Isolated Intrapulmonary Vascular Dilatations and the Risk of Developing Hepatopulmonary Syndrome in Liver Transplant Candidates

Mendizábal, Manuel; Goldberg, David S.; Piñero, Federico; Arufe, Diego; Fuente, María José De La; Testa, Pablo; Coronel, Matías; Baratta, Sergio; Podestá, Luis G.; Fallon, Michael B.; Silva, Marcelo O.

doi:10.5604/01.3001.0010.0289

Cited by 12 publications

(13 citation statements)

References 15 publications

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“…7,15 IPVD is also deemed to be an essential criterion for the diagnosis of HPS, while most of the researchers considered that there was no need to screen IPVD patients with normal oxygenation from cirrhotic patients in the past. However, Manual et al 16 found that approximately 35% of IPVD patients with normal gas exchange developed HPS by serial ABG measurement. IPVD-only patients were found to be in a hyperdynamic state, presenting as a higher cardiac output, cardiac index, and left ventricular stroke volume, leading to higher risk of dyspnea.…”

Section: Discussionmentioning

confidence: 99%

A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning

Zhong

Bai

et al. 2021

Journal of Clinical and Translational Hepatology

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Background and Aims: Screening for hepatopulmonary syndrome in cirrhotic patients is limited due to the need to perform contrast enhanced echocardiography (CEE) and arterial blood gas (ABG) analysis. We aimed to develop a simple and quick method to screen for the presence of intrapulmonary vascular dilation (IPVD) using noninvasive and easily available variables with machine learning (ML) algorithms. Methods: Cirrhotic patients were enrolled from our hospital. All eligible patients underwent CEE, ABG analysis and physical examination. We developed a twostep model based on three ML algorithms, namely, adaptive boosting (termed AdaBoost), gradient boosting decision tree (termed GBDT) and eXtreme gradient boosting (termed Xgboost). Noninvasive variables were input in the first step (the NI model), and for the second step (the NIBG model), a combination of noninvasive variables and ABG results were used. Model performance was determined by the area under the curve of receiver operating characteristics (AUCROCs), precision, recall, F1-score and accuracy. Results: A total of 193 cirrhotic patients were ultimately analyzed. The AUCROCs of the NI and NIBG models were 0.850 (0.738-0.962) and 0.867 (0.760-0.973), respectively, and both had an accuracy of 87.2%. For both negative and positive cases, the recall values of the NI and NIBG models were both 0.867 (0.760-0.973) and 0.875 (0.771-0.979), respectively, and the precisions were 0.813 (0.690-0.935) and 0.913 (0.825-1.000), respectively. Conclusions: We developed a two-step model based on ML using noninvasive variables and ABG results to screen for the presence of IPVD in cirrhotic patients. This model may partly solve the problem of limited access to CEE and ABG by a large numbers of cirrhotic patients.

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Section: Discussionmentioning

confidence: 99%

A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning

Zhong

Bai

et al. 2021

Journal of Clinical and Translational Hepatology

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“…Segundo Mendizabal et al, 2017 (11) a sobrevida em 5 anos dos pacientes com SHP que não são submetidos a transplante hepático é de 23%, enquanto a dos pacientes sem SHP chega a 63% no mesmo período. Ao se analisarem os pacientes submetidos a transplante hepático a sobrevida foi similar entre portadores e não portadores de SHP.…”

Section: Prognósticounclassified

“…Estudo recente que gerou grande interesse na comunidade mundial foi realizado pelo grupo de Mendizabal et al, 2017 (11) , e analisou 20 pacientes cirróticos assintomáticos. Todos foram submetidos à oximetria de pulso e a gasometria arterial para cálculo do gradiente AaO 2 .…”

Section: Critérios Diagnósticos De Shpunclassified

“…Todos foram submetidos à oximetria de pulso e a gasometria arterial para cálculo do gradiente AaO 2 . Em sete pacientes, que apresentavam oximetria de pulso maior que 97%, o gradiente de AaO 2 (método mais sensível para determinação de hipóxia pulmonar) apresentava-se com valores diagnósticos de SHP, mesmo quando a PaO 2 também estava em níveis aceitáveis (11) .…”

Section: Critérios Diagnósticos De Shpunclassified

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Triagem da síndrome hepatopulmonar: oximetria de pulso ou gasometria arterial?/ Hepatopulmonary syndrome screening: pulse oximetry or arterial gasometry?

