhosis complicated by chylous ascites, who had experienced multiple hospitalizations due to abdominal distension. Upon admission, comprehensive examinations and assessments were conducted. The treatment strategy focused on nutritional optimization through a low-sodium, low-fat, and high-protein diet supplemented with medium-chain triglycerides, therapeutic paracentesis, and diuretics. Following a multidisciplinary discussion and thorough evaluation of the patient's condition, surgical indications were confirmed. After informing the patient about the benefits and risks, and obtaining consent, a transjugular intrahepatic portosystemic shunt procedure was performed, successfully alleviating the abdominal swelling symptoms. This article details the clinical characteristics and treatment approach for this uncommon case, summarizing current management methods for hepatic cirrhosis complicated by chylous ascites. The aim is to provide valuable insights for clinicians encountering similar situations. CONCLUSION Optimizing nutrition and addressing the underlying cause are essential in the treatment of chylous ascites. When conservative approaches prove ineffective, alternative interventions such as transjugular intrahepatic portosystemic shunt may be considered.
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Affiliation(s)
- Zong-Qiang Chen
- Department of Gastroenterology, Guangdong Medical University, Zhanjiang 524000, Guangdong Province, China
| | - Shu-Jun Zeng
- Department of Gastroenterology, Huizhou Central People's Hospital, Huizhou 516000, Guangdong Province, China
| | - Chun Xu
- Department of Gastroenterology, Huizhou Central People's Hospital, Huizhou 516000, Guangdong Province, China.
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Liu X, Liu Z, Shen W, Xia S, Sun Y, Chang K, Xin J, An R, Liang C, Zhou C. Diagnostic imaging, therapeutic interventions and suggestions for thoracic duct congestion in postoperative hepatic lymphorrhea: a retrospective analysis of 20 cases. BMC Surg 2024; 24:352. [PMID: 39533287 PMCID: PMC11556192 DOI: 10.1186/s12893-024-02650-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 10/29/2024] [Indexed: 11/16/2024] Open
Abstract
OBJECTIVE To retrospectively evaluate thoracic duct (TD) congestion in hepatic lymphorrhea (HL) and propose treatment suggestions. METHODS Retrospectively analyze cases of postoperative HL admitted from August 2007 to November 2023. Twenty cases were enrolled and followed up. The medical history, ascites characteristics, lymphoscintigraphy, direct lymphangiography, and other clinical data were reviewed. RESULTS Twenty patients with ascites after cholecystectomy or radical gastrectomy were included. There were 15 patients with cirrhosis and 5 patients with hepatitis. Ascites were light yellow even if the patients had a non-low-fat diet. Triglyceride level mean of ascites was 0.61 ± 0.20 mmol/L. There were 94.1% (16/17) of patients whose ascitic cholesterol ≥ 45 mg/dL or SAAG < 11.0 g/L. Mild abdominal radioactivity was shown in 89.5% (17/19) patients. Left subclavian-jugular venous angle radioactivity was observed in 84.2% (16/19) patients. In 10% (2/20) cases, lipiodol presenting as oil droplets traveled upwards quickly and flowed into the vein rapidly. In 90% (18/20) cases, tortuous and dilated thoracic duct, stagnant lipiodol, and poor flow into the vein were demonstrated. One patient refused treatment and died soon. By thoracic duct outlet reconstruction combined with other treatments, 16 patients were cured and the ascites of another 3 patients were controlled. CONCLUSIONS TD congestion and elevated lymphatic pressure could be caused by increased lymph flow and TD outlet stenosis. TD decompression by outlet reconstruction may be an alternative approach to HL.
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Affiliation(s)
- Xin Liu
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Zhong Liu
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Wenbin Shen
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China.
