The hyperventilation of cirrhosis: Progesterone and estradiol effects

Abstract

treat hypoventilation disorders. 12 Although plasma progesProgesterone and estradiol are metabolized in the terone is elevated in cirrhotic patients because of decreased liver and are elevated in patients with cirrhosis. Progeshepatic metabolism, progesterone has not been proved to terone stimulates ventilation by activating progesterone cause their hyperventilation. receptors in the central nervous system; estradiol mayWe propose estradiol as a contributing factor to respiratory facilitate progesterone's actions by increasing progesalkalosis, although this has not been examined in humans. terone receptors. This study evaluated whether progesEstradiol is metabolized by the liver into estriol, which has terone and estradiol contribute to the respiratory alkaminimal estrogen effects. Estradiol has no direct respiratory losis common in cirrhotic patients. Arterial blood gases stimulatory effect; 13 however, estradiol increases the number and progesterone and estradiol levels were obtained in of progesterone receptors in animals and may facilitate pro-50 patients with cirrhosis. Multiple linear regression regesterone's actions. 14,15 vealed a statistically significant correlation between This report examines the roles of hyperprogesteronemia P a CO 2 and progesterone and estradiol (r Å .54, P õ .05).and hyperestradiolemia in producing hyperventilation in paPatients with severe hyperventilation (P a CO 2°3 0 mm tients with cirrhosis. Hg) had statistically higher levels of progesterone and estradiol than did patients with mild hyperventilation PATIENTS AND METHODS (30 õ P a CO 2°3 5) or normal ventilation (P a CO 2 ú 35) (P õ .05). Although the progesterone levels were two orders With written patient consent and approval from the University of of magnitude lower than those associated with hyper-Rochester Investigational Review Board, we prospectively studied 50 ventilation in pregnant patients, the increased ventila-patients presenting to liver clinic for possible liver transplantation. tory effect may be because of the altered blood-brain Premenopausal women, patients with chronic obstructive pulmonary disease or acute encephalopathy, or patients taking hormonal medibarrier (BBB) present in cirrhotic patients. Progestercations, narcotics, or benzodiazepines were excluded. All patients one and estradiol appear to contribute to the hyperven- 58.)the wrist. A 20-gauge catheter was then placed in a sterile fashion into the radial artery and taped in place. To ensure no hyperventilation from anxiety or pain, arterial blood was drawn into a heparinized Respiratory alkalosis is common in patients with hepatic syringe after several minutes, the arterial blood was placed on ice, cirrhosis 1,2 although the cause has proved elusive. Proposed and sent to the lab for immediate determination of blood gas results. mechanisms include increased ammonia, 3 decreased albuBlood was also sent for determination of estradiol and progesterone min, 4 hypoxia, 5 and elevated progesterone. 6 levels. Albumin and bilirubin levels and prothrombi...

Abnormal hyperventilation in patients with hepatic cirrhosis: Role of enhanced chemosensitivity to carbon dioxide

“…Moreover, no differences in the arterial partial pressure of oxygen was observed among the three Child-Pugh classes, nor was there any correlation with resting pulmonary ventilation. On the contrary, and consistent with the results of the previous findings [1,5,6,13], we found that patients with Child-Pugh class C cirrhosis demonstrated both alveolar hyperventilation and reduced PaCO 2 at rest compared to patients with less decompensated disease. In addition, patients in class C showed increased chemosensitivity to CO 2 and elevated values of plasma norepinephrine and serum progesterone compared to patients in class A. Progesterone is able to affect ventilation in healthy subjects and a strong correlation between PaCO 2 and serum progesterone levels has been observed in pregnant women [12].…”

“…Several mechanisms have been proposed, including increased serum ammonia [6], hypoxia [5], and, more recently, raised sex hormones (namely progesterone) [13]. Hyperammonemia is a common finding in cirrhotic patients: however, venous ammonia concentration has not been shown to correlate with minute ventilation [6].…”

“…A raised chemosensitivity either to hypoxia [9] or hypercapnia [10], due to hemodynamics and neurohormonal factors, has been described in chronic heart failure and linked to a respiratory pattern similar to the one observed in cirrhotic patients: rest hyperventilation, hypocapnia and alkalosis. Circulating sex hormones and in particular progesterone levels have been found to affect ventilation not only in healthy subjects [11] and pregnant women [12], but also in patients with impaired hepatic metabolism [13]. At present, the mechanism by which progesterone affects ventilation in cirrhotic patients is not known.…”

Dyspnea and respiratory muscle strength in end-stage liver disease

“…This result indicates that the presence of ascites and/or the progression of disease could lead to a further increase in central respiratory drive intensity. What triggers hyperventilation is yet unknown [32] . However, hyperventilation can explain in part the close correlation between chronic dyspnea and RMS in end-stage liver disease patients without ascites.…”

Splanchnic and Extrasplanchnic Thrombosis in Cirrhosis: Prophylaxis vs Treatment

“…A limitation in the analysis of risk factors is that they were not all investigated among different studies. Immobilization, estrogen levels or inflammation, have not been specifically analyzed, although these conditions are common in hospitalized patients with cirrhosis [37,38]. Similarly intestinal bacterial overgrowth and gut translocation may lead to a pro-inflammatory state in cirrhosis.…”