Congestive hepatopathy (CH) arises from chronically elevated right-sided heart pressures transmitted to the liver by passive venous congestion. Over time, CH can lead to hepatic bridging fibrosis, decompensated cirrhosis, and hepatocellular carcinoma. Currently, there are no evidence-based guidelines to direct appropriate screening or management of patients with CH, partly because of the inability of current clinical tools (serum tests, imaging studies, liver stiffness measurements, and liver biopsy) to accurately estimate hepatic fibrosis or the risk for hepatic decompensation. The Model for End-Stage Liver Disease excluding international normalized ratio (MELD-XI) score is the only validated serum-based test to predict clinical outcomes in CH. Noninvasive liver stiffness measurements are proving to be of minimal utility as all patients with CH have elevated values that currently cannot differentiate between congestion and fibrosis. In addition, fibrosis staging by liver biopsy is difficult to standardize because of heterogeneous collagen deposition in CH. Moreover, liver biopsy results have little predictive value for post-heart transplant hepatic outcomes in patients with CH. Evaluating liver nodules and masses is also complicated in CH as the finding of delayed venous washout in nodules is not specific for hepatocellular carcinoma in the background of a congested liver, and these lesions may require biopsy to confirm the diagnosis. The lack of effective clinical tools for predicting liver fibrosis and liver function suggests the need for the development of novel biomarkers in patients with CH to assist in the management of this complicated disease. (Hepatology 2018; 00:000-000).
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/10-6-reading-lemmer.html a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/10-6-interview-lemmer.html the interview with the author
Although pulmonary function tests (PFTs) are routinely performed in patients during the evaluation period before liver transplantation (LT), their utility in predicting post-LT mortality and morbidity outcomes is not known. The aim of this study was to determine the impact of obstructive and/or restrictive lung disease on post-LT outcomes. We conducted a retrospective analysis of patients who had pre-LT PFTs and underwent a subsequent LT (2007LT ( -2013. We used statistical analyses to determine independent associations between PFT parameters and outcomes (graft/patient survival, time on ventilator, and hospital/intensive care unit [ICU] length of stay [LOS]). A total of 415 LT recipients with available PFT data were included: 65% of patients had normal PFTs; 8% had obstructive lung disease; and 27% had restrictive lung disease. There was no difference in patient and graft survival between patients with normal, obstructive, and restrictive lung disease. However, restrictive lung disease was associated with longer post-LT time on ventilator and both ICU and hospital LOS (P < 0.05). More specific PFT parameters (diffusing capacity of the lungs for carbon monoxide, total lung capacity, and residual volume) were all significant predictors of ventilator time and both ICU and hospital LOS (P < 0.05). Postoperative pulmonary complications following liver transplantation (LT) are common and have been associated with increased morbidity and mortality. Infectious complications, prolonged ventilator time, need for reintubation, atelectasis, pleural effusions, acute respiratory distress syndrome, and pulmonary edema have been identified as the main pulmonary complications following LT.(1,2) Both preoperative and intraoperative variables are thought to play a role in the development of pulmonary complications, and although there have been significant advances in critical care and hemodynamic monitoring of LT recipients, pulmonary complications continue to be a significant problem.Studies have identified pre-LT risk factors for postoperative pulmonary complications, including age, (3) severity of liver dysfunction, (4)(5)(6) perioperative fluid administration, smoking history, (7) female sex,and preexisting diabetes. (8,9) Few studies have evaluated preexisting pulmonary dysfunction as a risk factor for Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; CT, computed tomography; DLCO, diffusing capacity of the lungs for carbon monoxide; ESLD, end-stage liver disease; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit; IQR, interquartile range; LOS, length of stay; LT, liver transplantation; MELD, Model for End-Stage Liver Disease; OR, odds ratio; PFT, pulmonary function test; RV, residual volume; SD, standard deviation; TLC, total lung capacity.Address reprint requests to Josh Levitsky, M.D., M.S.,
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