| | - Song Xia
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Yuguang Sun
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Kun Chang
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Jianfeng Xin
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Ran An
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Chen Liang
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
| | - Chenxiao Zhou
- Department of Lymphatic Surgery, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Clinical Center for Lymphatic Disorders, Capital Medical University, Beijing, China
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Marrapu S, Kumar R. Intestinal lymphangiectasia: Understanding the bigger picture. World J Clin Cases 2024; 12:3298-3303. [PMID: 38983414 PMCID: PMC11229932 DOI: 10.12998/wjcc.v12.i18.3298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/16/2024] [Accepted: 04/26/2024] [Indexed: 06/13/2024] Open
Abstract
Intestinal lymphangiectasia (IL) is characterized by the dilation of intestinal lymphatic vessels, which can rupture and cause loss of lymph into the intestine. Due to the high content of proteins, lipoproteins, and lymphocytes in the intestinal lymph, loss of lymph might result in hypoproteinemia, hypoalbuminemia, hypogammaglobulinemia, and lymphocytopenia. In addition, there may be a depletion of minerals, lipids, and fat-soluble vitamins. IL can be primary due to inherent malfunctioning of the lymphatic system, or secondly, a result of various factors that may hinder lymphatic drainage either directly or indirectly. This condition has emerged as a subject of significant clinical interest. Given that the intestinal lymphatic system plays an important role in the body's fluid homeostasis, adaptive immunity, nutrient and drug absorption, intestinal transport, and systemic metabolism, its dysfunction may have wider implications. Although primary IL is rare, with varied clinical features, complications, treatment response, and outcomes, secondary IL is more common than previously believed. The definitive diagnosis of IL requires endoscopic demonstration of whitish villi (which frequently resemble snowflakes) and histological confirmation of dilated lacteals in the small intestinal mucosa. Treatment of IL is challenging and involves dietary modifications, managing underlying medical conditions, and using medications such as sirolimus and octreotide. Recognizing its prevalence and diverse etiology is crucial for targeted management of this challenging medical condition. This article provides a comprehensive exploration of the clinical implications associated with IL. In addition, it offers valuable insights into critical knowledge gaps in the existing diagnostic and management landscape.
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Affiliation(s)
- Sudheer Marrapu
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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Zharikov YO, Zharkova MS, Gadjiakhmedova AN, Aliyeva AM, Nikolenko VN, Ivashkin VT. Parameters of the Component Composition of the Body and Their Relationship with the Development of Ascites in Liver Cirrhosis. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2024; 34:53-61. [DOI: 10.22416/1382-4376-2024-34-3-53-61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Aim: to evaluate the relationship of body composition components with the development of ascites in patients with liver cirrhosis.Materials and methods. One hundred and ten patients (44 men and 66 women) with the established diagnosis of liver cirrhosis were treated at the University Clinical Hospital No 2 of the Sechenov University. The assessment of the component composition of the patients’ body was carried out using the ABC-01 “MEDASS” device (“MEDASS”, Russia). Ascites diagnosis was performed using ultrasound examination of the abdominal cavity and retroperitoneal space.Results. The values of body mass index (p < 0.001), fat mass (p = 0.002), active cell mass (p < 0.001), and phase angle (p < 0.001) were lower in patients with ascites than without it. Patients with a lower percentage of body fat mass had a more severe ascites severity and vice versa, and the proportion of fat mass was generally higher in women than in men (r = –0.290; p = 0.002). Patients with lower active cell mass had higher ascites severity (r = –0.380; p < 0.001). However, this indicator was lower in women than in men. Significant negative correlations were revealed between fat mass, active cell mass, phase angle (r = –0.395; p < 0.001) and the severity of ascites.Conclusion. Our study confirms the importance of body composition parameters in the development of ascites in patients with cirrhosis of the liver. Insufficient amount of fat and muscle mass, as well as low values of the phase angle according to the results of bioimpedance can become predictors of the development of ascites. Evaluation of these components can be used in prognostic models to identify patients with an increased risk of ascites. Further research in this area will help to better understand the mechanisms of ascites development and develop effective methods of prevention and treatment of this complication in patients with liver cirrhosis.
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Affiliation(s)
- Yu. O. Zharikov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. S. Zharkova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - A. M. Aliyeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - V. N. Nikolenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University); Lomonosov Moscow State University
| | - V. T. Ivashkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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DiBattista JV, Odenwald MA, Te H. Successful Treatment of Refractory Chylous Ascites With Octreotide in a Patient With Decompensated Cirrhosis. ACG Case Rep J 2024; 11:e01322. [PMID: 38560017 PMCID: PMC10977527 DOI: 10.14309/crj.0000000000001322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Chylous ascites is a rare manifestation of decompensated cirrhosis that is associated with increased short-term mortality. Exclusion of other etiologies must be performed to allow for appropriate management, which itself can be a challenge in the setting of decompensated cirrhosis. We report a case of chylous ascites in a patient with decompensated cirrhosis that was successfully managed with octreotide before liver transplantation.