Mocelin

Rocha

Pacheco

2019

Arq Med Hosp Fac Cienc Med Santa Casa São Paulo

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Objetivo: Avaliar se a realização rotineira da gasometria arterial em todos os pacientes cirróticos pode ser substituída pela oximetria de pulso isolada para a triagem de SHP. Material e métodos: Estudo observacional, individuado e transversal do tipo inquérito, por meio da análise dos prontuários dos pacientes do ambulatório de gastroenterologia e hepatologia do Hospital Santa Casa de Misericórdia de Vitória, localizado na cidade de Vitória - ES, e por meio da análise da gasometria arterial destes pacientes. Como critérios para o diagnóstico de cirrose, foram utilizados a história clínica, o exame físico, a análise laboratorial e pelo menos um exame de imagem. Resultados: A amostra teve 75,4% de homens, com etiologia alcoólica sendo mais prevalente (53%). A idade média foi de 54 anos, não tendo correlação com a PaO2 (p = 0,754) e com a AaO2 (p = 0,574). A prevalência de pacientes Child A foi de 88,2% e Child B de 11,8%. A maioria (88,2%) dos pacientes apresentaram gradiente AaO2 ≥ 20 mmHg, compatível com critério diagnóstico gasométrico de SHP. Discussão: Não foi observada correlação significativa entre a oxigenação sanguínea medida pela gasometria arterial e pela oximetria de pulso. Pacientes com PaO2 < 60 mmHg apresentaram SatO2 mínima de 93% e mediana de 97%, DP 2,2, comparado com mínima de 85% e mediana de 87%, DP 3,9, nos pacientes com níveis ≥ 60 mmHg (p = 0,827). Portanto, nota-se que a SatO2 medida pela oximetria de pulso não é um bom parâmetro para triagem de SHP nos pacientes cirróticos. Conclusões: A gasometria arterial é indispensável em todos os pacientes cirróticos para triagem da Síndrome Hepatopulmonar, independente da classe funcional, não podendo ser substituída pela oximetria de pulso. Tal conduta visa acelerar o diagnóstico dessa síndrome, considerando a inexistência de correlação entre os critérios diagnósticos gasométricos já estabelecidos e os valores obtidos na oximetria de pulso e no escore Child-Pugh. Tendo em vista que a Síndrome Hepatopulmonar é uma indicação de transplante hepático, seu diagnóstico precoce pode adiantar o processo, melhorando a resposta terapêutica e a sobrevida dos pacientes.Descritores: Síndrome hepatopulmonar, Cirrose hepática, Transplante de fígado, Oximetria, GasometriaABSTRACTObjective: To evaluate whether routine arterial blood gas analysis in all cirrhotic patients can be replaced by isolated pulse oximetry for HPS screening. Material and methods: Observational, individualized and cross-sectional study, by analyzing the medical records of patients from the gastroenterology and hepatology outpatient clinic of the Santa Casa de Misericórdia de Vitória Hospital, located in the city of Vitória - ES, and by analyzing the laboratory results of the arterial blood gases of these patients. The criteria for the diagnosis of cirrhosis were clinical history, physical examination, laboratory analysis and at least one imaging exam. Results: A total of 75.4% of the sample consisted of males, with alcoholic etiology being more prevalent (53%). The mean age was 54 years, with no correlation with PaO 2 (p = 0.754) and AaO 2 (p = 0.574). The prevalence of Child A patients was 88.2% and of Child B was 11.8%. The majority (88.2%) of the patients presented a AaO2 gradient ≥ 20 mmHg, compatible with HPS gasometric diagnostic criteria. Discussion: No significant correlation was observed between blood oxygenation as measured by arterial blood gas and pulse oximetry. Patients with PaO2 <60 mmHg had a minimum SatO2 of 93% and a median of 97%, SD 2.2, compared with a minimum of 85% and a median of 87%, SD 3.9, in patients with levels ≥ 60 mmHg (p = 0.827). Therefore, it is noted that SatO2 measured by pulse oximetry is not a good parameter for screening for SHP in cirrhotic patients. Conclusion: Arterial blood gas analysis is indispensable in all cirrhotic patients in screening for Hepatopulmonary Syndrome, regardless of functional class, and cannot be replaced by pulse oximetry. Such conduct aims to accelerate the diagnosis of this syndrome, considering the inexistence of correlation between the already established gasometric diagnostic criteria and the values obtained in pulse oximetry and Child- Pugh score. Since the existence of Hepatopulmonary Syndrome is an indication for liver transplantation, early diagnosis may accelerate the process, improving therapeutic response and survival in patients.Keywords: Hepatopulmonary syndrome, Liver cirrhosisc Liver transplantation, Oximetry, Gasometry

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“…The presence of IVPDs is essential for the diagnosis of HPS, and if many IVPDs are present in POPH, it worsens transplant outcomes. 69…”

Section: Introductionmentioning

confidence: 99%

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Premkumar

Kajal

Kulkarni

et al. 2021

J Intensive Care Med

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Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

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Isolated Intrapulmonary Vascular Dilatations and the Risk of Developing Hepatopulmonary Syndrome in Liver Transplant Candidates

Abstract: Patients with IPVD appear to have a substantial risk of developing oxygenation impairment over time and progress to HPS. In our cohort, survival in patients with HPS and isolated IPVD is not different when compared to those without IPVDs.

Cited by 12 publications

References 15 publications

A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning

A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning

Triagem da síndrome hepatopulmonar: oximetria de pulso ou gasometria arterial?/ Hepatopulmonary syndrome screening: pulse oximetry or arterial gasometry?

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

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