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Affiliation(s)
- Jacob V. DiBattista
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Matthew A. Odenwald
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Helen Te
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
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Yano R, Hirooka M, Koizumi Y, Nakamura Y, Imai Y, Morita M, Okazaki Y, Watanabe T, Yoshida O, Tokumoto Y, Abe M, Hiasa Y. Lymphatic drainage dysfunction via narrowing of the lumen of cisterna chyli and thoracic duct after luminal dilation. Hepatol Int 2023; 17:1557-1569. [PMID: 37500943 DOI: 10.1007/s12072-023-10563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The chronological pattern of extrahepatic lymphatic vessel progression in the course of chronic liver disease has not been clarified. This study aimed to clarify the chronological changes in lymphatic vessels with liver disease progression. METHODS This was a prospective cross-sectional study that enrolled a total of 199 patients. The maximum diameter of the cisterna chyli (CC) or terminal thoracic duct (tTD) was measured using computed tomography or ultrasonography, respectively. Changes in the maximum diameters of the CC and tTD were evaluated with patients with chronic liver disease as the pilot set (n = 138). Subsequently, we examined whether CC/tTD could be used to re-allocate unclassified patients by the Baveno-VII criteria to appropriately diagnose clinically significant portal hypertension (CSPH) in the pilot and validation sets. RESULTS In the pilot set, a scatter-plot showed that both CC and tTD were narrowed as terminal features in chronic liver disease after dilation. Because there was a significant correlation between the CC diameter and hepatic venous pressure gradient (r = 0.724) in unclassified patients, the diagnostic value of CC and tTD for CSPH was good (AUC: 0.961 and 0.913, respectively). After re-allocation, 68 and 27 unclassified patients were reduced to 4 and 5 in the pilot and validation sets, respectively. CONCLUSION Both the CC and tTD narrow in the course of liver disease after dilation. Moreover, the maximum diameter of the CC and tTD can be used to re-allocate patients who are unclassified according to the Baveno-VII criteria. CLINICAL TRIAL NUMBER UMIN trial no. 000044857.
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Affiliation(s)
- Ryo Yano
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan.
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yoshiko Nakamura
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yusuke Imai
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Makoto Morita
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yuki Okazaki
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Takao Watanabe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Osamu Yoshida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yoshio Tokumoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitukawa 454, Toon, Ehime, 791-0295, Japan
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Ma R, Iwakiri Y. Lymphatic drainage dysfunction is related to clinically significant portal hypertension. Hepatol Int 2023; 17:1327-1330. [PMID: 37743398 DOI: 10.1007/s12072-023-10592-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Ruixue Ma
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, TAC S223B, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Yasuko Iwakiri
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, TAC S223B, 333 Cedar Street, New Haven, CT, 06520, USA.
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Kumar R, Marrapu S. Dietary salt in liver cirrhosis: With a pinch of salt! World J Hepatol 2023; 15:1084-1090. [PMID: 37970619 PMCID: PMC10642432 DOI: 10.4254/wjh.v15.i10.1084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/21/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
Patients with liver cirrhosis are advised to limit their sodium consumption to control excessive fluid accumulation. Salt is the most common form in which sodium is consumed daily. Consequently, various recommendations urge patients to limit salt intake. However, there is a lack of consistency regarding salt restriction across the guidelines. Moreover, there is conflicting evidence regarding the efficacy of salt restriction in the treatment of ascites. Numerous studies have shown that there is no difference in ascites control between patients with restriction of salt intake and those without restriction. Moreover, patients with cirrhosis may have several negative effects from consuming too little salt, although there are no recommendations on the lower limit of salt intake. Sodium is necessary to maintain the extracellular fluid volume; hence, excessive salt restriction can result in volume contraction, which could negatively impact kidney function in a cirrhotic patient. Salt restriction in cirrhotic patients can also compromise nutrient intake, which can have a negative impact on the overall outcome. There is insufficient evidence to recommend restricted salt intake for all patients with cirrhosis, including those with severe hyponatremia. The existing guidelines on salt restriction do not consider the salt sensitivity of patients; their nutritional state, volume status and sodium storage sites; and the risk of hypochloremia. This opinion article aims to critically analyze the existing literature with regard to salt recommendations for patients with liver cirrhosis and identify potential knowledge gaps that call for further research.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India.
| | - Sudheer Marrapu
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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Arya R, Kumar R, Kumar T, Kumar S, Anand U, Priyadarshi RN, Maji T. Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism. World J Hepatol 2023; 15:1140-1152. [PMID: 37970615 PMCID: PMC10642429 DOI: 10.4254/wjh.v15.i10.1140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization. AIM To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA. METHODS This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions. RESULTS A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003]. CONCLUSION Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.
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Affiliation(s)
- Rahul Arya
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India.
| | - Tarun Kumar
- Department of Pathology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Tanmoy Maji
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Kumar R, Kumar S, Prakash SS. Compensated liver cirrhosis: Natural course and disease-modifying strategies. World J Methodol 2023; 13:179-193. [PMID: 37771878 PMCID: PMC10523240 DOI: 10.5662/wjm.v13.i4.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 09/20/2023] Open
Abstract
Compensated liver cirrhosis (CLC) is defined as cirrhosis with one or more decompensating events, such as ascites, variceal haemorrhage, or hepatic encephalopathy. Patients with CLC are largely asymptomatic with preserved hepatic function. The transition from CLC to decompensated cirrhosis occurs as a result of a complex interaction between multiple predisposing and precipitating factors. The first decompensation event in CLC patients is considered a significant turning point in the progression of cirrhosis, as it signals a drastic decline in median survival rates from 10-12 years to only 1-2 years. Furthermore, early cirrhosis has the potential to regress as liver fibrosis is a dynamic condition. With the advent of effective non-invasive tools for detecting hepatic fibrosis, more and more patients with CLC are currently being recognised. This offers clinicians a unique opportunity to properly manage such patients in order to achieve cirrhosis regression or, at the very least, prevent its progression. There are numerous emerging approaches for preventing or delaying decompensation in CLC patients. A growing body of evidence indicates that treating the underlying cause can lead to cirrhosis regression, and the use of non-selective beta-blockers can prevent decompensation by lowering portal hypertension. Additionally, addressing various cofactors (such as obesity, diabetes, dyslipidaemia, and alcoholism) and precipitating factors (such as infection, viral hepatitis, and hepatotoxic drugs) that have a detrimental impact on the natural course of cirrhosis may benefit patients with CLC. However, high-quality data must be generated through well-designed and adequately powered randomised clinical trials to validate these disease-modifying techniques for CLC patients. This article discussed the natural history of CLC, risk factors for its progression, and therapeutic approaches that could alter the trajectory of CLC evolution and improve outcomes.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sabbu Surya Prakash
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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Proteomic changes associated with maternal dietary low ω6:ω3 ratio in piglets supplemented with seaweed. Part I: Serum proteomes. J Proteomics 2023; 270:104740. [PMID: 36191802 DOI: 10.1016/j.jprot.2022.104740] [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: 03/25/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 02/01/2023]
Abstract
This study examines whether maternal low ω6:ω3 ratio diet and offspring SW supplementation can improve offspring immunity and performance by elucidating the effects on piglet serum proteome. A total of 16 sows were given either a standard (CR, 13:1) or low ω6:ω3 ratio diet (LR, 4:1) during pregnancy and lactation and their male weaned piglets were supplemented with SW powder (4 g/kg, SW) or not (CT) in a 21-day post-weaning (PW) diet. Four PW piglet groups were then identified based on dam and piglet treatment, namely CRCT, CRSW, LRCT, and LRSW (n = 10 each). Piglet serum collected at weaning and d21 PW were analysed (n = 5 each) using TMT-based quantitative proteomics and validated by appropriate assays. The differentially abundant proteins (n = 122) displayed positive effects of maternal LR diet on anti-inflammatory properties and innate immune stimulation. Progeny SW diet activated the innate immunity and enhance the host defence during inflammation. These data demonstrate the value of decreasing ω6:ω3 ratio in maternal diet and SW supplementation in PW piglet's diet to boost their immunity and anti-inflammation properties. SIGNIFICANCE: This novel proteomic study in post-weaned piglets addresses the interplay between maternal and offspring nutritional interventions in a context of rapid and dynamic alterations in piglet metabolic status around weaning. Decreasing ω6:ω3 ratio in maternal diet and SW supplementation in PW piglet's diet can boost their immunity and anti-inflammation properties. This study also provides new insights into piglet serum proteome regulation during post-weaning, a critical development period in swine.
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Muacevic A, Adler JR, Jordan KG, Waters JK, Reznik SI. "Mega" Cisterna Chyli: A Case Report and Review of the Literature. Cureus 2023; 15:e34111. [PMID: 36843809 PMCID: PMC9946758 DOI: 10.7759/cureus.34111] [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: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Enlarged cisterna chyli is an infrequently encountered entity and is most often an asymptomatic, incidental finding on imaging for other reasons. The pathogenesis of cisterna chyli enlargement is not well elucidated and includes infectious, inflammatory, and idiopathic causes. In this report, we present the rare case of an asymptomatic, markedly dilated "mega" cisterna chyli in a 60-year-old female.
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Cisterna chyli as an optimal marker of tolvaptan response in severe cirrhotic ascites. Sci Rep 2022; 12:8124. [PMID: 35581243 PMCID: PMC9114325 DOI: 10.1038/s41598-022-11889-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/03/2022] [Indexed: 12/13/2022] Open
Abstract
For patients with cirrhosis, no definitive predictor of the efficacy and prognosis of tolvaptan treatment exists. We assessed the cisterna chyli's utility as an optimal marker. We retrospectively enrolled 172 patients with cirrhosis. The effect of tolvaptan was evaluated using post-treatment survival time. The overall response to tolvaptan was 52.3%. The median cisterna chyli diameter was 4.1 mm. Of 172 patients, 100 were included in the pilot set and 72 in the validation set. According to the Youden index, the cisterna chyli diameter's cutoff value was 4 mm, with a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of 92%, 83%, 86%, 91%, 5.43, and 0.09, respectively, in the pilot set. The area under the curve of the cisterna chyli diameter for evaluating tolvaptan's effect was 0.911 and 0.988 in the pilot and validation sets, respectively. During multivariate analysis, cisterna chyli narrowing and furosemide treatment were significant predictive factors for tolvaptan's insufficient effect. Cumulative liver transplantation-free survival rates were significantly higher in patients with cisterna chyli dilatation than in those without (p = 0.028). Our findings suggest a strong association of cisterna chyli with tolvaptan treatment response in patients with cirrhosis and hepatic edema.
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Monjotin N, Tenca G. Lymphotonic activity of Ruscus extract, hesperidin methyl chalcone and vitamin C in human lymphatic smooth muscle cells. Microvasc Res 2021; 139:104274. [PMID: 34717967 DOI: 10.1016/j.mvr.2021.104274] [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: 07/05/2021] [Revised: 10/10/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Besides actions including their venotonic, anti-inflammatory, and anti-oxidant effects, venoactive drugs are expected to act on edema via their action on lymphatics. The objective of this study was to evaluate the effect of the combination of Ruscus, hesperidin methyl chalcone and Vitamin C (Ruscus/HMC/Vit C) on intracellular calcium mobilization and contraction of human lymphatic smooth muscle cells (LSMCs) to better characterize the mechanism of its lymphotonic activity. METHODS Calcium mobilization was evidenced by videomicroscopy analysis of the fluorescence emitted by a specific Ca2+ sensitive dye and measured after injection of Ruscus/HMC/Vit C at 0.1, 0.3, 1.0, and 3.0 mg/mL into LSMCs. RESULTS Ruscus/HMC/Vit C induced a strong and reproducible concentration-dependent calcium mobilization in LSMCs. On the contrary, another venoactive drug used as comparator, micronized purified flavonoid fraction (MPFF), did not induce calcium mobilization whatever the tested concentration. CONCLUSION Although alternative mechanisms of action may result in potential lymphotonic effects, the efficacy of lymphotonic products is nonetheless related to their stimulating effect on the contractile activity of the smooth muscle cells surrounding lymphatic vessels. In the light of the results obtained in this study, the direct effect of Ruscus/HMC/Vit C on LSMC contraction may partially explain its clinical efficacy on lymphotonic activity, as has been observed in terms of objective signs of edema as reported in the recent guidelines on chronic venous disease.
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Affiliation(s)
- Nicolas Monjotin
- Institut de recherche Pierre Fabre, 17 Avenue Jean Moulin, 81106 Castres cedex, France.
| | - Guillaume Tenca
- Bioalternatives, 1 bis rue des plantes, 86160 Gençay, France
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